Women's Health

Global guidelines for HPV vaccination for cervical cancer prevention

The American Society of Clinical Oncology (ASCO) has issued a clinical practice guideline on human papillomavirus (HPV) vaccination for the prevention of cervical cancer. This is the first guideline on primary prevention of cervical cancer that is tailored to multiple regions of the world with different levels of socio-economic and structural resource settings, offering evidence-based guidance to healthcare providers worldwide.

The guideline includes specific recommendations according to four levels of resource settings: basic, limited, enhanced and maximal. The levels pertain to financial resources of a country or region, as well as the development of its health system � including personnel, infrastructure and access to services. The guideline complements ASCO�s two other global, resource-stratified guidelines on cervical cancer, also stratified to these four levels of resources.1,2

Key guideline recommendations:

  • In all environments and independent of the resource settings, two doses of human papillomavirus vaccine are recommended for girls ages 9 to 14 years, with an interval of at least 6 months and up to 12 to 15 months between doses.
  • Girls who are HIV positive should receive three doses.
  • For maximal and enhanced resource settings: o If girls are 15 years or older and have received their first dose before age 15, they may complete the two-dose series; o If they have not received the first dose before age 15, they should receive three doses; o In both scenarios vaccination may be given through age 26 years.
  • For limited and basic resource settings: if sufficient resources remain after vaccinating girls 9 to 14 years, girls who received one dose may receive additional doses between ages 15 and 26 years.
  • Vaccination of boys: in all settings, boys may be vaccinated, if there is at least a 50% coverage in priority female target population, sufficient resources, and such vaccination is cost effective.

Cervical cancer is the fourth most common cancer among women worldwide, with less developed regions suffering a disproportionate burden from the disease. In fact, 85% of cervical cancer diagnoses and 87% of cervical cancer deaths occur in less developed regions, including parts of Africa and Latin America.

�Because resource availability varies widely, both among and within countries, we need to adjust strategies to improve access to HPV vaccination everywhere,� said Silvia de Sanjos� MD, PhD, cochair of the Expert Panel that developed the guideline and head of the Cancer Epidemiology Research Program at Institut Catal��Oncologia in Barcelona, Spain.

�This guideline is unique in offering cervical cancer vaccination recommendations that can be adapted to different resource levels and we expect it to have a major impact on the global health community.�

HPV infection causes virtually all cervical cancers in the world. Although it may also lead to genital warts and certain other cancers, cervical cancer is by far the most common severe condition related to HPV infection. Unlike other existing HPV vaccination guidelines, ASCO�s guideline focuses on the use of HPV vaccination specifically for the prevention of cervical cancer.

�Although HPV vaccine has been around for more than a decade, the uptake of the vaccine has been less than ideal in many places, including in high-resource countries such as the United States,� said Silvina Arrossi, PhD, co-chair of the Expert Panel that developed the guidelineand an official and researcher at the Instituto Nacional del Cancer in Buenos Aires, Argentina. �As an organization of cancer doctors, ASCO continues to endorse HPV vaccination programs and efforts to help spare more women around the world from this very difficult cancer.�

Guideline methodology
The guideline recommendations were developed by a multinational and multidisciplinary panel of oncology, obstetrics/ gynecology, public health, cancer control, epidemiology/biostatistics, health economics, behavioural/implementation science, and patient advocacy experts, including some of the world�s foremost research leaders on HPV and HPV vaccines.

The Expert Panel reviewed relevant literature published from 1966 to 2015, including systematic reviews, existing guidelines, and cost-effective analyses. This guideline reinforces selected recommendations offered in the World Health Organization (WHO) guideline, US Centers for Disease Control and Prevention (CDC) guidelines, National Advisory Committee on Immunization guideline (Canadian), German guidelines, and Immunise Australia guideline.


  1. Jeronimo J, et al. Secondary Prevention of Cervical Cancer: ASCO Resource-Stratified Clinical Practice Guideline. Journal of Global Oncology - published online before print October 28, 2016
  2. Chuang LT, et al. Management and Care of Women With Invasive Cervical Cancer: American Society of Clinical Oncology Resource-Stratified Clinical Practice Guideline. Journal of Global Oncology 2, no. 5 (October 2016) 311-340.
  • doi: 10.1200/JGO.2016.008151

The Primary Prevention of Cervical Cancer: American Society of Clinical Oncology Resource-Stratified Clinical Practice Guideline

Academics call for greater research into endometriosis and the treatments available to patients

A new study has raised concerns over women�s experiences gaining treatment for endometriosis - with many forced to live with painful side-effects and some reporting that medical staff don�t take their concerns seriously.

