Women’s Health

Breast reconstrucion
with re-innervation
– a better alternative to implants after mastectomy

Doctors in the Group for Advancement of Breast Reconstruction Surgery are pioneering new methods of breast reconstruction after mastectomy without the need for implants. Using the patient’s own tissue and with microsurgery to reintroduce blood flow and nerve sensation they are able to recontruct a breast near identical to the original. Patti Muck reports.

Middle Eastern women once feared the stigma of breast cancer more than the disease itself. They whispered the words, keeping breast cancer secret and ignoring symptoms until the disease was so advanced it could not be treated effectively.

For many, death was less fearful than the shame of divorce or receiving treatment from a male physician – or even jeopardising their own daughters’ marriage opportunities because of genetic concerns.

Times have changed, and today many Middle Eastern countries push public awareness through education campaigns, free breast cancer screenings and more research and collaboration. Former US First Lady Laura Bush’s 2006 visit to the region launched a host of breast cancer initiatives and drew international attention to a disease that remains the leading killer of women in the Middle East.

“For some reason, breast cancer is more prevalent and it happens in a younger patient population in the Middle East,” says Dr Aldona J. Spiegel, director and founder of the Center for Breast Restoration at Methodist Hospital’s Institute for Reconstructive Surgery in Houston. “Patients get identified at later stages.”

While physicians with a keen interest in women’s health issues want to understand the reasons behind the disparity, Dr Spiegel says there are no existing databases to accurately address the questions. Middle Eastern women are empowered with greater awareness and earlier diagnosis, but multidisciplinary centres to treat the entire spectrum of breast cancer – including reconstruction and restoration – are often lacking.

Many breast cancer patients still don’t get the full story when it comes to reconstruction and breast restoration. The information vacuum is not limited to countries like Saudi Arabia, the United Arab Emirates, Kuwait, Jordan and other Middle Eastern countries. Even in the United States, where powerful organisations like Susan G. Komen for the Cure have focused attention and resources to bring down death rates and raise awareness, women still remain in the dark on major issues like restoration options after mastectomies.


Dr Spiegel, a specialist in microsurgery, says 90% of the estimated 200,000 US women diagnosed with breast cancer this year will undergo breast implant surgery – and most will be led to believe the implant is the only option available. Yet new procedures pioneered in the last decade offer a host of alternatives that use the patient’s own tissue, oftentimes sparing underlying muscle and preserving feeling through re-innervation or restoration of nerve function.

“That’s not to say that implants are bad,” Dr Spiegel explains. “But the average age nowadays for breast cancer reconstruction is in the mid 40s. If you look at the statistics for long-term problems with implants versus autologous (using patients’ own tissue) reconstruction, it’s quite significant. Implants can have problems long term versus using patients’ own tissue. It’s frustrating that women don’t have more access to this information.”

At a recent US conference of the National Consortium of Breast Centers, Dr Spiegel says she was shocked to discover that microsurgery and restoration are not routinely offered at national and international cancer centres.

One of the main reasons behind this information gap is training. Microsurgery itself presents a huge learning curve. “It takes special training, it takes special focus and, I think, a passion to do this,” Dr Spiegel says. “It takes time to get the expertise.”

Reimbursement is another issue. Most plastic surgeons consider breast implant surgery a bread and butter staple of their specialty, and the traditional cosmetic implant surgery is faster, cheaper and easier to perform. For many surgeons – the majority of them male plastic surgeons – the time-consuming and complex techniques needed to restore sensation in the breast are not worth it.

In discussions at conferences around the US, Dr Spiegel says many plastic surgeons don’t believe restoring feeling and sensation are as important as restoring patients cosmetically.

“If you talk to the patients, it is important,” Dr Spiegel says. “The breast needs to have sensation, not for erogenous issues, but to feel like it’s a part of you. If you’re truly trying to get the ideal breast reconstruction, sensation certainly needs to be a part of it.”

