Current Women's Health Reviews - Volume 2, Issue 1, 2006

Every Women Count The World Health Report 2005 - Make Every Mother and Child Count, says that this year almost 11 million children under five years of age will die from causes that are largely preventable. Among them are 4 million babies who will not survive the first month of life. At the same time, more than half a million women will die in pregnancy, childbirth or soon after. The report says that reducing this toll in line with the Millennium Development Goals depends largely on every mother and every child having the right to access to health care from pregnancy through childbirth, the neonatal period and childhood. All of those who chose to work on women health are aware of the significance of this WHO statement and our willingness is to see the effect of our efforts in every woman of the world and this enormous responsibility has been taken by journal Current Women's Health Reviews. Health equity of women at the highest level possible is the aim to achieve. An avoidable maternal death can not be admitted anymore and the best quality of life in every period for every woman needs to be reached. The present copy of the journal Current Women's Health Reviews is the second volume of the journal. I am happy that journal completes its one year successfully and all the issues of first volume comprise a variety of good articles with up-to-date information regarding every aspects of women's health. My aim as Editor-in-Chief is to provide scholarly publications that are useful to clinicians and obstetricians. This issue also shows a diversity of information with a good balance of contributions to women global health. Researchers from developing and developed countries can provide contributions to attain journal's aim and contribute to achieve the best equalitarian women global health. The issue starts with an article by Olâh gives an update of the surgical management of vesico vaginal fistulae. Up to 80,000 women each year develop fistulae. Between 500,000 and one million women are currently living with fistulae. Many of these women become social outcasts turned out of homes and rejected by their husbands and families. Regardless that every woman in labour should have access to an appropriate control of labour to prevent the fistulae, surgical repair will relief these women and allow their family and social reinsertion. Two articles of this issue referred to contraception, a need of women to avoid grand multiparity and to attain reproductive health. According to WHO, "reproductive health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. In line with the above definition of reproductive health, reproductive health care is defined as the constellation of methods, techniques and services that contribute to reproductive health and well-being by preventing and solving reproductive health problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases" one is an illustrative study performed in India by Kumar in article 2, shows the lack of knowledge and access to contraception of these women particularly in rural areas and that surgical sterilization is an accepted option for these women. There is a need of studies like this, looking for women expectations in order to design methods and approaches based on their culture and expectations. Another study about emergency contraception by Misro shows the amazing lack of knowledge and availability of this method in developing countries in article 4. The maternal and perinatal consequences of grand multiparity, and the increased risk of antepartum and postpartum haemorrhage in women is the most important issue which results in Perinatal mortality. This analytical study is carried out by Yves in article 3. Hemoglobinopathies in Pregnancy is a sensitive theme which is covered in an article 5 by Hassell and have discussed sickle..........

The occurrence of a vesicovaginal fistula is rare in the developed world, and usually follows gynaecological surgery for benign conditions. In the developing world it is still a common occurrence, usually as a result of prolonged labour, foetal demise and ischaemic necrosis of the vaginal and bladder walls. Regardless of the cause, and accurate diagnosis and the most appropriate management for the fistula is important to define, whether it be by conservative therapy or a surgical approach. Most gynaecologists favour the vaginal approach to fistula repair, whilst urologists generally opt for an abdominal operation. Where other abdominal procedures are necessary an abdominal approach would be sensible. Surgery, if required should be performed by a surgeon trained in fistula repair, and there is an argument for referring such patients to a regional centre for treatment.

Studies show that health education and better access to temporary contraceptives decreases the popularity of sterilization and that most Indian women report no knowledge/no use of other contraceptives prior to sterilization. However, data from this survey of 169 Indian urban and rural women demonstrates that poor women chose sterilization more for personal and socio-economic reasons (low income, dissatisfaction with other methods, achieved parity, poor health and living conditions) than for lack of awareness of other contraceptives. Urban women were significantly more likely to have tried one or more forms of available contraceptives, while rural women were significantly more likely to be unaware of other available methods (p<0.001). Literacy was significantly associated with contraceptive use in both urban and rural groups (p<0.01). At least one child of each sex was desired. A need for improvement of literacy, health education programs, and enhanced family planning services for rural women was evident.

