Current Women's Health Reviews

ISSN: 1573-4048

Current Women’s Health Reviews
Volume 4, Number 1, February 2008

Contents


Editorial: Women Deliver Pp. 1-2
José M. Belizán


Menopause, A Universal Female Experience: Lessons from Mexico and Central America Pp. 3-8
Tracie D. Locklear, Brian J. Doyle, Yue Huang, Alice L. Perez, Armando Caceres and Gail B. Mahady
[Abstract]


Female Infertility and Assisted Reproduction: Impact of Oxidative Stress Pp. 9-15
Natalie Krajcir, Hyndhavi Chowdary, Sajal Gupta and Ashok Agarwal
[Abstract]


The Detrimental Effect of Smoking on Female Fertility and IVF Success Pp. 16-24
Michael S. Neal, Warren G. Foster and Edward V. Younglai
[Abstract]


Suggested Markers for the Diagnosis of Endometriosis Pp. 25-28
Ioannis M. Matalliotakis, Simon Vassiliadis, Anastasia G. Goumenou, Yvoni Fragouli and Irene Athanassakis
[Abstract]


Postmenopausal Persistent Unilocular Ovaria Formations are not Risk Factor for Ovarian Carcinoma. A Long-Term Follow-Up Cohort Study Pp. 29-32
Tirso Pérez-Medina, Francisco Salazar and José Bajo-Arenas
[Abstract]


Antiangiogenic Therapy and Ovarian Cancer Pp. 33-44
Richard T. Penson, J. Alejandro Rauh-Hain and Neil S. Horowitz
[Abstract]


The Role of Angiogenesis as a Prognostic Factor of Breast Cancer: Recent Review Pp. 45-55
Angeliki Koletti, George Zografos and Nikos Kavantzas
[Abstract]


Forceps: Still an Option? Pp. 56-75
Alfredo F. Gei and Luis D. Pacheco
[Abstract]




Abstracts


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Editorial: Women Deliver
José M. Belizán

“Since the human race began, women have delivered for society. It is time now for the world to deliver for women” [1]. In October 2007 the Conference Women Deliver brought together almost 2,000 participants from 109 countries to look for joint actions to improve global maternal outcome.

Many important initiatives were joined together and also relevant publications emerged previously and after the Conference.

In a special issue of The Lancet many articles and editorials gave important information about the current situation and the relevance of the problem. Ann Starrs mentioned that “20 years ago the global health community came together to highlight the most striking inequity in public health: half a million women, 99% of them in the developing world, were dying every year in pregnancy and childbirth [1]. High fertility, inadequate and inaccessible health services, and women’s low status meant that women in the poorest regions of the world were 500 times more likely to die from pregnancy-related complications (one in 20 risk) than women in northern Europe (one in 10 000 risk) [2]. The global Safe Motherhood Initiative was launched to generate political will, identify effective interventions, and mobilize resources that would rectify this horrifying injustice” [1].

Today, 20 years into the initiative, maternal mortality has declined in some regions, especially in middle-income countries in Latin America and northern Africa [2]. However, today each year still 536 000 women die from complications of pregnancy and childbirth—99% in the developing world—and another 10–20 million women have severe health problems, including obstetric fistula. Of all health indicators, maternal mortality reveals the greatest gap between rich and poor women, both between and within countries [1,2].

In 2005, women in developed countries had a one in 7300 lifetime risk of dying from pregnancy-related causes, compared with a one in 75 risk in developing countries. In Africa, the lifetime risk is one in 26. Little change has been seen in the hardest hit areas and the gap is widening [1,2]. At the midpoint in the timeline to achieve the Millennium Development Goals (MDG), the absence of progress in reduction of maternal mortality and morbidity is unacceptable. No woman should die giving life [1].

The Conference Women Deliver was willing to create the energy, the commitment, and the knowledge to fundamentally shift how women's health and women's contributions are viewed in the global agenda [3]. Women deliver babies, certainly, and that was a central theme of the conference. But women also deliver in many other ways: food, goods, and income for their families; education, affection, and care for their children; and energy, creativity, and inspiration for their communities [3].

Participants of the Ministers’ Forum of this conference made the following statement: We, the participants in the Ministers’ Forum of the Women Deliver Conference, once again declare our commitment to invest in women and children and to achieve Millennium Development Goals (MDGs) 4 and 5. All the MDGs will best be achieved within a human rights framework, which incorporates sexual and reproductive health and rights, and by recognizing that health and development are inextricably linked. Without substantial reduction in maternal mortality, there is little hope of achieving the overarching MDG goal of reducing poverty by half.

Investing in women pays off in terms of social and economic benefits to the family, the community and society at large. Gender equality and women’s empowerment are central. We recognize that poverty, income inequalities, underdevelopment, gender disparities, discrimination, poor education, conflict, gender-based violence, food and nutrition insecurity all contribute to the poor health of women and children. Therefore, interventions to address maternal and newborn health need to be multisectoral to maximize their impact. Efforts need to include education of women and girls, economic empowerment, including access to microcredit and micro-finance and legal reforms to deepen a woman’s power of choice over her reproductive health. Special attention should be paid to the poorest of the poor, particularly women in rural areas, as well as other vulnerable populations such as immigrants, displaced persons and adolescents, and the impact of globalization on the health of these groups [3].

