Women's health

The women who can most afford motherhood are the least likely to have babies Young women today think long and hard about when, and even whether, to become mothers. They observe the changes that occur in their sisters' or friends' lives when they have babies; changes that are for the most part dramatic and, of course, irreversible, and it gives them serious pause for thought. It is not something most of them are going to do until they are really, really sure that it is the right thing — and the right time — for them. Most young women want to wait until they have experienced the world, then acquired a financial base and made sure they are with the right man before embarking on the long journey of parenthood. Sometimes, after waiting until their early 30s to get everything in place, they find they can't bring themselves to change. They are not sure they can cope with the dislocation and chaos a baby will bring into their lives. There is a big decision to be made and, for the first time in history, women are in control of that decision. Exercising it gives them a great sense of power — and a freedom previous generations of women could not even have dreamed of. Australian women today are the first generation to effectively have total control of their fertility and this has dramatically changed everything for them. One hundred and fifty years ago, nearly half of all Australian women could expect to have around nine confinements.1 Early in the 20th century, it was not uncommon for a woman to have "a toddler at her skirt, another at her breast and a third in her womb".2 Less than 50 years ago, in 1961, women were having on average 3.6 children each. Today, around 28% of women will not have children at all and those who do have them are having fewer than any previous generation. In 1993, the fertility rate in Australia (the number of babies a woman will bear over her lifetime) was 1.9, down from 2.1 in 1976. The 1970s rate was the same as the previous lowest level — in 1934, during the Great Depression. Rural women still have more babies — an average of 2.27 in 2001, and the rate for Indigenous women was 2.21, whereas in the same year the national average birth rate had fallen further to 1.7. In some areas it is even lower, for instance in metropolitan Melbourne, which has a birth rate of just over 1.5. A birth rate of 2.1 is required for a country to reproduce itself, so Australia now has to rely on immigration just to maintain its population. This phenomenon of a dramatically declining birth rate is sometimes called the "baby bust" — in contrast to the post-World War II "baby boom", from 1946 to 1963, during which Australia's birth rate soared. Demographers, politicians, editorialists and others are constantly fulminating against this decline. What can they do (they bluster with increasing frustration) to make women have more babies? Why are women having fewer and fewer babies? The reasons are complicated, but the answer in some ways is surprisingly simple. As a society, we ask women to give up too much when they have children and we give them far too little in return. The pleasures of children are, in the pragmatic calculus now undertaken by most young Australian women, not compensated for by what they have to forgo. They are expected to give up their jobs or at least cut back on them, often after having been given a hard time while they were pregnant. They can expect to suffer a significant loss in earnings, from which over a lifetime they will never recover, as they will rarely be able to return to do the same level of work as before. Even the government admits that stopping work to have a child means "the family cash income will drop sharply". According to Fact Sheets on Work and Family issued in 2002 by Senator Amanda Vanstone, the federal Minister for Family and Community Services, when a double-income family, both on average weekly earnings, moves to a single income, they suffer a 38% fall in income that government payments do not come close to redressing. Economist Dr Bruce Chapman from the Australian National University and others have calculated that a woman who has completed secondary education will forgo lifetime earnings, after tax, of around $160 000 for a first child, and about $12 000–$15 000 for each additional child.3 Unlike a similarly industrialised country such as the United States, where mothers are far more likely to return to full-time work even when their children are quite small, Australia seldom makes this a feasible option for new mothers who wish to retain an attachment to the full-time workforce. As a consequence, it will be difficult for mothers to hang on to their skills, let alone to upgrade them so they can keep up with their former colleagues. There are now clear trends showing that the more educated a woman is, and the higher her income, the fewer children she will have. Women aged 30 years and over with a university or higher degree have the lowest birth rate. Women in this group have slightly less than half the number of children of other, less qualified women of the same age. Since the rate of women's participation in university education is continuing to increase (from 8.4% in 1986–87 to 20.2% in 2000–01),4 it seems likely that the fertility rate will also continue to decline. Professional women are almost twice as likely to be childless as women in clerical and sales occupations, and when fertility is correlated with the socioeconomic status of where women live, those in the highest status areas have less than half the number of children than those in the poorest areas.5 In other words, the women who can most afford motherhood are the least likely to have babies. They know how much they would be giving up in a society that pays lip service to maternity, but which in fact treats mothers very badly. Is it any wonder there is a "baby bust"? As a society we do almost nothing to make it easier for women to combine a satisfying and productive life with having a family. Instead, we place all sorts of obstacles in her way, and we cruelly force her into choices that are unfair and discriminatory. Men expect to be able to have families and still enjoy their jobs or careers and, increasingly, so do women. Women are no longer prepared to sacrifice themselves on the altar of maternity, or to be doormats for their families. They want a life — and they are entitled to have one. If we refuse to let them have it, something has to give and, as we have already had amply demonstrated to us over the past 10 years, that something will be having children. Finally, women — younger women especially — are starting to put themselves first.

