Loop Electrosurgical Procedure (LEEP) and the Risk of Premature Labor.

Abnormal Pap smear can be classified as low grade disease or high grade disease or cancer of the cervix. The treatment of the low grade disease may involve observation with Pap smears or freezing of the cervix. The high grade diseases are usually treated with removal of the affected area of the cervix by LEEP (Loop Electrosurgical Procedure). The treatment of cancer of the cervix is radical hysterectomy depending on the stage of the disease.

The benefit of the LEEP procedure in the treatment of precancerous disease of the cervix is that it removes the diseased cervix which is examined by a pathologist to determine the severity and the extent of the disease.

I had a patient who had severe dyspalsia on the cervix for which she had LEEP procedure. She got pregnant. At 13 weeks, I discussed cervical cerclage with her becasue of her short cervix. She had to see another physician because of insurance issues. The new physician refused to place the stich in the cervix. At 24 weeks she went into premature labour and had to stay off work throughout the pregnancy.

It is therefore interesting that a recent study in Danish pregnant women looking at the relationship between previous LEEP procedure and subsequent risk of preterm labor showed that women who had LEEP procedure had 2x chance of having premature labor.

If you have had LEEP procedure, you should let your obstetrician or midwife know about it. Your caregiver may measure the length of your cervix in early pregnancy with ultrasound to determine whether your cervix needs to be stitched or not. If your cervix is long enough to hold the baby, you may still have your baby early and hence you need to be followed up closely.

Reference:
Acta Obstet Gynecol Scand. 2007; 86(5):596-603

Antidepressants In Pregnancy. Are they Safe?

Depression is a common condition that afflicts women. Depressed pregnant women are at risk of preterm labor and worsening of their depression. Hence, treatment of these patients is important. That is why two recent articles that appeared in the New England Journal of Medicine about drug treatment of depression in pregnancy are important.

Previous studies implicated the selective serotonin reuptake inhibitors (SSRI's) like Paxil, Prozac and Zoloft in causing birth defects. These two new studies agree that the SSRI's have low risk of causing fetal abnormalities. Pregnant women who have depression should take comfort that they can take the SSRI's without having to worry about having abnormal babies. The abnormalities found in previous studies are rare.

Reference: New England Journal of Medicine.

Depressed Women May Have Premature Babies

A study done in England on depressed pregnant women showed the severely depressed women who were not taking medications had premature labor.

That depression produces stress hormones is exemplified by this study. Dr. O'Keane, a perinatal psychiatrist at the King's College in London measured corticotrophin releasing hormone (CRF) in 25 depressed pregnant women who were not on any antidepressant medications and 35 pregnant women who had no depression.

Levels of CRF and cortisol, hormones related to stress and also produced  by the placenta in pregnancy were found to be higher in women with depression.

While none of the mothers that were not depressed had premature deliveries, on the average, the depressed mothers had their babies 2 days earlier and 3 of them had premature deliveries.

During the follow up visit, the babies whose mothers had depression had high levels of cortisol in their saliva, a sign that their mothers' stress had effect on them..

The study involved a few patients. More studies are needed to elucidate the findings of this interesting small study. The take home message is that depressed pregnant patients' stress may have effect on their unborn babies. The effect may even continue after delivery. Hence pregnant women who are depressed should be treated with antidepressants despite the fear that some of the antidepressants may have effect on the newborn babies.

 

Reference: From issue 2599 of New Scientist magazine, 14 April 2007, page 18

Estrogen Therapy is good for the Young Postmenopausal Woman’s Heart.

The estrogen therapy controversy has not been put to rest yet. The WHI study that was highly publicized showed that postmenopausal women who took estrogen did not benefit from the estrogen replacement therapy and may even be at an increased risk of having heart disease.

In 1994, the Women Health Initiative trial using estrogen alone showed no adverse effect from the estrogen therapy. That study was stopped prematurely.

A study published by Manson and her colleagues in the most recent New England Journal of Medicine showed that estrogen therapy in younger women (50 -59 years), who have recently undergone hysterectomy with removal of their ovaries and hence have had surgical menopause, have protection against heart disease by keeping the lumen of the blood vessels open. Without the estrogen, calcium is deposited in the walls of the blood vessels thus causing narrowing.

The take home message is that in women who have had hysterectomy with removal of their ovaries in their 40’s to early 50’s, estrogen replacement therapy may be beneficial to the heart as it slows down the narrowing of the blood vessels.

Oral Sex Is Not Free. It Can Cause Throat Cancer.

A study which is appearing in this week's New England Journal of Medicine showed that both men and women who claimed they had six or more oral sex partners during their lifetime had about 9x increased risk of having cancer of the base of the tongue or the tonsils. The Human Papilloma Virus (HPV) was the culprit. In the study, the participants who had HPV infection were 32 times more likely to develop this type of oral cancer than those without the HPV infection.

The Gardasil vaccine contains 4 types of HPV viruses, namely 16 and 18 that cause about 70% of all cervical cancers and 6 and 11 that cause genital warts. In this study, of the 100 cancer patients enrolled, 72 had HPV 16. Two major risks that promote throat cancer are smoking (3 times greater) or drinking (2.5 times greater). These cancers are more common in men than in women. Does it mean that to prevent oral cancer in men who practise oral sex, these men should be offered the Gardasil vaccine? Only more studies can tell.

Between 12,000 and 15,000 new cases of oral and pharynx cancer are diagnosed each hear. 3000 people die form it. Dr. Robert Haddad, clinical director of the Head and Neck Oncology Program at the Dana-Farber Cancer Institute has seen younger men in their 30's and 40's getting this cancer. The bottom line is that since men don't know which women will have cancer causing viruses in their vagina, they should avoid oral sex as the price has become too much to ignore.

Reference:

New England Journal of Medicine (NEJM)