The medicalization of female fertility--points of significance for the study of menopause

This paper illustrates the need for human biologists to take into account the far-reaching influences of biomedicine in the study of reproductive aging. Data were drawn from western Massachusetts and Puebla, Mexico, to illustrate the effects of hysterectomy rates, tubal ligations and hormone replacement therapy (HRT) on studies of age and symptom experience at menopause. First, in examining age at natural menopause in relation to level of education, a country-specific, non-random pattern of participant exclusion due to hysterectomies was encountered. Second, in examining symptom frequency in relation to late childbearing, sample sizes were very small in part due to a high frequency of tubal ligations (43%) in Puebla, Mexico. Third, hot flash frequency during the two weeks prior to interview was, unexpectedly, not lower among women who used HRT. Human biologists who study the biological process of reproductive aging must also attend to the cultural influences of biomedicine.     

Outpatient management of first trimester therapeutic abortions with and without tubal ligation

In busy hospitals the increasing numbers of abortions must be performed without disturbing other hospital functions. Local anesthesia, vaginal tubal ligation and the use of outpatient beds are the operative and administrative adaptations described. Of 1545 abortions performed in Victoria Hospital, London, in 1971, 428 (32%) were done under local anesthesia; 14 of these patients also had vaginal tubal ligation under local anesthesia. There were 405 sterilizations (26.2%) among this group of patients, of which 390 (96.3%) were vaginal tubal ligations. Of the total number, 891 (57.7%) were dealt with as outpatients and these comprised 62.0% of patients having therapeutic abortion only, and 46.7% of patients having tubal sterilization as well as abortion.     

Profile of women who request reversal of tubal sterilization: comparison with a randomly selected control group.

The characteristics of 96 women who requested reversal of tubal ligation at two fertility clinics in Montreal were compared with those of 403 randomly selected sterilized women in Quebec. The two groups were found to have a similar socioeconomic profile. In only two respects were the groups significantly different: the women who requested reversal generally had been sterilized at an earlier age and had more complex marital histories.     

Long term effects of hysterectomy on mortality: nested cohort study

Objectives To investigate the long term risk (mean > 20 years) of death from all causes, cardiovascular disease, and cancer in women who had or had not had a hysterectomy.Design Nested cohort study.Setting Royal College of General Practitioners'' oral contraception study.Participants 7410 women (3705 flagged at the NHS central registries for cancer and death who had a hysterectomy during the oral contraception study and 3705 who were flagged but did not have the operation).Main outcome measures Mortality from all causes, cardiovascular disease, and cancer.Results 623 (8.4%) women had died by the end of follow-up (308 in the hysterectomy group and 315 in the non-hysterectomy group). Older women who had had a hysterectomy had a 6% reduced risk of death compared with women of a similar age who did not have the operation (adjusted hazard ratio 0.94, 95% confidence interval 0.75 to 1.18). Compared with young women who did not have a hysterectomy those who were younger at hysterectomy had an adjusted hazard ratio for all cause mortality of 0.82 (0.65 to 1.03). Hysterectomy was not associated with a significantly altered risk of mortality from cardiovascular disease or cancer regardless of age.Conclusion Hysterectomy did not increase the risk of death in the medium to long term.     

Gynaecological Illness after Sterilization

A total of 374 patients were followed up for at least 10 years after tubal ligation, and 43% required further gynaecological treatment. Major gynaecological surgery was needed by 25%. There seems a good case for the selective use of hysterectomy as a method of sterilization.     

Deliveries in teenagers at a Newfoundland general hospital.

A study of deliveries in teenagers was undertaken for the year 1975 in a hospital that had recorded 2797 births, 371 (13%) of which were to women under 20 years of age. Conception had occurred out of wedlock in 314 (85%) of the 371 pregnancies; 124 of the 314 women had married during the pregnancy, most often in the 3rd or 4th month of gestation. The peak months for conception out of wedlock were June and December. This was not the first pregnancy for 65 women (18%), 21 of whom had married during a previous pregnancy. Of the "heads of the households" 36% were labourers and 27% were unemployed. Cesarean section was the method of delivery for 51 (14%) of the women, and 63 (17%) were reported as having had toxemia. There were seven perinatal deaths and seven infants had severe congenital abnormalities. The frequency of low birth weight was 6% overall but 13% for the infants of single women. Five women underwent tubal ligation post partum.     

