Journals Watch - HRT risks, home births and BV

Too busy to catch up on the latest research? Let Dr Gwen Lewis update you on some recent papers.

HRT and ovarian cancer - JAMA 2009; 302: 298-305
We are all aware of the breast cancer risk associated with use of HRT but I was less aware of the association between HRT and ovarian cancer. Some studies have suggested an increased risk of ovarian cancer among women taking HRT.

This prospective cohort study of all Danish women aged 50-79 years; a total of over 900,000 women, between 1995 and 2005 looked at ovarian cancer rates. In an average of eight years of follow-up, 3,068 ovarian cancers occurred.

The risk declined with years since last use of HRT. Current users of HRT had an incidence rate ratio of 1.38 compared with never-users of HRT, or one extra ovarian cancer for 8,300 women taking HRT every year.

HRT was associated with an increased risk of ovarian cancer regardless of duration of use, HRT formulation, estrogen dose, type of progestogen, regimen or route of administration.

This is another reason to think twice about prescribing HRT.

Treatment of acid reflux - BMJ 2009;339:b2,576
Many studies seem to concentrate on cost and cost-effectiveness of treatments. This study compared the relative costs of laparoscopic fundoplication versus medical management with proton pump inhibitors (PPIs).

Male patients aged 45 years who were stable on medical treatment for gastro-oesophageal reflux disease (GORD) received either continued PPIs or laparoscopic fundoplication. Quality adjusted life years and GORD-related costs to the health service over a lifetime were estimated.

Surgery was found to be more cost-effective on average than medical treatment in many cases. It may be less so if medical treatment is not required on a long-term basis. I am rather sceptical about whether there will be sufficient numbers of surgeons to undertake this surgery though.

Treatments for tennis elbow - Br J Sports Med 2009;43:471-81
Lateral epicondylosis, or tennis elbow, is an important and relatively common condition. Treatments include NSAIDs, physiotherapy, relative rest, eccentric exercise and steroid injections.

In spite of these treatments, in some cases the problem fails to resolve and of course some patients are not happy with the length of time taken for resolution of the symptoms, which may last for six months or even two years.

I recently attended an orthopaedic meeting in which whole blood and platelet-rich injection therapies to aid healing were discussed, so I was interested to read the results of this study, which compared injection treatments for tennis elbow.

Nine trials of injection treatment were reviewed: three trials involving prolotherapy (the injection of hyperosmolar dextrose), two involving polidocanol (a vascular sclerosant) injection, three trials of autologous whole blood and one trial involving platelet-rich plasma. All studies were small but reported sustained, statistically-significant improvement in symptoms.

For those patients with prolonged duration of symptoms these treatments, which are apparently very easy to use, might be worth considering.

How safe are home births? - BJOG 2009; 116: 1,177-84
Women are again being encouraged to consider a home birth. I am frequently asked about the safety of home births by pregnant patients in my care.

I was therefore encouraged to read the results of this large study involving the entire Netherlands and more than half a million low-risk women.

No significant differences were found in terms of intrapartum and neonatal deaths at any stage up to seven days post delivery between planned home and planned hospital births. There was also no difference in the admission rate to a neonatal intensive care unit between the two groups.

Safe home delivery does rely on the availability of well-trained midwives and good transport mechanisms to hospital if the need arises. Two of my patients have recently had happy experiences during their deliveries at home.

I do now feel better equipped to answer questions about home delivery.

Bacterial vaginosis - Sex Transm Infect 2009; 85: 242-8
I have always found bacterial vaginosis (BV) rather confusing and somewhat difficult to explain to patients. This is partly because the aetiology is unknown but also because there is no one definite test as there is for gonorrhoea or chlamydia. Instead we are reliant on the patient history, clinical examination, pH and smell of the discharge (the whiff test) and on the finding of 'clue cells' on microscopy.

This study sought to establish the clinical characteristics of BV and the relationship between the BV and the microbe causing it.

Fifty women with endometritis, which was proven not to be chlamydial or gonococcal in origin, were tested for bacteria, some of which I had never heard of: bacterial vaginosis-associated bacteria 1 (BVAB1), lepto-trichia sanguinegens/amnionii, atopobium vaginae and several ureaplasma bacteria.

BV characteristics varied according to pathogen. The only universal finding was that of elevated pH.

Only one of the ureaplasma bacteria was associated with abnormal vaginal discharge. Other bacteria caused a positive 'whiff test'. There was concern that many of these bacteria do not cause vaginal discharge and therefore patients may not recognise they have an infection.

I remain confused.

  • Dr Lewis is a GP in Windsor, Berkshire, and a member of our team who regularly review the journals

The Quick Study

  • HRT use increases the risk of ovarian cancer.
  • Fundoplication for GORD is cost-effective compared with PPI treatment.
  • Lateral epicondylosis symptoms may improve when the patient receives an injection of whole blood or platelet-rich plasma.
  • Home births are as safe as hospital births as long as there are trained staff in charge.
  • Bacterial vaginosis characteristics vary according to the pathogen causing it.

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