Hysterectomy and other highlights

Hysterectomy is one of the most common operations worldwide. While usually the indications are clear-cut, management has been undergoing changes, not least with the levo-norgestrel intrauterine devices, with a renewed use of the vaginal approach for hysterectomy and with laparoscopic hysterectomy, even assisted by robot techniques. The old subtotal techniques have also come to the fore as one laparoscopic modality. They were always popular in the Nordic countries anyway, following the work done by Pentti Kilkku and co-workers in Turku, Finland, some 30 years ago and largely published in AOGS 1-3. So a systematic review on hysterectomy cost-effectiveness from Finland (Kriistna Pynnä and colleagues, Helsinki, pp. 225–232) is a valuable contribution. This is a matter of importance for the practising gynecologist and in relation to use of health-care resources, which the authors also discuss in this well-written article, not least the Introduction and Discussion. The debate on what is best in terms of cost and quality of life will continue as surgical approaches are modified and new angles of research are perfected. In this respect the following randomized trial on local anesthesia infiltration paracervically during vaginal hysterectomy (Ana-Marija Hristovska and colleagues, Copenhagen, Denmark, pp. 233–238) is also of interest. Such technical amendments need greater attention and use in order to shift the balance of cost-effectiveness in a positive way, in this case for the vaginal approach. Rectovaginal endometriosis is one of the major gynecologic challenges and one where treatment options need better investigation. Clinical and observational studies such as the one by Umberto Maggiore and co-workers in Genoa, Italy (pp. 239–247) give clues to management. While randomized studies are ultimately needed to resolve such issues, they are not easy to do in this situation. The options were recently reviewed in this journal 4. While expert surgery is of benefit for many women, the medical approach described here and elsewhere has a role in primary treatment and as an adjunct to surgery. This is a difficult field and one where management must be multi-factorial and probably often highly personalized. The article by Trille Kjaer and co-workers at two major institutions in cancer research in Copenhagen, Denmark (pp. 269–276) on divorce rates among women with fertility problems highlights hidden tragedies, which add up and affect many of the couples who have to resign to a life without children. Having a child is so fundamental to life that when this is not achieved it is hard to find the fulfillment that children give in other ways. The study population is substantial and the results clear: over a quarter of the couples are no longer together a decade later. For the first time, but not the last, we have now also a comment from one of our highly qualified reviewers at the end of this article. We have also called attention to these results in a press release, because they have wide implications clinically and for society. As the authors point out in their readable article, more research is needed to confirm this in other societies. It is also necessary to know more about the background factors. There will always be those whose dreams can not be realized, but practitioners must not shrug shoulders and say “that′s life”. It should be part of infertility treatment to avoid the detrimental effects of disharmony, which this study suggests is too often happening. AOGS has been a venue for several contributions on training, both in obstetrical and in gynecologic circumstances. It is increasingly realized that effective training methodology and re-training, even revalidation, is a key factor for improving health services, in high-resource and low-resource situations. Multiple modes of teaching apply and it is no longer just the old “see one, do one” situation. Structured training and thoroughly considered methodology, starting in simulated circumstances, is a logical first step. Ellen Nelissen and colleagues at several centers in Tanzania, the Netherlands, Norway and Denmark have looked at simulation-training to reduce postpartum hemorrhage in a low-resource setting (pp. 287–295). This is doubtless of value, but to what extent and for how long does such training retain a lasting effect among the trainees? Research is needed to ensure this and thus make the whole exercise worthwhile. Rheumatoid arthritis is a not uncommon disease among women of childbearing age. Marianne Wallenius and co-workers in Bergen and Trondheim, Norway, and Lund in Sweden (pp. 302-307), have looked at this in relation to birth outcome compared to the general population. There is not much of a difference, but still a discernible trend towards more complications, particularly in a first pregnancy, as would be expected of such a chronic inflammatory condition. These women may often feel better during pregnancy, but are nontheless a risk group. As winter starts to recede and the sun is higher on the horizon, you may be reminded to think about the summer′s coming professional attractions listed here below and decide on attendance, not least at NFOG 2014 in June in Stockholm. This bi-annual congress is now, as it has been for some eight decades, the venue for obstetricians and gynecologists in the Nordic countries and from further afield to meet, socialize and share knowledge and experiences. A warm summer evening in Stockholm is a life-time′s must….., “sakta vi går gennom stan”…… There are hormonal differences between premenstrual tension varieties, – in particular as androgens are concerned, – which affect sexual interest (pp. 248–255). Lympadenectomy does not make a difference in Stage I ovarian cancer, but staging is often inadequately done in these early disease situations (pp. 256–260). Start to prepare for attending the NFOG Congress in Stockholm, Sweden, on June 10–12th 2014. Reserve the dates, and prepare your abstract submission. For more information look at www.nfog.org. The 1st European Spontaneous Preterm Birth Congress is in Svendborg, Denmark, on 22–24th May 2014 (www.ESPBC.eu). The 23rd European Congress of Obstetrics and Gynecology is in Glasgow, Scotland, UK on 7–10th May 2014 (www.ebcog2014.org).