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Current
Women's Health Reviews
ISSN: 1573-4048
Current Women’s Health
Reviews
Volume 4, Number 3, August 2008
Contents
Editorial: Addressing Health Inequities
in Women Care Pp. 147
José M. Belizán
Nutritional Aspects Relating to the Developmental Origins
of Health and Disease Pp. 148-157
M. Renee Prater
[Abstract]
Maternal Nicotine Exposure: Long-Term
Effect on Lung Integrity in the Offspring Pp.
158-166
Gert S. Maritz
[Abstract]
The Effectiveness of Interventions to
Address Health Inequalities During Pregnancy: A Review of
Relevant Literature Pp. 167-176
Angela Hallam
[Abstract]
Increasing Access to HIV Testing for
Women by Simplifying Pre- and Post-Test Counseling Pp.
177-184
Matthew F. Chersich and Marleen
Temmerman
[Abstract]
Botulinum Toxin Treatment of Pelvic Floor
Disorders and Genital Pain in Women Pp.
185-192
Laura Bertolasi, Emma Frasson and Alessandra
Graziottin
[Abstract]
Emerging Trends in Endometriosis Treatment
- Review Pp. 193-204
Warren B. Nothnick and Xuan Zhang
[Abstract]
The Complex Dynamics of Breast Cancer
Pp. 205-214
Fabio Grizzi, Sonia Di Biccari, Antonio
Di Maggio and Pier Carlo Muzzio
[Abstract]
Postcaesarean Ovarian Vein Thrombosis.
Evaluation by Ultrasound and Multislice Computed Tomography
Pp. 215-216
Maria Isabel Pardo Pumar, Eugenia García
Giménez, María José Alonso Vaquero, José
Carlos Pardo Belda, Miguel Puig Sáez and José
Manuel Pumar Cebreiro
[Abstract]
Abstracts
[Back to top]
Editorial: Addressing Health Inequities in Women Care
In the 1980s, I was working on a health and nutrition
program for the inhabitants of coffee plantations (fincas)
in the highlands of the west coast of Guatemala. One night,
around 8 p.m., a nurse in charge of one of these fincas called
me with an emergency. When we entered the dwelling, in a unique
room where the family would eat, cook and sleep, I saw a table
placed in the centre of the room, with a boy lying on this
table surrounded by candles. The boy was around 8 years old,
thin, with impressive beautiful black eyes, breathing slowly.
Seated on the floor in silence, forming a circle around the
table, were some women and men dressed in colourful indigenous
clothing. Any new person coming into the room lit a candle
and took a seat in the same way. We could not convince the
parents to allow us to take care of the child, to take him
to the hospital and treat him. Their refusal was based on
accumulated experiences in the community: the child would
die anyway in the hostile hospital, and in order to receive
his dead body and bury him, the family would need to pay to
a mortuary company a sum of money unaffordable for them. Allowing
the child to die at home would give them the opportunity to
bury their child in a family cemetery without costs. Coming
out of this dwelling with our hearts destroyed, we could see
the mansion where the owner of the finca lived—the windows
were lit, and we could hear the sound of soft music and the
noise of knives and forks, which were sometimes interrupted
by laughs. The next day, the nurse reported to us that the
child had died around 2 a.m.
Health workers around the world are faced with different aspects
of health inequities as the one described above. The role
of social and economic situation on health deliver and outcome
is a well-known situation for health providers.
Recent epidemiological research has shown that fetal growth
has long term implications on the quality of life of an individual.
Two articles in this issue show the implications of fetal
life. Prater article describes the effect of maternal nutrition
on long term outcomes of the progeny and Maritz article shows
the long-term effect on lung integrity of the offspring of
maternal nicotine exposure. Again, another contribution on
how inequities could influence quality of life since it is
expected that low income populations would have poorer fetal
growth and low possibility to receive preventive interventions
to improve maternal habits.
Hallam article shows an initiative from a high income country
to address health inequities during pregnancy. It is an interesting
approach since the author has look for evidence based interventions
that can be applied in a high income country and could ameliorate
the differences in outcome due to inequities. In middle and
low income countries a set of evidence based interventions
could have a great impact on maternal survival and the challenge
is how to improve the implementation of such interventions.