Anne Summers AO PhD

The epidemic is subsiding as we improve the delivery of assisted reproductive technology The multiple birth rate in Victoria rose from 12 to 17 per 1000 pregnancies between 1986 and 1997.1 There were comparable increases in the United Kingdom and United States. During this period, the rate of all multiple births increased, but the more significant increases were in high-order multiple pregnancies. In Victoria, the triplet pregnancy rate increased more than three-fold from 0.19 to 0.61 per 1000 pregnancies between 1986 and 1998.1 There was a similar three-fold rise in the rate of triplet pregnancies in the United Kingdom,2 while in the United States, the rise was six-fold for triplets and 12-fold for quadruplets.3 These rates of multiple pregnancies peaked at the end of the century and are now slowly falling. There are several reasons why there has been an increase in twin pregnancies and the "epidemic" of high-order multiple pregnancies with low birth rates in the developed world. Monozygotic twinningMonozygotic twinning occurs independently of ethnicity, maternal age, parity, nutritional status and environmental factors. It is a random genetic event occurring in 1 in 250 pregnancies. Although the incidence of monozygotic twinning may be doubled after induction of ovulation, and is increased with in-vitro fertilisation for reasons that are yet to be explained, monozygotic twinning has contributed minimally to the global epidemic of multiple pregnancy. 4,5 Dizygotic twinningIn developed countries, there was a global decline in dizygotic twinning rates from 1960 until the mid-1970s. Although the exact cause remains unknown, this decline has been attributed to either environmental pollutants or a reduction in sperm quality.6 Chronologically, the fall in dizygotic twinning can be attributed to reduced fertility after oral contraceptive pill use became widespread. From the 1980s, the steady increase in dizygotic twinning related to agents that induce ovulation may have masked a true, progressive decline in the spontaneous dizygotic twinning rate.6 The rate of dizygotic twinning is increased in women aged 35–39 years, with higher parity and tall stature. Rates fall in severely malnourished women. Dizygotic twinning runs in families. If a mother or a sister has dizygotic twins, a woman has double the risk of having dizygotic twins herself. If she has dizygotic twins herself, her risk of having future dizygotic twins is quadrupled.7 Folic acid supplementation at the time of conception is widely promoted for reducing the risk of neural tube defects. A systematic review of periconceptual supplementation with folic acid or multivitamins, or both, identified a tendency to an increased risk of twinning (pooled relative risk 1.40; 95% CI, 0.93–2.11).8 It is unclear why such an association exists; possibly folic acid improves early fetal survival rather than promoting multiple ovulation. Assisted reproductionThe most significant cause for the increase in the multiple birth rate in developed countries has been the use of assisted reproductive technology. Inducing ovulation with clomiphene citrate carries an 8% risk of a multiple pregnancy, and with gonadotrophins, a 20% risk. These agents (which act by hyperstimulation of ovarian follicles resulting in one or more oocytes being released per cycle) are responsible for most high-order multiple pregnancies. Ultrasound monitoring can detect the potential for multiple ovulation in a woman's cycle, and she can be advised accordingly. However, even with ultrasound monitoring, and in the most careful and experienced hands, multiple ovulations can occur. With in-vitro fertilisation (IVF) and gamete intrafallopian transfer (GIFT), multiple pregnancy rates vary with maternal age and the number of embryos transferred; a 20% multiple pregnancy rate with double embryo transfer and 25% with triple embryo transfer is typical. The increased use of microinjection techniques has seen an increase in monozygotic multiple pregnancies. Improvements in stimulation and laboratory culture techniques have improved embryo quality and, subsequently, the success of IVF and GIFT, particularly in recent years. Risks of multiple pregnancyObstetric complications occur more frequently in multiple pregnancies (Box 1), and perinatal mortality escalates with increasing fetal number. The most recent Victorian figures indicate a perinatal mortality of 9.2 per 1000 pregnancies for singletons, 42.9 per 1000 for twins (first twin 37.8; second twin 47.9), and 145.5 per 1000 for triplets (first triplet 145.5; second triplet 127.3; third triplet 163.6).1 Preterm delivery is the major cause of adverse outcomes (both short-term and long-term), and is directly related to fetal number (Box 2). The consequences of prematurity (including cerebral palsy, hearing and visual disturbance, behavioural disorders and respiratory disease, among many others) can result in significant social, emotional and financial burdens for families. Costs to the community also increase with the number of infants. Monochorionic twins have specific risks because they share a placenta. These risks are twin–twin transfusion syndrome, twin reversed arterial perfusion sequence, monoamnionicity and conjoined twins. All of these conditions have very significant risks of fetal and neonatal mortality and morbidity. The risks associated with being born in a multiple pregnancy do not end with delivery. Apart from the consequences of prematurity, or the morbidity associated with monochorionicity, children born as twins or in higher order multiple pregnancies have increased rates of neonatal death, speech and reading difficulties, and behavioural disorders including attention deficit hyperactivity disorder. Twins have a four-fold, and triplets a 20-fold, increase in cerebral palsy compared with singletons. If a twin develops cerebral palsy, the risk of its co-twin developing cerebral palsy is 12%. Death of a co-twin increases the risk of cerebral palsy for the survivor to around 5% with the risk rising to 40% with monochorionicity.10,11 Preventing multiple pregnancyAll women undergoing ovulation induction should be offered monitoring of follicular development. They should be fully advised of the potential for a multiple pregnancy, and should be made aware of the consequences of pursuing a conception when multiple follicles are present. It is axiomatic that the fewer the number of embryos transferred after IVF, the lower the risk of a multiple pregnancy. It has been recent practice to offer women the transfer of only two embryos to optimise the chance of pregnancy without significantly increasing the risks of a multiple pregnancy. This practice also helps reduce the costs to the patient associated with repeated embryo transfers. However, with the continuing improvement in pregnancy rates with IVF, single embryo transfer should now be considered by all women, particularly those who are younger and those who already have children. Multifetal pregnancy reduction (MFPR) by intracardiac potassium chloride injection to reduce the number of "excess" fetuses is often seen as the answer to reducing the risks and avoiding the complications of high-order multiple pregnancy. Notwithstanding the social, moral and ethical issues associated with this technique, there are significant risks to the remaining fetuses associated with the procedure. For example, MFPR from a triplet to a twin pregnancy is associated with an 8% risk of miscarriage of the remaining twins. However, the procedure offers a marginal reduction in perinatal mortality and reduces the handicap rate from 1.5% to 0.6% per fetus.12 ConclusionsMultiple pregnancy usually has a satisfactory outcome, culminating in the birth and development of healthy children, often long awaited, and much loved by their parents. However, the consequences of some multiple pregnancies for the parents, the children and the community remain significant. Multiple pregnancies reached epidemic proportions in the late 1990s as a consequence of assisted reproductive technology. The rate is now falling and this trend should continue as practitioners respond with careful monitoring of ovulation induction and with reduced numbers of embryos transferred after IVF. 1: Significant risks associated with twin pregnancies1,2,9 Obstetric complication Risk* Anaemia x2 Pre-eclampsia x3 Eclampsia x4 Antepartum haemorrhage x2 Postpartum haemorrhage x2 Fetal growth restriction x3 Preterm delivery x6 Caesarean section x2 * Compared with singleton pregnancies 2: Rates of preterm delivery by fetal number1 Delivery Number of fetuses < 28 weeks < 37 weeks Singleton 0.7% 6.2% Twins 4.4% 52.1% Triplets 21.8% 98.2%

Mark P Umstad MB BS, MD, MRCOG, FRANZCOG · Michael J Gronow MB BS, MD, MRCOG, FRANZCOG

The range of contraceptive options and consumer awareness of new contraceptive methods have both increased significantly over the past 10 years. New methods available in Australia include lower-dose oral contraceptive pills, new oral progestogens, progestogen implants, a progestogen-bearing intrauterine device and polyurethane female condoms. Contraceptive options which may soon be introduced in Australia include novel methods of administering combined (oestrogen–progestogen) contraception, such as dermal patches and vaginal rings.

Therese M Foran FACSHP

In addition to providing safe and effective contraception, both the combined oral contraceptive pill (COCP) and selected long-acting progestogen-only contraceptives have significant health benefits. The COCP may reduce menstrual blood loss, dysmenorrhoea and premenstrual syndrome; unequivocally reduces the later incidence of endometrial and ovarian cancer; appears to help protect future fertility, probably by reducing the risk of acute pelvic inflammatory disease, endometriosis and uterine fibroids. The quality of evidence for individual non-contraceptive health benefits of the COCP is very variable.

Ian S Fraser MD, FRANZCOG, CREI · Gabor T Kovacs MD, FRANZCOG, FRCOG

The main indication for hormone replacement therapy (HRT) is to control menopausal symptoms and improve quality of life. Ideally, withdrawal of HRT should be attempted after 4–5 years of therapy. HRT reduces fracture risk and remains appropriate therapy for osteoporosis, particularly in women with symptoms. HRT is not appropriate for primary or secondary cardioprotection. HRT leads to a small increase in breast cancer incidence, which increases with duration of therapy and age. HRT increases the risk of thromboembolism. Patient management and therapy should be reviewed annually with risk–benefit counselling.

Rodney J Baber B Pharm, FRACOG, MRCOG · Justine L O'Hara BSc(Biomed Sci) · Frances M Boyle PhD, FRACP

The risk–benefit ratio of traditional postmenopausal hormone therapy is considered by many to be unacceptable. Low-dose oestrogen–progestin therapy (oral or non-oral and continuous or pulsatile) may have a better risk–benefit ratio, but this remains unproven. Steroids with selective tissue activation, such as tibolone, alleviate symptoms and protect against bone loss, but long-term safety data are lacking. Selective oestrogen receptor modulators (SERMs), such as raloxifene, prevent bone loss when used alone, and may soon be combined with oestradiol to treat symptoms and prevent osteoporotic fracture. Effects of SERMs on the cardiovascular system are currently being evaluated.

