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Current
Women's Health Reviews
ISSN: 1573-4048
Current Women’s Health
Reviews
Volume 2, Number 2, May 2006
Contents
Editorial Pp. 97
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The Need to Avoid the Routine Use of Episiotomy
Pp. 99-102
Giselle Tomasso, Fernando Althabe, María L. Cafferata,
Alicia Alemán and Claudio Sosa
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Probiotics in the Prevention of Urogenital Tract Infections:
Mechanisms Involved Pp. 103-117
Maria. E. F. Nader-Macías
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Secondary Recurrent Miscarriage - A Unique Entity
with Respect to Etiology and Treatment Pp. 119-124
Ole B. Christiansen, Astrid M. Kolte and Henriette
S. Nielsen
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Menopausal Transition and Chronic Diseases
Pp. 125-132
Riitta Luoto
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Double Strand Break Repair Activities of p53 as Potential
Tumor Suppressor Function Co-unteracting Mammary Tumor Development
Pp. 133-143
Lisa Wiesmüller and Rolf Kreienberg
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Challenges in Diagnosis of Reproductive Dysfunction
Pp. 145-154
Tarala D. Nandedkar
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Vesicovaginal Fistula Pp. 155-162
Clifford Y. Wai and Amanda B. White
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Abstracts
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EDITORIAL : Basing the Practice on Scientific
Evidences
An article of this issue show how a clinical practice has
been universally introduced without any scientific evidence,
based only on opinions and soon after its introduction, well
designed clinical trials showed that this practice is useless
and also deleterious. This is a paradigmatic example on how
we should not proceed and the need of the critical analysis
of available research to give support to our daily practice.
The objective of the Journal is to provide scientific evidences
on initial care required for women’s health related
problems. The diversity of the articles of this issue shows
us that how fascinating is the search for the evidences and
how we need research to advance our achievements. For instance,
probiotics looks as a very promising approach for the treatment
of infections and the author of this article shows us not
only its potential but also the willingness and need of clinical
trials to assess it efficacy and further implementation.
Many paradigmatic experiences show us that only the knowledge
of the physiopathology of a drug and clinical experience are
not enough to highlight the efficacy and safety of a drug.
This is the dramatic example of the use of diethylstilbestrol
that was implemented without any scientific evidence and further
careful research demonstrated its harm and lack of any benefit
in issues concerning pregnancy. On the other hand, researchers
guided by an observation in animals for a potential benefit
of maternal corticosteroids administered in humans in a randomised
controlled trial and demonstrated the benefits of such a treatment
without major harmful effects. Since then, this treatment
has played a significant role in saving lives of many children.
In this context, we need that every new proposal of treatment,
diagnostic or prognostic method should be strictly evaluated
by proficient research. Also, to be aware that fortunately
research provides us new evidences that bring about changes
in the practise incorporated in our early stages of training.
To be the best providers, we should accept such changes and
incorporate new findings or discontinue the use of practices
demonstrated as useless. In this context, we should not be
attracted by the propaganda of new and sophisticated technologies
and should not implement them before being confident about
their benefit. A rationale use of the scarce resources on
health care is also the concern of providers.
A scientific Journal is a fascinating world where the advancements
and the challenges are set. The aim here is to attain a better
quality of care to women, and provide them the best quality
of life.
José M. Belizán
Department of Mother &
Child Health Research
Institute for Clinical Effectiveness
and Health Policy (IECS)
Viamonte 2146 (3er Piso)
(C1056ABH) Buenos Aires
Argentina
E-mail: belizanj@allstat.org
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The Need to Avoid the Routine Use of Episiotomy
Giselle Tomasso, Fernando Althabe, María L. Cafferata,
Alicia Alemán and Claudio Sosa
The justification of the routine use of the episiotomy arose
at the beginning of 20th century. It was based
on personal beliefs without scientific basis that endorsed
this recommendation. This led to the incorporation of episiotomy
in daily practice being a routine procedure, especially in
nulliparous women. Since 1985 many researches of good experimental
design were generated to verify if routine episiotomy was
justified.