Implementation science is a young science promoting research
looking for mechanisms to scale-up well known interventions
of benefit. Such approach is described in Chersich article
testing a simple intervention to improve the access to HIV
testing for women.
It is highly encouraging to see the effort of the medical
scientific community to ameliorate the consequences of health
inequities and to improve survival and quality of life of
those with major needs.
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
Tel/Fax: (+54-11) 49534058
E-mail: belizanj@allstat.org
[Back to top]
Nutritional Aspects Relating to the Developmental
Origins of Health and Disease
M. Renee Prater
Introduction: Evidence is mounting to suggest that maternal
nutritional factors during pregnancy will have both short-
and long-term consequences to the health of the child. Recent
studies show a direct connection between gestational environment
(nutrition, chemical exposure, stress, and exercise) and elevated
risk of chronic disease in the adult offspring, many decades
later. These studies strongly emphasize the importance of
proper prenatal care and nutrition as they relate to both
improved neonatal outcome, and long-term adult health of the
child.
Objective: The objective of this article is to provide
a comprehensive review of the relationship between prenatal
nutritional choices and relative risk of chronic disease in
adult offspring.
Methods: A systematic search of the literature was
performed and reviewed, that focused on gestational nutritional
aspects that are thought to substantially relate to birth
outcome and risk of adult-onset chronic central nervous, cardiovascular,
reproductive, musculoskeletal, immune, metabolic, and neoplastic
diseases in offspring. Three databases were searched and relevant
original works, retrospective and prospective studies, and
review articles from all available years were selected; studies
involving human subjects and animal models of human disease
were included, whereas veterinary studies were excluded. Databases
searched included Pub Med, Biological Abstracts from Ovid,
and CAB Abstracts. The major MeSH search terms for Pub Med
were “embryonic and fetal development”, with “physiology,
immunology, and genetics” as subheadings, AND “prenatal
nutrition” with same subheadings; this search yielded
27 results. Search terms constructed in Biological Abstracts
included “fetal programming AND nutrition”, and
yielded 559 results. Results of search using “fetal
programming” search term in CAB Abstracts from CAB Direct
yielded 132 results.
Results and Discussion: The theory of the “developmental
origins of health and disease” was coined by David Barker,
and suggests that maternal environment can alter fetal programming
during times of genetic plasticity, and modify the trajectory
of development into adulthood. This theory hypothesizes that
the fetus adapts to a suboptimal gestational environment by
choosing pathways of gene expression and cell differentiation
resulting in adoption of a structure, physiologic state, or
behavior that best suits the current situation. This results
in manifestation of an alternate thrifty phenotype in anticipation
of possible future suboptimal postnatal environments. However,
if the postnatal environment does not accurately reflect what
was anticipated by the fetus prenatally, the epigenetic changes
adopted by the child before birth may inadequately prepare
him or her for healthy postnatal life. The phenotypic changes
that result from adverse maternal caloric, protein, carbohydrate,
fat, or micronutrient intake, are thought to not be repaired
postnatally, and unwittingly predispose the adult offspring
to a higher incidence of cognitive dysfunction, obesity, hypertension,
diabetes mellitus, immune dysfunction, infertility, cardiovascular
disease, osteoporosis, and cancer. Putative mechanisms and
current theories are discussed in this review.
[Back to top]
Maternal Nicotine Exposure: Long-Term Effect on Lung Integrity
in the Offspring
Gert S. Maritz
Nicotine occurs in tobacco smoke. It is a habit forming
substance and is prescribed by health professionals to assist
smokers to quit smoking. It is rapidly absorbed from the lungs
of smokers. It crosses the placenta and accumulates in the
developing fetus. Nicotine induces formation of oxygen radicals
and at the same time also reduces the anti-oxidant capacity
of the lungs. Nicotine and the oxidants cause point mutations
in the DNA molecule thereby changing the program that controls
lung growth and maintenance of lung structure. The data available
indicate that maternal nicotine exposure induces a persistent
inhibition of glycolysis and a drastic increased cAMP level.
