STIs – Update on diagnosis, management, outcomes, for herpes, warts and monilial infection.

COLM O’MAHONY

GENITAL WARTS

Genital warts are a cosmetic nuisance. There are no medical complications. There is no link with cervical cancer in patients who have obvious genital warts. However, the vast majority of patients who get infected with these warts are distraught and deeply embarrassed about the ugly lesions. At last, however, home treatments are available that take all the embarrassment and frustration out of this conditions and patients can manage themselves in the comfort and dignity of their own home. The ancient practice of weekly podophyllin is now totally inappropriate. We use a combination of cryotherapy to debulk initial lesions and then Warticon if the lesions are soft and fleshy or Aldara (imiquimod) for more keratinised and more extensive warts or warts that have recurred. Aldara is also first line in peri-anal warts. There is no need for cervical cytology in these patients other than the national screening programme intervals (NHS Cervical Screening Programme categorically states this).

HERPES

From a medical point of view genital herpes is a cold sore in an awkward location. Psychologically, however, the consequences can be devastating. In our practice, the management of herpes more emotional than anti-viral. In community practice, it should be a clinical diagnosis and anti-viral therapy should be commenced as soon as possible. The management of recurrence is highly individual and only rarely is long term maintenance appropriate. It is often contracted within a stable monogamous relationship, ie. 70% of our vulval isolates are Herpes Simplex Type 1. In the UK, HSV Type 2 sero-prevalence varies enormously from 10% in the low risk populations to one report showing 94% HSV 2 antibodies in HIV Positive women.

MONILIAL INFECTION

Chronic candidiasis is a distressing and frustrating condition. Women and their partners often present demanding that “something must be done”. Generally the treatment for occasional episodes of candida are very effective, as evidenced by the success of treatments sold over the counter. However, chronic infection, needs sympathy and ingenuity. Diagnosis is generally clinical, but it often requires confirmation and exclusion of other STDs. Candida is not a sexually transmitted infection, although the friction of intercourse can be a common precipitator. The best management strategies are the ones that allow the patient diverse methods of treating her condition early without needing a medical consultation.

Cervical screening – what do the new changes mean in clinical practice?

MICHAEL QUINN

It is clear that the Pap smear test has served us well, but its false negative rate is high and this has generated a number of new approaches. Current best estimates suggest a false negative rate of about 60-70% with two-thirds of these being due to sampling or preparation errors and one-third due to screening errors. Since nearly 800 women in Australia continue to develop cancer of the cervix annually, it is not unreasonable for us to look at alternatives, and of course these include liquid based cytology (LBC) and HPV testing.

Liquid based cytology has a number of attractive features. It is clear that more than 80% of cell sample from a routine smear collected with a brush and spatula is left on the device and that interpretation of the routine Pap smear is often difficult due to inflammation, atrophy, menstruation, blood, etc. There is a huge amount of literature now attesting to the benefits of LBC but the 2002 MSAC Review in Australia suggested that there was no need to change the current situation since there was “insufficient evidence” to support its use.

Since MSAC, a Scottish pilot study of LBC has shown an 84% increase in the pick up rate of high-grade abnormalities and a 76% reduction in unsatisfactory and borderline smears and this has led to the uniform introduction of liquid based cytology in Scotland last year. A similar study was undertaken in England and Wales showing a 17% increase in detection of high-grade abnormalities and a 78% decrease in unsatisfactory and borderline smears, again resulting in the adoption of liquid based cytology across the board. Since the UK studies have been published there has been a further meta analysis of liquid based cytology suggesting about a 12% improvement in sensitivity and 7% improvement in specificity. It is clear that not only will liquid based cytology be cost effective in Australia, but extra value will be achieved since more slides can be read per day and the liquid medium can be used for testing for HPV, Chlamydia and other STIs.

HPV testing is almost with us routinely. It is clearly a good test for triaging abnormal smears of uncertain significance and other inconclusive smears for colposcopy. It is far too early to recommend its use in the follow up of treated abnormalities and a recent study from the UK – the HART study – would suggest that it may be a valuable test as a primary screen in women older than 35….when positive colposcopy is undertaken.