Susan R Davis FRACP, PhD

Female sexual arousal disorders constitute a varied spectrum of difficulties, ranging from the total absence of genital or subjective pleasurable arousal to feelings of persistent genital arousal in the absence of sexual desire. Arousal disorders can be associated with physical factors (eg, vaginal dryness) or psychological factors (eg, anxiety, distraction), or a combination of both. The most common complaint is the absence of subjective sexual excitement or pleasure despite adequate physical arousal (eg, lubrication). Pharmacological and physical treatments include the use of oestrogen, lubricants and vibrators. There may be a place for drugs that increase vasocongestion and vasodilation. Psychological therapy addresses inhibitions, and interpersonal and motivational factors.

Sandra R Leiblum PhD

In consultations with older women, doctors should ask about sexual problems. A holistic approach is needed to examine the many different factors that can affect sexuality. Hormonal changes associated with ageing have an impact on women's sexuality. Doctors need to have a clear idea of the place of hormonal treatment for different sexual problems. Physical changes associated with ageing, including illness and disability, may interfere with sexual expression. Diseases of the endocrine, vascular and nervous systems will most commonly affect sexual function. A broad range of psychosocial factors associated with ageing may influence sexuality.

Lesley A Yee MB BS(Hons), MM(Psych) · Kendra J Sundquist EdD, MHlth, Sc(Ed)

Health inequalities exist for lesbian and bisexual women, largely related to experiences of discrimination, homophobia and heterosexism. These issues can lead to avoidance of routine healthcare and screening and reduced disclosure of sexual orientation within consultations. Lesbian and bisexual women have specific healthcare needs in areas of sexual and cervical health, reproductive health and parenting, mental health, substance use, and ageing. Facilitation of disclosure of sexual orientation, identity and behaviour within the consultation is desired by most lesbians and important for addressing specific health needs. Healthcare providers should develop "cultural competence" in lesbian issues to enhance their care of lesbian and bisexual women. Healthcare providers have a role in promoting awareness of lesbian health issues and inequalities in the arenas of healthcare provider education, research and health policy.

Ruth P McNair MB BS, DRACOG, DA

Have recent controlled trials ended the debate? Each year in Australia over 10 000 women are diagnosed with breast cancer and around 2600 women die. Early diagnosis improves survival chances. Imagine the following scenario. You have just completed an annual examination of a married, 36-year-old mother of two, when she casually asks: "Doctor, would you recommend that I practise monthly breast self examination?" What do you tell her? What if this patient happened to be a healthy 59-year-old postmenopausal woman, or, for that matter, a "senior citizen" of 81 years, or a woman with a family history of breast cancer? What advice would you proffer? Would you rely on evidence-based data and diplomatically state: "Well, there really is no evidence that breast self examination reduces mortality rates", or would you say "We don't endorse breast self examination, but it would be advisable for you to develop an awareness of your breasts"? What "endpoints" are uppermost in your mind — mortality, detection, even prevention? Perhaps more significantly, what "endpoints" are uppermost in your patient's mind? This is a common dilemma confronting clinicians as they grapple with the vagaries of epidemiology, clinical experience and patients' needs for information and advice. For decades, public health campaigns have targeted women with the message that early detection of breast cancer translates into improved survival chances, and that examination of breasts and mammography are the first steps on the road to early detection. However, following recent trial results,1 those advising women appear to have forgotten this vital relationship between breast self examination, early detection and consequent improved survival. "Detection" has become the "poor cousin" of survival, mortality, and the teaching and practice of breast self examination. The result is confusion, ambivalence and, at times, contradictory or nonsensical advice. This is clearly reflected in the various statements promulgated by Australian cancer organisations, which now tread very carefully when using those three, once so helpful, words, "breast self examination". BreastScreen NSW has dropped them from its recommendations and state cancer councils, the National Breast Cancer Centre and the NSW Breast Cancer Institute are in the process of doing same, or are carefully rephrasing them to being simply "breast self aware". As an example, The Cancer Council NSW Fact Sheet2 recommends gaining awareness "by looking at your breasts in the mirror and feeling them from time to time". This sounds pretty much like self examination of breasts to us, only without the previous instructions on how to do it effectively. The Fact Sheet sensibly continues "some women feel that regular breast self examination is worthwhile. It's up to you". Advice from other cancer organisations contains similar hedging statements. These messages reflect the difficulty of interpreting evidence-based data derived from studies with differing endpoints — both for the clinical situation and for the commonsense advice sought by women. The National Breast Cancer Centre's position statement is largely based on the comprehensive 1999 literature review of studies of breast self examination by Clarke et al.3 Of considerable significance are the methodological shortcomings of those studies and their diversity of endpoints. But most compelling is that, of the seven trials reported, none provided National Health and Medical Research Council Level I evidence, two gave Level II and the others Level III — not overly convincing! In 2002, the eagerly awaited final report of the trial by Thomas et al1 became available. Despite the fact that Thomas and colleagues concluded that this was a trial of the teaching of breast self examination (ie, the specific technique), not the practice of breast self examination (nor, indeed, a trial of the breast examination that many aware women do whether or not they are trained in the "breast self examination" technique), the editorial in the Journal of the National Cancer Institute trumpeted the study's results as signalling the "death" of breast self examination.4 An editorial in the British Medical Journal 5 claimed that Thomas and colleagues had provided "conclusive" evidence that breast self examination was not effective in reducing mortality, and concluded that the study should put an end to a decade of controversy. We believe that this statement is most unhelpful and could lead to delayed detection of breast cancer, particularly in younger women, for whom mammography is less effective.6,7 While acknowledging that this was the largest trial ever conducted on the relationship between breast self examination and mortality from breast cancer, how transferable are results from women in Shanghai to women in Australia? A growing body of literature8-10 casts some doubt on the universality of the findings of Thomas and colleagues, as cultural context and associated values and behaviours were ignored. Potential confounding factors, such as attitudes towards breast self examination and healthcare, were not investigated. The position of the Breast Cancer Action Group (NSW and VIC) is the commonsense approach — that women should be physically familiar with their breasts and seek advice if they notice any non-normal changes. If you feel a lump or notice other changes — and how else can this be done other than by physically examining the breasts? — take the next step on the triple-test path of mammography, ultrasound examination and biopsy. Further concerns in this debate relate to the suggestion that encouraging awareness of breast changes will distress women, and will possibly increase the health dollars spent on unnecessary investigation. The first claim is patronising, even demeaning, and the second runs counter to the evidence-based public commitment to increase screening modalities for Australian women. What is indisputable for Australian women is that breast examination is the predominant method of detecting breast cancer. In Australia, mammographic screening accounts for just over 30% of detected breast cancers (37% of early disease, 14% of advanced disease);11 the remainder are found by women themselves and their medical advisers. How are they found? By examining their breasts! For younger women this is usually the only avenue for detection — early or late — as clinicians rarely offer clinical breast examination, and mammography is not effective. Our research priority in this area would be for careful and well designed studies of the relationship between breast self examination and early diagnosis. What interests us is increased early detection, whether this be via breast self examination, mammography, or ultrasound examination. It is imperative that clear and unambiguous messages are transmitted to give women the best chance of survival. Resorting to the semantics of "being breast aware" fails this imperative. Common sense suggests that it is not possible for us to somehow be "breast aware" without examining them.

