Adenomyosis to uterine transplantation

We are coming into the autumn months now, with the days getting shorter at northerly latitudes, and it may be a good time to not let go of this issue of the journal just yet, but now that you have opened it anyway to sit down and run through its contents, find what might interest you, decide on what to by-pass and then to get deeper into what is close to your own professional scene. This month we are likely to have some things that could fit the bill. There is, for example, a focus on a mysterious condition, adenomysosis, in a systematic review by Rita Champaneria and coworkers from Birmingham and London, a group where there is pioneering experience with this rigorous way of evaluating the existing evidence (pp. 1374–1384). While they show that both magnetic resonance imaging and transvaginal ultrasound can assist in the diagnosis of this often distressing condition of the later fertile years, the origin of adenomysois continues to be an enigma. Sitting at the junctional zone where the myometrium meets the endometrial stroma (1), we still do not know if the condition is inherited and congenital or whether the old theory of repeated stretching followed by rapid postpartum uterine involution is at the root of the problem. Despite better diagnostic modalities and better understanding of the disease, the clinical findings and traditional bimanual palpation continue to hold their firm place here and treatment has been radically changed through the levonorgestrel intrauterine device. This is followed by another review by Päivi Tommola and colleagues in Helsinki (pp. 1385–1395), who in the wake of last years successful NFOG course on vulval disease write about surgical treatment of vulvar vestibulitis, another no less enigmatic condition in its pathophysiologic origin. Both reviews are highly informative and worthy of any obstetrician/gynecologist's attention. The study by Eduardo Bergel and colleagues from the WHO in Geneva, Switzerland, Buenos Aires and Rosario in Argentina (pp. 1396–1402), is a study we have had a press release on because of its new message of calcium supplementation during pregnancy having a positive effect on the dental status in childhood. That added calcium should have such a positive effect on the developing fetus is remarkable and has never been noted before. This demonstrates a benefit from a careful follow-up of a randomized trial in order to assess long-term effects that may not be revealed until many years later. The study had three highly able reviewers including from academic dentistry, and they all recognized the importance of these new findings. These new findings call for allied studies from a nutritional and epidemiological perspective, which could be done in the Nordic countries where calcium intake is probably high in many parts of the population. The effect of calcium to prevent hypertensive disorders in pregnancy in the original study was modest (2), but a positive health effect on the offspring might give that story a new dimension. We have three studies on congenital anomalies and related issues. One is from Ingvild Eidem and colleagues in Oslo and Bergen, Norway (pp. 1403–1411), confirming the doubled risk in type 1 diabetes, now seen in the large Norwegian medical birth registry, not least for cardiovascular anomalies. The time around conception and in the first 6 weeks thereafter is crucial. However, so many pregnancies “happen” at a time when diabetic control may not be particularly meticulous and by the time the pregnant status is realized and measures taken to optimize blood sugar levels, it may be too late and an adverse intrauterine environment has already done damage. Therefore, outpatient services for young diabetic women matter so much to ensure pre-pregnancy planning and the best possible control of blood sugar throughout implantation and embryonic development. The other study is a sizeable observational study on the longstanding ultrasound screening program in Linköping, Sweden (Eric Hildebrand and colleagues on pp. 1412–1419) showing the merits of established times for screening scans in late first trimester and early second trimester and what can be expected in terms of results from such screening. Their discussion contains several valid points. Lastly, there is a useful study from Pedro and Maribel Acién in Alicante in Spain on the association between unilateral renal agenesis and genital anomalies, which is a useful reminder of these complex situations (pp. 1424–1431). The article by Anne Ørbo and colleagues from Tromsö in Norway (pp. 1438–1446) is relevant for many clinicians dealing with endometrial hyperplasia in order to explain the rationale behind the effectiveness of the levonorgestrel intrauterine device for treatment of this condition and the so often associated heavy bleeding. Progesterone receptors in the endometrium seem to go silent. Take time to read through this article for greater familiarity with what happens in the endometrium, with its receptors and programmed cell death or renewal. AOGS has wanted to maintain an outlook on conditions in the European countries near to the Nordic ones. We now publish an article on contraceptive use in Poland (Jaroslaw Olszewski and colleagues from Gdansk and Wejherowo, pp. 1447–1452). Providing good contraception services is widely regarded as one of the basic duties of medical practitioners and part of that must be education about reproductive health, as a modern right in society. One feels saddened to note that our colleagues in Poland are not in a good position to help their community in that simple way. There are too many countries in the world where reproductive rights set forth by the World Health Organization and the International Planned Parenthood Federation (you might google their web-sites) are still rather distant targets. Egil Johnson and coworkers in Oslo, Norway (pp. 1466–1472), show that after secondary suturing of perineal rupture and attempts to restore defective function after that, success is moderate, and continence function tends to become less adequate with time. This is not a surprise. Prevention is probably best as now shown in a new Norwegian study (3) and thereafter adequate primary suturing (4), in which increasing collaboration between obstetricians and colo-rectal surgeons is likely to benefit women directly. We did issue a another press-release on a major report from Gothenburg, Sweden, and Valencia, Spain, showing for the first time that a viable pregnancy can be achieved in a transplanted uterus (Cesar Diaz-Garcia and coworkers, pp. 1491–1494). Do not omit to look at this important article. This group is among the foremost in the world in this field and is approaching transplantation in the human after careful long-term preparatory work (5) of which this article is a part. Figure 1 has the proof. Many years ago transplantation of organs like the heart, kidneys or liver would have seemed an impossibility. So would IVF or cryopreservation of ovarian tissue. Yet out in society there are quite many women born without a uterus for whom uterine transplantation may be a solution to their understandable and deep desire for their own progeny. Points for observance: Acupressure is most likely to only have an effect in the initial stages of labor (pp. 1453–1459). Risk factors for cardiovascular disease in women with hypertensive or diabetic pregnancies and in their children might be modified by intervention strategies focused on life style alterations, with emphasis on weight management, physical activity and diet (pp. 1478–1485 and pp. 1486–1490).