Current Women's Health Reviews - Volume 3, Issue 1, 2007

All those inspiring to provide a better health to women should aim at the different options open to obtain better outcomesand also to counter health inequities. To achieve this aim, innovative approaches based on the culture and conditions of the target population are needed.Biological science should be closely linked to social science in the search of plausible interventions to improve health in themyriad of situations of the world. Also, the knowledge of the local situation is mandatory to orient the focus of research andinterventions. Two articles of this issue highlight that it is not only the biological outcome but also the satisfactory care that needs to beconsidered regarding issues related to women health. We need to address women expectations about care and also share withthem, the limitations of the diagnostic and prognostic tools used in care as well as the concept of diversity on responses tointerventions and their potential side effects. A review by Manno et al. clearly shows the problem of ovarian hyperstimulation as a consequence of fertility treatments. Another review by Miller et al. addresses an innovative approach to treat maternal haemorrhage, a pneumatic garment thatcan be used at every level of care. Maternal haemorrhage particularly postpartum, is a major contributor of maternal death. Weare eager to see the results of trials testing such approach that could imply a significant contribution on the decrease of globalmaternal mortality.

Annually, over 500,000 women die from complications of pregnancy and childbirth; the majority die fromhemorrhage and shock. Obstetrical hemorrhage of all etiologies, such as uterine atony, ruptured uterus, and rupturedectopic, can cause massive blood loss resulting in severe shock. Unless women can access fluid replacement, bloodtransfusions, and, often, surgery, the shock leads to organ failure and death. Therefore, the majority of maternalhemorrhage deaths occur in developing countries. The non-pneumatic anti-shock garment (NASG) is a light-weight,reusable, neoprene and Velcro compression device that can be rapidly applied to a hemorrhaging woman to shunt bloodfrom the lower extremities to the core organs, heart, lung and brain, and to decrease blood loss. We review literature onthe history, mechanisms of action, and use of Anti-Shock Garments (ASGs) in emergency medicine, focusing on the useof inflatable or Pneumatic ASGs (PASGs) for obstetrical, gynecological, and urological hemorrhage. We describesimilarities and differences between the PASG and the newer NASG. We then review recent studies on the NASG forobstetrical hemorrhage in Pakistan, Nigeria, and Egypt, and conclude with recommendations for the types of researchnecessary to bring the NASG into wider use.

In this article a PubMed (www.ncbi.nlm.nih.gov/entrez), ISI Web of Science (www.isinet.com/isi) and Lilacs(www.bireme.br) literature review was carried out from 1986 to 2005, to search for publications which assessed theassociations between maternal stress/distress and low birth weight (LBW), preterm birth and intrauterine growthrestriction (IUGR). The studies investigated have yielded different results. The reasons are probably related to theterminology of stress and distress (not yet standardized); utilization of different instruments and populations to evaluatethese psychological disorders; the fact that a considerable percentage of the studies did not use adequate sample sizes, andthat some of them were retrospective in design. The impact of stress/distress on preterm birth and LBW seems to be moreimportant than its impact on IUGR. According to the majority of the studies assessed in this review, women exposed toacute stress in early pregnancy and to distress (anxiety, depression, etc) in late pregnancy are at significantly increasedrisk of shortened gestation. In conclusion, interventions to prevent stress/distress have to start before conception.Appropriate programmes should be carried out to address the origins and effects of stress/distress to pregnant women, toimplement relevant preventive interventions.

