Anorexia to obesity: problems for now and the future

The rather gynecologically oriented August issue has an initial focus on two of the most difficult conditions a gynecologist can encounter, anorexia nervosa and chronic pelvic pain. In the former condition gynecologists, psychiatrists and general practitioners may consider the oral contraceptive pill a benefit since it would be supposed to be associated with weight gain and perhaps a psychological advantage for these young women. Ingrid Bergström and her colleagues at several specialized facilities in Stockholm, Sweden (pp. 877–880), caution that this is not always good advice until menstrual activity has resumed after weight gain is achieved. Estrogen is important for the maintenance of bone through estrogen receptor actions regulating bone formation, but in these anorectic young women the long-standing amenorrhea and estrogen deficiency will cause osteopenia 1. Our reviewer for this Commentary pointed out that this is controversial, since estrogens, including ethinyl estradiol used in the oral contraceptive pill, have a moderate and positive effect on aspects of bone mineral density. Adolescent menstrual dysfunction requires thorough evaluation and this includes attention to underlying eating disorders. Not to conceal such problems by oral contraceptives must be thought of. Another common and debilitating disorder is chronic pelvic pain. No gynecologic cause is found in up to a third of the women, but psychologic problems do often co-exist there as well and even multidisciplinary treatment can be difficult; yet women are thankful when their complaints are taken seriously 2. The underlying link to a history of abuse must not be forgotten either 3. Comprehensive guidelines exist for diagnosis and treatment 4. Seema Tirlapur and co-workers at a unit in London, UK, specializing in evaluating evidence, consider one aspect of treatment for chronic pelvic pain and bladder pain syndrome, – neuromodulation in refractory cases, on pp. 881–887. Robotic surgery is being explored for its place in operative gynecology and one field easily centralized to robot facilities is complicated cancer surgery, such as para-aortic lymphadenectomy for cancer staging. Maxime Fastrez and colleagues in Brussels, Liege and Leuven, Belgium report their positive experiences on pp. 895–901. It is easy to see the advantages in this multicenter study. The time has, however, come to call for robotic surgery evaluations in the framework of randomized studies, since this will best show its place in the surgical armamentarium. Smaller observational studies have largely reached a saturation point. In relation to robotic surgery we must also address the sensitive issue of centralization; – if not in gynecologic cancer where this is accepted, then in the surgical management of more benign gynecologic conditions. Susanne Åhlund and co-workers in Stockholm, Sweden (pp. 909–915, have looked in a randomized study at ways of improving pelvic floor muscle training at home. It comes not as a surprise that this seems to work when there is well organized follow-up and when the women are relatively lean, well educated and well motivated non-smokers, but the important aspect is that this can be done with what must be quite modest costs and with a measure of success which it must be possible to translate to other strata of women. It is of value to show in a randomized trial (Aleida Huppelschoten and colleagues at several centers in the Netherlands, pp. 916–924) that on the whole it makes little difference how one closes the skin at cesarean section, whether with staples or subcutaneous sutures, with and without some stitches in the subcutaneous fat and superficial fascia layers. It is how the incision is made and the need to avoid wound infection that matter as far as the cosmetic result is concerned. Costs of staples vs. sutures matter to the health care provider as well. This study shows that here is perhaps one of the few areas in medicine where it can still be left to the surgeon′s personal preference what she or he does and offers the patient, as long as it is neatly carried out and some additional evidence-based precautions are taken when there is much fat around. So I can continue to advocate and teach my method. My trainees should also experiment with the ways of my consultant colleagues, to eventually settle on what they reason is best and suits them and their patients. Ever since Björn Westin popularized the symphysis-fundus measurement in the Nordic countries and wider afield 5, s-f curves have been used. They were originally not made with ideal methodology and improving on this and upgrading reference curves is worthwhile. Aase Pay and colleagues in Bergen and Oslo, Norway, and Gothenburg, Sweden, present on pp. 925–933 a new population-based reference curve with supplementary material. This is a good development, since this work is done in a comprehensive way on a current and securely dated sample. The oldest curves can now be substituted by a better basis and the value of this cheap measure to indicate adequate fetal growth should thus improve. It must still be recognized that the symphysis-fundus measurement has low predictive value for finding intrauterine growth restricted babies 7 and the chief value of the s-f curve lies mainly in indicating absence of a growth problem for the fetus. Hossam Hamed and colleagues in Assiut, Egypt and Buraidah, Saudi Arabia, show in a clinical study that cutaneous lupus erythematosus is not the same as the systemic disease (pp. 934–942) with regard to feto-maternal risk and Maximilian Franz and co-workers in Vienna, Austria and Munich, Germany confirm the worse cardiovascular profile that women who have had preeclampsia do exhibit, particularly after early and thus more severe preeclamptic disease (pp. 960–966). This supports the by now considerable information establishing hypertensive disorders in pregnancy as a marker for later hypertension, ischemic heart disease and possibly stroke. Here obstetricians have a duty to warn the patients, and hopefully influence subsequent health behavior and lifestyle, – much like after gestational diabetes. On pp. 982–987 Jan Stener Jørgensen and colleagues in Odense, Denmark, provide a report on a conference on obesity in relation to obstetrics and gynecology. This was a successful venture highlighting most of the wide-ranging problems that healthcare staff now face and will increasingly see in the coming years. The obesity “epidemic” is being followed by the diabetic “epidemic”. Both will place an enormous burden on society. A very recent article in the BMJ (25th June) is worth your attention 8, for candid comments on what really must be done in terms of halting the problem, if we are not literally going to see health services suffocate from the burden of obesity. Fathers can be terrified of childbirth and this can get worse at the actual birth (pp. 967–973). The 10th congress of the European Society of Gynecology, Bruxelles, Belgium 18–21 September 2013 (www.seg2013.com). The 39th Nordic Congress of Obstetrics and Gynecology (NFOG 2014) in Stockholm, 10–12th June 2014 (www.nfog2014.se).