Sally Crossing BEc · Rosetta Manaszewicz

Vaccination has the potential to reduce the global burden of disease from genital HPV infection Cervical cancer is the third most common cancer worldwide and, for women, the second most common after breast cancer. Each year there are about 466 000 new cases globally, and around 232 000 women die of cervical cancer.1 Eighty per cent of cases occur in developing countries, where it is the leading cause of cancer-related death among women.1 Precursor lesions (high-grade dysplasias) precede the development of cancer by years. With appropriate screening programs and early diagnosis and treatment, this reproductive health problem becomes a preventable public health issue. However, data for the past 5 years indicate that only about 5% of women in developing countries are screened, compared with 40%–50% of women in developed countries. Further, because of the insensitivity of the Papanicolaou (Pap) test, even in countries with appropriate screening programs, 50% of adenocarcinomas and at least 25% of squamous cell carcinomas occur in adequately screened women. Association between human papillomavirus and cervical cancerMolecular biology has finally established the causal association between persistent infection with certain human papillomavirus (HPV) genotypes and cervical cancer, supporting previous observations relating cervical cancer to sexual activity.2-4 HPV genotypes 16 and 18 are now categorised as human carcinogens,2 and it is noteworthy that these two HPVs are present in over 70% of cases of cervical cancer worldwide.2-4 Further, in a study of almost 1000 cervical cancer cases worldwide, the prevalence of HPV infection was 99.7%.3 Recently, less prevalent oncogenic HPV genotypes (31, 33, 45, 52, 58, 59) have also been found to be strongly associated with cervical cancer, with odds ratios several hundredfold.4 With such high relative risks, the association between persistent oncogenic HPVs and cervical cancer is the strongest for any environmental factor and human cancer. From recently completed longitudinal studies, we now know that genital HPVs are the commonest sexually transmitted viral infection. They are largely transient, usually asymptomatic and most are of no clinical consequence. The mean duration of carriage is 4 months for low-risk oncogenic types and 8 months for high-risk oncogenic types, with HPV-16 carriage being even longer.5 Genital warts are caused by genotypes 6 and 11 (low-risk HPVs), while persistent infection with oncogenic genotypes (over years and in a minority of patients) results in severe dysplasia or, ultimately, carcinogenesis. This process involves other cofactors (host and/or exogenous factors, such as high parity, cigarette smoking) and complex pathways, which are not completely understood. HPV DNA as a marker for precursor lesionsPersistent infection with oncogenic HPVs precedes virtually all high-grade dysplasias or neoplasias. Thus, persistent positivity for high-risk HPV DNA is a marker for current or subsequent development of precursor lesions,5 with persistent HPV DNA type-specificity being an even stronger predictive factor.6 Cohort analyses show that negative baseline Pap and HPV DNA tests are associated with very low risks of high-grade disease (0.16%). By comparison, women with positive HPV DNA tests and abnormal Pap smear results have a 4.54% cumulative incidence of high-grade dysplasia or cancer.7 HPV DNA testing, with its higher sensitivity for detecting underlying high-grade lesions than the Pap test (and the advantage that it can be performed on self-collected samples), is being reviewed for its clinical utility, either in triage of inconclusive or minimally abnormal smears, in conjunction with the Pap test, or as a stand-alone test in primary screening.5 It may also have a role as a test of cure after ablation for cervical dysplasia; persistence of HPV DNA after treatment could be an accurate predictor of residual disease or relapse.5 Of note, in the United States, HPV DNA (Hybrid Capture 2) testing was recently approved for use with the Pap test for women 30 years and over.8 Vaccination prevention at last?The preliminary results of a recent trial of a monovalent HPV genotype 16 vaccine were received with great interest and enthusiasm (Box). The vaccine provided vaccinees with high-level protection for incident and persistent HPV-16 infection (as a surrogate for invasive cancer) and HPV-16-related cervical intraepithelial neoplasia (CIN).9 Now awaited are larger studies to prove that clinical disease is prevented by vaccination, and the results of current clinical trials evaluating multivalent vaccines (HPV types 6, 11, 16 and 18). If these vaccines are as successful as the interim monovalent vaccine,9 they have the potential to prevent genital warts and over 70% of dysplasias and cancers, as well as reduce the occurrence of abnormal Pap smear results and the costs of their follow-up and management. Pivotal in the development of these vaccines was the production of virus-like particles (VLPs) — an Australian first.10 The VLPs used for the HPV-16 vaccine are viral subunits, composed of the major capsid protein L1 or outer shell of HPVs. Being devoid of DNA, they are not infectious. In Phase 1 and 2 clinical trials, VLPs have been shown to be not only immunogenic and safe, but able to induce strong cell-mediated and humoral immune responses. Most encouraging is that VLPs produce neutralising antibodies in animal models that are protective against challenge as well as long lasting. We need to see whether VLPs induce similar long-lasting immunity in humans. Second-generation vaccinesSecond-generation vaccines will need to be easier and cheaper to develop, give a broader coverage, have a better delivery system, allow better mucosal delivery, and possibly incorporate both prophylactic and therapeutic cover. The initiatives of the Gates Foundation to reduce cervical cancer in developing countries, where the disease is most common, are to be commended.11 Initiatives to promote second-generation vaccines (eg, vaccines that are cheaper to manufacture and available in a non-injectable form) have been discussed at a meeting of HPV vaccine experts, convened by the Gates Foundation in Seattle, Washington, in September 2002. Therapeutic vaccines have been successful in animal models, and there have been various Phase I and II trials in humans using HPV subunits (modified fragments of the HPV E6 and E7 genes), as well as chimeric and DNA viral approaches.12 These trials have shown some encouraging results for intraepithelial neoplasias, although clinical trials are not as advanced as for the prophylactic vaccines. An important question for vaccine development is whether there will be any cross-protection between types (immunity induced by natural infection is type specific), or whether effective vaccine-induced immune responses to one common high-risk HPV might simply open the door to another, currently less common type. In Australia, mortality from cervical cancer has been reduced substantially by an effective Pap screening program, but this comes at a considerable cost, both to the health budget and to women who face the psychological impact of having an abnormal Pap smear result. Ultimately, successful vaccination has the greatest potential to reduce the global burden of disease from genital HPV infection. Development of a vaccine for a sexually transmitted infection, the infective agent of which can not be grown by traditional methods in the laboratory, could be seen as a very important breakthrough, particularly for Australia (as VLPs were developed here).10 An effective prophylactic vaccine could ultimately obviate the need for population-based Pap smears, while an effective therapeutic vaccine could provide a change to conventional management of cervical disease, including reducing the need for colposcopy. However, lowering the incidence of dysplasia and neoplasia will take many years. In the meantime, the various prevention strategies still need to be endorsed and maintained. Apart from cervical cancer, other anogenital cancers and some non-melanoma skin cancers are also attributed to oncogenic HPVs. A successful vaccine could ultimately have an even greater impact on HPV-related diseases. Other challengesBesides vaccine delivery, vaccine implementation would include educating the general public about HPV (public awareness and acceptance), de-stigmatising HPV infection, and gaining acceptance for vaccinating adolescents (or pre-adolescents), possibly of both sexes, for a sexually transmitted infection before their sexual début. For the future, we need a better understanding of the transmission dynamics of HPV. A public health policy will need to be guided by mathematical modelling of the impact of an HPV vaccine on Pap screening. This also applies to the interrelationship between HPV and abnormal Pap smear results, and any concomitant psychological impact on women faced with an abnormal result of an HPV DNA test or a Pap smear. A controlled trial of a human papillomavirus (HPV) type 16 vaccine, by Koutsky et al9 Study population: 2392 young women, 16–23 years old (no more than five male sexual partners during their lifetime). Intervention: Intramuscular vaccination with three doses of placebo or HPV-16 virus-like particle (VLP) vaccine (Day 0, Month 2, Month 6). Follow-up: Month 7, 12 and thereafter 6 monthly to 48 months (Pap test, and HPV DNA 16 and HPV-16 antibody assayed). Colposcopy biopsy tissue evaluated for cervical intraepithelial neoplasia (CIN). Primary endpoints: Persistent HPV-16 infection (the detection of HPV-16 DNA in samples obtained at two or more visits ≥ 4 months apart, in those HPV DNA negative at Day 0 and Month 7) and HPV-16-related CIN. Results: After a median follow-up of 17.4 months, the incidence of persistent HPV-16 infection was 3.8/100 woman-years (placebo group) and 0/100 woman-years (vaccine group) (100% efficacy; 95% CI, 90–100; P < 0.001). Nine cases of HPV-16-related CIN occurred, all in the placebo group. 99.7% of the women vaccinated seroconverted and with a robust antibody response. Conclusion: HPV-16 vaccine reduced the incidence of both HPV-16 infection and HPV-16-related CIN. The study is continuing.