High-quality methodological studies gave strong evidence that
the episiotomy should not be done routinely in view of the
fact that it does give benefits neither for the women nor
for the newborns. Its use should be restricted to certain
clinical situations.
However, the episiotomy continues to be a customary practice
even though the available evidence for more than one decade
ago shows that it does not improve maternal or perinatal health.
This suggests that there is a need for implementing interventions
to change practitioner’s behaviour.
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Probiotics in the Prevention of Urogenital Tract Infections:
Mechanisms Involved
Maria. E. F. Nader-Macías
Urogenital tract infections affect a very high number of
women worldwide, producing many clinical situations that imply
increasing costs to the health systems, and a consequent morbility
and mortality. The Urinary Tract Infections are more common
in pre pubers or postmenopausal women, while the Genital Infections
are more related to Sexually Active Women. Many of the applied
therapeutics imply the use of antibiotics or other drugs that
produce adverse effects not only in the urogenital tract,
but at general level. This tract is also affected by other
external or internal factors that have effect on the equilibrium
of the urogenital microbiota, increasing the incidence of
infections. During the last years the preventive measures
are being applied around the world. In the urogenital tract,
they are considerably important by the relationship with pregnancy
development, newborn status and mother complications. The
application of probiotics for many clinical situations, and
for the restoration of the urogenital microbiota and prevention
of infections, is more and more frequent. Probiotics are defined
as live microorganisms administered in high numbers to the
host to produce a physiological effect. The mechanisms involved
in the probiotic effect include the production of antagonistic
substances, the competitive exclusion phenomenon, the competition
for nutrients, the colonization ability, the biofilm formation
and/or the stimulation of the immune system. Some of these
mechanisms have been showed by “in vitro”
assays, but not yet in many “in vivo”
experiments. The diversity of strains claimed as probiotics
is higher every time, without the publication of clinical
trails supporting their beneficial effect. These aspects and
other related with the rationale of probiotic application
in the urogenital tract are discussed in the present review.
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Secondary Recurrent Miscarriage - A Unique Entity
with Respect to Etiology and Treatment
Ole B. Christiansen, Astrid M. Kolte and Henriette
S. Nielsen
In the literature, a distinction between patients with secondary
recurrent miscarriage (RM), defined as RM after a previous
birth, and primary RM with no preceeding birth is often not
made. In this review we point out that there are fundamental
epidemiological, clinical and paraclinical differences between
these two major subsets of RM patients. There are indications
that most cases of secondary RM are caused by an abnormal
reaction of the adaptive immune system against the fetus or
trophoblast whereas primary RM has a more mixed etiology with
many cases caused by disturbances in the coagulation pathways
or in the innate immune system. These differences in pathogenesis
are reflected in the different responses of the two patient
subsets to immunotherapy: many primary RM patients benefit
from allogeneic lymphocyte immunization whereas most patients
with secondary RM benefit from intravenous immunoglobulin.
It is important in future case-control studies or trials of
therapy clearly to report the main outcome measures separately
for patients with primary and secondary RM, respectively.
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Menopausal Transition and Chronic Diseases
Riitta Luoto
Menopausal transition modifies the prevalence, incidence
and timing of many chronic diseases, such as cardiovascular
diseases, depression or musculoskeletal disorders. Women with
early menopause, before age 45 years, have increased cardiovascular
disease morbidity. This is due to interactions between menopausal
transition and family history, lifestyle and socioeconomic
factors. The aim of this review is to update current knowledge
concerning menopausal transition and prevalence and prevention
of chronic diseases, such as cardiovascular disease and mental
health disorders, especially depression. Longitudinal cohort
studies are the main references of the review. In conclusion,
the role of early menopause in chronic disease prevention
may be larger than earlier expected. Chronic disease prevention
through lifestyle changes (especially increase of physical
activity) is a useful tool around menopausal transition.
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Double Strand Break Repair Activities of p53 as Potential
Tumor Suppressor Function Co-unteracting Mammary Tumor Development
Lisa Wiesmüller and Rolf Kreienberg
Correct repair of DNA double strand breaks (DSBs) is central
to the maintenance of the genome integrity, since errors give
rise to translocations, deletions, duplications, and expansions,
thereby accelerating the multistep process of tumorigenesis.