Introduction : Controversy exists over psychological risks associated with termination of pregnancy(TOP). Although some studies recently shed some lights on the consequences of TOP on women's emotions andmental health, the positive and negative psychological and psychiatric impacts of TOP on sexual psychodynamicand intimate relationships have been poorly investigated. Objective :The objective of this article is to review the studies focusing on women's sexual function and intimaterelationships after TOP. Methods: A systematic search of the literature was performed. Studies had to have a quantitative or qualitativeevaluation of sexuality after TOP. Results: Fourteen studies were included. Sexual dysfunctions were reported in up to 30% after TOP. Womenundergoing a TOP had significantly more conflicts in their partnerships. This was similar in all studies. Separationoccurred in about one quarter of all couples. Nevertheless, long-term effects of TOP on sexual function were lessfrequent than short-term impacts. Discussion :Some studies show an increase in sexual dysfunction after TOP. Nevertheless, follow-up studies showthat persisting negative impacts of TOP on sexual function and intimate relationships are rare. In about half of thecouples separated after a TOP, TOP seemed not to have directly led to the separation. Rather, psychological factors,together with intimate relationship problems might have played a role in failed contraception. Sexual response ispsychosomatic and so often difficult to understand. A detailed exam is thus needed before and after TOP in order toestablish the importance of either its organic or psychological factors.

Background: Although multiple births are associated with poorer clinical and psychological outcomes, there isa perception that couples choose multiple embryo transfer because they would prefer a multiple IVF birth. Objective :To review literature concerning the attitudes of infertile couples to a multiple birth and to explore factorsinfluencing couples' decisions about embryo transfer. Methods: Thirteen research articles were identified in the medical literature that examined women's choices concerningmultiple IVF pregnancies. A cross-sectional survey was conducted at one centre for the treatment of infertility in the EastMidlands, UK. Sixty-eight couples undergoing in-vitro fertilisation (IVF) with at least two embryos available for transferwere recruited to the study. Outcome measures were couples' ratings of factors influencing the number of embryostransferred. Results: Eight of the 13 studies found couples favouring a multiple birth to be in the majority. Most studies, however, hadrequired hypothetical or retrospective judgments. In the present survey no patient had chosen single embryo transfer(SET), 56 (76%) had had 2 embryos transferred and 16 (24%) had 3 embryos transferred. Patients strongly perceived thatSET would reduce the chances of having a child. Only 13 women (19.1%) considered that a desire for twins hadinfluenced their decision. Of more importance was the desire to increase the chance of pregnancy (92.7%), the medicaladvice received (91%) and a desire to avoid further treatment (57.3%). The majority of couples found the decisionregarding embryo transfer easy but a third would have liked more information. Participants with children were less likelyto report a desire for twins (p<0.06) but other demographic factors had no influence. Conclusions: Although the literature has suggested that infertile couples have strongly positive attitudes to multiplepregnancies, most patients are not seeking a twin birth when they choose multiple embryo transfer and physicians have animportant role to play in helping patients make informed decisions.

Ovarian hyperstimulation syndrome (OHSS) is the most serious iatrogenic disorder resulting from ovarianstimulation during assisted reproductive techniques (ARTs). It can result in renal failure, thromboembolic phenomena,adult respiratory distress syndrome and, occasionally, death. Almost all previous preventive strategies resulted ineffective. Vascular Endothelial Growth Factor (VEGF) plays a pivotal role in the pathophysiology of this syndrome so VEGFantagonism has been suggested for OHSS prevention. Since VEGF is also a physiological regulator of folliculogenesis,progesterone secretion and endometrial angiogenesis, its complete inactivation by monoclonal antibodies could producepotential undesirable effects. Administration of Human Chorionic Gonadotropin (HCG) stimulation of VEGF productionis fatal for the developing of OHSS; the use of GnRH agonist instead of HCG for ovulation triggering, is a promisingstrategy. Recently dopamine D2 agonists have been shown to counteract VEGF induced vascular permeability. The lack oftoxic or teratogenic effects could make cabergoline an effective and safe aetiological approach for OHSSprevention/treatment. A recent meta-analysis has indicated that the administration of metformin significantly preventsOHSS development in polycystic ovary syndrome, an high risk group. In the light of these new studies we believe that recent guidelines on OHSS prevention need a substantial revision.