The findings, which highlight the ongoing challenges experienced by many women living with the condition, were shared as part of Endometriosis Awareness Week in March in the United Kingdom by researchers at Birmingham City University�s Faculty of Health, Education and Life Sciences.

Many reported the ongoing failure of treatments and described an array of negative side-effects including weight gain, hair loss, abnormal hair growth and depression. Women also felt that there is a lack of understanding about the condition from medical staff; whilst others spoke of their �desperation� in searching for treatment options to help alleviate their pain.

Endometriosis is a condition where cells similar to those found in the lining of the womb are found elsewhere in a woman�s body. It can cause painful periods, tiredness, bowel and bladder problems, and in some severe cases it can even lead to infertility. It is the second most common gynaecological condition in the UK, affecting 1.6 million women, a figure similar to the number of women affected by diabetes.

The study, which forms part of a larger research trial, looked at the experiences of women living with endometriosis and the various medical treatments available to them, including the pill, the coil and the injection.

Women described the frustration of trying to get a diagnosis. One woman stated: �I feel like the times that I was referred to the hospital � you really weren�t taken seriously� I�m 22 and it was like when I was speaking to them they were like, �You�re just a young girl it�s fine, you�ve had the symptoms for a while, you know, it�s nothing serious.� It was like people just weren�t really willing to listen.�

Another commented: �I think you get to the point where you�re so desperate. It�s so hard to get people to take endometriosis seriously anyway.�

After receiving the diagnosis, a woman describes the merrygo- round of ineffective treatments she�d been given to manage her endometriosis symptoms: �They started me on Depo- Provera, and that made it really, really bad� Then they put the coil in me and that, for a year and a half, was agonisingly painful. And they stopped that, and then they put me back on Depo-Provera actually. And then my symptoms got worse again, and then I was like, �I can�t do this.� So then they put me on the pill. They tried that for six, seven months, and it didn�t do anything. Then they put me back on the coil for a month!�

Currently there is no cure for the condition and treatment options vary but can include surgery, hormone treatment, nutrition, and pain management.

Researcher Dr Annalise Weckesser said: �Endometriosis has long been a neglected area of research and funding. We know that the average waiting time for women to receive a diagnosis is seven years, which is unacceptable. Our pilot study shows that even once women receive a diagnosis, for some their struggle with managing their symptoms has only begun.�

Professor Emeritus Elaine Denny, who was also part of the team of researchers said: �As there is no definitive treatment for endometriosis, many women will be prescribed a range of medical treatments with distressing side effects, such as symptoms of the menopause. Yet their effectiveness may be short lived or non-existent, and they may temporarily impact on fertility. We desperately need more research into the condition to help the millions of women who are living with the condition.�

Why fertility declines with age

Researchers at the University of Montreal Hospital Research Center (CRCHUM) have discovered a possible new explanation for female infertility. Thanks to cutting-edge microscopy techniques, they observed for the first time a specific defect in the eggs of older mice. This defect may also be found in the eggs of older women.

The defect causes the choreography of cell division to go awry, and leads to errors in the sharing of chromosomes. These unprecedented observations are published in Current Biology.

�We found that the microtubules that orchestrate chromosome segregation during cell division behave abnormally in older eggs. Instead of assembling a spindle in a controlled symmetrical fashion, the microtubules go in all directions. The altered movement of the microtubules apparently contributes to errors in chromosome segregation, and so represents a new explanation for age-related infertility,� said CRCHUM researcher and Universit�f Montreal professor Greg FitzHarris.

Women � and other female mammals � are born with a fixed number of eggs, which remain dormant in the ovaries until the release of a single egg per menstrual cycle. But for women, fertility declines significantly at around the age of 35. �One of the main causes of female infertility is a defect in the eggs that causes them to have an abnormal number of chromosomes. These so-called aneuploid eggs become increasingly prevalent as a woman ages. This is a key reason that older women have trouble getting pregnant and having full-term pregnancies. It is also known that these defective eggs increase the risk of miscarriage and can cause Down�s syndrome in full-term babies� explained Prof FitzHarris.