Suzanne M Garland FRCPA, FACSHP, RANZCOG ad eund, MD

Achieving and maintaining a high rate of attendance for screening and two-yearly re-screening is essential for the success of the BreastScreen Australia program. A low participation rate will result in fewer breast cancer-related deaths being prevented. Results of two recent large randomised trials do not show that a systematic approach to breast self examination finds breast cancers early or impacts on survival. "Breast awareness" and the prompt reporting of breast symptoms are important early detection messages for women of all ages. General practitioners have a key role in the promotion and provision of information about effective public-health initiatives for the early detection of breast cancer.

Helen M Zorbas MB BS

Cervical screening in Australia is a successful public health initiative. Since the introduction of the National Cervical Screening Program in 1991, there has been a significant fall in incidence of and mortality from cervical cancer. Laboratory quality procedures are critical to ensuring optimal outcomes. Laboratory accreditation procedures are being reviewed in line with recent government recommendations. For a sustainable program, cost-containment issues need to be considered; screening interval, management of screen-detected abnormalities, and new technologies are the critical drivers of cost.

Annabelle Farnsworth FRCPA, FIAC · Heather S Mitchell FRACP, FAFPHM

Ovarian cancer is the leading cause of death from gynaecological malignancies. No precancerous lesions have been identified. Bimanual examination has not been proven to be of value as a screening test. Transvaginal ultrasound examination, with or without measurement of CA 125 levels, is currently being evaluated for population screening. Women at high risk of ovarian cancer should be screened annually — with measurement of CA 125 level and transvaginal ultrasound examination.

Cleola Anderiesz PhD · Michael A Quinn MGO, FRANZCOG, FRCOG

Routine screening for endometrial carcinoma is currently not justified. Postmenopausal women need to be educated about the importance of seeking attention if any vaginal bleeding occurs. All postmenopausal bleeding requires review and appropriate investigation. Women taking tamoxifen have a higher risk of endometrial cancer and should report any bleeding or spotting; however, ultrasound screening is not recommended for asymptomatic women taking tamoxifen. Families with hereditary non-polyposis colon cancer have a higher risk of endometrial cancer and require counselling about this risk. A Pap test is not a screening test for endometrial cancer, but the incidental finding of endometrial cells on a Pap smear in a postmenopausal woman requires investigation.