One patient who lost both her mother and her sister to breast cancer underwent a mastectomy seven years ago. She learned about Dr Spiegel’s reconstruction expertise from a news release, underwent restorative surgery last year and wrote that she is in better shape now than before surgery. “It seems to me that every woman considering breast reconstruction would choose this method if she had the choice to. Diagnosis of a serious disease is devastating enough without having to suffer through a diminishing experience of make-do reconstruction surgery.”

A Texas woman who underwent reconstructive surgery last year learned about her options on the Internet and wrote to thank Dr Spiegel and her staff following her reconstruction surgery:

“A diagnosis of breast cancer can turn your entire world upside down. I cannot even try to describe the emotional roller coaster that I found myself riding on. Regaining my feeling was very important to me. Thank you so much for reconnecting my nerves and for making me look and feel normal again.”

The bottom line, Dr Spiegel says, is to find the right option for the individual, and every woman is different.

Many women around the world have been empowered by their own research on the Internet. In the past year, Dr Spiegel updated her site (www.breastrestoration.org) to include more patient education content, videos and detailed explanations of reconstruction surgery options. Plans to translate the website into Arabic and Spanish are under way.

She also is collaborating with colleague Dr Constance Chen on an interactive and functional breast reconstruction handbook with photos, lists, step-by-step instructions following diagnosis and other valuable information designed to guide a breast cancer patient through the process from start to finish. The book is scheduled for release in October 2010.

Along with Dr Robert Allen, a plastic surgeon who pioneered many of the microsurgical techniques used in breast restoration, Dr Spiegel founded the Group for Advancement of Breast Reconstruction Surgery (GABRS) and several plastic surgeons are now pooling information on their surgeries for future study and a national database. No medical certification currently exists to let prospective patients know whether a surgeon is qualified in breast reconstruction; GABRS hopes to raise the bar in the specialty and perfect techniques that eventually can replicate the original breast.

“We’re getting close,” Dr Spiegel says. “We’re working on sensation; we’re working on skin-sparing techniques for a mastectomy; and we’re working on minimising donor site problems.”

Members of GABRS believe the most important facet of treating breast cancer patients is tailoring treatment to the individual. Women diagnosed later in life usually have vastly different post-surgery needs than younger women. Identifying their expectations from different perspectives – social, body image, medical and oncological – is crucial to treating the “whole” patient. For plastic surgeons, that means being able to offer everything from the simplest reconstruction to the most complex.


Breast cancer patients researching their options are bombarded with unfamiliar terms. Most are familiar with the term “implants,” which means reconstruction using a separate manufactured part to replace the missing tissue from a mastectomy. In microsurgical reconstruction, surgeons use the patient’s own tissue – usually harvested from the excess skin and fat of the lower abdomen.

Today, the gold standard for microsurgical reconstruction is the TRAM flap, a traditional tissue transplant using abdominal fat and skin as well as much of the underlying muscle and blood vessels to reconstruct the breast. Many patients consider it a blessing – a tummy tuck and new breasts simultaneously. But it’s not always as easy as it sounds.

Dr Spiegel and other GABRS have gone beyond the TRAM flap. They routinely perform DIEP and SIEA flap reconstructions in which they take only the tissue needed and meticulously separate arteries and veins from the abdominal muscle to spare it. The DIEP procedure is used in patients whose blood supply is deeper in the muscle. Patients whose blood vessels are in the fatty layer of abdominal tissue can use the SIEA flap, in which less dissection is needed. Surgeons usually make the decision on which surgery to use as reconstruction begins, since not all patients have the more superficial blood vessels that allow the less invasive SIEA flap surgery.

“Everything in plastic surgery is about allowing the tissue to have blood flow,” Dr Spiegel explains. “The TRAM flap is routine. But we’re working to say, ‘Wait a minute. Just because you can remove the muscle doesn’t mean you should.’ I get a lot of patients who have terrible problems after a TRAM flap. They come to me because I do muscle-sparing surgery, and they think I can do something to help them. But once that muscle is gone, it’s gone.”

