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Dr Sarah Jarvis reviews recent papers that could change the way you practise

Dr Sarah Jarvis reviews recent papers that could change the way you practise

How do I manage heavy menstrual bleeding?

The paper
National Institute for Clinical Excellence. Heavy Menstrual Bleeding (HMB). NICE clinical guideline 44, 2007.

Method
In the early 1990s, it is estimated that at least 60% of women with HMB went on to have a hysterectomy. This excellent guideline provides a review of all the major published studies on efficacy of options.

Results
HMB does not require measurement of menstrual blood loss, either direct or indirect. Any woman for whom menstrual bleeding is interfering with physical, emotional, social or material quality of life should be included. Efficacy and risks of the various options are compared.

Conclusion
Hysterectomy should be considered a last resort – pharmacological treatments are first line and surgical methods such as endometrial ablation should be considered next.

What I'm going to do now
For women needing pharmacological treatment of HMB, the Mirena IUS (levonorgestrel-releasing intrauterine system) should be first-line intervention, unless hormonal treatment is unacceptable. Tranexamic acid, non-steroidal anti-inflammatory drugs and the combined oral contraceptive pill (COC) should be considered as second-line pharmacological treatment.

Does HRT increase risk of CHD?

The paper
Rossouw JE et al. Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. JAMA. 2007 297(13):1465-77.

Method
In 2003, there were two million women in the UK taking HRT. The publication of the Women's Health Initiative study – which linked HRT with an increased risk of CVD – and the Million Women Study – which linked long-term HRT with an increased risk of breast cancer – have resulted in a huge drop (to fewer than one million in the UK) in women taking HRT. This study examined whether the link with CVD applies to all women.

Results
In women starting HRT less than 10 years after the menopause, there was no increase in the incidence of CHD associated with taking HRT, and a non-significant trend for reduced total mortality among younger women (under 60) who take HRT. The risk of stroke is slightly increased at all ages, but the absolute increase in younger women is extremely small.

Conclusion
In women starting HRT around the time of the menopause, there is no increased risk of CHD or mortality.

What I'm going to do now
Reassure women taking HRT around the menopause that they are not increasing their risk of CHD – but continue to advise them that long-term (more than five years) HRT may slightly increase the risk of breast cancer.

How effective is HPV vaccination?

The paper
Smith J et al. Human papillomavirus type distribution in invasive cervical cancer and high-grade cervical lesions: A meta-analysis update, Int J Cancer 2007; 121:621-32.

Method
There are two HPV vaccinations which will be licensed in the UK when the HPV immunisation programme is introduced. One (quadrivalent vaccine, Gardasil) immunises against HPV types 6 and 11 (which cause 90% of cases of genital warts) in addition to types 16 and 18. The other (bivalent vaccine, Cervarix) targets types 16 and 18. Both vaccines provide almost 100% protection against types 16 and 18. This meta-analysis compared the incidence of different types of HPV in invasive cervical cancer worldwide.

Results
HPV types 16 and 18 account for 74-77% of invasive cervical cancer in Europe.

Conclusion
Both vaccines are likely to offer direct protection against at least three-quarters of cervical cancer cases in the long term.

What I'm going to do now
Reassure parents and patients that HPV immunisation will definitely cut the risk of cancerous or pre-cancerous cervical changes by 75%. Further studies on cross-protection provided by the two vaccines suggest the protection may be greater than this, but results are awaited.

Will HPV vaccination increase or reduce workload?

The paper
Brown R et al. Costs of detection and treatment of cervical cancer, cervical dysplasia and genital warts in the UK. Curr Med Res Opinion 2006; 22: 663-70.

Method
The annual UK cost of HPV infection was estimated from cervical cancer screening data and Health Protection Agency data for genital warts, in combination with estimates of treatment patterns for genital warts by GUM clinicians.

Results
Direct medical costs associated with detection and management of cervical cancer, cervical dysplasia and treatment of genital warts in the UK in 2003 was £208m, of which £46.8m relates to management and treatment of cancerous and pre-cancerous cervical changes. The annual cost of managing new and recurrent or persistent cases of genital warts in the UK is about £22.4m.

Conclusion
In the longer term (more than 20 years), referral rates for colposcopy and secondary care management of possible cervical cancer are likely to reduce substantially. In the short term (less than 10 years), the incidence of, and workload associated with, genital warts is likely to be hugely reduced if quadrivalent HPV immunisation is widely taken up.

What I'm going to do now
The short-term workload related to introduction of HPV immunisation will depend on whether school nurses or primary care do the immunisation. In the longer term, any increase in workload is likely to be offset by a reduction in abnormal cervical smears and genital warts.

Dr Sarah Jarvis is a GP in Hammersmith, London, and RCGP spokesperson on women's health
Competing interests Dr Jarvis has received honoraria for lecturing and sitting on advisory boards for Sanofi Pasteur MSD?

Women's health

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