Socioeconomic variation in admission for diseases of female genital system and breast in a national cohort aged 15-43.

OBJECTIVE--To investigate socioeconomic variation among young women in the risk of hospital admission for diseases (including neoplasms) of the female genital system and breast and for the common surgical procedures of dilatation and curettage and hysterectomy. DESIGN--Large nationally representative cohort study with individual records of confirmed admissions to NHS and private hospitals since birth and data on occupational and educational experience. SETTING--England, Scotland, and Wales. PATIENTS--General population sample of 1628 women, 1549 of whom had a complete admissions record for the ages of 15-43 years. MAIN OUTCOME MEASURES--The percentage of women admitted for neoplasms or other diseases of the female genital system and breast or who had dilatation and curettage or hysterectomy between the ages of 15 and 43 years. RESULTS--By the age of 43, 35% of women had been admitted, 17% had undergone dilatation and curettage at least once, and 10% had had a hysterectomy. There were significant inverse educational gradients, the risk of admission increasing more than twofold between the most and least educated women. The differential risk was most striking for disorders of menstruation, in which only 1% of those with the highest educational qualifications and 19% of those with minimal qualifications had been admitted to hospital. There was a significant educational gradient in the hysterectomy rate (from 1% to 15%) and a twofold difference in the risk of dilatation and curettage. There were also significant gradients in risk of admission and of hysterectomy according to partner''s social class. CONCLUSIONS--Socioeconomic variations in the risk of dilatation and curettage and of hysterectomy were large. Lessening the socioeconomic gradient in risks of admissions and surgery for diseases of the female genital system and breast, particularly for menstrual disorders, could have important resource implications.     

An analysis of paternal age and 47,+21 in 35,000 new prenatal cytogenetic diagnosis data from the New York State Chromosome Registry: no significant effect

Summary In 35,680 fetuses of women who had prenatal cytogenetic diagnosis done upon amniotic fluid specimens obtained during 2nd trimester amniocentesis and in whom there was no increased cytogenetic risk except for age, there was no statistically significant evidence for an increase of 47,+21 at any paternal age after adjustment for maternal age. The ratio of observed-to-expected numbers in fathers less than 30 years old was 1.0 and in fathers 40 years or older was 0.9 when compared with numbers derived from maternal-age-specific rates in men 30–39 years old. The ratio was 1.1 for those younger than 34 years when compared with rates in fathers aged 34–39 years old. Only for men 55 years or older was there any, even suggestive, increase. The ratio was roughly 1.5 (9 observed to about 6 expected). This was not statistically significant, and moreover, the increase such as it was, was in men married to women 37–42 years old. Regression analyses using several additive parental age models introducing a parabolic function for paternal age, failed to reveal any paternal age contribution.     

Effects of Gonadotropins on Motility of Human Ovary

THE occurrence of smooth muscle cells in the ovaries of many mammalian species suggests their possible function in the rupture of the ripe follicle by their contractions¹. In the rabbit, pig and sheep ovarian follicles, true smooth muscle cells are present in either or both the theca interna and externa. In women, follicles are surrounded by a network of reticular fibres and cells which resemble smooth muscle cells without fibrils². In a recent report, the ovaries of the cat have not only demonstrated spontaneous contractions in vitro but have also responded to adrenergic stimulation³. On the basis of these findings and in view of the fact that the stromal region of the ovaries of many species, including man, has adrenergic innervation, it has been proposed that contractions of the fibromuscular tissue may play a role in rupture of the follicle and extrusion of the ova³. In this report we describe changes in human intraovarian pressure which seem to result from contraction of the surrounding fibromuscular tissue. In some women marked changes in intraovarian pressure were observed after administration of human menopausal gonadotrophin and chorionic gonadotrophin. The study was carried out in six women of reproductive age who had to undergo abdominal surgery for correction of tubal occlusion (four patients) or tubal ligation. The two patients undergoing tubal ligation were on contraceptive pills for 3–5 years before the operation.     