Scientists previously believed that eggs are more likely to be aneuploid with age because the �glue� that keeps the chromosomes together works poorly in older eggs. This is known as the �cohesion-loss� hypothesis.

�Our work doesn�t contradict that idea, but shows the existence of another problem: defects in the microtubules, which cause defective spindles and in doing so seem to contribute to a specific type of chromosome segregation error,� said Prof FitzHarris.

Microtubules are tiny cylindrical structures that organize themselves to form a spindle. This complex biological machine gathers the chromosomes together and sorts them at the time of cell division, then sends them to the opposite poles of the daughter cells in a process called chromosome segregation.

�In mice, approximately 50% of the eggs of older females have a spindle with chaotic microtubule dynamics,� said Prof FitzHarris.

The researchers conducted a series of micromanipulations on the eggs of mice between the ages of 6 and 12 weeks (young) and 60-week-old mice (old).

�We swapped the nuclei of the young eggs with those of the old eggs and we observed problems in the old eggs containing a young nucleus,� explained Shoma Nakagawa, a postdoctoral research fellow at the CRCHUM and at the Universit�e Montr�. �This shows that maternal age influences the alignment of microtubules independently of the age of the chromosomes contained in the nuclei of each egg.�

Prof FitzHarris�s team notes that spindle defects are also a problem in humans. In short, the cellular machinery works less efficiently in aged eggs, but this is not caused by the age of the chromosomes.

This discovery may one day lead to new fertility treatments to help women become pregnant and carry a pregnancy to term.

�We are currently exploring possible treatments for eggs that might one day make it possible to reverse this problem and rejuvenate the eggs,� explained Prof FitzHarris.

  • doi: 10.1016/j.cub.2017.02.025

Big women have nearly threefold greater risk of atrial fibrillation

Big women have a nearly threefold greater risk of atrial fibrillation than small women, according to research presented at EuroPrevent 2017. The study included 1.5 million women who were followed-up for more than 30 years.

Atrial fibrillation is the most common heart rhythm disorder, with a 20% lifetime risk. It occurs most often in people over 60 years of age and increases the risk of stroke and heart failure.

�Our research has previously shown that a large body size at age 20, and weight gain from age 20 to midlife, both independently increase the risk of atrial fibrillation in men,� said author Professor Annika Rosengren, professor of internal medicine at the Sahlgrenska Academy, University of Gothenburg, Sweden. �In this study we investigated the impact of body size on atrial fibrillation risk in women.�

The study included 1,522,358 women with a first pregnancy aged 28 years on average. Data on weight early in pregnancy, height, age, diabetes, hypertension and smoking were obtained from the Swedish Medical Birth Registry. Information on hospitalisation with atrial fibrillation was collected from the Swedish Inpatient Registry.

Body surface area (BSA) in m2 was calculated by a standard formula based on weight and height. Women were divided into four groups according to BSA: 0.97�1.61, 1.61�1.71, 1.71�1.82, and 1.82�3.02 m2.

During a maximum follow up of 33.6 years (16 years on average) 7,001 women were hospitalised with atrial fibrillation at an average age of 49 years. Compared to women in the lowest BSA quartile, those in the second, third, and fourth (highest) quartiles had a 1.16, 1.55 and 2.61 times increased risk of atrial fibrillation, respectively, after adjustment for age at first pregnancy, diabetes, hypertension and smoking.

�We found that bigger women have a greater risk of atrial fibrillation,� said Professor Rosengren. �There was a stepwise elevation in risk with increasing body size. The group with the highest body surface area had nearly three times the risk as those with the lowest body surface area.�

BSA is influenced by both height and weight. Compared to women with the lowest BSA, those with the highest BSA were 9 cm taller (161 versus 170 cm), 28 kg heavier (54 versus 82 kg), and had a higher body mass index (BMI: 21 versus 28 kg/m2).