Gregory Robertson FRCOG, FRANZCOG, CGO

This 19th century US gynaecologist still arouses controversy in the 21st century To the indomitable courage of these long-suffering women, more than to any one other single circumstance, is the world indebted for the results of these persevering efforts. J Marion Sims, 18581 "Pass me the Sims" is a request heard every day during gynaecological surgery and as often in outpatient practice. The Sims speculum has been a valuable gynaecological aid throughout the world since the first example was crudely fashioned from a pewter spoon in 1845 by James Marion Sims, a general practitioner in Montgomery, Alabama.2 Sims went on to perfect the instrument that, with little variation, is still widely used in most vaginal surgery and for outpatient assessment of cervical and vaginal conditions, especially prolapse and fistulas. "Sims' position" or the exaggerated left lateral position was devised a little later, as Sims experimented with the repair of vesicovaginal fistula in a small hospital he built for black women slaves with this condition. It is also widely used in surgery and examination today. In the United States, Sims has often been referred to, rather quaintly, as the "Father of Gynaecology"; certainly, he was one of those who developed gynaecology as a separate medical discipline.3 His statue stands in Central Park in New York (Box 1). However, in the latter part of the 20th century, the earlier idealistic views of Sims have been challenged by feminist writers and social historians.4-6 He experimented with women's bodies, these writers have said, in particular those of women slaves, and he did not use anaesthesia. While these criticisms are valid, I believe they warrant further examination. Sims and fistula repairSims was born in South Carolina in 1813 and studied medicine (indifferently, according to many biographers) at Charleston and later at Jefferson Medical College in Philadelphia.7-9 He returned to the South to practise and soon established a reputation as a skilful surgeon. He became interested in the condition of vesicovaginal fistula in 1845 when a young slave woman, known to posterity only as Anarcha, developed a fistula after a prolonged first labour. Until then, Sims had had little interest in "women's problems". Surprisingly, within days, two more slaves with this condition, Betsey and Lucy, were referred by their owners. Scanning the available literature on fistula repair, Sims determined that there was no surgical cure and decided not to operate.2,3,7,9 However, another event that occurred within days changed his mind.7 He was summoned to a Mrs Merrill — a stout lady who had fallen from a pony and landed heavily on her pelvis, suffering an acutely painful retroversion of the uterus. Uncertain what to do, Sims placed her in the knee–chest position and in the course of his subsequent digital examination applied firm pressure to her perineum, allowing a large amount of air to enter the vagina. This vaginal distension together with the exaggerated knee–chest position caused the uterus to return to its anteverted state.2,3,7 As Pasteur would later observe, chance favours the prepared mind: Sims reasoned that a speculum that holds back the perineum, unlike the two- or three-pronged intravaginal models then in use, would similarly expose the upper reaches of the vagina, the site of vesicovaginal fistulas.9 This realisation led Sims to purchase a pewter spoon from a hardware store in Montgomery and to bend it into a U shape (Box 2). The following day, he examined Betsey in the knee–chest position with the bent spoon. Subsequently, he wrote: I saw everything, as no man had ever seen before. The fistula was as plain as the nose on a man's face. The edges were clear, and well-defined . . . and the opening could be measured as accurately as if it had been cut out of a piece of plain paper . . . I said at once, Why can these things not be cured . . . there is nothing to do but to pare the edges of the fistula and bring it together nicely, introduce a catheter in the neck of the bladder and drain the urine off continually, and the case will be cured. I felt I was on the eve of one of the greatest discoveries of the day.7 In fact, Sims penned this florid prose long after these events, in The story of my life, when he was well established as a gynaecologist in New York and Europe. Never short on self confidence, he was much given to embellishment and flowing narrative in his later accounts of his work. However, although Sims did give fascinating descriptions of his achievements, he did not spare himself in describing his failures.3,7,9,10 Sims had specula and other instruments made and deliberately set out to cure fistulas. Initially, he continued to use his specula with the woman in an exaggerated knee–chest position, which is excruciatingly uncomfortable for any length of time. Later he realised that the exaggerated left lateral position afforded a better view of the upper and anterior vagina, and this became the position in which he continued surgical experiments (Box 2), and in which established procedures were henceforth performed.7,11 In his autobiography, Sims explains that slaves (the original three and others) were subject to numerous attempts at closing their fistulas — without anaesthesia (which was not then widely available). Opium was administered during and after the procedures (Box 3). Sims claimed that he explained his intentions to the women, who were agreeable. He did not question the racial and social system that made his experiments possible, although in his later writing he did express concern for the welfare of the women involved. He also stated that the "stoicism of the Negro" made it possible for him to continue his surgical experiments — some 30 operations over four years on Anarcha before her fistula was successfully closed. His first operation, on Lucy, was particularly agonising for her, as he had not yet developed the catheter that he subsequently used for the bladder drainage essential for the success of any fistula repair. He used instead a piece of sponge which became infected and encrusted and difficult to remove.2,7 Initially, Sims used silk to close the fistulous openings, but healing was never complete. Finally in 1849, he tried silver wire held with perforated lead shot which, when compressed in a pair of forceps, enabled the sutures to be tied high in the vagina.9 Anarcha's fistula was closed permanently (according to Sims), and soon afterwards those of the other women.1,12 Subsequent writers have cast doubt on Sims' claims of complete cure, and it may be that, although the fistulous opening was healed, bladder function remained compromised — even after modern fistula surgery, stress and urge incontinence can be problems.12-15 However, there is no doubt that Sims had made great progress in the understanding and techniques of fistula repair (Box 4). In 1850, Sims, suffering poor health, moved to New York with the idea of founding a women's hospital for the treatment of vesicovaginal fistula and, later, other gynaecological ailments. The New York Woman's Hospital opened its doors on Madison Avenue in 1855, later moving to the current site of the Waldorf–Astoria.2 However, the hospital opened only after a great deal of interpersonal wrangling with certain New York doctors and financial difficulties for Sims; nevertheless, he persevered with his unique idea. Many poor Irish immigrant women were among those treated for fistulas at the Woman's Hospital, as Sims and other surgeons perfected fistula repair and other operations.2,7,9,18 During the 1860s, Sims went several times to Europe, partly because of his unhappiness at the political events that culminated in the Civil War, and partly to demonstrate his surgical techniques. There is no doubting his surgical brilliance, which he displayed throughout the British Isles and in Paris. He treated European royalty, including the Empress Eugenie, wife of Napoleon III of France, who apparently had suffered an obstetric fistula. During the Franco–Prussian war of 1870, Sims took part in the Anglo–American Ambulance Corps, which treated the wounded of both sides.7 Returning to the United States, he became president of the American Medical Association in 1876, and founder and then president of the American Gynaecological Association. In defence of SimsIt is not surprising that the idealistic view of Sims has been challenged,4-6 given his turbulent life and self-promotion. It is true that his initial experiments on fistula repair were on slave women, and that he did not use anaesthesia. However, other factors must be considered. Firstly, the nature of vesicovaginal fistula itself — without surgery, these women were condemned to the most miserable existence. Better understanding of labour and avoidance of a prolonged second stage by operative delivery means that obstetric fistulas rarely occur in countries with good obstetric services, and modern writers with no experience of the condition have tended to overlook the appalling results of fistulas.4-6 "A sadder situation can hardly exist than that of a woman afflicted with a vesico-vaginal fistula", wrote Johann Friedrich Dieffenbach in 1836, "a source of disgust, even to herself, the woman beloved by her husband becomes, in this condition, the object of bodily revulsion to him . . .".10 Dieffenbach's concern for women with fistulas was shared in the late 20th century by Drs Reginald and Catherine Hamlin, who founded the famous Ethiopian Addis Ababa Fistula Hospital, and Dr Kees Waaldijk, who has established a similar service in northern Nigeria; "these patients are the forgotten women, rejected by their husbands and sometimes by their families because their bodies have suffered excessive trauma during childbirth", Waaldijk has said.14,19 More than 150 years after Sims' first successful repairs, more than two million women in the world suffer from obstetric fistulas, a preventable condition. Most are in resource-poor countries, especially in Africa, parts of Asia and Papua New Guinea, where antenatal and intrapartum care are minimal or non-existent, and where early childbearing and poor nutrition contribute, as in the pre-Civil War southern United States, to the development of fistulas. Although Sims recognised the obstetric causes of fistulas, he lived in an era that preceded the safe use of caesarean section, synthetic oxytocic drugs, antibiotics and the many other aids to safe childbirth that are now available. He was not in a position to prevent the formation of the fistulas he attempted to treat. Partly because of the path Sims' life followed and because of his writings, some historians have accused Sims of being motivated principally by a desire to experiment on black women with a view to later treating wealthy white women.4-6 However, as a young man living in the deep South and treating black women with a condition largely associated with their poverty, Sims could not have anticipated the later course of his life or expected that fistula repair would make him competent in the practice of gynaecology, a specialty that did not exist in the 1840s. Hideous as the accounts of his surgery may appear to sensitive 20th century eyes, undoubtedly Sims was at least partly motivated by a desire to improve the lot of his slave patients.2,7 In this, he was no different from many 19th century surgeons experimenting with the techniques that are the foundation of current surgical practice, gynaecological and otherwise. The lives of the slave women on whom Sims experimented would have been even more miserable without their subsequent cures, and the knowledge gained has been applied to fistula repair for thousands of women since. Secondly, Sims did not use anaesthesia for his early fistula repairs because it was not yet widely available. Humphry Davy had discovered the anaesthetic properties of nitrous oxide in 1799, but its usefulness for surgery was not immediately appreciated. Sulfuric ether was first used by Crawford Long in Georgia in 1842, but he did not write about his discovery until 1849. By the early 1840s, a small number of doctors and dentists knew of the existence of anaesthetic agents, but the idea that they could be safely used to numb the pain of surgery, like the concept of antisepsis some time later, took years to be universally accepted. In 1845, Horace Wells unsuccessfully demonstrated anaesthesia for dentistry; in 1846, William Morton in Boston was more successful. The Lancet of 1845 carried only five short mentions of ether in 780 pages, and, as late as 1850, when James Young Simpson published his recommendations for the use of ether and chloroform in midwifery, he had to contend with vociferous opposition from clergymen who pronounced anaesthesia to be against the will of God.20,21 It is then not surprising that Sims in Alabama in the 1840s did not anaesthetise his patients. Certainly all previous attempts at fistula repair, like virtually all other surgery, on free white people as well as slaves, had been done without anaesthesia. Later in New York, Sims did use chloroform, which he pronounced "both delicious and dangerous".7 Interestingly, Sims was remarkable for his attention to cleanliness in his surgery, well before the advent of Listerism, which probably contributed to his ultimate surgical success. Sims' role in the development of gynaecology is incontestable, but in remembering his contribution to vesicovaginal fistula repair the names of Anarcha, Betsey and Lucy should also be remembered. Others of his contributions are remembered daily by every generation of gynaecologists — the Sims' speculum and Sims' position. 1: Statue of Sims in Central Park, New York The statue was sculpted by Ferdinand von Miller III and installed elsewhere in New York in 1892, before being moved to Central Park in 1934. 2: Sims' speculum and Sims' position (From Sims' original text, Silver sutures in surgery, 1858.1) 3: The fistula operation on Betsey An original painting by Robert Thom depicting the event with some artistic licence 100 years later (commissioned by the Parke–Davis Company, from A history of medicine in pictures, edited by Bender GA, 1961). 4: Fistula repairs before Sims Sims was not the first to repair vesicovaginal fistulas successfully. There are some reports of European surgeons doing so. In 1836, John Peter Mettauer in Virginia and, in 1839, George Hayward in Massachusetts succeeded in closing fistulas. Twenty-five years before Sims' experiments, Montague Gosset in England had used silver wire in a fistula repair, and the use of lead shot to hold wire sutures in place was also known.1,16,17 However, what Sims did do was to combine and apply all these principles systematically, with skill and persistence, and to publicise his techniques.