Objective :Female urinary incontinence is often considered a problem that occurs primarily during pregnancyand after childbirth. The aim of this article is to review the literature addressing pelvic floor muscle training in theprevention and treatment of urinary incontinence during pregnancy and after delivery. Method :Only full publications of prospective controlled studies were included. Urinary incontinence was the primaryoutcome variable and pelvic floor muscle training was the main intervention. Results: Four randomised controlled trials (RCTs) assessing the effect of pelvic floor muscle training during pregnancywere found. Ten articles were identified addressing the effect of pelvic floor muscle training postpartum; seven of thesepresented RCTs, two presented matched controlled studies and a controlled study. Three were follow-up studies. Theinterventions included pelvic floor muscle training, however, various training protocols were used. All studies, except fortwo, reported statistically and clinically significant effects of the interventions, with a significant reduction in symptomsor frequency of urinary incontinence after the intervention period. No adverse effects of the interventions were reported. Conclusions: This review suggests that women should be encouraged to perform pelvic floor muscle training duringpregnancy and postpartum to prevent and/or treat urinary incontinence.

Declining fertility in women occurs as a result of ovarian ageing - a process associated with a reduction in thenumber and quality of oocytes. Knowledge of ovarian age is important at a time when many women tend to delaypregnancy and childbirth. As the natural history of ovarian ageing is unknown, it is difficult to predict, prevent or treat thisphenomenon. The evaluation of ovarian reserve has been largely restricted to women undergoing assisted reproduction.Hence, the predictive value of some of the commonly used tests, in a general population of women is unknown. In thisreview we discuss the natural history and the potential causes of ovarian ageing. We also assess available methods ofprediction and treatment of this condition including the use of techniques such as in vitro maturation and oocytecryopreservation.

Obesity has reached epidemic proportions globally. Multi-system and morbid ramifications of obesity arerecognized in both sexes that are at least partly reversible following significant and sustained weight reduction. Bariatricsurgery is a relatively recent intervention in the therapeutic armamentarium for the management of morbid obesity andutilization of bariatric surgery as an option for weight loss is escalating. We provide an overview of the effects of morbid obesity on the hypothalamic-pituitary-ovarian (HPO) axis, reproductiveand sexual performance. This review focuses on the alterations in reproductive physiology, with specific regard to thealterations in fertility status, efficacy of oral contraception and sexuality following bariatric surgery. Our perusal of thepublished literature reveals that although non-surgical weight loss in morbidly obese improves fertility, data onreproductive performance after weight loss by bariatric surgery is sparse and somewhat controversial. In the currentsetting of an increasing utilization of this therapeutic modality in the reproductive age population, this underscores a needfor better appreciation of the alterations in physiology following bariatric surgery by well-designed trials. The suboptimalefficacy of oral contraceptives after weight loss by bariatric surgery needs to be further evaluated and in the interim, whenprescribing OCP's to patients anticipating undergoing bariatric procedures, counseling should include a discussion onpotential contraceptive failure after surgery. Although an improvement in sexual performance and satisfaction may followdramatic weight reductions, the possibility of a detrimental influence specifically after bariatric surgery remains to bedetermined by future trials.

A local hormone environment based on local transfer of hormones between adjacent blood vessels is importantfor the normal function of the genital system. The hormones from a large follicle or a corpus luteum are transferred locallyfrom ovarian venous blood to the ovarian arterial blood, thus the ipsilateral organs (ovary, Fallopian tube, and uterinecorner) receive blood with an increased hormonal content compared to that on the contralateral side. Likewise, messengersubstances from the uterus and Fallopian tube will reach the ovary through local transfer. A similar system exists withtransfer from vagina to uterus and urethra. The system of local transfer can be utilized for local treatments targetedtowards the urethra or uterus through drug deposits into the vagina. A small vaginal oestrogen dose will, for example,prevent post-menopausal degenerative changes in the urethra without inducing systemic effects.