Prevalence of Reproductive Abnormalities Among Women with Familial Partial Lipodystrophy

ObjectiveTo compare the risk of having polycystic ovary syndrome (PCOS) or ovarian cysts among women with genetically confirmed familial partial lipodystrophy (FPLD) with that in the general population of healthy women.MethodsTwenty-five women with FPLD who were 18 to 80 years old were interviewed regarding a history of PCOS or ovarian cysts (composite primary outcome) as well as for secondary outcomes of interest including menstrual irregularities, hirsutism, gynecologic surgical procedures, and fertility or obstetric complications. From the 2005 National Ambulatory Medical Care Survey, 3,326 women, aged 18 to 80 years (control subjects), were assessed for the presence of the primary outcome based on appropriate International Classification of Diseases, Ninth Revision, Clinical Modification codes.ResultsFour of the 25 patients with FPLD (16%) had a history of PCOS or ovarian cysts, in comparison with 14 of the 3,326 control subjects (0.42%), resulting in an age- and body mass index-adjusted odds ratio of 40.6 (95% confidence interval, 12.1 to 136.7; P < .0001) among the patients with FPLD. Furthermore, 5 women with FPLD (20%) required at least 1 oophorectomy during their lifetime, and 6 (24%) had had hysterectomies at a young age (≤ 55 years).ConclusionWomen with genetically confirmed FPLD have an increased risk for PCOS and ovarian cysts, as well as early hysterectomies, in comparison with the general population. Therefore, timely involvement of gynecologists in the care of these patients is warranted. (Endocr Pract. 2008;14:1126-1132)     

Under-use of adjuvant chemotherapy in women aged ≥70 years diagnosed with breast cancer in a university hospital

Introduction

Patient age often limits the therapeutic efforts of the oncologist. The aim of this study was to determine whether chemotherapy is used less frequently in elderly women aged 65-69 years diagnosed with breast cancer, compared to younger women.

Methods

A retrospective study was performed including women greater than 65 years old who had localised breast cancer and were treated at a University Hospital. Patients were classified into two groups, 65-69 years old and ≥ 70 years old. The differences in patient characteristics, tumour characteristics, chemotherapy treatment and chemotherapy-associated toxicity were analysed in both groups.

Results

A total of 164 women, with an average age of 73.7 years, were included in this study. There were no significant differences in the characteristics of the patients or their tumours. However, 75% of women <70 years old were treated with chemotherapy compared to just 34% of the older women (P<.001). The resulting levels of toxicity were similar between age groups.

Conclusions

Women ≥ 70 years old were treated with chemotherapy less frequently, even though the features and tumour characteristics of the women, as well as the toxicity of the treatment, were similar to that in younger women.     

Increased incidence of menstrual abnormalities and hysterectomy preceding primary biliary cirrhosis.

A study was performed to assess the incidence of previous hysterectomy and dilatation and curettage among women with primary biliary cirrhosis. In 87 patients with primary biliary cirrhosis hysterectomy or dilatation and curettage had been performed significantly more often than among 100 age matched normal controls and 80 age matched patients with chronic active hepatitis or alcoholic liver disease. Among the 47 patients with primary biliary cirrhosis who had undergone hysterectomy or dilatation and curettage operations had been performed at a mean of 10.7 years and 13.2 years, respectively, before the onset of disease. The main indication for hysterectomy among patients with primary biliary cirrhosis and controls was menorrhagia. These menstrual disorders may be a consequence of high concentrations of oestrogens in patients with primary biliary cirrhosis.     

Cervical Cancer Screening among University Students in South Africa: A Theory Based Study

Introduction

Cervical cancer is a serious public health problem in South Africa. Even though the screening is free in health facilities in South Africa, the Pap smear uptake is very low. The objective of the study is to investigate the knowledge and beliefs of female university students in South Africa.

Methods

A cross sectional study was conducted among university women in South Africa to elicit information about knowledge and beliefs, and screening history.

Results

A total of 440 students completed the questionnaire. The average age of the participants was 20.39 years (SD  = 1.71 years). Regarding cervical cancer, 55.2% (n = 243) had ever heard about it. Results indicated that only 15% (22/147) of the students who had ever had sex and had heard about cervical cancer had taken a Pap test. Pearson correlation analysis showed that cervical cancer knowledge had a significantly negative relationship with barriers to cervical cancer screening. Susceptibility and seriousness score were significantly moderately correlated with benefit and motivation score as well as barrier score. Self-efficacy score also had a moderate correlation with benefit and motivation score. Students who had had a Pap test showed a significantly lower score in barriers to being screened compared to students who had not had a Pap test.