Another procedure surgeons like Dr Spiegel are perfecting is a skin-sparing mastectomy in which the only part removed in the breast envelope itself is the nipple, but surgeons spare the areola. Since the ducts empty into the nipple, it must be removed in a mastectomy. In the past, the areola was taken with it and had to be tattooed onto the reconstructed breast. It never looked as good as the natural body part, Dr Spiegel explains.

Now surgeons are keeping the original areola and reconstructing the nipple, with such natural results that Dr Spiegel says she’s actually had to write letters to patients’ gynaecologists confirming that they indeed do have a reconstructed breast and no longer need a mammogram.

Primary prevention of cervical cancer and other HPV-related diseases

The statistics are shocking. Worldwide, every two minutes a woman dies of cervical cancer. And women in the Developing World, who are least likely to have access to screening, are most at risk. Professor Suzanne Garland looks at the causes of cervical cancer and the measures that can be taken to prevent it.

Worldwide, every two minutes a woman dies of cervical cancer; each year more than 500,000 women will be newly diagnosed and more than 270,000 women will die. Projections indicate that, without a dramatic improvement in cervical cancer prevention, there could be over a million new cases each year by 2050.

Cervical cancer is the second most common lifethreatening cancer among women, with an incidence rate of 4.8 per 100,000 women per year in the Middle East and 9.9 per 100,000 women in United Arab Emirates. The UAE’s Cancer Registry Program revealed that the annual average number of reported cervical cancer cases in 2005 was triple that of 1998. Unfortunately, there is no organised cervical screening programme and cervical Pap smears are opportunistically offered to patients attending hospitals and primary health centres in the UAE. The alarming increase in the incidence of cervical cancer in the UAE highlights the need for greater awareness and the implementation of preventative screening programmes.

Human papillomavirus

The main cause of cervical cancer is human papillomavirus (HPV) infection. Most individuals infected with HPV do not know that they are infected because they do not experience detectable HPV-associated disease. Most low-grade cervical lesions spontaneously regress, but approximately 10% to 13% will progress to a high-grade lesion, which will eventually put the individual at risk for invasive cervical cancer.

HPV is a non-enveloped, double-stranded DNA virus. Over 100 types of doublestranded HPV have been isolated and completely sequenced thus far. HPV are grouped into low-risk (nononcogenic) types, such as type 6 and type 11, which cause benign anogenital warts (condyloma accuminata), and high-risk (oncogenic) types, such as types 16, 18, 31, and 45, which occasionally lead to cancer. In more than 90% of cases, genital warts are caused by HPV types 6 and 11. Among the approximately 15 different high-risk HPV genotypes the most common worldwide are HPV 16 and HPV 18, which account for more than 70% of all cervical cancer cases globally.

Cervical cancer

HPV infection can precede cervical cancer by some decades with the highest burden of diagnosis of cervical cancer seen among women aged over 45 years, although 30% of cases occur in women under the age of 45. Cervical cancer is one of the few avoidable human cancers. Two directions of cervical cancer prevention are feasible: primary prevention by prophylactic vaccination, and secondary prevention by cervical screening and or HPV DNA testing.

Secondary prevention approaches, such as cervical cancer screening have greatly reduced morbidity and mortality. It is generally agreed that combining HPV DNA testing with the Pap smear test improves the performance of early detection (secondary prevention). However, screening cannot prevent infections and effective coverage rates for cervical cancer screening services are very low outside of developed countries, with women at the highest risk of developing cervical cancer among the least likely to be screened. In addition, adenocarcinomas, which form 5-10% of all cervical cancers, are more difficult to spot as they usually start high up in the cervical canal and may not be picked up by a smear test.


Vaccination as a means of primary prevention has obvious advantages in countries where screening programmes are not established but may also offer advantages in developed countries, where secondary prevention by screening and treating premalignant lesions is not only expensive but sometimes imprecise, resulting in unnecessary anxiety and intervention for some women, while at the same time failing to detect lesions in others. However, it must be noted that it is important to continue regular cervical screening even with vaccination as vaccines do not protect against all HPV strains.