We hope that the Women Deliver Conference would be a point of inflection on the many efforts that are devoted worldwide to improve maternal outcome and decrease maternal deaths. Appropriate maternal care should be seen as a human right and the lack of provision of adequate care should be seen as a violation of this right.

Readers and contributors of this Journal are committed to provide better care of women and particularly to improve women reproductive outcome. In addition to our scientific development we should be actors and advocates to obtain a better equity in the world on maternal health and rights. Any action in any of our settings towards this aim will sum.

[1] Starrs AM. Delivering for women. Lancet 2007, 370: 1285-7

[2] Hill K, Thomas K, AbouZahr C, on behalf of the Maternal Mortality Working Group. Estimates of maternal mortality worldwide between 1990 and 2005: an assessment of available data. Lancet 2007; 370: 1311–19.

[3] http://www.womendeliver.org/. Accessed December 11, 2007


José M. Belizán
(Editor-in-Chief)
Department of Mother &
Child Health Research
Institute for Clinical Effectiveness
and Health Policy (IECS)
Viamonte 2146 (3er Piso)
(C1056ABH) Buenos Aires
Argentina
E-mail: belizanj@allstat.org


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Menopause, A Universal Female Experience: Lessons from Mexico and Central America
Tracie D. Locklear, Brian J. Doyle, Yue Huang, Alice L. Perez, Armando Caceres and Gail B. Mahady

In Mexico and Central America, women typically experience menopause up to 10 years earlier than their U.S. counterparts. This may be due in part to numerous pregnancies, long periods of lactation, poor nutrition, extreme environment, and the heavy workload of the Maya women. Unlike Western culture, there is no stigma associated with aging and the menopausal period in the Mayan culture. In fact, menopause is considered to be a welcome natural phenomenon in Central America that all Maya women, who come of age, will experience. Anxiety, negative attitudes, health concerns and stress for the Maya woman are all events that are commonly associated with pregnancy and childbearing, not with menopause. Maya women perceive the menopausal period very positively, as they are no longer burdened with menstrual bleeding and child bearing, and are more relaxed about sexual activities.

Thus, compared with their U.S. counterparts, Maya women have a better overall perceptions and attitudes toward the menopausal transition, have symptoms that appear to be short-lived, do not generally use HRT and appear to have a lower prevalence of osteoporosis. Besides genetics, diet and life-style may play a significant role in the overall impact of menopause in these women, as their diet is primarily plant-based, they get plenty of exercise over a lifetime, and they use primarily plant-based medicines and massage to control menopausal symptoms. Thus, the impact of culture and attitude on the menopausal transition in Mexico and Central America appears to be a positive one. Future research should focus on why the prevalence of osteoporosis is low in Maya women and how women in the U.S. might benefit from this information. In addition, collections of data on cognition, as well as cardiovascular and cancer risk between these groups would be of benefit, considering that Maya women do not generally use HRT.


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Female Infertility and Assisted Reproduction: Impact of Oxidative Stress
Natalie Krajcir, Hyndhavi Chowdary, Sajal Gupta and Ashok Agarwal

Oxidative stress (OS) occurs with an overabundance of reactive oxygen species (ROS) generation and the inability of scavengers, i.e. antioxidants, to neutralize excessive loads of ROS. OS has a role in the etiopathologenesis of many factors causing natural infertility. Infertility is a problem of great magnitude affecting 6 million American women. The etiologies of unexplained infertility and recurrent pregnancy loss remain unclear and present a scientific challenge. Oxidative stress may be a piece in this puzzle. Although investigation of the exact mechanisms by which OS causes pathological processes affecting female fertility is ongoing, research has clearly shown that the redox state affects gametes, their interactions, and the resultant embryo. OS has adverse effects on assisted fertility including IVF/ICSI and in-vitro maturation. This article addresses the role of OS in female infertility, the effect it has on assisted reproductive techniques, and OS prevention strategies including the use of in-vivo and in-vitro antioxidant supplementation.


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The Detrimental Effect of Smoking on Female Fertility and IVF Success
Michael S. Neal, Warren G. Foster and Edward V. Younglai

Tobacco smoking is a widely recognized health hazard and a major cause of preventable morbidity and mortality, but smoking remains prevalent in our society. Approximately 30% of women and 35% of men of reproductive age smoke. But more importantly, the incidence of smoking is increasing among adolescents and specifically teenage girls. Recently, substantial harmful effects of cigarette smoke on the ability to become pregnant have become apparent. Women who smoke take longer to achieve a natural pregnancy, require more hormonal stimulation during IVF treatment with reduced success, and reach menopause earlier than their non-smoking counterparts. Cigarette smoke constituents have been isolated at higher levels in the serum and follicular fluid of women exposed to mainstream (MS) and passive or sidestream (SS) smoke compared to non-smokers implying that cigarette smoke may act as an ovarian toxicant as one mechanism to disrupt female fertility. Cigarette smoke exposure may induce toxic effects and compromise fertility through several direct or indirect mechanisms.