�Atrial fibrillation is the result of obesity- related metabolic changes but there is also a second cause,� said Professor Rosengren. �Big people � not necessarily fat, but big � have a larger atrium, which is where atrial fibrillation comes from. People with a bigger atrium have a higher risk of atrial fibrillation.�

�Generally it�s better to be tall because you have less risk of stroke and heart attack, and better survival,� continued Professor Rosengren. �Taller people are often are better educated, have higher socioeconomic status, and may have received better nutrition at a young age and in the womb. But in this case being tall is less desirable because it alters the structure of the heart in a way that may be conducive to atrial fibrillation.�

Professor Rosengren pointed out that the absolute risk of atrial fibrillation in these young women, regardless of weight, height or BSA was very low (less than 0.5%). �In general young women need not worry about their risk of atrial fibrillation, whatever their body size,� she said. �For older women and men, being big could be an indicator that you are at increased risk of atrial fibrillation. In the clinic I have seen many big people with atrial fibrillation.�

She concluded: �If you are very tall, I think that it could be a good idea to avoid accumulating excess weight. That would apply to both men and women.�

Creating a different future for people with JMC

Expert care coming from Nemours/Alfred I. duPont Hospital for Children

Thanks to Dr. MacKenzie at Nemours/ Alfred I. duPont Hospital for Children in Wilmington, Delaware, Neena received care for her Jansen metaphyseal chondrodysplasia (JMC). For Neena, however, the road to Nemours/Alfred I. duPont Hospital for Children began in Dubai.

Born in Dubai, Neena was sick and spent most of her time as an infant in the NICU. Her bones were soft and there was little, if any, cartilage, causing her legs and arms to be bowed and turned inward. As a result, she was delayed developmentally, and didn�t begin walking until she was almost 4 years old. Doctors diagnosed her with rickets, then polio, and treated Neena with a variety of medications � but nothing helped. She was confined to a wheelchair for 10 years, but despite the overwhelming amount of pain and more than 30 surgeries, Neena persevered.

After graduating from college, Neena got a job and began living on her own. She ultimately met Adam online. Adam was living in Nebraska and they communicated online for 10 months. Finally, Adam flew to Dubai to meet Neena. They were married two weeks later and have been married 10 years.

Doctors said Neena would likely never have children and, if by some chance she did, the baby would not go to term. Neena did carry a baby boy, Arshaan, to term without any complications. However, when Arshaan was 2 and Neena was pregnant with her second son, Neena noticed Arshaan�s legs were beginning to turn outward, just like hers did. Then at her fourmonth checkup, the limb measurements of her unborn child were off. A pediatric geneticist tested Arshaan, and he was diagnosed with nephrocalcinosis, a condition doctors never detected in Neena.

Diagnosed with Jansen metaphyseal chondrodysplasia
Blood work was then sent to Germany and Jansen metaphyseal chondrodysplasia (JMC) was confirmed as the diagnosis. Jansen type metaphyseal chondrodysplasia (JMC) is an extremely rare progressive disorder in which portions of the bones of the arms and legs develop abnormally with unusual cartilage formations and abnormal bone formation at the bulbous end portions (metaphyses) of these long bones (metaphyseal chondrodysplasia). As a result, affected individuals exhibit unusually short arms and legs and short stature, findings that typically become apparent during early childhood. Abnormal cartilage and bone development may also affect other bones of the body, particularly those of the metacarpals and metatarsals. During childhood, affected individuals may begin to show progressive stiffening and swelling of many joints and/or an unusual waddling gait and squatting stance.

Neena, Arshaan and Neena�s second son, Jahan, are three of just 30 people in the world with JMC. Following their diagnosis, Neena and her family moved from Dubai to the United States so they could receive care from Dr Mackenzie at Nemours/Alfred I. duPont Hospital for Children. Arshaan and Jahan have each had four surgeries in Wilmington, Delaware: osteotamies with ring fixators to straighten and support their legs, followed by extensive physical therapy. For the boys, ages 6 and 8, the toughest part has been relearning how to walk after each surgery.

With the intention of finding a cure for JMC, Neena established the Jansen�s Foundation. In partnership with a prominent researcher from Boston, the concept behind a cure is that this condition could be managed as a chronic illness similar to the way diabetes is managed via an insulin pump. For JMC, when calcium levels drop too low, a pump would infuse calcium to keep the bones strong. If all goes as planned, Neena will be the first person to try this experimental cure, followed by her sons.

Since the creation of the Jansen�s Foundation, Neena was contacted by a girl from Paraguay with JMC. Neena and Adam hope they can bring her to Nemours/Alfred I. duPont Hospital for Children to meet Dr Mackenzie.

Hamburg-based private fertility clinic offers advanced expertise in �oasis of calm�

Fertility Clinic Valentinshof is a private fertility clinic in Hamburg, Germany, where couples wishing to have a child but struggling with infertility problems fi nd expertise and professionalism. In this pure and welcoming practice there is an �oasis of calm� � a place where couples can catch their breath and relax, because they know that they and their needs are the focus of our practice.