Conclusion

This study showed that educated women in South Africa lack complete information on cervical cancer. Students who had had a Pap test had significantly lower barriers to cervical cancer screening than those students who had not had a Pap test.     

安康地区人乳头瘤病毒感染特征及其与宫颈癌的关系研究

目的:调查安康地区女性人乳头瘤病毒(HPV)感染的基因型别及年龄分布特征,分析其与宫颈癌的关系,为宫颈癌防治及HPV疫苗研发提供可靠的依据。方法:收集2010年6月-2012年8月间在本院及安康市部分县级医院妇产科就诊的2736名女性的液基细胞学和组织学标本,分为8个年龄组:16-24岁119例、25-29岁230例、30-34岁343例、35-39岁472例、40-44岁574例、45-49岁512例、50-54岁206例、55-86岁280例,进行病理学分类及HPV分型检测,分析不同年龄组及不同类型宫颈组织中的HPV感染率。结果:2736例女性中发生HPV感染720例(26.32%),共检出21种型别,感染率最高的基因型别是HPV16(25.05%),其他常见型别依次为HPV58、HPV52、HPV6、HPV11。单一感染占76.25%,多重感染占23.75%。HPV感染率在16-24岁、35-39岁和55-86岁三个年龄段出现高峰;而高危型HPV的感染率在35-39岁和55-86岁两个年龄段分别出现高峰。HPV的检出率随着宫颈病变的严重程度而增加,其中正常或炎症人群的HPV感染率显著低于宫颈病变及宫颈鳞状细胞癌患者(均P0.05),且意义未明的不典型鳞状细胞(ASCUS)、CIN1-3及宫颈鳞状细胞癌患者的HPV感染率对比结果存在显著差异(P0.05)。CIN1组、CIN2-CIN3组及宫颈鳞状细胞癌组单一感染率逐渐增加(P0.05),且其二重、三重感染率比较差异均有统计学意义(P0.05)。结论:安康地区HPV16型别感染较广,临床需加强对HPV16型单一感染宫颈病变患者的癌症预防工作。     

10-year survey of 485 sterilisations. Part I--Sterilisation or hysterectomy?

A survey was made of all sterilisations performed in an obstetric and gynaecological unit in Dunfermline in 1965-74 to determine the outcome and complications. Altogether 547 women were sterilised by the modified Pomeroy method, and 485 (88.7%) were interviewed and examined. No sterilisation was followed by serious complications, and the incidence of even minor complications was low (4.12%). There were no subsequent pregnancies. Altogether 57 women had to be referred for gynaecological operations in the years after sterilisation but only 18 of these had to have hysterectomies. At interview 59 women were found to have gynaecological symptoms (menstrual disorders in 46), and examination showed that 83 women had a gynaecological condition, which was in most cases unsuspected by the patient. Most of these conditions were minor but three women had carcinoma-in-situ of the cervix. Although 46 women suffered menstrual disorders after sterilisation 104 had done so at some time before the operation. These results therefore offer little support for the wider use of hysterectomy as a form of sterilisation.     

Attendance at Cervical Cancer Screening and Use of Diagnostic and Therapeutic Procedures on the Uterine Cervix Assessed from Individual Health Insurance Data (Belgium, 2002-2006)

Objective

To assess the coverage for cervical cancer screening as well as the use of cervical cytology, colposcopy and other diagnostic and therapeutic interventions on the uterine cervix in Belgium, using individual health insurance data.

Methods

The Intermutualistic Agency compiled a database containing 14 million records from reimbursement claims for Pap smears, colposcopies, cervical biopsies and surgery, performed between 2002 and 2006. Cervical cancer screening coverage was defined as the proportion of women aged 25–64 that had a Pap smear within the last 3 years.

