Updates

UPDATES

Thyroid screening guidelines

The American Thyroid Association now advises that adults be routinely tested for thyroid disorders, beginning at age 35 and every 5 years thereafter [Arch Intern Med. 2000;160:1573-1575]. "The indication for screening is particularly compelling in women," the consensus statement notes.

The new guidelines accept serum TSH measurement as a reliable test, sufficient to identify all common forms of hyperthyroidism and primary hypothyroidism. But for persons suspected of having central (secondary) hypothyroidism, a serum FT₄ concentration should also be obtained, since in these cases TSH concentrations may be low, normal, or mildly elevated.

Norplant alert

Women who received Norplant implants from lots distributed on or after October 20, 1999, should use backup birth control methods because these implants may be ineffective, announced the manufacturer, Wyeth-Ayerst Laboratories of American Home Products Corp.

In routine laboratory tests, implants from certain lots released relatively low levels of levonorgestrel; the impact of this on contraceptive effectiveness is uncertain. The lots in question include numbers 3990729, 3990775, 3990776, 3993006, 3003127, 3003166, and 3003355. Unused kits from these lots can be returned to Wyeth-Ayerst, which has an information line at 800-364-9809 for questions about Norplant. The company will reimburse up to $100 to cover alternative contraception costs for women who can provide statements from their health-care providers that they have the affected implants.

Partial hydatidiform moles and choriocarcinoma

Contrary to common belief, it turns out that partial hydatidiform moles (PMs) can transform into choriocarcinoma and may do so 20% of the time [Lancet. 2000;356:36-39].

Researchers studied 3,000 patients with PMs. Of those, 15 required chemotherapy for persistent gestational trophoblastic disease. Five of these women were later found to have choriocarcinoma, and three (the only ones for whom suitable material was available for genetic analysis) of the five choriocarcinomas were genetically determined to have arisen from the PM.

While most women with choriocarcinoma are treated successfully with chemotherapy, more than 10% die, usually because of delayed diagnosis or inadequate follow-up of hCG levels. The authors of the study recommend that all women with PMs have their hCG carefully monitored and that clinicians in doubt of the diagnosis obtain expert pathological review.

Diabetes more likely in children of older moms

Maternal age at delivery was strongly related to the risk of type 1 diabetes in the child in a recent British study, with a relative risk of 3.11 for children of women who were 45 and older when they gave birth, compared to those who were less than 20 years old [BMJ. 2000;321:420-424].

The likelihood of type 1 diabetes increased by 25% for every additional 5 years of maternal age. It also increased with paternal age, by 9% for every 5 years. Increased birth order, however, reduced the risk of the disease—it was highest for firstborn children and went down progressively by 15% for each child born.

"Increasing maternal age at delivery of the first child may have contributed to the rising incidence of childhood diabetes," the researchers suggest.

More moms receiving prenatal care

From 1989 to 1997, the percentage of pregnant women in America who received late or no prenatal care went down from 25% to 18%, according to the Centers for Disease Control and Prevention [MMWR. 2000;49:393-398].

In spite of this improvement, as of 1998, no state had met the national health objective for 2000 of increasing to at least 90% the proportion of pregnant women who begin prenatal care in the first trimester of pregnancy. The most common reasons women gave for delays were not knowing they were pregnant, lack of money or insurance, and inability to get an earlier appointment.

And the good news did not apply equally to everybody: A higher proportion of non-white women still do not receive timely prenatal care. In 1997, the percentage of black and Hispanic women who received delayed or no prenatal care remained approximately twice that of white women.

Heart attacks deadlier in women than men

A recent retrospective observational study of over 1,000 people admitted to a hospital after an acute myocardial infarction found that women have a significantly higher hospital mortality rate, as well as a higher rate of nonfatal complications, than men [Am J Cardiol. 2000;85:921-926]. Moreover, among patients younger than 65, women were only half as likely as men to receive thrombolysis, and not getting thrombolysis increased the risk of death independent of other factors. Similarly, older women were less likely to be admitted to coronary care units than older men.

Raloxifene and quality of life

In a 12-month study that randomized healthy, postmenopausal women to ERT, raloxifene, or placebo, a 60-mg/day dose of the selective estrogen-receptor modulator improved anxiety levels while having no effect on other quality-of-life measures [Obstet Gynecol. 2000;96:359-365]. The mean age of the women was slightly under 55.

All the study groups equally retained their baseline overall quality of life and had unchanged scores for depressed mood, somatic symptoms, memory and concentration, sexual behavior, and sleep problems. Among women taking estrogen (0.625 mg/day), vasomotor symptoms improved but menstrual complaints worsened. Among those taking raloxifene, vasomotor symptoms were unchanged, contrary to previous studies that had reported complaints of hot flashes.

The authors conclude, "asymptomatic postmenopausal women should expect to maintain a stable quality of life with raloxifene, unopposed conjugated equine estrogens, or no treatment."

Many choose BRCA testing and prophylactic surgery

More than half (57%) of healthy women with a genetic risk of 50% for a mutation want BRCA1 and BRCA2 gene testing, according to a recent study conducted in the Netherlands [Lancet. 2000;355:2015-2020]. In addition, 51% of women with an identified mutation opt for bilateral mastectomy, and almost two thirds (64%) opt for oophorectomy.

Younger women, those with children, and those at highest risk for a mutation were the most likely to pursue genetic testing. The presence of children also increased the likelihood that women with a genetic mutation would opt for prophylactic mastectomy, though it was not a predictor for prophylactic oophorectomy.

Literature News
Predicting cervical cancer risk

Years before a clinical diagnosis can be made, a quantitative test that measures the amount of human papillomavirus (HPV) 16 DNA in Papanicolaou smears can help identify women who are likely to develop cervical cancer, according to two articles published in Lancet.