Altered DSB repair activities have been closely linked to
the development of both inherited and sporadic breast carcinomas,
as indicated by frequent mutations or abnormal expression
of DSB repair-related genes. Mammary epithelium appears particularly
dependent on proper p53 function as indicated by the high
frequency of TP53 mutations in sporadic breast cancers
and the high incidence of breast cancer among Li-Fraumeni
syndrome patients with mutated p53. Convergent studies demonstrated
that p53 regulates recombinative DSB repair independently
of classic tumor suppressor functions in transactivating target
genes that are implicated in growth control or apoptosis.
Moreover, physical and genetic links were established between
p53 and recombination factors, such as Rad51, BRCA1 and BRCA2.
Mechanistically, p53 restrains DNA exchange events involving
imperfectly homologous sequences, thereby suppressing error-prone
genome rearrangements. p53 as a DNA repair factor may, therefore,
significantly contribute to the suppression of mammary tumor
development, which is supported by the observation that the
functional status of p53 as a tumor suppressor closely parallels
its regulatory activities in recombination.
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Challenges in Diagnosis of Reproductive Dysfunction
Tarala D. Nandedkar
Ovarian function and hence cyclicity in women is initiated
at puberty and regular menstrual cycles continue until menopause,
the point of reproductive senescence. Disturbances in normal
cyclicity are usually indicative of a reproductive disorder
in women. Disturbance/s may be manifested as oligomenorrhoea,
dysmenorrhoea, amenorrhoea or anovulation etc and aid/s in
early detection of the clinical condition. On the other hand,
in certain ovarian disorders, such as ovarian cancer, symptoms
of dysfunction are observed only in the advanced stage of
the disease. It is therefore imperative to develop tests/techniques
for detecting the disorder at an initial stage in order to
facilitate timely treatment. In case of some ovarian conditions
such as Polycystic Ovarian Syndrome (PCOS) and Premature Ovarian
Failure (POF), the diagnostic criteria and methods of detection
are well – defined. However, in a majority of disorders
the cause of the disease is not clear, thus posing limitations
in the development of new methods of detection or improvement
of the existing ones. For instance, an increase in CA125 is
widely used for the prognosis of ovarian cancer but the same
is not a specific marker since CA125 is known to increase
in other cancers as well as endometriosis. Identification
of highly specific markers for the multitude of ovarian pathologies
is therefore essential.
In recent years, development of molecular diagnostic techniques
such as Polymerase Chain Reaction (PCR), Single nucleotide
polymorphism (SNP), has gained momentum over currently available
methods of detection such as ultrasonography, radioimmunoassay
to elucidate the extent of damage to the reproductive organ.
In the review, recent progress in detection of diseases at
the cellular and molecular level, and possible research avenues
in diagnosis and prognosis of reproductive disorders has been
highlighted.
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Vesicovaginal Fistula
Clifford Y. Wai and Amanda B. White
Genitourinary fistula, an abnormal communication between the
urinary (ureters, bladder, urethra) and the genital (uterus,
cervix, vagina) systems is a serious problem that is associated
with quality of life issues, hygiene, social outcasting, has
legal ramifications, and potential exposure for additional
surgery. Although the true incidence of genitourinary fistulae
is unknown, the general consensus is approximately 0.1-2%.
The clinical presentation varies, but most present with continuous
leakage within days to weeks after the initial insult. The
cause is due to obstetric trauma in developing countries and
surgical injury in developed parts of the world. The diagnosis
is achieved from a thorough history and physical. In addition
to the ‘tampon’ test, radiologic tests provide
confirmation, localization and characterization of the fistula.
A trial of conservative management including continuous urinary
catheter drainage is warranted, especially if the fistula
is small and diagnosed early. Surgical management varies and
may be approached laparoscopically, vaginally, or abdominally
depending on the characteristics of the fistula and expertise
of the surgeon. The optimal route of repair has not been determined.
However, the basic principles remain the same: hemostasis,
layered closure, tension-free repair and continuous post-operative
bladder drainage.
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