It is likely, therefore, that liquid based cytology will eventually be introduced into Australia, that HPV testing will be undertaken when the smear test is considered unsatisfactory or there are cells of uncertain significance. The screening interval may be extended and more “rigorously policed” but further studies are required to ensure that appropriate management of women with low-grade smears is undertaken and a place for HPV in primary screening of the population still waits to be defined.

Fertility: Options and Outcomes – what can we tell women?

GAB KOVAKS

ABSTRACT:

The three basic fertility parameters are:

1. the right number of sperm have to be placed in the right place at the right time
2. ovulation has to occur
3. the eggs and sperm have to be transported together.

Recently there has been a lot of publicity about the decline in fertility for women with age. This basically relates to the poor quality of oocytes being produced. Not only is natural fertility decreased but there is also evidence that assisted reproductive technology is less successful as a woman matures.

Unfortunately even the new techniques of pre-implantation of genetic diagnosis do not seem to improve the prognosis for the older woman.

The role of the general practitioner is to determine the possible cause of the sub-fertility, so that appropriate referrals can be undertaken. If it is principally a sperm problem, the most suitable referral is an andrologist. In the case of ovulatory problems, a reproductive gynaecologist would be the best resource.

Initially investigations therefore should determine the normality of sperm count, appropriate timing of intercourse, anatomical normality in the female, as well as the mid luteal hormone assessment for progesterone and prolactin. It is also imperative to check rubella immunity early as re-immunisation may delay treatment, which frustrates patients.

Although many women can be helped with simple methods of treatment, IVF seems to be the common denominator and a last resort for many couples. Although initially developed for tubal disease, it can also be used to overcome endometriosis as well as unexplained sub-fertility. About 40% of couples going through IVF now do so because of male factor, as there is little that can be done to improve an abnormal sperm count.

With the surgical techniques developed to obtain sperm, obstructive azoospermia, including previous vasectomy can also be overcome by IVF.

Hormone Therapy after the Women’s Health Initiative

GINO PECORARO

The role of hormonal treatments for women undergoing menopausal symptoms is examined in light of recent evidence. A review of the major studies’ methodologies and findings are discussed and an attempt made to interpret where this leaves the modern clinician dealing with a patient across the desk.

It is hoped that registrants will be familiar with what hormonal therapy can and cannot offer and be able to intelligently discuss the available evidence to help guide a patient to the ultimate decision with regards to their treatment.

PANEL SESSION – Sexually Transmitted Diseases

COLM O’MAHONY, CHERYN PALMER, BARBARA LEGGETT, MELISSA KANG

TO BE ADDED

NASH: What is it? Should we screen for it? How is it managed?

BARBARA LEGGETT

Non-alcoholic fatty liver disease is the most common cause of abnormal liver tests in the Australian population and is becoming more frequent as the prevalence of obesity rises. The spectrum of liver abnormality ranges from simple steatosis (fatty liver with no scarring or inflammation) to nonalcoholic steatohepatitis (NASH) where there is steatosis with inflammation, injured “ballooned” liver cells, Mallory’s hyaline and fibrosis. Eventually cirrhosis develops in up to 15% of patients and many of these patients die of liver failure or liver cancer.

The major cause of fatty liver disease is insulin resistance associated with obesity and Type 2 diabetes. Amongst obese patients 60% have steatosis, 20% have NASH and 2-3% have cirrhosis. In most patients the disease is detected through the incidental finding of abnormal liver tests though some have fatigue and non-specific epigastric or RUQ pain. Occasionally patients first present with the complications of cirrhosis. The liver tests most elevated are the ALT and AST but levels are seldom more than 3 times normal. Screening tests for other liver diseases are negative except for the frequent occurrence of a moderately elevated serum ferritin which reflects leakage from damaged hepatocytes rather than iron overload. The pathology of this disease is identical to alcoholic liver disease and the distinction is based on an accurate history. Alcoholic liver disease can be excluded in patients known to drink less than 2 standard drinks per day.
Liver imaging has a high sensitivity for confirming steatosis but cannot reliably determine inflammation or fibrosis. Liver biopsy will give this important prognostic information but is not justified in all patients. Referral for biopsy should certainly be considered in those over 50 and those with severe obesity, diabetes and hyperlipidaemia as cirrhosis is more likely in these patients. Women are at greater risk of developing cirrhosis.