These metabolic changes are thought to contribute to the faster
aging of the lungs of the offspring of mothers that are exposed
to nicotine via the placenta and mother’s milk.
The lungs of these animals are more susceptible to damage
as shown by the gradual deterioration of the lung parenchyma.
The rapid metabolic and structural aging of the lungs of the
animals that were exposed to nicotine via the placenta
and mother’s milk, and thus during phases of lung development
characterized by rapid cell division, is likely due to “programming”
induced by nicotine and not by inadequate placental perfusion
pressure and nutrient supply. It is therefore not advisable
to use nicotine during gestation and lactation.
[Back to top]
The Effectiveness of Interventions to Address Health Inequalities
During Pregnancy: A Review of Relevant Literature
Angela Hallam
Introduction: This paper presents a summary of what is
known about the effectiveness of interventions to address
health inequalities during pregnancy. The research was carried
out as part of a wider review of the literature relating to
interventions to address inequalities in the early years.
This contributed to the work of Scotland’s Ministerial
Task Force on Health Inequalities, which reported in June
2008.
Objectives: The objectives of this article are to
provide a broad summary of the evidence base; highlight the
known effectiveness of specific interventions; and identify
gaps.
Methods: The review is based on analysis of data
from publications/work in progress recommended and/or produced
by the Scottish Government, its agencies and those conducting
relevant research within universities and other organisations
across Scotland.
Findings: Evidence supports school and community-based
sex and relationship education as effective in averting pregnancy
at a young age. During pregnancy, intensive and direct interventions,
such as vouchers and provision of food, have a greater chance
of improving nutritional status than simply providing advice
and information. Multi-faceted initiatives (information, advice
and counselling) are more likely to be effective in addressing
smoking cessation than a single service. Antenatal care programmes
may improve outcomes for both teenage mothers and their infants,
but little research has been carried out on the content of
antenatal classes, and there is little evidence relating to
Scotland or to the rest of the UK.
Conclusions: There is good evidence to show the effectiveness
of a range of initiatives, both at the level of the population
and the individual, although the most vulnerable groups are
inevitably the most difficult to engage. Tapping into the
popularity of computer games and other technological approaches
may help young people engage with issues relating to relationships
and the care of young infants, although initiatives have yet
to be evaluated in the UK. Families who are hard to reach
by traditional services may feel more comfortable receiving
antenatal home visits from volunteers within their own community,
although it is important that such volunteers receive appropriate
training and support.
[Back to top]
Increasing Access to HIV Testing for Women by Simplifying
Pre- and Post-Test Counseling
Matthew F. Chersich and Marleen
Temmerman
Only small proportions of women are aware of their HIV
status and can enter HIV treatment and care. The remainder
cannot access essential HIV services, placing them at high-risk
for early death and facilitating HIV transmission. To rectify
this, many international organisations now recommend routine
HIV testing in clinical settings. Provider-patient encounters
in reproductive health services provide an ideal opportunity
and conducive environment for testing. While rapid HIV tests,
with results available the same day, have simplified testing,
insufficient efforts have been made to modify pre- and post-test
counselling.
We argue for increased emphasis on group pre-test information
given during health talks, especially in antenatal and child
health clinics. Brief individual pre-test sessions would then
only be for confirming information was comprehended. Little
evidence supports effectiveness of behaviour change counselling
for HIV-negatives. Consequently, more abbreviated and focused
post-test information (or printed leaflets) could be given
for those testing negative. Conversely, substantial evidence
shows post-test counselling for HIV-positives is effective,
and should be prioritised and meet pre-set standards of quality.
Though attention is needed to ensure high-quality interventions
before and after testing, simplifying pre-test information
and post-test information for negatives could facilitate a
rapid increase in testing coverage and frequency.
[Back to top]
Botulinum Toxin Treatment of Pelvic Floor Disorders and Genital
Pain in Women
Laura Bertolasi, Emma Frasson and Alessandra
Graziottin
Background and Objective: Botulinum neurotoxin (BoNT),
now commonly used for reducing muscular spasms in other neuromuscular
disorders, is now increasingly proposed also for treating
pelvic floor disorders, including chronic pelvic pain syndromes,
vaginismus, vulvodynia and vulvar vestibulitis syndrome. To
provide up-to-date information on these advances we reviewed
the literature about BoNT injections for pain and spasms related
to pelvic floor disorders.