Caroline M de Costa FRANZCOG, MPH

In this issue of the Journal, Priest and colleagues report a further study showing the lack of effectiveness of "debriefing" after a traumatic event in preventing psychological disorders — in this case, in women after childbirth.1 Their use of debriefing for this purpose indicates how widely the enthusiasm for this intervention has spread in the past decade. On superficial examination, early interventions are an appealing ...

Alexander C McFarlane MD, DipPsychother, FRANZCP

Objective: To test whether critical incident stress debriefing after childbirth reduces the incidence of postnatal psychological disorders.Design: Randomised single-blind controlled trial stratified for parity and delivery mode.Setting: Two large maternity hospitals in Perth.Participants: 1745 women who delivered healthy term infants between April 1996 and December 1997 (875 allocated to intervention and 870 to control group).Intervention: An individual, ...

Susan R Priest M Psych, PhD · Jenni Henderson BSc, MPH · Sharon F Evans MSc, PhD · Ronald Hagan MB BCh, MBA

To the Editor: Chlamydial infection is the most common bacterial sexually transmitted infection in Victoria and Australia, and notifications are increasing significantly. Most chlamydial infections are asymptomatic and, if untreated, lead to significant morbidity.1 The direct costs of these infections to the Australian healthcare system have been estimated at $90–$160 million annually.2 Chlamydial infection has been implicated in as many as 50% of cases of infertility.3 Widespread screening is cost effective and reduces both the prevalence of infection and the rate of complications.4 Screening is recommended in a number of countries and in the recently released Victorian Chlamydia Strategy.2 To determine if there has been an increase in the proportion of women tested for chlamydial infection who are asymptomatic in Victoria, we analysed notification and enhanced surveillance data. Since 1997, the Department of Human Services has collected enhanced surveillance data using a standard questionnaire distributed by laboratories to clinicians. The forms record information on risk factors and the reason for testing. Data from the Health Insurance Commission were obtained to provide an indication of trends in testing through Medicare. The number of notifications almost doubled between 1997 and 2001, from 2059 to 3977 notifications (Box). In 2001, enhanced surveillance data were available on 2300 notifications (58%). Symptomatic presentation remained the major reason for testing (53%), with no significant change in the proportion tested for this reason since 1997. However, when data for the two sexes were analysed separately, the proportion of men who were symptomatic fell significantly between 1997 and 2001, from 77% to 65% (P = 0.02), while there was no change in the proportion of women who were symptomatic — 42% in 1997 and 41% in 2001 (P = 0.35) (Box). From 1997 to 2001, the number of positive chlamydial tests notified relative to the number of tests conducted has remained constant (9.7%, 8.8%, 11.8%, 11.5% and 9.8% in consecutive years, respectively), despite the increase in number of tests performed. However, even if all tests had been performed in the 20–30-year-old age group, they would represent only 10% of the population in that age group tested each year. Our data suggest that the reasons for testing over the past 5 years have not changed, and, in particular, that there has been no change in the proportion of women tested who are asymptomatic. Chlamydial infection meets the World Health Organization criteria for a screening program,5 and screening for this infection is cost effective.4 Although chlamydial infections are a significant public health concern for women, targeted screening is not occurring widely. Chlamydia notifications and enhanced surveillance data for Victoria, 1997–2001 1997 1998 1999 2000 2001 Male Female Male Female Male Female Male Female Male Female Number of notifications 788 1271 948 1542 1181 1761 1328 1915 1631 2346 Number with enhanced surveillance data 484 782 619 954 735 968 858 1037 992 1308 Reasons for testing* Symptomatic 76.9% 42.3% 75.8% 46.0% 73.9% 44.1% 68.6% 39.4% 64.9% 41.1% STI Screen 7.2% 25.4% 6.5% 25.6% 9.0% 26.3% 9.8% 27.2% 12.3% 27.2% Asymptomatic contact 13.8% 15.5% 16.2% 17.5% 15.8% 18.7% 18.1% 16.9% 18.9% 17.4% Abnormal examination 0.2% 3.2% 0.6% 3.8% 0.7% 4.0% 0.2% 1.6% 0.8% 2.3% Pre-termination screen 0 9.3% 0 5.5% 0 5.6% 0 5.6% 0 3.7% Other/not stated 1.9% 4.3% 0.9% 1.7% 0.6% 1.2% 3.2% 9.3% 3.1% 8.4% Total notifications 2059 2490 2942 3243 3977 STI = sexually transmitted infection. * Mutually exclusive choices presented to clinicians in the surveillance questionnaire.

Megan L Counahan · Jane S Hocking · Christopher K Fairley

To the Editor: Murray et al recently suggested that after an initial screening urinalysis, routine urinalysis could be eliminated from antenatal care without adverse outcomes for women.1 Their conclusions are based on a prospective observational study of 1000 women, 26 of whom developed pre-eclampsia, with 6/24 (25%) developing new proteinuria before the onset of hypertension. We have concerns about the authors' claims, which, we believe, are not justified by their findings. Pre-eclampsia remains a major cause of maternal and perinatal mortality.2 A study of 26 cases of pre-eclampsia is clearly underpowered to evaluate important morbidity and mortality outcomes. Therefore, one must place great emphasis on potentially undetected cases of pre-eclampsia, such as those that repeatedly appear as examples of substandard care in the Report on confidential inquiries into maternal deaths in the United Kingdom.3 That the initial screening urinalysis detected only 2/26 (8%) women who subsequently developed pre-eclampsia is no surprise. In contrast, routine urinalysis at antenatal visits detected 25% of cases of pre-eclampsia before the onset of hypertension. In the UK, this would amount to 4500 women per annum. The detection of proteinuria provokes further antenatal visits earlier than would normally be planned, facilitating early detection and management of pre-eclampsia. Intervals of 2–4 weeks between visits are usual in the early part of the third trimester when the risks to mother and fetus of severe early onset pre-eclampsia are greatest.4 By eliminating routine urinalysis from antenatal care, a quarter of affected women are potentially exposed to the risk of ongoing undetected pre-eclampsia for up to four weeks. Murray et al suggest that most women would be detected by risk assessment at the initial visit. While there are known risk factors for pre-eclampsia, the largest group who develop pre-eclampsia are primigravid women with no previous history of note. In addition, there are no reliable studies to justify this claim of Murray et al. Recent randomised controlled trials have suggested that the frequency of antenatal visits could be reduced without demonstrating harmful effects.5 None of these trials, however, have the power to demonstrate safety. Even the recent large World Health Organization trial involving 24 526 women6 would have required 490 000 women for 80% power, and 649 910 women for 90% power, to exclude the 40% increase in maternal mortality actually observed with reduced antenatal care. Changes in well-tried methods of antenatal care need to be assessed with more stringency before it is concluded that they are safe.