The mainstays of therapy remain diet and exercise. Liver tests usually improve if weight loss of 10% or more can be achieved. The difficulty is achieving long term maintenance of weight reduction. Bariatric surgery has been shown to have beneficial effects but NASH can worsen during initial precipitous weight loss and patients with pre-existing cirrhosis may decompensate. Exercise improves insulin resistance even in the absence of weight loss. Oxidative stress is thought to play a role in progression from steatosis to NASH and anti-oxidants such as Vitamin E and betaine are currently being trialed. Optimal control of diabetes is important. There are likely to be particular advantages to the use of agents such as metformin and piaglitazone and rosiglitazone which improve insulin resistance. However these agents have significant side effects and their use is only currently justified in patients with overt diabetes. Patients with NASH often have hyperlipidaemia and these abnormalities should be treated appropriately because of the risk of vascular disease. Statins and gemfibrozil may also improve NASH but this is still under trial and their use is not yet justified solely on these grounds.

Bloating to bleeding: what matters?

JENNY DOUST

Symptoms such as PR bleeding and abdominal bloating are common in general practice and it is difficult to determine which patients may have significant pathology and which do not. Who needs further testing and who needs urgent referral? When can you afford to wait and see? This talk will discuss what is known about bowel symptoms and signs in general practice and how they contribute to diagnosis.

Adolescent Sexuality: the practical implications

MELISSA KANG

TO BE ADDED

The Range of Menstrual Problems

IAN FRASER

Disturbances of menstruation are extremely common. Most women will consult their doctor for menstrual bleeding problems at some time in their lives, and about 10% of women in the reproductive age group will consult a doctor during any given year. Currently, there is world-wide confusion about terminology and definitions of menstrual symptoms and causes, and these will be reviewed. Mechanisms of menstrual disturbances will also be reviewed.

There is now sufficiently widespread access to good modern technology that diagnoses and assessment can be made with considerable precision, allowing sound and logical choices for therapy. A wide range of therapeutic options is now available, and an attempt will be made to put these into perspective. The presentation will concentrate particularly on the effective use of tranexamic acid (Cyklokapron; Pharmacia) and the levonorgestrel-intrauterine system (Mirena; Schering) for menorrhagia, and various means of attempting to deal with the problems of breakthrough bleeding with long-acting hormonal contraceptive methods.

Relevant website: www.wdxcyber.com (a great deal of information, but a very American perspective).

Are Sex, Love, Passion & Desire, compatible with long term relationships ?

COLM O’MAHONY

It is true, “Men are from Mars and Women are from Venus”. How they ever managed to get on together in a relationship is a source of constant amazement. The thought processes are just so different that hurt and misunderstanding are an inevitable feature.

People working within the health care specialties work extremely hard and in a conscientious fashion, and often do allow their work to interfere with their family life.

Most relationships start off with love and hope, but the realities of jobs, mortgage, children and family life gradually erode into the time available for each other. Changing aspirations and needs are not communicated or understood. Low self esteem, common in our profession, makes it difficult to ask for what we want in an open honest manner.

Relationship and sex issues will be discussed in a humorous fashion, but there is a message to be taken away at the same time. Much of the talk is based on past experience over many years working in sexual health, and a useful book list is attached, which can help people examine their own lives and get their act together. It’s never too late !

B00K LIST

• Men are from Mars, Women are from Venus
  
  A practical guide for improving communication and getting what you want in your relationship by John Gray
  
  ISBN: 0-7225-2840-X
• Mars and Venus in the bedroom
  
  A guide to lasting romance and passion by John Gray
  

  ISBN: 0-09181-529-0

• Families and How to Survive them
  
  by Robin Skynner and John Cleese
  
  ISBN: 0-7493-0254-2
• The road less travelled
  
  by M Scott Peck
  
  The new psychology of love, traditional values and spiritual growth.
  

  ISBN: 0-7126-1819-8

• Too good to leave, too bad to stay
  
  by Mira Kirshenbaum
  
  A step by step guide to resolving your relationship
  
  ISBN: 0-7181-4177-6
• Becoming orgasmic
  
  by J R Heiman & J Lo Piccolo
  

  A sexual and personal growth programme for women
  
  ISBN: 0-86188-798-0

• Self esteem
  
  by Tony Humphreys
  
  The key to your child’s education
  
  ISBN: 0-7171-2484-3
• Sixty minute marriage
  Nigholas Parsons
• FPA Books & Training
  
  by Family Planning Association
  
  2-12 Pentonville Road, London N1 9FP
  
  Phone: 0171-837-5432 Fax: 0171-837-3026
  
  The FPA (Family Planning Association) publish an excellent catalogue of books. The section on Sexuality is particularly useful, listing often over 15 books and / or videos dealing with relationships and sexuality. This is updated at least yearly.