The two case-control studies show that the risk of cervical carcinoma in situ (CIS) increases with the quantity of HPV 16 DNA in Pap smears and that women with persistently high loads over time have the highest risk. The authors of the first trial report that women who were in the top 20% in terms of amount of HPV 16 DNA were 60 times more likely to develop cervical cancer than those who showed no evidence of HPV 16 [Lancet. 2000;355:2189-2193].

The second study documents consistently higher loads of HPV 16 DNA more than a decade before cervical cancer diagnosis, when many smears were still cytologically normal [Lancet. 2000;355:2194-2198]. Among women younger than 25 years, a full one quarter of those with a high viral DNA load developed CIS within 15 years.

As the author of an accompanying editorial points out, it is uncertain who should be tested for HPV 16 DNA and what treatment should be offered to women identified as being at high risk for CIS.

Quick test for group B strep during labor

Polymerase-chain-reaction (PCR) assays rapidly and reliably detect group B streptococci in anal and vaginal samples taken from pregnant women during labor, a comparison of tests shows [N Engl J Med. 2000;343:175-179]. The infection is a leading cause of sepsis, meningitis, and death among newborn infants.

The study compared the efficacy of a conventional PCR assay, a new fluorogenic real-time PCR assay, and traditional culture, at detecting group B streptococci during delivery. Researchers obtained specimens from 112 pregnant women.

Both the conventional and fluorogenic PCR assays detected 32 of 33 cases, providing a sensitivity of 97%. The negative predictive value of both assays was 98.8%, and the specificity and positive predictive value was 100%. Rupture of membranes did not significantly affect the ability of PCR tests to successfully identify group B strep carriers.

The length of time to obtain results was 30 to 45 minutes for the fluorogenic assay and 100 minutes for the conventional PCR assay, versus 36 hours for culture. Therefore, PCR assays facilitate earlier treatment of infected neonates.

About 18% of all pregnant women are considered to be at risk of transmitting group B strep to their babies and are treated empirically with antibiotics, but of these only about 20% are actual carriers. Screening women during pregnancy, as is currently the custom, misses those who become infected after being tested or who do not receive prenatal care.

Women feel better with testosterone after oophorectomy

Transdermal testosterone improved sexual function and psychological well-being in women who had undergone bilateral oophorectomy and hysterectomy, in a recent placebo-controlled trial [N Engl J Med. 2000; 343:682-688].

The authors reason that women who have bilateral oophorectomy experience reduced sexual desire and activity and a lessened sense of general well-being because of the lack of ovarian androgen production. The 75 women in the study, 31 to 56 years old, received conjugated equine estrogens and were randomized to 150 or 300 mg of testosterone transdermally per day, or placebo, for 12 weeks.

The placebo response was substantial, overwhelming the effect of the lower testosterone dose. At the 300-mg dose, however, sexual activity and pleasure scores increased two to three times from baseline and the general well-being index improved beyond the placebo effect.

Even though they had been receiving standard ERT, these women had significantly impaired sexual functioning at baseline, compared to those of similar age. The testosterone did not seem to have any effect on serum estrogen concentrations, did not counteract the beneficial effects of ERT on hot flashes and high-density lipoprotein cholesterol levels, and did not result in significant changes in acne or hirsutism.

But an editorial in the same issue warns that "long-term daily use of the 300-mg patch is likely to be associated with clinically important androgenic effects" and the role of androgen therapy in women needs to be further investigated.

Clinical exams help detect breast Ca early

Clinical breast examinations (CBEs) performed in community settings are as effective as those done in clinical trials and may modestly improve early detection of breast cancer, concludes a study of 752,000 records from a surveillance program for low-income women [J Natl Cancer Inst. 2000;92:971-976].

About 7% of CBEs were recorded as abnormal and five cancers were detected per 1,000 CBEs performed in the program. Contrary to common belief, CBEs even uncovered some in situ cancers; 1.2 in situ breast cancers were detected per 1,000 women, in addition to 3.8 invasive ones.

Overall, the sensitivity of CBEs was 58.8%, specificity was 93.4%, and positive predictive value was 4.3%—figures consistent with those from other screening studies. CBEs identified some cancers that mam-mography had missed. The authors estimate that about 5% of the cancers in the data set might have been missed if CBEs had not been done.

An accompanying editorial argues that the real value of CBE may be higher than that reported in the study. The editorialist points out that the guidelines provided to the screening sites did not mention subtle signs of breast cancer, such as asymmetric thickening of breast tissue or slight asymmetry of breast contour. Looking for these during CBEs might lead to more cancers being detected.

Minilaparoscopic ovarian drilling for PCOS

In a study that included university hospitals and a private day-surgery center, 62 infertile women with polycystic ovary syndrome (PCOS) were randomized to minilaparoscopic ovarian drilling under local anesthesia and conscious sedation or traditional laparoscopic ovarian drilling under general anesthesia [Fertil Steril. 2000;74:376-379]. About 72% of the women in the first group were discharged 2 hours after surgery, but none of the women in the second group.

Less than 22% of the women in the minilaparoscopy group required additional analgesics, compared to 53% of the conventional laparoscopy group. Hormonal profiles after surgery were similar for the two groups and there were no significant differences in ovulation and pregnancy rates within 1 year.

Minilaparoscopic ovarian drilling, the authors conclude, achieves a reduction of androgen levels comparable to laparoscopic ovarian resection or electrocauterization, "with the additional benefit of being a less invasive technique that can be performed as an outpatient procedure without the need for general anesthesia."

 

Chidem Kurdas. Updates. Contemporary Ob/Gyn 2000;10:138-148.