Aim: The aim of this study was to perform a systematic review on the maternal and fetal/neonatal outcome of grand multiparity (defined as a woman giving birth for the fifth to ninth time) and on the outcome of great grand multiparity (women delivering for the tenth or following time). Methods: A Medline (1966-2004) and Google Scholar search was performed. Studies reporting on grand multiparity or great-grand multiparity and comparing these women with a control group were retained. Results: On the subject of grand multiparity 19 comparative studies could be identified, of these 9 used para 5 to 9 as the definition of grand multiparity. Grand multiparous women show more obesity, gestational diabetes and chronic hypertension but less pre-eclampsia). Grand multiparous women more frequently have a suboptimal prenatal care. Concerning labour and delivery grand multiparous women have less malpresentation, induction, oxytocin use, caesarean section and instrumental delivery although they more often give birth to a macrosomic child. Grand multiparous women demonstrate more placenta previa and postpartum haemorrhage. Considering fetal and neonatal complications the risk of a low Apgar-score after 5 min. is higher, perinatal death is less frequent. No significant differences were found for maternal anaemia, breech position, meconium stained amniotic fluid, placental abruption or retention and fetal or neonatal death. Four articles on great grand multiparity were included. A significant increase was found for diabetes, hypertension, breech presentation, meconium stained amniotic fluid, caesarean section and macrosomia. Significant decreases were found for anaemia, prematurity, induction of labour and instrumental delivery. No significant differences were demonstrated for postmaturity, placenta previa, abruptio placentae, fetal distress, postpartum haemorrhage, low birthweight and congenital malformations. Conclusion: Grand multiparous women have higher rates of suboptimal prenatal care and are to be considered high risk obstetric patients. Data on great grand multiparous women are relatively scarce, problems seem to be related to macrosomia and non-cephalic presentation resulting in a higher caesarean section rate.

Emergency contraception (EC) is defined as the contraceptive measure capable of preventing pregnancy following an unprotected vaginal intercourse. It works by mainly preventing ovulation and fertilization. Efficacy for different available methods of EC is now well established. Side effects of emergency contraception are less and manageable. Dedicated emergency contraceptive regimens are available for use in many countries. Levonorgestrel compared to other hormonal combinations is favored as the emergency contraceptive pill of choice because of its better efficacy and less side effects. Besides fulfilling the unmet need for contraceptives among young adolescents, emergency contraception is considered as one of the best alternative and back-up approaches of contraception in married women. However, awareness and use of emergency contraception is not widespread in developing countries, which account for a majority of world's population. In the present review we attempt to bring together the current status on various methods of emergency contraception and the issues related to availability, accessibility and use of EC among the prospective users.

Hemoglobinopathies, including sickle cell disease and thalassemia, present unique health care challenges during pregnancy. Women with sickle cell disease generally tolerate pregnancy well, with low maternal and perinatal mortality, when provided access to coordinated high-risk obstetrical and hematological care. Pregnancy may be complicated by pre-term labor, intrauterine growth retardation, small-for-gestational-age births and increased sickle cell pain crises and complications. Transfusion support does not improve maternal or fetal complications, even if used to correct severe anemia, but does lessen the incidence of sickle cell events, and should be reserved for women with severe anemia (hemoglobin<6.0 gm/dl), frequent severe pain crisis or other sickle cell complications. Women with sickle cell trait have an increased incidence of bacturia during pregnancy, but do not experience manifestations of sickle cell disease. Other hemobinopathies, including hemoglobin EE and hemoglobin CC disease, do not significantly affect pregnancy. Few pregnancies have been reported in women with Cooley's anemia (β°thalassemia) due to infertility; these women and some with hemoglobin H disease (severe α-thalassemia) require transfusion support during pregnancy. The presence of high-affinity hemoglobins has not been associated with adverse pregnancy outcomes. Recognition and accurate diagnosis of a maternal hemoglobinopathy is imperative for appropriate management and genetic counseling.

Pregnancy is accompanied by altered levels of coagulation factors, which are likely responsible for an increased risk of thrombosis, including an increased risk of deep vein thrombosis, pulmonary embolism, stroke and myocardial infarction. Women with thrombophilia, an acquired or inherited predisposition to thrombosis, are at an even greater risk of thrombosis during pregnancy than other women. The presence of thrombophilia, which may protect women from blood loss at the time of childbirth, does not improve the outcome of pregnancy. Women with thrombophilia are more likely to experience placental abruption, preeclampsia, fetal growth restriction, stillbirth, and possibly recurrent miscarriage. There are no randomized trials of the use of anticoagulation to reduce maternal thromboembolism, but in women with thrombophilia and a history of thrombosis, anticoagulation is generally recommended. In women with thrombophilia and a history of poor pregnancy outcome, anticoagulation may improve fetal outcomes.