COGNITIVE BEHAVIOUR THERAPY WORKSHOP

JANE TURNER

This interactive workshop provides an overview of the theory underpinning cognitive behaviour therapy, and includes an update on the effectiveness of cognitive behaviour therapy in conditions common in General Practice such as insomnia, fatigue, obesity, and chronic pain. The workshop has a practical focus and aims to assist participants to improve their skills in applying cognitive behaviour therapy techniques in their clinical practice. All workshop participants are required to participate in role-plays

Polycystic Ovarian disease

GABS KOVACS

Ever since first described by Stein and Levanthal in 1935, polycystic ovary syndrome has been puzzling the medical community. The first treatment reported was wedge resection, and although this was used as early as 1935, its mechanism of action has never been fully understood.

Although PCOS is often thought of as a reproductive disease, it actually is far more widespread than this. As there is a basic biochemical abnormality of insulin resistance, this is programmed into the genome of every cell. It is also highly likely that PCO is an inherited disease. Population studies suggest an incidence of between 20 and 25% in our community for PCO. Why only about a quarter of these women develop symptoms and PCOS is not understood. It is however understood that gaining weight and having a sedentary lifestyle will increase the risk of developing symptoms.

If a woman has polycystic ovaries on ultrasound plus symptoms, she is then described as having PCOS. The most common symptoms are that of excess androgen secretion resulting in oligomenorrhea, acne, hirsutism, weight gain, often associated with bio-chemical abnormalities of increased androgens circulating, with decreased sex hormone binding globulin.

The diagnosis of PCOS can often be made on history and examination alone. Nevertheless, in the 21st century, most women feel more comfortable having a vaginal ultrasound confirming the diagnosis.

As it is now recognised that women with PCOS probably have an increased risk of developing diabetes and possibly a higher risk of cardio vascular disease, measuring base line parameters for insulin resistance and lipids is also indicated. How many androgenic hormones one measures is debatable, whilst these do give a baseline reference range, they won’t influence treatment to any significant degree. It is always important to measure prolactin.

Treatment will then depend on the particular problem for that woman. The most common reason for seeing a gynaecologist is in relation to infertility and this is often easily remedied by clomiphene treatment. Recently metformin has been advocated but there is a lot of confusion about how this compares as an alternative or even an adjunct to clomiphene. Women who don’t respond to oral medication can then undergo ovarian cautery or ovulation induction with gonadotrophins.

There is no evidence that administering metformin in any way prevents long term complications. Fortunately most women with PCOS and subfertility do not need to progress on to IVF unless there is a complicating factor.

Obesity in 2004 – What’s Happening?

IAN CATERSON

Obesity is often in the news and the problem of obesity and its potential effects is starting to sink into the understanding of physicians, health departments and governments. Obesity is far more prevalent in all areas of the world. With this comes increasing disease, particularly metabolic disease (type 2 diabetes, hypertension, dyslipidaemia & NASH) but as well there are increases in several cancers including bowel, breast, prostate, renal and pancreatic cancers. In Australia, obesity, physical inactivity and lack of fruit and vegetables (all interwoven factors ) are the major risk in our burden of disease. Obesity is also increasing in children and adolescents. Such excess adiposity does track into adulthood and as well, there is an increase in type 2 diabetes in adolescents. Disease is occurring earlier.

In Asia, obesity associated disease appears to occur at a lower Body Mass Index (BMI) and/or waist circumference. This may be due to either a relatively greater fatness in Asians or a greater propensity to deposit abdominal fat. Certainly the “action points” for treating obesity need to be lower in Asian populations, but there is a need to collect more data before this issue is fully understood.