Decades of research have led to the development both quadrivalent and bivalent prophylactic HPV vaccines for primary prevention of cervical cancer. These are Cervarix, a bivalent HPV 16/18 vaccine from GlaxoSmithKline, and Gardasil (also known as Silgard in Europe), a quadrivalent HPV 16/18/6/11 vaccine from Merck. Both vaccines are reported to be highly effective against the clinically most important high-risk HPV types 16 and 18 in females naïve to these types. These HPV types are responsible for approximately 70% of all cervical cancers worldwide. In addition, the quadrivalent vaccine provides protection against two further HPV types – 6 and 11 – known to cause 90% of genital warts.

Multiple randomised controlled trials have convincingly shown that the vaccines can effectively prevent cervical cancer, and for the quadrivalent vaccine, genital warts as well. Indeed, the quadrivalent vaccine has been studied in 33,000 women and men in 33 countries and is licensed in more than 109 countries. This data constitutes sufficient evidence to support global policy recommendations for the introduction of an HPV vaccine.

Furthermore, Gardasil is the only vaccine approved for the prevention of cervical cancer and Condyloma acuminata (genital warts) for girls and women aged 9 to 26 years by the FDA. Routine vaccination of all girls aged 11 to 12 years and catch-up vaccination for females aged 13 to 26 years has been recommended by the US Centers for Disease Control and Prevention (CDC) and endorsed by several medical organisations worldwide. Recently, the quadrivalent vaccine also received approval for the prevention of vulvar and vaginal cancer.

The quadrivalent vaccine, Gardasil, is made using the outer coat of the HPV viruses (types 6, 11, 16, 18), known as the virus-like particles, which resemble the virus physically and immunologically. Thus, these particles are capable of inducing an immune response very similar to a natural infection of HPV virus. The outer coat particles are not capable of causing infections and inducing cell changes leading to cancer or pre-cancer of the cervix. The immunity thus induced by the outer coat HPV particles prevents the natural infection by a complete virus.


With the availability of an effective, safe vaccine, there is real hope for reducing the global burden of cervical cancer. Although achieving broad coverage of young adolescents, negotiating tiered pricing and securing financing will be challenging, it is sobering to realise that with every 5-year delay in bringing vaccination to developing countries, 1.5 million to 2 million more women will die. Vaccination has the potential to save many lives.

It is important to vaccinate patients before the age at which exposure is likely to occur. Studies have shown that immunisation would be costeffective if aimed at younger school-age females. Moreover, HPV screening after vaccination can be optimised by prolonging the screening intervals and by using more sensitive tests. In addition, a single vaccination, such as Gardasil, can cross cover a range of HPV genotypes and protect against other conditions such as genital warts.

In conclusion, HPV infection is common in young women. Most infections are benign, but persistent infections of HPV types with high malignant potential are associated with the development of cervical cancer. Cervical cancer causes significant morbidity and mortality, interfering with the quality of life of the patients and their families. It also poses a major financial burden for healthcare systems worldwide, taking into account the high costs implicated in the screening, diagnosis, staging and management of the disease. It is a characteristic paradigm of preventable diseases.

The use of conventional Pap smear testing together with the more recent implementation of HPV DNA testing contributes to the early diagnosis of precancerous lesions, resulting in the reduction of diseaseassociated mortality. The recent institution of the bivalent and quadrivalent vaccines offers a significant tool for the prevention of HPV infection. Vaccination against HPV infection reduces the risk of infection and, most importantly, would decrease the global burden of cervical cancer.

● Professor Suzanne Garland is Director of Microbiological Research and Head of Clinical Microbiology and Infectious Diseases at the Royal Women’s Hospital. She is also Senior Consultant Microbiology at the Royal Children’s Hospital and Professor, Faculty of Medicine, Dentistry and Health in the Department of Obstetrics and Gynaecology at the University of Melbourne, Australia.


Guidelines for clinical management of abnormal Pap smears

The Pap smear remains the most effective cervical cancer screening test available. Dr Nada C. Macaron, a Consultant Pathologist at Medsol and Diplomate of American Board of Anatomical Pathology and Dermatopathology, looks at the latest guidelines for management of abnormal Pap smears and the integration of HPV testing with cervical cytology screening.

