Human papilloma virus to the cervical mucus plug

At the start of a new year we are at AOGS hopeful that the status of journal will rise in it′s 93rd year, both as regards standards, downloads, citations and impact. It is often pleasant and surprising to hear positive comments on the journal, even from outside the regular Nordic readership. We commence 2014 with two reviews from within the subspeciality of gynecologioc oncology, both centering on a major problem, ovarian cancer. Malene Svahn and co-workers in Copenhagen, Denmark (pp. 6–19) write about the human papilloma virus (HPV) and find from their analysis of the mostly observational studies that the virus is not likely to play a role in populations on either side of the North-Atlantic, but evidence gravitates surprisingly towards an association elsewhere in the world. There cannot be much of a difference between populations of European origin, but Asia could be another matter. The study methodologies or tissue types could not in this review explain heterogeneity between populations. It seems beforehand not so likely that environmental or genetic reasons will serve as a basis for population differences with regard to HPV rates. The disease is the same everywhere in histopathological and clinical terms. Parity issues, contraceptive practices, smoking rates and the prevalence of infectious agents could nonetheless play a modulating role. HPV is a key factor in a few other gynecologic cancers that affect epithelial surfaces. The authors discuss well how the viral transmission pathways might be. It is striking that the number of women included in the eligible studies is less than a thousand. Here is clearly a field which needs much more intensive studies on many more patients in order to clarify population differences and get closer to understanding how viruses and oncogenes, cytokines, enzymes and growth factors interact to bring about the master of clinical disguise, ovarian cancer. Then Lene Heidemann and her colleagues in Copenhagen and Odense, Denmark, go on pp. 20–31 through the links between ovarian cancer and endometriosis, discussed in another setting not so long ago in the journal in an article from Sweden 1. With endometriosis the link is not to the serous and mucous adenocancer varieties, but to clear-cell and endometrioid ovarian cancer. Both articles provide thorough and well written modern approach overviews on the latest evidence in their respective fields. They should be useful reading for all practicing gynecologists who have to discuss this difficult and disappointing disease with their patients. We go on to more about endometriosis on pp. 38–44, where Sihyun Cho and co-workers in Seoul, Yongin and Incheon in Korea present data on the debated issue of how to treat women with ovarian endometrioma after surgery. A problem here as with so many similar studies is the short follow-up, but from what is there, it seems that the levonorgestrel intrauterine system (LNG-IUS) is at least as good an option as oral contraceptives and it has lesser side-effects. There are several sources of bias in retrospective studies of this type and it is a field where only prospective and randomized careful designs can solve the clinical issues at stake. Studies such as this one may still give valuable clues on treatment effects. It does not come as a surprise that women who have had to undergo a termination of pregnancy are more exposed to violence from their partner than other women 2. Abortion is connected to worse contraceptive use and adverse social situations for many women who need this solution to a mistimed pregnancy. Marielle Öberg and colleagues in Uppsala discuss this on pp. 45–51. The article also shows the high prevalence of violence against women, – a problem that has just gradually come to light in recent decades, especially in the last few years. Obstetricians and gynecologists and their allied staff need constant vigilance and learning to detect this and to be able support the women who volunteer such information. The estimates of women in Sweden exposed to intimate partner violence and mentioned in the article are not likely to be overestimated, rather the converse. The article from Modena in Italy by Angelo Cagnacci and colleagues brings us back to the old topic of the retroverted uterus (pp. 58–63). Does that situation confer a disadvantage? It seems it is the flexion of the uterine body relative to the cervix which matters, but this is often greater when the organ is retroverted. This is one of the “good idea” studies where one wonders why did oneself not get the idea of using ultrasound to check up on this? The article has a balanced discussion on what is of relevance here. In many countries assisted reproduction is expensive and might seem a good way to generate revenue from those who need these techniques to achieve the dream of a child. The Nordic countries have private clinics for this to a large extent, but treatment is regulated legally/centrally and in part through publicly funded reimbursement. This, along with the ingrown sense of a need for equality, does keep costs down compared to what is seen in many other countries. In this issue Terkel Christiansen and colleagues from Odense, Copenhagen and Holbæk in Denmark and Cardiff, UK (pp. 64–72), are considering costs of artificial reproduction in Denmark. They show that treatment costs for older women are considerably higher than for those who are younger. Postponement of pregnancy until 35 years of age and beyond that is thus a worry for society. The overall cost is deemed modest for Denmark. A policy in society that encourages women to try for a pregnancy at a younger age without compromising career and education prospects is clearly an advantage for all, the tax-payer = state, the health services and the individual. Measuring lactate in amniotic fluid during labor is still being evaluated for use in clinical practice as a measure of uterine muscle function and indirectly as an indicator of fetal compromise. The questions raised by Eva Wiberg-Itzel and co-workers from Stockholm and Umeå, Sweden, Dar es Salaam, Tanzania. Liverpool UK, and Basel in Switzerland (pp. 80–85) on the use of lactate to estimate the efficacy of oxytocin use in labor and get a further handle on rational labor management, will need repetition and debate. 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). Substantial numbers of human immature oocytes can be obtained in connection with cortical tissue freezing and fertility preservation, but developmental competence in terms of resuming meiosis is poor for these oocytes and negatively affected by transport of the ovary prior to freezing (pp. 30–35). Of women in their fifties a third experience heavy menstrual bleeding which is associated with negative perceptions and limited social and professional activities. Quality of life is thus worse for these women (pp. 50–55). Late preterm neonates have a raised risk of short-term hepatobiliary, respiratory, metabolic and nervous system disorders, as well as infection problems compared with term babies, but neurodevelopmental and physical outcomes at one year are the same (pp. 107–110).