Adipose tissue is not just a storage organ, it produces many hormones and probably plays a direct role in the production of vascular disease by other factors it secretes. Whilst leptin is the best known adipose tissue factor, others include resistin, adiponectin and ZAG. The latter two factors are reduced in obesity and this reduction may be important in both insulin resistance (adiponectin is an insulin sensitiser) and in the perpetuation of obesity (ZAG is a cachexin).

While it has not been possible to prevent obesity (so far), current treatment is effective. The emphasis should be on a modest weight loss of 5-10% of original body weight rather than on returning weight to “normal”. Such a weight loss produces changes in disease state and improvement in risk factors. Though long term outcome studies of weight loss are lacking, there is now data on 4 year weight reduction. Treatment with orlistat and a lifestyle program will produce sustained weight loss of 6-7kg over that time. Diabetes incidence can be reduced by such maintained weight loss. Currently there is a study of weight loss and cardiovascular outcomes (SCOUT). In other studies we have shown that a mildly hypocaloric diet with a lifestyle program and orlistat treatment will maintain more than 11kg weight loss in one year together with a reduction in risk factors. There are also 2 year studies with sibutramine showing similar results and in these there is a rise in HDL cholesterol above that expected by the weight loss. There are also new treatments being trialled. Obesity treatment does have significant cost benefits for the health system.

However what is important is prevention. It has been shown (in several studies) that a lifestyle program can produce modest weight loss and reduce diabetes incidence. Several trials are being performed to determine whether weight loss can be maintained long term and it is reasonable to assume that the current approaches, when applied to a more general population may help prevent obesity.

Pot pourri of common skin problems

JIM MUIR

“The skin is afflicted by numerous disorders ranging from the merely annoying to the fatal. Many can be diagnosed at a glance or via simple investigations. Skin disease is seen in every facet of medical practice. Contrary to non-dermatological prejudice nearly all skin conditions are treatable and some (one or two) are even curable. Successful treatment relies on accurate diagnosis. In this session a myriad of conditions, their diagnosis and management will be dealt with. There will be particular emphasis on diagnostic techniques and topical therapy.”

Clinical Problems and Hormones

IAN FRASER, GAB KOVACS, GINO PECORARO, SUE ROBERTS

TO BE ADDED

Vulval Problems

JIM MUIR, COLM O’MAHONY, MICHAEL QUINN

VULVA INTRA-EPITHELIAL NEOPLASIA (VIN)

VIN is on the increase, almost certainly due to HPV infection. No screening test is currently available. It is characterised histologically by abnormal cell maturation, nuclear enlargement, atypia and mitoses. There are three different patterns: warty VIN, basaloid VIN and differentiated VIN, the last of which may be the most pre-malignant. It is clear that VIN is a pre-cancerous change. If untreated, the risk of developing a malignancy is up to 85% whereas if appropriate treatment is undertaken then this can be reduced to 4%.

The majority of high-grade VIN is due to HPV16/18 with 30-40% of patients with VIN having been treated for CIN in the past. Likewise, if VIN is present, CIN will co-exist in about 30% of cases so it is mandatory to perform a Pap smear and colposcopy in women when VIN is diagnosed.

VIN is usually unifocal in older women but younger patients have multifocal disease presumably reflecting an HPV origin in the majority of cases. Most patients are asymptomatic, but up to one-third will have pruritus, or will notice an area of pigmentation or de-pigmentation in the skin. Occasionally patients present with a condylomata resistant to treatment.

The natural history of VIN is not well-defined with regression occurring in some but persistence in the majority if untreated. Diagnosis is usually following colposcopic assessment and treatment includes wide local excision, particularly when VIN affects hair bearing areas and laser particularly when affecting non-hair bearing areas.

Recently, the use of Imiquimod has been seen to be of value in multifocal VIN although it is highly irritant and patients need great support during the treatment programme.

Tackling Lifestyle Changes for Women: smoking, physical activity, nutrition

IAN CATERSON, NANCY HUANG, CAROLYN RUSSELL

TO BE ADDED

Sexual Health and its problems

SUSAN CARR, MELISSA KANG

TO BE ADDED

Episodes from the History of clinical trials

PAUL GLASZIOU

TO BE ADDED

DEBATE: “Don’t worry about lifestyle changes – just give all women the polypill”

FOR: CHRIS DEL MAR, GERALDINE MOSES

AGAINST: CLAIRE JACKSON, IAN SCOTT

TO BE ADDED

Alternative treatments for impoving libido and weight loss – do they work? Are they safe?