The Papanicolaou (Pap) smear is the single most effective cervical cancer screening test to date and has been used since 1941 for detection and prevention of cervical cancer. The strength of the Pap smear is in detecting precancerous cervical neoplasia, which if treated properly, will prevent the development of cervical cancer.

The Pap smear is a screening and not a diagnostic test. It provides an “interpretation” of morphological findings. An abnormal Pap smear warrants further diagnostic evaluation and it’s only after integration of the histological and clinical findings that one can confirm a final diagnosis. In the past, the emphasis of the Pap smear was in detecting squamous intraepithelial lesion of any grade because treatment of any grade was advocated. Currently, the central purpose and emphasis of Pap smear screening is in detecting highgrade lesions as most lowgrade lesions, especially in young women, are self-limited while high-grade lesions are associated with persistence and risk of progression.

TBS 2001

The Bethesda System (TBS) is the most commonly used system for reporting results of cervical cytology. It was developed as a uniform system of terminology to facilitate communication between the laboratory and the clinician and to provide clear guidance for clinical management. TBS 2001 updates the earlier Bethesda System, first published in 1989 and revised in 1991. TBS 2001 reflects important advances in the biological understanding of cervical neoplasia and addresses new screening technologies that appeared in the past decade.

The general categories included in TBS 2001 are “Negative for Intraepithelial Lesion or Malignancy (NILM)” and “Epithelial cell abnormality”.

The NILM category encompasses reactive cellular changes, organisms and other benign cellular changes. The squamous epithelial abnormalities include: Atypical squamous cells of undetermined significance (ASC-US). Atypical squamous cells, cannot exclude high-grade intraepithelial lesion (ASCH), low-grade squamous intraepithelial lesion (LSIL) (encompassing Human Papilloma Virus (HPV) changes and mild dysplasia (CIN1)), high-grade squamous intraepithelial lesion (HSIL) (encompassing moderate squamous dysplasia (CIN2), severe squamous dysplasia (CIN3) and carcinoma in situ (CIS)) and squamous cell carcinoma. The glandular epithelial abnormalities include atypical endocervical, endometrial or glandular cells, not otherwise specified or favour neoplasia, endocervical adenocarcinoma in situ and adenocarcinoma.

Proper management of cervical intraepithelial neoplasia (CIN) is of paramount importance as mismanagement can increase the risk of cervical cancer on one hand and cause complications from over treatment on the other.


In 2007, The American Society for Colposcopy and Cervical Pathology (ASCCP) published new guidelines for management of abnormal Pap smears based on the most recent understanding of the biology of cervical neoplasia, with an additional objective of integrating management of HPV testing with cervical cytology screening. As recommended by the ASCCP, HPV DNA testing should target “only high-risk (oncogenic) types” when used for management, follow up or screening purposes. Testing for other non-oncogenic types is unacceptable.

Recommended management of women >20 years with Atypical Squamous Cells of Undetermined Significance (ASC-US): Options include HPV testing, repeat cervical cytology or colposcopy. HPV testing is the preferred approach if Liquid-Based Cytology or co-collection for HPV testing was done at the time of obtaining the smear. Women with ASC-US that are HPV negative, can be followed up with a Pap smear at 12 months and those that are HPV positive, will be referred to colposcopy. For management of women with ASC-US, who tested HPV positive, but no CIN was detected, acceptable options are HPV testing at 12 months or repeat cytology at 6 and 12 months. If repeat cytological testing is opted for managing women with ASCUS, then repeat Pap smears at 6 month intervals until two consecutive NILM results are achieved is recommended. If an abnormal Pap result appears on follow up, then colposcopy is recommended. After two NILMs, women can return to routine screening. When colposcopy is used to manage women with ASC-US, a repeat Pap smear at 12 months is recommended if no CIN is detected. If CIN is detected, then women should be managed according to the ASCCP consensus guidelines for management of CIN.

