Women's Health

"Abortion pill" considered by FDA

Mifepristone, the controversial "abortion pill," may soon be available in the US, but the distribution rules may be so strict that they "hurt access." The Population Council, an international nonprofit research institution that holds the drug’s US patent, wants the drug to be easily available from a range of health care providers to increase women’s access. Under the US Food and Drug Administration (FDA) proposal, only doctors trained to provide surgical abortions would be allowed to prescribe the drug and these doctors must have privileges at a hospital within one hour of their offices in case a blood transfusion is necessary (a rare occurrence with mifepristone, according to the Population Council). CMAJ 2000;163(5):586.

Care of prisoners

A survey of inmates at the Burnaby Correctional Centre for Women (BCCW) found that 75 of 100 survey respondents would be willing to undergo a Papanicolaou test. Disturbingly, however, an earlier study found that only 15% of BCCW inmates had undergone Pap smear screening while they were incarcerated. The researcher says that factors such the short stays of inmates — in 1998, 70% of BCCW’s inmates were awaiting sentencing and most spent less than two weeks at the institution —and the need to deal with inmates’ urgent medical needs contribute to this disparity. She adds, however, that the willingness of female inmates to receive Pap smear screening could help reduce the occurrence of invasive cervical cancer in Canada, as long as steps are taken to ensure the testing is done. CMAJ 2000;162(5):657-8.

A related editorial argues that medical care for prisoners in Canada must be improved. The authors point out that failure to provide adequate screening and timely treatment may simply increase the burden of ill health later on and may also increase costs to the health care system. CMAJ 2000;162(5):664-5.

Canada’s only human milk bank may close

An advocacy group is protestin the possible closure of Canada’s last human milk bank by year’s end. The bank at the BC Children’s Hospital costs about $100,000 a year to operate and provides milk to about 20 infants a year. There are seven other milk banks in North America, including one in Mexico. CMAJ 2000;163(3):319.

Estrogen and surgical risk

A recent randomized controlled trial showed an increased risk of gallbladder disease among postmenopausal women given estrogen replacement therapy. Researchers used information from health administrative databases for approximately 800,000 elderly female Ontario residents to examine the connection between cholecystectomy and appendectomy with the use of estrogen, levothyroxine or a dihydropyridine calcium-channel antagonist (DCCA). The authors report that those taking estrogen were significantly more likely to undergo cholecystectomy and appendectomy. No significant difference was found between the levothyroxine users and the DCCA users. CMAJ 2000;162(10):1421-4.

Folate status serves as harbinger for newborn health

It is well known that taking folate and multivitamins around the time of conception reduces the risk of several congenital anomalies in babies. Researchers report that this may be due to the fact that approximately 27% of the women they surveyed in the province of Newfoundland in 1997 had low red blood cell folate levels. The research team collected blood samples from 1,424 pregnant women at the time of their first prenatal visit (at approximately 16 weeks’ gestation) and found that serum levels indicated that about four% of the women had deficient or indeterminate folate levels. However, in measuring the red blood cell folate levels the authors found that 27% had a deficient or indeterminate folate level. The authors were unable to correlate the low folate levels with relevant patient variables such as dietary preferences, multivitamin usage or other factors. Newfoundland does have one of the highest rates of neural tube defects in Canada. The fact that 27% of the pregnant women presented with deficient or indeterminate red blood cell folate levels is a serious public health concern and should be addressed, stated the authors. CMAJ 2000;162(11):1557-66.

A related editorial laments the missed opportunities for taking daily supplements of folic acid. CMAJ 2000;162(11):1571-2.

HPV infection and cervical cancer

An estimated 82% of cervical cancers in the developed world can be attributed to sexually transmitted human papillomavirus (HPV) infection. The proportion is even higher (91%) in the developing world, where physician scarcity is one limitation of screening programs. Researchers analyzed the prevalence of HPV infection among Ontario women. The highest rate (24%) was among women aged 20–24, and there was a strong association between HPV and abnormal cervical cytology results. CMAJ 2000;163(5):503-7.