GERALDINE MOSES

TO BE ADDED

Recent changes in contraceptive options and avaiability in Australia

IAN FRASER

Recent major changes in the contraceptive field in Australia have included the availability (now over the counter) of levonorgestrel-only emergency contraception (POSTINOR; Schering), introduction of the drosperinone-containing combined oral contraceptive (YASMIN; Schering), the widespread use and some controversies surrounding the etonogestrel-releasing subdermal implant (IMPLANON; Organon), the availability on the PBS of the intrauterine levonorgestrel system (MIRENA; Schering), the planning for introduction of the first contraceptive vaginal ring in Australia (NUVARING; Organon), and the new hysteroscopic sterilisation technique (ESSURE; Conceptins, USA). All of these are highly effective and acceptable techniques if used appropriately, but each one also has some disadvantages. In the not-too-distant future, we may also have access to the transdermal combined oestrogen-progestogen contraceptive patch (EVRA; Ortho) and perhaps the new progestogen-only desogestrel minipill (CERAZETTE; Organon).

Relevant website: www.who.int/reproductive-health (this is the website of the Human Reproduction Program of the World Health Organization, and focuses specifically on contraceptive issues).

These developments considerably extend the available choices for Australian women. Our big challenge as health providers is to ensure that women and their partners have sufficiently good information to allow them to make sensible choices.

Gynaecological cancer – what’s new

MICHAEL QUINN

(1) Vulva Cancer

Just as in cancer of the cervix, there is the high possibility that vaccination against the development of vulva disease, which is predominantly related to HPV infection, may be realistic for the future, and of importance is the concept that vaccination against the major HPV sub-types will give protection against cervical, vaginal and vulval disease. A recent ‘proof of principle’ study from Manchester using vaccinia virus as a vector for HPV16 protein has successfully shown an immune response in 13 of 18 patients and in 8 of these a more than 50% reduction in size of VIN. Interestingly, as we have found in our own studies in cervix cancer, viral load reduction did not seem to correlate with response.

Sentinel node biopsy is almost with us in vulva disease. So far its negative predictive value is almost 100% and we are now able to suggest that extra staining techniques do not improve the sensitivity. One of the problems is that not all vulva cancers have identifiable sentinel nodes but nonetheless it is clear that this is going to be of enormous benefit in relation to the extent of surgery, particularly in younger women.

Advocates for the recognition of vulva disease are becoming more vocal and this is impacting enormously on women’s health. In the US there is a “vulva underground” site on the web which is extraordinarily comprehensive and a very valuable resource for information. Here in Australia, GAIN is becoming very proactive and politicised.

(2) Cervical Cancer

By the time of the meeting in Queensland, the February meeting of the NHMRC Guidelines Committee will have met to examine various proposals, including screening intervals (it has been a suggested a move from 2 to 3 years), and the management of low-grade abnormalities. Both these areas will cause great controversy. Given the fact that up to 25% of women with low-grade abnormalities will have biopsy-proven high-grade disease on colposcopy, it seems rather cavalier to adopt a conservative course such as repeat smears in 12 months.

The publication in 2002 in which it was shown that HPV quadrivalent vaccine protects against the development of dysplasia is the first study that has shown protection by a viral vaccine against HPV and subsequent development of dysplasia. This is very exciting and bodes well for future trials, including our own in Australia.

As regards to treatment of cancers of the cervix, chemo-irradiation has now become the standard of care, both in advanced disease and also in early stage disease with positive nodes.

(3) Endometrial Cancer

There has been little progress in the management of this disease, although the role of adjuvant treatment is better defined. We are still seeing poor results with papillary serous and clear cell tumours and the role of adjuvant chemotherapy is currently being explored under these circumstances. Of note is the suggestion that in some of the P53 positive papillary serous tumours herceptin may be of value. Uterine sarcomas are still a major problem but it has become clear that the use of adjuvant radiation therapy reduces local recurrence but not overall survival.