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Suggested Markers for the Diagnosis of Endometriosis
Ioannis M. Matalliotakis, Simon Vassiliadis, Anastasia G. Goumenou, Yvoni Fragouli and Irene Athanassakis

Endometriosis is a multifactorial and enigmatic disease since the causal clusters of conditions leading to one of the four stages of the malady comprise, but are not limited to, anatomical, pathological, genetic and immunological dysfunctions. Since the early 80’s, immunologic parameters appear associated with the evolving entity of the disease influencing directly or indirectly the pathophysiology factor(s) implicated. We hereby propose a hypothesis on how regulation of the immune system by cytokines and other molecules actively participating in immune conditioning and reactions, sets the conditions for the manifestation of the disease and also how this information may lead to a novel diagnostic evaluation tool bypassing surgery.


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Postmenopausal Persistent Unilocular Ovarian Formations are not Risk Factor for Ovarian Carcinoma. A Long-Term Follow-Up Cohort Study
Tirso Pérez-Medina, Francisco Salazar and José Bajo-Arenas

Objective: To assess the potential for malignancy in ultrasonographic low-score persistent ovarian formations in postmenopausal women.

Methods: In the Department of Gynecology of a University Hospital, an expectant management was offered to a cohort of 86 postmenopausal patients with unilocular persistent ovarian formations between 50 and 100 mm diameter. After informed consent, they were prospectively followed by means of transvaginal ultrasonography and CA 125 serum measurement annually for 9 years.

Results: Of the 86 women, 41 (47.6%) had no changes in ovarian cyst diameter (mean diameter 69 mm, range 52–95) or CA 125 serum concentrations in the follow-up period. In 24 women (27.9%), the cyst disappeared between different follow-up visits. 21 patients (24.4%) underwent surgery for any reason and the ovaries were resected. No ovarian malignancy was diagnosed in any case in our series.

Conclusion: Consistent with our hypothesis, follow up with transvaginal sonography and serum CA 125 measurement is not strictly necessary in postmenopausal patients with unilocular ovarian formations between 50 and 100 mm diameter.


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Antiangiogenic Therapy and Ovarian Cancer
Richard T. Penson, J. Alejandro Rauh-Hain and Neil S. Horowitz

Epithelial ovarian cancer is the most lethal of gynecologic malignancies in the United States and while current therapies are successful for many years, cure remains elusive. Angiogenesis is the physiological process of new blood vessel growth, and a normal process in growth, development, and wound healing. However, angiogenesis is also a fundamental step in the transition of tumors from a dormant state to a malignant state. Preclinical data and preliminary clinical data suggest that antiangiogenic therapy targeting the vascular endothelial growth factor (VEGF) pathway will change the natural history of epithelial ovarian cancer. With a proven survival advantage in a growing number of tumor types, antiangiogenenic therapy is an exciting field. Important questions remain: the mechanism of activity, optimal integration with chemotherapy, and the benefits and risks of targeting multiple pathways, these are being addressed through a series of clinical trials, designed to evaluate the tumor microenvironment and surrogate endpoints, such as wound healing, leading to a more rationale triaging of patients to this potentially dangerous and costly therapy. The scientific background, and clinical trials with novel agents are reviewed in this exciting new paradigm of care.


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The Role of Angiogenesis as a Prognostic Factor of Breast Cancer: Recent Review
Angeliki Koletti, George Zografos and Nikos Kavantzas

Angiogenesis is the growth of new vessels and plays an essential role in tumour progression, expansion and metastasis. It is a multiple process that depends upon cooperation and interaction between a variety of cells, growth factors and other molecules. There is a large body of evidence in the literature that angiogenesis has prognostic relevance in certain tumors, including breast cancer. It is becoming increasingly apparent that the angiogenic phenotype may be acquired early in tumor evolution. In particular, ductal carcinoma in situ (DCIS) represents a heterogeneous group of lesions that show important differences in biological behavior and although it is not a fatal disease, the development of invasive recurrence for DCIS patients emphasizes the necessity to develop new measures and strategies for its prevention. This review profiles angiogenesis in regard with breast cancer development, outlines the available methods for measuring and assessing neovascularization, and discusses the likely therapeutic roles of angiogenesis in breast cancer and specifically in ductal carcinoma in situ.


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Forceps: Still an Option?
Alfredo F. Gei and Luis D. Pachecos

Labor and Delivery; United States; 2005: SM, a 24 year old Asian female with a monochorionic diamniotic twin gestation at near term has been pushing for 4.5 hours. The presenting twin is in an occipito-transverse position at +2 station. The second twin is in a cephalic presentation and showing variable decelerations.