In a second paper, the researchers performed their analysis for HPV on vulvar, vaginal and urine specimens collected by the women themselves. The specimens proved adequate, the methods were acceptable, and 86.2% of women with biopsy-proven high-grade cervical intraepithelial neoplasia were identified through vaginal swabs. This approach may offer a viable alternative to women in the developing world and to others reluctant to present for Pap smears. CMAJ 2000;163(5):513-8.

A related commentary relates these findings to research being done in other parts of the world. While unconvinced that self-sampled vaginal material will replace cervical smears obtained by a clinician, the authors state samples collected by women themselves may provide a good alternative for women in developing countries who have no access to screening programs. CMAJ 2000:163(5):535-8.

A third article from the same group of researchers reports the results of a randomized controlled trial comparing the performance of immediate HPV DNA testing with delayed (six-month) repeat Pap testing in detecting high-grade cervical intraepithelial neoplasia (CIN 2 or 3). Among the 159 women who completed the trial, 17 had histologically confirmed CIN 2 or 3. HPV DNA testing identified CIN 2 or 3 in 87.5% (7/8) of these women. In the repeat Pap test group, smears showing high-grade squamous intraepithelial lesions (HSIL) identified only 11.1% (1/9) of the confirmed cases, and smears showing any abnormality (atypical squamous cells of undetermined significance, low-grade squamous intraepithelial lesions or HSIL) identified 55.6% (5/9). Corresponding specificities were 50.6%, 95.2% and 55.6%. HPV DNA testing proved more costly, but there was significantly less loss to follow-up. CMAJ 2000;163(6):701-7.

Induction of labour

Induction of labour is appropriate when the potential risks of continuing a pregnancy outweigh the benefits. Induction is associated with increased risk for fetal distress, uterine hyperstimulation and cesarean section. In an attempt to reduce what was felt to be a high induction rate, the British Columbia’s Women’s Hospital and Health Centre instituted a continuous quality improvement program, involving the development of clear criteria for induction, a new induction booking system and daily peer review of inductions, with particular attention given to communicating changes and their rationale to caregivers. The overall induction rate for the institution decreased, and this change has been maintained. CMAJ 2000;163(9):1163-6.

Morning after pill debated

Five hundred BC pharmacists are preparing to dispense emergency postcoital contraception with a prescription, in part to help reduce the number of abortions and the amount of violence against physicians who perform abortions. CMAJ 2000;162(6):876-7.

Neonatal hypernatremia and breast-feeding

The number of anecdotal reports of neonatal hypernatremia has been increasing. To explore a possible association with breast-feeding malnutrition, a group of researchers reviewed the charts and interviewed the mothers of all neonates with a serum sodium level of more than 145 mmol/L who were seen at a Vancouver hospital or breast-feeding clinic during 1991–1994. Of the 21 cases identified, five of the mothers had failure of lactogenesis associated with postpartum blood loss, seven had failure of galactopoiesis associated with inadequate breast stimulation, and eight had inefficient milk removal associated with poor breast-feeding technique. The authors conclude that prenatal or early postpartum screening could have identified all of these factors. CMAJ 2000:162(5):647-52.

Reducing the risk of diabetes among pregnant Cree women

Evidence exists that reducing weight gain in obese women during pregnancy may reduce increases in fasting insulin concentration. Given that the Cree women of the James Bay, Que., region have high rates of gestational diabetes and type 2 diabetes, a McGill researcher and her colleagues set out to determine if regular diet counselling and physical activity sessions could help reduce maternal weight gain. They report no significant differences between subjects and controls at six weeks post partum. The authors suggest that a culture that favours plumpness in women and the fact that the interventions may not have been intense enough in frequency of contact or approach to diet may have been contributing factors. CMAJ 2000;163(10):1247-51.