There has been a recent move towards a more conservative management of Grade 1 tumours, particularly in young women desirous of fertility. These women usually have polycystic ovarian syndrome, so it is mandatory that the endometrium is monitored, particularly when an ovulation is prolonged. One of the difficulties in trying to decide who should be managed conservatively is a sensitive test to ensure that the cancer has not spread into the myometrium. At this point, MRI seems to be the better test although transvaginal scan still has its role. Progestagen therapy has been shown to be successful in about 60% of such young women and of importance is a recent case report of a woman treated with Metformin whose Grade 1 cancer reverted to normal within 6 months.

The clustering of families with breast and endometrium serves to reinforce the importance of a family history. It is becoming increasingly obvious that much cancer is genetically based. For instance, when the mother has an endometrial cancer the risk of an endometrioid ovarian cancer developing in her daughter is more than 3 times that when such a family history does not exist.

The recent observation that Anastrozole is as good if not better than Tamoxifen in adjuvant treatment of post-menopausal women with early stage breast cancer will obviate the anxieties around Tamoxifen-induced endometrial neoplasia.

HNPCC is associated with at least a 50% risk of the development of endometrial cancer. It has recently been shown that screening the endometrium does detect atypical hyperplasia in these cases and we currently recommend an annual transvaginal scan in such women who carry these mismatch repair gene defects.

(4) Ovarian Cancer

PET scanning is the new imaging best practice in ovarian disease. It is particularly useful in CA125 detected recurrences when CT scans are usually negative and often will show a discordant response following chemotherapy, emphasising the chemo-sensitivity of one site of metastatic disease compared to the other.

Mucinous cancers of the ovary have been linked with smoking in the past and a recent study from Boston has reinforced this – one more reason to get your women patients to discontinue smoking!

Early stage ovarian cancer used to be problematic since up to 30% of patients still died of the disease but it was not clear if giving chemotherapy following primary surgery was of value. This has now changed with publication of the ICON 1 and ACTION Study showing that in 924 randomised patients a four year hazard ratio for the chemotherapy group was reduced to 0.64 translating into about an 8% benefit to overall survival.

There have been a huge number of molecular studies in ovarian cancer published in the last few years. All concentrate by and large on genomics and proteomics and it is clear that these studies are going to allow us to identify unique markers for screening and also will allow us to screen tumours for chemo resistance de novo which will allow us greater selection of cytotoxic adjuvant treatment.

Finally, it is also clear that we will see in the future much larger multi-centre studies than we have hitherto. This is particularly since the advent of the Gynecological Cancer Intergroup of which Australia is a member. For instance, GOG study 182 has accrued more than 3,500 patients in the last 3 years and within 18 months we will know whether the addition of a variety of agents to the standard treatment with Carboplatin and Paclitaxel is of benefit

Women and HIV

COLM O’MAHONY

It is always an emotionally devastating consultation. There is no way in the world a woman can be prepared for the realisation that her life, her relationship, her future plans, are all in turmoil. In my cohort of female patients, the diagnosis is usually made after a “husband” has become ill and is finally diagnosed with HIV. The woman then has to deal with the consequences of her infection, a sick partner, and the realisation that her relationship was suspect. Further revelations about how he acquired the infection often compounds the distress, as it’s usually through homosexual relationships. The teenage children can be very unforgiving when all is revealed.

The medical management of these patients is generally not difficult. It’s the social and family issues that cause the greatest angst for both the patients and the carers. Clinical progression is quite similar to male patients, except that manifestations of immunodeficiency do tend to show at higher T4 counts than in male patients. Triple therapy (HAART) is therefore often commenced at higher T4 counts in women than in men.

Cervical intra-epithelial neoplasia (CIN) is commoner in women with HIV. Annual cytology is recommended.

Pregnancy, of course, is a major issue, and at least now the information is a lot clearer. In the United Kingdom, the British HIV Association guidelines are followed and women are commenced on triple therapy, usually Combivir and either Nevirapine or Nelfinavir to suppress viral load. If the viral load becomes undetectable it is debatable whether a Caesarean Section should be done or not.

In many communities, most of the support structures were geared around gay men and their health, so in some localities the support for women is scanty.

As with all HIV disease, the prognosis is better the earlier it is diagnosed, and routine antenatal testing of all pregnant women is appropriate, even in areas of low prevalence. Each detected case that prevents transmission to the foetus saves the health service 1/2 million pounds.

Website for clinicians and patients from HIV I-Base (authors of HIV-treatment bulletin)
www.i-base.info/pub/guides/pregnancy/03/index.html