The team consists of fi ve highly skilled doctors and biologists. That is Dr Anja Dawson, gynaecologist and obstetrician, with specialization in reproductive medicine and prenatal medicine; Dr Nuray Aytekin, gynaecologist and obstetrician, with specialization in reproductive medicine; Dr Ulrich Knuth, gynaecologist and obstetrician, with specialization in reproductive medicine and andrology, as well as; Dr Elke Leuschner, reproductive biologist and Dr Andreas Schepers, reproductive biologist and senior clinical embryologist, who run the IVF laboratory.

Fertility Clinic Valentinshof has exceptional success in pregnancy rates, especially in couples who have �given up�. Their highly experienced doctors, embryologists, the advanced technology they use and the quality of their laboratory as well as the empathy they offer, are all reasons for this success.

Fertility Clinic Valentinshof offers a complete range of fertility treatments � from optimizing the body�s natural cycle to assisted or in-vitro fertilization (IVF/ICSI).

Their holistic approach is also focussed on the male partner: He is directly included in the therapy. They know from discussions with their patients that couples appreciate this approach. They also work with partners in associated disciplines such as nutrition, osteopathy, psychology, TCM and urology.

They draw information on the latest fertility treatments from international con-gresses and publications. Any signifi cant developments that they fi nd worthy are directly integrated into their work.

�We work with the most modern equipment in our own IVF laboratory. In constructing our practice, we paid special attention to using clean, low-pollutant materials throughout,� says Dr Dawson.

They guarantee their patients the greatest possible discretion, keep the waiting times as short as possible and they offer individual rooms in their consultation area.

�We are an independent clinic that is not bound to any health or laboratory company. We are only bound by our service to you, and by the traditional values of the medical profession,� says Dr Dawson.

Women suffer from asthma symptoms more frequently and more severely than men

Women suffer more frequently and more severely from pollen and food allergies and therefore also from asthma, according to Erika Jensen-Jarolim from MedUni Vienna�s Institute of Pathophysiology and Allergy Research.

She explains that female sex hormones increase the risk and symptoms of asthma and allergies and, adds that hormone preparations such as the contraceptive pill play a role.

These factors should be given more consideration than was previously the case, says Jensen-Jarolim.

Up until the age of 10, boys are more likely to suffer from allergies and asthma and to have more severe symptoms. But the increased production of the sex hormone oestrogen associated with the onset of sexual maturity and puberty means that girls become much more susceptible. Jensen- Jarolim explains: �Oestrogens cause inflammatory cells, such as the mast cells, for example, to react more sensitively to allergens. Conversely, the male hormone testosterone seems to exert a kind of protective function.�

This phenomenon accompanies women through the waves of hormone production in their respective life phases � from their first period to the taking of contraceptives, pregnancy through to hormonal replacement therapy at the menopause. In addition to that, they become more sensitive to environmental pollutants, especially smoking.

Nowadays, taking hormones is almost unavoidable because of life and family planning and also to avoid falling hormone levels, which play a significant role in the development of osteoporosis, for example.

�Such hormone treatments can trigger hypersensitivities, which, on top of that, are characterised by atypical symptomatology,� explains Jensen-Jarolim. These atypical symptoms include migraines, joint pain, eczema, worsening of acne and breathing difficulties. �We still do not pay enough attention to these links in the interaction between allergology and gynaecology.� Hormone treatments also play an increasing role in transgender medicine and must be borne in mind.

Hormonal factors in allergies
�Where am I in my cycle? Am I taking hormone preparations? Do I already suffer from asthma?� � these questions should be considered and discussed between doctor and patient, advises Jensen-Jarolim. Especially if the woman is pregnant. �The hormone balance changes again in pregnancy. Asthma can worsen in one third of pregnant women � and an asthma attack during pregnancy represents a serious risk to mother and child.� It is therefore advisable to have an allergy diagnosed at an early stage, preferably before pregnancy � because an untreated allergy is the first step towards asthma.

A field of research that is still in its infancy but is becoming increasingly important and affects women is that of allergy to hormones themselves, that is to say a �hormone allergy� in connection with contraceptives, which can lead to miscarriage. The scientists at MedUni Vienna believe there is a pressing need not only to initiate research in this area but also to improve diagnostics together with the gynaecologists.


Date of upload: 14th Mar 2017

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