Endometrial polyps

Endometrial polyps are a common gynaecological problem with the normal treatment being polyp removal, commonly as a day surgery procedure. Polyps may be removed blindly with polyp forceps, resected with an operating hysteroscope or be removed with a mechanical hysteroscopic morcellator.

Smith et al report a multicentre single blind randomised controlled trial comparing hysteroscopic morcellation with a 2.9mm rotary morcellator, with a disposable bipolar hytseroscopic electrosurgical system.¹ All procedures were performed in the office setting without general anaesthesia or conscious sedation. Women were excluded from the study if they wished to be treated under a general anaesthetic, or if they were considered by the surgeon to be unable tolerate an office polypectomy. In all, 121 women were randomly allocated to the two groups.

Women in the morcellation group had a significantly higher rate of complete removal of the polyp, a significantly shorter procedure time and a significantly lower pain rating during the procedure, but not afterwards. A significantly higher number of women rated the morcellation technique as totally acceptable; however, only one woman rated either technique as totally unacceptable. The authors concluded that office hysteroscopic morcellation of endometrial polyps is faster and less painful than electrosurgical resection. It is a modality that warrants consideration when dealing with this common problem.

Caesarean section and endometriosis

EThe rate of caesarean section (CS) continues to rise, with the Australian Institute of Health and Welfare reporting a rate of 32.3 per cent in 2011.¹ One possible long-term complication is endometriosis. While endometriosis in the caesarean scar is well-known, this Swedish study² seeks to answer whether the risk of pelvic endometriosis is increased by CS. Andolf et al performed a prospective cohort study linking ICD diagnoses of endometriosis from the Swedish Patient Register with mode of delivery data from the Swedish Medical Birth Registry. Women were included in the study if they gave birth to their first child between 1986 and 2004, for a total of over 700 000 women. Of these, 3110 were treated as inpatients for endometriosis between 1987 and 2005 when the data were retrieved for analysis.

The rate of endometriosis in the CS group was 0.6 per cent while in the vaginal delivery group it was 0.4 per cent. Women who had vaginal deliveries before CS were included in the CS group after that delivery, while women having a vaginal birth after CS remained in the CS group. The authors report a significantly increased risk for endometriosis after CS compared to having all vaginal deliveries (hazard ratio =1.7; 95 per cent CI 1.7-1.9). They also report that there would be one extra case of endometriosis over ten years for every 325 CS performed. Merits of this study include the large numbers; however, association does not necessarily mean causality and their results require further study.

Mammography and breast cancer mortality

This Canadian paper¹ has received considerable publicity and debate since its publication. We should be aware of its main findings and of the lessons that may be learned for gynaecological screening programs. Miller et al report a randomised screening trial comparing mammography to no mammography over a 25-year period in Canada. Nearly 90 000 women aged 50–59 were enrolled into the trial between 1980 and 1985 and over five years received either annual mammography screens or no mammography. Women aged 40–49 in the mammography arm and all women aged 50–59 in both study arms received annual physical breast examinations, while women aged 40–49 in the control arm received a single physical breast examination before being returned to normal care in the community. Diagnoses of breast cancer and deaths attributed to breast cancer were ascertained from linkage to records including the Canadian Cancer Registry and the Canadian national mortality database.

The results found, during the five-year screening period, in the mammography arm there were 666 diagnoses of invasive breast cancer and 180 deaths from breast cancer (over the entire follow-up period), while in the control group there were 524 diagnoses and 171 deaths. The rate of mortality was not significantly different between the two groups.

Over the whole study period, there were 3250 diagnoses and 500 deaths from breast cancer in the mammography group, and 3133 diagnoses and 505 deaths in the control group. The authors also conclude that 22 per cent of screen-detected breast cancers were over diagnosed. The conclusion of the study was that mammography did not significantly reduce mortality from breast cancer compared to physical breast examination or usual care when adjuvant therapy for breast cancer was freely available. This result has been predictably controversial. A similar Swedish study on breast screening in 2011² reported a 31 per cent decrease in mortality in the screening arm. Criticism since the publication of the Miller et al study has also included discussion of better screening results from more modern imaging technology; however, it raises important questions of the evaluation of screening programs. In the case of breast cancer, improved treatments may have altered the value of mammography over time. In gynaecology, we will see a similar debate regarding the effect of the HPV vaccine on cervical screening. Both programs are expensive and governments will be keen to spend their health budget optimally.