Results

Cervical cancer screening coverage was 61% at national level, for the target population of women between 25 and 64 years old, in the period 2004–2006. Differences between the 3 regions were small, but varied more substantially between provinces. Coverage was 70% for 25–34 year old women, 67% for those aged 35–39 years, and decreased to 44% in the age group of 60–64 years. The median screening interval was 13 months. The screening coverage varied substantially by social category: 40% and 64%, in women categorised as beneficiary or not-beneficiary of increased reimbursement from social insurance, respectively. In the 3-year period 2004–2006, 3.2 million screen tests were done in the target group consisting of 2.8 million women. However, only 1.7 million women got one or more smears and 1.1 million women had no smears, corresponding to an average of 1.88 smears per woman in three years of time. Colposcopy was excessively used (number of Pap smears over colposcopies = 3.2). The proportion of women with a history of conisation or hysterectomy, before the age of 65, was 7% and 19%, respectively.

Conclusion

The screening coverage increased slightly from 59% in 2000 to 61% in 2006. The screening intensity remained at a high level, and the number of cytological examinations was theoretically sufficient to cover more than the whole target population.     

Therapeutic abortion with concurrent sterilization: comparison of methods

Among patients seeking abortion are a group who request concurrent sterilization. This study compared three combinations of abortion and sterilization techniques. Suction termination with laparoscopic tubal ligation appears to be the combination of choice, for the mean hospital stay of patients undergoing this procedure was two days and the operative morbidity was 3.1%. For suction termination with tubal ligation at laparotomy, and hysterotomy with tubal ligation the mean hospital stays were 6 and 5.7 days respectively and the operative morbidity was four to five times greater.     

Common Complications of Hysterectomy

Some of the common complications associated with abdominal and vaginal hysterectomy, performed in a teaching hospital, are reviewed. Case records of 284 abdominal hysterectomies and 101 vaginal hysterectomies are analyzed.The incidence of blood transfusion and of urinary tract infection was greater following vaginal hysterectomy than abdominal hysterectomy. The morbidity rate of vaginal hysterectomy was two and a half times as great as that of abdominal hysterectomy. Neither the age of the patient nor the factor of previous abdominal or major gynecological surgery influenced the morbidity of vaginal hysterectomy.It is apparent that the preoperative recognition and treatment of urinary tract infection and anemia should reduce the incidence of postoperative morbidity and the use of postoperative blood transfusion in both abdominal and vaginal hysterectomy.     

Breast reconstruction in older women: advantages of autogenous tissue

As the population ages, the treatment of breast cancer among elderly women is becoming increasingly common. Decisions with regard to breast reconstruction require not only consideration of patient age and comorbidities but also a need to balance life expectancy with quality of life. Although it is often assumed that implant-based breast reconstruction is the least disruptive method, especially among patients who may be facing limited survival times, it was hypothesized that autogenous tissue breast reconstruction is a well-tolerated and perhaps preferable means of reconstruction for older women who choose to undergo reconstruction following mastectomy. No large series of autogenous tissue reconstructions in this age group has been presented. A retrospective study of 84 postmastectomy reconstructions (66 unilateral and 18 bilateral; 78.6 percent immediate) performed at the authors' institution for 81 women 65 years of age or older, between April of 1987 and December of 2000, was undertaken. Reconstructions were implant-based ( = 26), latissimus dorsi flap-based ( = 24), or transverse rectus abdominis myocutaneous (TRAM) flap-based ( = 34). Of the 34 TRAM flaps, 21 were free or supercharged. Breast complications were more frequent ( < 0.05) among recipients of implant-based reconstructions (76.9 percent) than among recipients of latissimus dorsi flap (41.7 percent) or TRAM flap (35.3 percent) reconstructions. In multivariate logistic regression analyses, comorbidities, smoking, radiotherapy, and body mass index had no effect. Medical complications without long-term sequelae were observed for two patients who underwent latissimus dorsi flap reconstructions and two patients who underwent free TRAM flap reconstructions; the difference in the rates of medical complications was not significant. At the mean follow-up time of 4.2 years, 92.8 percent of all study patients exhibited no evidence of disease. Notably, despite being free of disease, seven of the 26 patients (27 percent) who underwent implant-based reconstructions abandoned further reconstructive efforts after complications necessitated implant removal. It was concluded that age alone should not determine the type of breast reconstruction and that autogenous tissue breast reconstruction can be a safe successful alternative for women 65 years of age or older.