Deirdre J Murphy · Christopher W Redman

In reply: We agree with Murphy and Redman that pre-eclampsia remains an important disorder and a major cause of maternal and perinatal mortality. However, we disagree with their interpretation of our data. Murphy and Redman allege that, by eliminating routine urinalysis, a quarter of cases of pre-eclampsia may remain undetected for up to four weeks. As we pointed out in our article,1 three of the six women who developed dipstick proteinuria before they developed pre-eclampsia were already considered "at risk" for pre-eclampsia — two because of multiple pregnancies and one with a history of prior pre-eclampsia. These women would, in our practice, continue to have routine urine tests during their pregnancies. The argument is then whether it is justifiable to undertake repeated urinalysis in almost 1000 women to detect three who have dipstick proteinuria, but no other warning signs before the onset of their hypertension. In practice, we would have had to increase antenatal clinic visits for 338 women with dipstick proteinuria (most of whom will have had false-positive results2) to detect these three women with proteinuria before they developed pre-eclampsia. It is already our normal practice for women to have antenatal visits every second week in their third trimester. Therefore, it is just as likely that their blood pressure changes would have been detected by our routine surveillance as by the knowledge that they had dipstick proteinuria. We did acknowledge clearly in our discussion that our study had a potential for type II error and that the best approach is a randomised controlled trial of outcomes between those who do and do not have continued urinalyses during pregnancy. None of this belittles the importance of pre-eclampsia, nor the need for us to separate women considered at "low risk" from those considered "at risk" for pre-eclampsia on the basis of well recognised risk factors. The latter group should never be considered among those in whom routine urinalysis can be omitted.

Mark A Brown · Caroline S E Homer · Gregory K Davis · George Mangos

To the Editor: As practitioners in a community-controlled Aboriginal and Torres Strait Islander primary healthcare centre, striving to better meet the healthcare needs of our community, we would like to offer some thoughts on a recent article by Coory et al.1 In reporting on cervical cancer screening participation rates in Indigenous communities in Queensland, Coory et al identified the communities but did not inform them that the study was being conducted. We feel that such an approach is unhelpful and reflects a paternalistic attitude. The accompanying editorial2 rightly drew attention to the lack of direct consultation with the communities involved and the consequences of this in terms of future interventions. Without a true partnership with the women and their communities, the authors were unable to do more than imply that participation rates were better in centres with a primary-healthcare approach to screening. Information about the types of services and choice of Pap smear providers available in each community, in addition to the Pap smear screening participation rate, would be of great interest. It would, in part, answer the question the authors themselves posed about the role of primary healthcare in improving Pap smear participation rates. Already scarce funds could then be committed to improving access to quality primary healthcare rather than to conducting further trials. A further factor, which was not explored in either the study or the editorial, was health promotion. The cornerstone of health promotion in the Indigenous community remains the "kit-video" model, comprising posters, leaflets and a video. In contrast, mainstream health promotion often involves expensive multimedia campaigns promoted by national celebrities. Such campaigns have been shown to increase Pap smear screening in the wider community.3,4 To date, these campaigns have rarely had an Indigenous focus, and it might be argued that a consequence of this is the low Pap smear participation rate documented by Coory et al. In our experience,5 the Indigenous community does respond to culturally appropriate holistic primary healthcare. The study by Coory et al demonstrates a lack of commitment, collaboration and innovation — essential features for the delivery of quality primary healthcare — that is all too common in the current approach to Indigenous health.

Katie S Panaretto · Sarah Larkins · Vivienne Manessis

In reply: Black has argued that the role of evidence in policy development is to create concern and set agendas.1 This was the aim of our article. Although there has been a national, organised approach to preventing cervical cancer since 1991, our study found that screening rates for Indigenous women still lag well behind those of non-Indigenous women. Workers in Indigenous health might have suspected as much, but valid data have not previously been available for a wide geographical area. As Murray and Lopez point out, the lack of good data on a health issue is often taken to mean that the problem is not important.2 We agree that the development of effective programs should be done in consultation and partnership with Indigenous communities. However, there is an additional need to influence decision-makers and budget-holders at national, State and regional levels. An evidence base that identified effective interventions would facilitate this process. Such evidence need not come from randomised controlled trials. On the other hand, case reports of successful interventions in a single community that cannot be sustained when key personnel leave are not very persuasive. It is also useful to demonstrate that the situation is not hopeless. The encouraging finding from our study was that the participation rate in cervical cancer screening was more than 50% in three of the 13 communities studied.

Michael D Coory · Patricia S Fagan · Jennifer M Muller · Nathan AM Dunn

Community-based surveys indicate that about a fifth of women have significant vulval symptoms lasting over three months at some time in their lives. Common causes of itch or pain are dermatitis, recurrent candidiasis and the recently recognised pain syndromes — vulvar vestibular syndrome and dysaesthetic vulvodynia. Diagnosis is usually apparent after a thorough history and examination, although conditions commonly coexist and are complicated by prior treatment. Skin lesions not responding to treatment require biopsy. Treatment aims to control symptoms rather than to cure; avoiding soaps and other irritants is central to management. An early, accurate diagnosis should enhance management of vulval conditions, particularly pain syndromes.

Belinda M Welsh FACD · Karen N Berzins DRANZCOG, Dip Ven · Kathy A Cook FRACOG · Christopher K Fairley FRACP, PhD

To the Editor: We urge caution about the recently published findings of Durna and colleagues on use of hormone replacement therapy (HRT) by breast cancer patients.1 They found no increase in risk of breast cancer recurrence or reduction in life expectancy in women using HRT after treatment for primary breast cancer, leading them to conclude that HRT seems a safe treatment for women with a history of breast cancer. We believe that their study has many limitations and consequently their conclusions are unfounded Durna's group conducted a retrospective, observational study using unmatched patient groups. The HRT group was statistically younger, with smaller tumours and fewer positive nodes, and thus had better prognosis. The authors discussed regression analyses for age of diagnosis and stage to reduce potential bias, but did not include these data. The omission of tumour grade and receptor status in the analysis is an obvious flaw. The mean duration of HRT use was short compared with many previous studies (mean, 1 year). This is particularly important, as any risk is likely to be cumulative.2 There were also statistically more women in the HRT group who had received HRT before diagnosis, and for a longer duration (mean, 6.5 years v 3 years). This too may bias results, as breast cancer that develops after HRT has been suggested to carry a better prognosis.3 There was also no subgroup analysis of those who took concomitant tamoxifen. Durna and colleagues also do not address the concerns raised by the Women's Health Initiative study, which showed an excess of cardiovascular and thromboembolic events in "healthy" women taking HRT.4 Many of these events occurred in the first years of HRT use, the time assessed in Durna's study. The risks of short-term HRT in breast cancer patients may be not only tumour-related, but may also include cardiac and thrombotic events, which were not specifically considered by Durna and colleagues. Of additional concern is the extensive portrayal in some sections of the media that this study is conclusive regarding the risks of HRT use by women with breast cancer. The importance of correct media interpretation of studies is discussed in the accompaning editorial by Patel and colleagues.5 Despite this editorial and the inadequacies of Durna's study, the results of this study, released through the media, inaccurately suggested safety and even a possible benefit of HRT.6 This simply adds to the "HRT furore". All studies addressing this issue to date have been small and non-randomised, often with no control group or unmatched groups.2 Because of these limitations, no clear recommendation can be made about the safety of HRT in women with breast cancer. Until results are available from rigorous randomised controlled trials, such as the ongoing HABITS (Hormone Replacement Therapy After Breast Cancer — Is It Safe?) study (IBCSG 17-98), we should not be "advocating" HRT to breast cancer patients. For Durna's group to suggest otherwise is very premature. In addition, there are well studied, effective alternatives to HRT for treating menopausal symptoms in breast cancer patients (eg, venlafaxine),7 and these would seem the current safer option.

Theresa M Hayes · Craig R Underhill · Kerrie Clarke · Martin HN Tattersall