Methods: We conducted a Medline search using the
terms botulinum neurotoxin, pelvic floor disorders, levator
ani myalgia, vaginismus, vulvar vestibulitis, vulvodynia,
dyspareunia, interstitial cystitis, recurrent cystitis, and
postcoital cystitis. We sought information on the indications
and techniques used for BoNT treatment for pelvic floor dysfunctions,
and related pain syndromes in women.
Results: Our search identified 12 studies for review
(including a randomized controlled trial) showing that BoNT
effectively reduces pain in chronic genital pain syndromes
associated with pelvic floor spasm. Before BoNT trials, patients
with idiopathic lifelong vaginismus and dyspareunia, associated
with hyperactive pelvic floor muscles, had no effective treatment
options. BoNT injected under electromyographic (EMG) guidance
in pelvic floor muscles improves vaginismus, helping to restore
a normal sexual life. BoNT injections also seem to improve
vulvodynia and vulvar vestibulitis. Though some patients need
periodic injections, in about 65% of affected women BoNT achieves
permanent benefit.
Conclusions: These encouraging evidence-based results
suggest that BoNT injected intramuscularly should extend treatment
options for women with lifelong or acquired pelvic floor disorders
and genital pain.
[Back to top]
Emerging Trends in Endometriosis Treatment - Review
Warren B. Nothnick and Xuan Zhang
Endometriosis is an enigmatic, debilitating disease which
affects as many as 15% of all women of reproductive age and
is characterized by pelvic pain and infertility. Current treatment
regimes used to manage the disease do so by inducing a hypoestrogenic
state. While the absence of circulating estrogen levels lead
to a regression of the disease, this hypoestrogenism also
induces many unpleasant side-effects. As such, these and other
shortcomings of current drug therapies emphasize their limitations
and the necessity for the development of novel endometriosis
treatments. In this review, current therapies for medical
management of endometriosis are discussed as are their shortcomings.
Potential target areas which may be attractive alternatives
to current therapies are also reviewed. Emphasis is placed
upon the emerging research using TNF inhibitors, their potential
benefits over current treatment regimes and the development
of future potential therapeutic targets.
[Back to top]
The Complex Dynamics of Breast Cancer
Fabio Grizzi, Sonia Di Biccari, Antonio
Di Maggio and Pier Carlo Muzzio
Despite years of intensive investigation that has been
made in understanding women’s susceptibility to breast
cancer, it remains a major cause of death worldwide.
In mathematical terms, breast cancer can be outlined as a
non-linear system that advances in time and in space through
different states and a number of transitions from one state
to another over a certain time interval. Breast cancer emerges
from multiple spontaneous and/or inherited alterations that
induce changes in expression patterns of genes and proteins
that function in complex networks controlling critical cellular
events. Here, we discuss breast cancer as a dynamical
disease using the basic principles of the mathematics
of non-linear systems and chaos theory. Additionally, some
of the critical concepts necessary to give meaning to its
underlying physical complexity are introduced. This way of
thinking may help to clarify concepts, indicate alternative
experiments and categorie the actual knowledge.
[Back to top]
Postcaesarean Ovarian Vein Thrombosis. Evaluation by Ultrasound
and Multislice Computed Tomography
Maria Isabel Pardo Pumar, Eugenia García
Giménez, María José Alonso Vaquero, José
Carlos Pardo Belda, Miguel Puig Sáez and José
Manuel Pumar Cebreiro
Puerperal ovarian vein thrombosis (POVT) is an uncommon
but potentially fatal complication of post gynecological surgery,
which is often diagnosed by clinical findings and indirect
radiologic signs. Ultrasound (US) and multislice computed
tomography (MCT) imaging now offer reliable and accurate methods
for suspected POVT. We present here a case of postcaesarean
ovarian vein thrombosis and describe its clinical and radiological
findings. Differential diagnosis and management are discussed.
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