In a related commentary, written by a special working group of the Cree Regional Child and Family Services Committee, the authors suggest culturally appropriate ways of modifying interventions to reduce maternal weight gain and gestational diabetes. CMAJ 2000;163(10):1273-4.

Screen females for abuse beginning at age 12

A task force in London Ont., hoped to make screening for females who have been abused as much a part of the physician-patient relationship as taking a pulse or applying a blood-pressure cuff. A report from the Task Force on Health Effects of Woman Abuse contains 29 recommendations for identifying and preventing such abuse. CMAJ 2000;163(11):1492.

Screening mammography

On the basis of results showing the success of screening mammography in reducing breast cancer mortality, 22 countries, including Canada, established population-based screening programs by 1998. A physician and her coworkers report on 1996 screening results for seven provincial screening programs. The recall rates after first and subsequent screens were 9.5% and 4.6% respectively, and the cancer-detection rate per 1000 women was 6.9 and 3.8 respectively. CMAJ 2000;163(9):1133-8.

A related commentary considers the additional factors required for effective screening programs: validity and acceptability of the screening test, early diagnosis of progressive disease, effective therapy and good compliance within the at-risk population. CMAJ 2000;163(9):1150-1.

Selecting women for bone densitometry

The annual number of bone densitometry tests performed in Ontario increased from 34,402 to 165,630 between 1992 and 1997. Researchers have developed and validated the Osteoporosis Risk Assessment Instrument (ORAI), a simple screening tool to assist clinicians in identifying women for whom bone densitometry is appropriate. By examining the data collected for the Canadian Multicentre Osteoporosis Study they selected clinical and demographic variables associated with low bone mineral density (BMD). They found that the ORAI, which uses age, weight and current estrogen use, accurately selected over 94% of study subjects with osteoporosis and 93% of those with low BMD for further testing, and selected less than 43% of those with normal BMD values.

Incidence rates for hip fracture are projected to double within the next 15 years. The authors state that while dual-energy x-ray absorptiometry (DXA) testing for low bone mineral density identifies which women are most in need of preventive treatment, the ORAI may help limit unnecessary costs by reducing the amount of unnecessary testing among those with normal bone mineral density. CMAJ 2000;162(9):1289-94.

Self-collected Pap smears

Past sexual abuse, childhood trauma and fear of invasive procedures lead some women to say "No" to physician-collected Pap smears. Believing that these women might prefer to collect their own specimens, a physician author ponders the problem and explores possible designs and techniques of self-collected cervical specimens. A design similar to the pet toothbrush might have potential, although the bristles would need to be re-oriented. CMAJ 2000:162(5):666-7.

Silent assaults

Previously published research has determined that 94% of sexual assaults never come to the attention of the criminal justice system. Why don’t more women report sexual assault to the police? After reviewing the charts of 958 individuals seen between 1993 and 1997 by the Sexual Assault Service in Vancouver, researchers concluded that, among other factors, the presence of physical injury and the fact that the assailant was a stranger predicted police involvement. The authors are concerned that these results indicate that victims are influenced and inhibited by the perpetuated social myth that rape must involve physical injury by a stranger to be considered genuine. CMAJ 2000;162(5):659-60.

War and sexual violence

Another tragic consequence of war is sexual violence against women and children. It occurs because of the breakdown of social structures, but it can also be used systematically to subdue and demoralize a population and to force pregnancy as a means of "ethnic cleansing." According to two physician researchers, the immediate actions of medical personnel working in conflict settings should include recognition and documentation of the sexual violence, and provision of antibiotic prophylaxis and emergency contraception. Public advocacy can sometimes be effective in bringing pressure to bear on responsible governments, and recently cases of rape have been successfully prosecuted as a war crime and as an act of genocide. CMAJ 2000;163(9):1152-6.

Copyright 2000 Canadian Medical Association or its licensors