Recommended management of women with Atypical Squamous Cells, cannot exclude high-grade intraepithelial lesion (ASC-H): Colposcopy and biopsy is the only recommended management of women with ASC-H. If CIN2 or 3 is not identified histologically, then follow up with HPV testing at 12 months or cytological testing at 6 and 12 months is acceptable. Referral to colposcopy is then recommended for women who test positive for HPV or have an abnormal cytology of ASCUS or higher on repeat cytology. If the HPV test is negative or if two consecutive repeat Pap smears are NILM, then routine cytological screening is recommended.

Recommended management of women with Low-Grade Squamous Intraepithelial Lesion (LSIL): Colposcopy and biopsy is the recommended management of women with LSIL. Endocervical sampling is preferred for the non-pregnant patient and if colposcopy is unsatisfactory. Endocervical sampling is acceptable for those with a satisfactory colposcopy and if a lesion is identified in the transformation zone. If CIN1 or no CIN are identified on biopsy, acceptable subsequent management would be either follow up cytology at 6 and 12 months or HPV testing at 12 months for high-risk types. If two consecutive repeat Pap smears or HPV testing are negative, then the patient can go back to routine screening.

If either the HPV test or the repeat cytology is abnormal with a diagnosis of ASC-US or higher, then colposcopy and biopsy are recommended to exclude development of CIN2 or 3. Women with LSIL on cytology and initially found to have a CIN2 or 3 on colposcopy, should be managed according to the ASCCP consensus guidelines for management of CIN. For women who have LSIL on cytology, but with CIN1 or no CIN on colposcopy it is not recommended to treat by ablative therapy or diagnostic excisional procedure.

Recommended management of women with High-Grade Squamous Intraepithelial Lesion (HSIL): Acceptable options for management of women with HSIL on cytology include either immediate loop electrosurgical excision or colposcopy with endocervical sampling. If CIN2 or 3 are not identified histologically after a colposcopic biopsy, any of the following three options are acceptable, provided that the colposcopy is satisfactory and the endocervical sampling is negative. The first option would be proceeding to a direct excisional procedure. The second option would be to review the cytological, histological and colposcopic findings to see if there is any change in the diagnosis. If the review yields a revised diagnosis, then management should be according to the guidelines for the revised diagnosis. The third option is observation with colposcopy and cytology at a 6 month interval for one year and if this is elected, then a diagnostic excisional procedure is recommended if HSIL is detected on repeat cytology at either the 6 or 12 months visit. If after a year of observation and no cytological abnormalities are detected on two repeat smears, then the patient can return to routine screening. A diagnostic excisional procedure is the recommended step for women with HSIL in whom the colposcopy was unsatisfactory except in special populations (e.g. pregnant women). Triage of patients with HSIL by repeat cytology alone or HPV testing is unacceptable.

Recommended management of women with Atypical glandular cells (AGCs):
Atypical glandular cells of any category on cytology including atypical glandular, not otherwise specified, atypical glandular, favour neoplastic and adenocarcinoma in situ (AIS) should be managed by colposcopy with endocervical sampling. Endometrial sampling should also be done as well in women 􀀪 35 years with all subcategories of AGCs and AIS. Endometrial sampling should be done in women <35 who may be clinically at risk for neoplastic endometrial lesions (e.g. unexplained vaginal bleeding or chronic anovulatory cycles). Women with a diagnosis of Atypical endometrial cells on cytology can be evaluated with endometrial and endocervical sampling, with the option of doing colposcopy initially or deferring it until after the initial work up showed no endometrial pathology. HPV testing is also preferred in women with Atypical endocervical, endometrial or glandular cells not otherwise specified (NOS). Triaging women with AGCs of any category and AIS with HPV testing alone or repeat cervical cytology alone is unacceptable.

Subsequent postcolposcopy management of women with AGCs depends on whether the initial cytology was AGCs, NOS or AGS, favour neoplasia or AIS.

In women with a previous AGCs, NOS who are not found to have CIN or glandular neoplasia on the initial histological work up, the recommendation depends on whether the HPV status is known or not. If the HPV status is known, the recommendation is to repeat cytology and HPV DNA testing at 6 and 12 months if the HPV is positive, and at 12 months if the HPV is negative with subsequent colposcopy if they test positive for HPV or have ASCUS or greater on follow up cytology. If both tests are negative, then they can go back to routine screening.