Female sexual steroids strongly influence different steps of coagulation. This explains why women's health during different life spans is affected significantly by thrombophilias. The aim of this review article is to summarize current knowledge on thrombophilias regarding oral contraception (OC) and hormonal replacement therapy (HRT). More than a hundred million women worldwide use female sexual steroids as OC or HRT. The understanding of acquired and inherited thrombophilias has increased dramatically over the last two decades. At present, it is not recommended that all OC or HRT users should be routinely screened for acquired or inherited thrombophilias. The usefulness of testing for these disorders in the presence of multiple thrombotic risk factors should be considered on an individual basis.

A considerable body of literature is accumulating regarding the therapeutic potential of androgens in women with sexual dysfunction. Most of the studies point to a beneficial role of androgens in improving sexual function in women with limited adverse events. Nevertheless, use of androgens in women remains highly debated and controversial. With the advent of new testosterone preparations for women, albeit not FDA approved, it is anticipated that renewed interest in androgen therapy in women will emerge. It is expected that the availability of new androgen preparations will spur both consumer interest and scientific interest and will lead to additional basic and clinical research. As new clinical data become available, issues pertaining to safety and efficacy of androgens in management of women with sexual dysfunction will be resolved. The emerging consensus on androgen insufficiency in pre- and post-menopausal women and the prevalence of sexual dysfunction, together with data from clinical and pre-clinical studies necessitate development of new strategies towards evidence-based management of women's sexual dysfunction with androgen therapy. The focus of this review article is to: 1) provide an historical perspective of use of androgen in women, 2) review the basic biochemistry of the biosynthesis and metabolism of androgens in women and 3) summarize new information from clinical studies to provide new insight for potential use of androgens as therapeutic agents in the treatment of women with sexual dysfunction. The overall aim of this review is to discuss the role of androgens in overall women's health, sexual function and dysfunction.

Gender specificity of the clinical presentation and the course of diseases may - at least in part - be mediated by polymorphic genetic variation. In addition, different pharmacogenetic effects in men and women may be accounted for by the carriage of polymorphisms. A variety of studies have investigated these issues with respect to blood lipids and found clear indications for gender-specific effects depending on the carriage of particular alleles. For example, apolipoprotein E (APOE) 2 gene-treatment interactions for statin therapy with atorvastatin were observed in men, but not in women. The risk for myocardial infarction while taking simvastatin is modulated by the APOE 4 allele in men, but not in women. Gene-environment interactions between alcohol use and LDL cholesterol levels are dependent on the APOE genotype exclusively in men. In addition, the APOE genotype significantly influences bone mineral density at the hip and lumbar spine dependent on hormone replacement status. Variance in the apolipoprotein A (APOA) 5 gene influences triglyceride levels in both men and women, but in different ways. Besides the activities and effects of apolipoproteins, research has demonstrated that hormone sensitive lipase is also genetically controlled with pronounced gender-specific variations. While it seems clear that gender specificity and genetic variation due to polymorphisms are interrelated phenomena, the functional reason for these gender-specific effects is unknown. Data in the literature show that the distribution of specific alleles and genotypes is not different between men and women. Thus, other factors have been advocated, namely the influence of sex steroids on expression patterns and effects of genes and gene products, respectively.

Polycystic ovary syndrome (PCOS) is a syndrome of ovarian dysfunction showing cardinal features of hyperandrogenism and polycystic ovarian morphology. It is one of the most common reproductive endocrine disorders in young adult women, showing clinical signs of menstrual disorder, anovulation, hirsutism, acne, and obesity. Frequently, this group of patients present with infertility due to chronic oligoovulation or anovulation. In cases that do not respond to medical induction of ovulation, ovarian surgery such as ovarian wedge resection via laparotomy or ovarian drilling by trans-abdominal laparoscopy has been utilized. Laparoscopic ovarian drilling (LOD) by the trans-abdominal approach has been widely used to induce ovulation in PCOS women after failure of treatment with clomiphene citrate. So far, many authors have reported high rates of ovulation (∼ 80%) and pregnancy (∼ 60%) following LOD. Recently, a transvaginal method for laparoscopy, named transvaginal hydrolaparoscopy (THL), was developed near the end of the 20th century. Since then, THL has been performed for diagnostic purposes in infertile women. More recently, THL has been performed for operative laparoscopy, especially for ovarian drilling in women with PCOS. This novel technique, transvaginal hydrolaparoscopic ovarian drilling (THLOD) using a laser or bipolar electrosurgery, appears to be an effective minimally invasive procedure to induce ovulation in women with PCOS. Larger studies to assess the safety and long-term efficacy of THLOD are needed. This review article describes the minimally invasive operation for infertile women with PCOS by THLOD.