Experts Preview STD Guidelines, Revised Staging Of Endometrial CA

The 4th Current Issues Update yesterday offered late breaking news in five specialty areas: urogynecology, STD treatment guidelines, reproductive medicine, gynecologic oncology, and maternal-fetal medicine.

Anal incontinence, or AI, was the biggest news from Stephen Young, MD, President of the American Urogynecologic Society. "This is something that has not received appropriate attention from anyone until recently," he said. In a recent survey, just 11.4% of patients sought care for AI and only 17.1% of health-care providers questioned their patients.

"This attests to the sense of embarrassment that surrounds the topic, Dr. Young said.

Risk factors for AI include a prior instrument delivery, episiotomy, and higher infant birth weight. Increasing age is also a factor.

"If we don't ask, our patients will not tell us about AI," Dr. Young said. "If we ask and they tell us, we may be able to help."

Dr. Young also discussed midurethral slings (the recent transobturator products are too new to evaluate against the widely used transvaginal tape models), grafts and meshes in prolapse surgery (Gore-tex meshes produce higher erosion rates than polypropylene products and there are no good data yet on organic grafts), and sexual function following total hysterectomy versus supracervical hysterectomy (no difference).

Gail Bolan, MD, Chief of the California Department of Health Services STD Control Branch, previewed STD guidelines expected to be released by the Centers for Disease Control and Prevention in April 2006. Current guidelines were reviewed last month and proposals will be posted at http://www.cdc.gov/std/treatment.

For the first time, Dr. Bolan said, STD testing will be specifically addressed in the guidelines. "You can't treat appropriately unless you appropriately diagnose your patient," she noted.

Look for recommendations to employ nucleic acid amplification (NAC) to test for many STDs. NAC can detect up to 40% more infections than other methods and is less dependent on use in a clinical setting.

Recommendations for chlamydia will also change. For starters, Dr. Bolan said, look for a change in terminology, from "screening" to "testing." Patients see testing for a disease as a more accurate description.

Azithromycin is recommended for first-line treatment, with erythromycin as an alternative. Also new will be a recommendation for Expedited Partner Treatment, a treatment plan that has the caregiver counseling one partner and prescribing the appropriate drug therapy for both.

Changes in gonorrhea guidelines focus on treatment. Resistance to fluoroquinolones is rising dramatically, especially in California and Hawaii. Oral cephalosporin will be recommended and an alternative, but since it is widely unavailable, cefpodoxine and cefuroxime will be the first-line agents for most patients.

CDC will also likely call for expedited partner therapy for both men and women as well as retesting to confirm eradication of the disease.

New guidelines for bacterial vaginosis call for treatment with metronidazole as more effective than clindamycin cream.

Syphilis guidelines will note rising resistance to azithromycin. Ceftriaxone may become the preferred alternative. Practitioners who use a penicillin should remember to write for Bicillin LA, the long-acting formulation, rather than Bicillin CR, a short-acting version that is not effective for syphilis. And all practitioners should be on the lookout for positive test results, which have been occurring with surprising frequency at some health systems.

David Adamson, MD, Director of Fertility Physicians of Northern California in San Jose, CA, discussed the latest developments in infertility medicine. "It is important to begin the infertility investigation earlier than is the usual practice," he said.

Women under 35 should be seeking help from an ob/gyn after 12 months without conception and an infertility clinic 6 months later. Women over the age of 35 should shorten the cycle and women over 40 should see an ob/gyn as soon as they decide to attempt pregnancy. Increasing infertility is highly associated with advancing age.

A late scientific flash: the number of oocytes may not be fixed. Recent animal data show that new oocytes can be created after sexual maturation. The finding has not been extended to humans.

Definitions of male infertility are also on the move. A sperm count less than 13 million is now considered infertile, compared to the old standard of 20 million. Motility less than 32% is cause for concern, as is strict morphology less than 4%.

Ob/gyns should be referring the male partner to urologists, Dr. Adamson said, and not trying to treat both within a single practice. "Urologists are the experts in this on the male side. Your patient is best served if her partner is also getting expert care."

James W. Orr, Jr., MD, President of Florida Gynecologic Oncology in Ft. Myers, FL, and Immediate Past President of the Society of Gynecologic Oncologists, provided an update on endometrial cancer. There has been a slight increase in the incidence of endometrial cancer (EC) in recent years, he said, and a large increase in mortality. Reasons for the shift have not been determined, but racial factors could be at work. African-American women have worse survival than other groups and are being diagnosed in growing numbers.

Age is also a factor. The age-related risk of EC is significantly higher after age 75, a stage more and more women are reaching.

The most significant change in treatment, Dr. Orr said, is the move from clinical staging of disease to surgical staging. Clinical staging using MRI or other imaging techniques as well as testing and examination is simply not accurate. MRI has a 30% false-negative rate, he explained. PET misses 16% of uterine cancers. And once the abdomen was opened, a third of patients classified as Stage I based on preop clinical measures were found to have extensive disease that had spread beyond the uterus.

"Women are at risk, period," Dr. Orr said. "You need to have that staging discussion preoperatively and be prepared to resect extensively."

The latest news in fetal-maternal medicine is the formation of the Maternal Fetal Medicine Foundation (MFMF) in January 2005. The new group was created to train and certify practitioners in specific technologies, such as nuchal translucency for Down syndrome risk assessment.

"NT should be considered another analyte and subject to quality control, checked for accuracy over time like another other analytical procedure," explained Mary D'Alton, MD, from Columbia-Presbyterian Medical Center in New York. "Training is absolutely necessary to maintain NT reproducibility."

The problem, Dr. D'Alton continued, is the shift from second-trimester screening to first-trimester procedures. Earlier is better, she said, but earlier is also more exacting. NT, for example, requires very specific techniques and conditions to produce a usable image. Like chemical analysis, reproducible results from NT are essential. Poor-quality imaging puts patients at risk and opens physicians to liability claims.

MFMF offers training, proficiency testing and image review, credentialing, and ongoing quality monitoring for NT practitioners. The group is also offering hands-on training in Phoenix, New Orleans, Miami, and Washington, DC, over the next year.

In the past 3 months, Dr. D'Alton said, more than 300 ultrasound providers have enrolled in the credentialing program. "As we see it, most labs will require credentialing by January, 2006," she said. "Credentialing will help patients assess risk and will help physicians by showing that a quality control program is in place and being followed."

Information and enrolment is available online at www.mfmf.org