Women with atypical endocervical, endometrial or glandular cells NOS and unknown HPV status and negative postcolposlcopy workup for CIN and glandular neoplasia should have repeat cytologic testing at 6 month intervals and can go back to routine cytological screening after 4 consecutive NILMs. If CIN but no glandular neoplasia is identified histologically during the initial work up of women with atypical endocervical, endometrial or glandular cells NOS, management should follow the recommended guidelines for CIN. If an invasive disease is not detected histologically after the initial work up of women with atypical endocervical, endometrial or glandular cells, favour neoplasia and AIS on cytology, then a diagnostic excisional procedure with intact interpretable margins is recommended. Concomitant endocervical sampling is preferred.

Other forms of glandular abnormalities including benign appearing endometrial cells and benign appearing glandular cells posthysterectomy: For benign appearing endometrial cells, no further evaluation is recommended for asymptomatic premenopausal women; however, endometrial assessment is recommended for postmenopausal women irrespective of symptoms. For posthysterectomy patients with benign appearing glandular cells on cytology, no further evaluation is recommended.

HPV DNA testing as an adjunct for cytology in screening women 􀀪 30 years old: A combination of cervical cytology and highrisk HPV testing significantly increases the sensitivity of detecting CIN2 or greater than either test alone. Women >30 years old who are negative by both cytology and HPV testing should be rescreened at 3-year intervals. Follow up of women with cytology-negative, HPV-positive tests at 12-month intervals is recommended. If both are negative on follow up, then the patient should be rescreened in 3 years. If HPV is persistently positive with negative cytology, then referral to colposcopy is recommended.


In summary, with the implementation of the above newer evidence-based algorithmic guidelines for management of abnormal cytology in conjunction with HPV molecular diagnostic testing, women can have better cervical cancer screening and clearer cytological interpretations which will improve outcomes and potentially reduce cost. Hopefully with this at hand, we will be marking the beginning of the end of cervical cancer.


Guidance for evaluating ovarian insufficiency in girls and young women

A comprehensive plan to help healthcare professionals diagnose and treat primary ovarian insufficiency – a menopause-like condition affecting girls and young women that may occur years before normal menopause is expected – has been developed by a US researcher. Middle East Health reports.

In primary ovarian insufficiency, the ovaries stop releasing eggs and producing estrogen and other reproductive hormones. The sudden cessation of ovarian function results in a condition similar to that of normal menopause: loss of menstrual periods, infertility, hot flashes and night sweats, sleep loss, and increased risk for bone fracture and heart disease. The sudden and unexpected loss of fertility frequently results in feelings of grief, anxiety and depression.

Lawrence Nelson, MD, head of US National Institutes of Health’s (NIH) Integrative and Reproductive Medicine Unit, provides recommendations based on the research he has conducted at the NIH. His recommendations are published in the Clinical Practice feature of the 5 February 2009 New England Journal of Medicine.

Treatment consists of hormones to replace those no longer produced by the ovaries and counselling to help women cope with the grief, anxiety and depression that may result from the diagnosis and the loss of fertility.

“The early indicators of primary ovarian insufficiency are subtle and the condition can be difficult to diagnose,” said Duane Alexander, MD, director of NIH's Eunice Kennedy Shriver National Institute of Child Health and Human Development, where Dr Nelson conducts his research. “Dr Nelson’s report provides helpful information for healthcare professionals and patients on how to recognise the early symptoms of the condition so that women can benefit from prompt diagnosis and early treatment.”

Because ovulation may sometimes occur in this group of women, primary ovarian insufficiency is more accurate than other terms that have been used to describe the condition, such as premature menopause or premature ovarian failure, Dr Nelson writes. Primary ovarian insufficiency occurs in women younger than age 40 – the age at which menopause may begin.

A woman can be considered to have primary ovarian insufficiency if she has not experienced a menstrual cycle in 4 months or more, and if at least two tests taken more than 1 month apart show that she has abnormal levels of follicle stimulating hormone (FSH). FSH is produced by the pituitary and stimulates the ovaries to produce estrogen and prepare an egg for release.

Specifically, girls and young women with primary ovarian insufficiency have high FSH levels like those of women in menopause.

Dr Nelson writes that in rare instances, primary ovarian insufficiency may resolve spontaneously, and normal menstrual cycles and fertility will be restored. In 5% to 10% of cases, women become pregnant after having been diagnosed with primary ovarian insufficiency.

Dr Nelson outlines a number of steps healthcare professionals can take to identify potential causes for the cessation of a woman’s menstrual cycle. These include learning whether the woman has an underlying disease or condition, is exercising excessively and perhaps eating too little, or has had prior chemotherapy or radiation therapy. The diagnosis of primary ovarian insufficiency is made largely by the presence of FSH levels in the menopausal range. Once the diagnosis is made, additional tests for various chromosomal conditions and hormonal abnormalities should also be performed.

Dr Nelson adds that it is not appropriate to attribute missing or irregular menstrual periods to stress without further evaluation.

“A disordered menstrual cycle should be viewed as a vital sign that something could be wrong and a signal indicating the need for further evaluation,” Dr Nelson says.

Dr Nelson writes that 4 months or more of missing, irregular, too few, or too frequent, menstrual periods merit further evaluation.

Fragile X syndrome

In 90% of cases, the cause of primary ovarian insufficiency is unknown. In the remainder of cases it can be attributed to a genetic condition or to autoimmunity – a condition in which the immune system attacks the body’s own tissues. Women in families affected by Fragile X syndrome – an intellectual disability resulting from an abnormality on the X chromosome – are at increased risk for primary ovarian insufficiency.

The unexpected loss of fertility that accompanies primary ovarian insufficiency can be emotionally devastating for many women, Dr Nelson says. Patients should be monitored for signs of severe emotional distress and, when appropriate, referred for counselling or other sources of emotional support.

Earlier research has found that treatment with the hormones estrogen and progestin to relieve the symptoms of menopause increases the risk of heart disease. Dr Nelson notes that the results of that research do not apply to girls and women with primary ovarian insufficiency, who are too young to have undergone normal menopause. He added that most health care professionals agree that treatment with estrogen and progestin is appropriate for women with primary ovarian insufficiency, to replace the hormones their bodies would otherwise produce.

Pregnancy is unlikely in primary ovarian insufficiency but does sometimes occur, so sexually active women with the condition should be aware of this possibility. Dr Nelson adds that some evidence indicates that oral contraceptives may not be effective for this group of women, and so they need to rely on other forms of contraception.

Because women with primary ovarian insufficiency are at risk for low bone mineral density, they should also be advised to consume adequate calcium and vitamin D, and to get sufficient exercise, methods which have been proven to safeguard bone health.

Giving birth: Upright positions shorten first stage labour

Lying down during the early stages of childbirth may slow progress, according to a new systematic review. Cochrane Researchers found that the first stage of labour was significantly shorter for women who kneel, stand up, walk around, or sit upright as opposed to lying down.

Using data from 21 studies carried out in developed countries since the 1960s, involving 3,706 women, the researchers found that the first stage of labour was around an hour shorter in those who adopted upright positions compared to those who lay down.

“In most developing countries, women stand up or walk around as they wish during the early stages of birth with no ill effects,” says Annemarie Lawrence, who works at the Institute of Women’s and Children’s Health at the Townsville Hospital in Queensland, Australia. “This review demonstrates that there is some benefit and no risk to being upright and or mobile during first stage labour.”

“Based on these results, we would recommend that women are encouraged to use whichever positions they find most comfortable, but are specifically advised to avoid lying flat,” says Lawrence.

The researchers stress that more information is urgently needed to understand how birthing positions relate to levels of pain, control and satisfaction among birthing women.

● Citation: Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews 2009, Issue 2. Art.No.: CD003934. DOI: 10.1002/14651858. CD003934.pub2.

ate of upload: 15th July 2009


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