Gender-specific research essential

Traditionally, medical research has focused heavily on men, but as women are becoming more aware of gender-specific conditions and treatment options for these conditions, this is changing. Many of the conditions detailed below were not understood by women, particularly the causes, symptoms or the treatment options available, and those who were affected often lived with painful conditions for years without reporting them to their healthcare practitioners.

For women all over the world the research and development of innovative medical solutions has increased the quality of their lives. However, few have stopped to consider the significance of female-specific research.

Healthcare is one area where we need to keep gender separate and develop a more in-depth understanding of physiological differences. Research indicates that differences in the intrauterine environment triggered by the foetus’s sex may lay the groundwork for later health. These differences continue throughout life, establishing biological differences in health and disease. This means we have a responsibility to adopt dedicated approaches to healthcare for men and women.

There are now more treatment options available, partly because companies such as Cook Women’s Health (www.cookmedical.com) have dedicated research into the treatment of these conditions and are educating women on what options are available.

Below we look at three conditions, which are female specific and particularly common in women who have given birth. These include pelvic organ prolapse, postpartum haemorrhage and chronic pelvic pain.

PELVIC ORGAN PROLAPSE

Pelvic organ prolapse (POP) is a common condition, particularly among older women and those who have had more than one natural birth. It is estimated that half of women who have children will experience some form of prolapse in later life. In the UK genital prolapse accounts for 20% of women on the waiting list for major gynaecological surgery.1

Symptoms

The pelvic organs are kept in place by a co-ordinated interaction between the pelvic floor muscles and the surrounding connective tissues of the pelvic cavity.

In an adult woman, the cervix and upper border of the vagina are tethered to the sacrum by a pair of quite strong connective tissue bands, called the uterosacral ligaments. Below this level, the muscular walls of the vagina form a pair of hammocks. The back hammock joins with uterosacral ligaments to help suspend the vagina, and it also forms a partition that separates the vagina from the bowel. If this structure is damaged, two adverse events can occur: either the uterus/upper vagina can fall out of the vagina, or the rectal wall can bulge forwards, disrupting the mechanics of normal bowel evacuation. The front wall of the vagina forms a highly specialised hammock that cradles the bladder. If this hammock is torn, the bladder can bulge forwards and/or urinary leakage can occur with laughing, coughing or lifting.

When the pelvic muscles and tissues are torn or damaged, most commonly by childbirth, they lose their ability to support the organs. Prolapse can be partial or severe and mild genital prolapse may be asymptomatic. But generally, symptoms common to all types of prolapse are feelings of dragging or a lump in the vagina. The following have also been noted in patients:

• Pelvic pressure, fullness, heaviness, a bearing down sensation, sensation of a lump coming down, groin pain, backache.
• Difficulty retaining tampons.
• Coital difficulty, pain during intercourse (dyspareunia), loss of vaginal sensation.
• Spotting in the presence of ulceration.
• Urinary symptoms, including stress incontinence, urinary retention and recurrent symptoms of urinary tract infection.
• Bowel symptoms, including constipation and incontinence.2

Treatment options

There are a number of options available to treat prolapse, including physiotherapy and surgery. The choice of treatment depends on a variety of factors, such as the type of prolapse, the severity of symptoms, a woman’s age and other health issues, including whether or not a woman wants children in the future and personal preference.

POP can be a long-lasting condition, but it does not have to disrupt a woman’s life. If symptoms are not relieved as a result of lifestyle changes, treatment will need to be considered before considering surgery. Options include:

• Vaginal pessary: a removable device that is placed into the vagina to support areas of prolapse.
• Medication: this will not cure or reverse prolapse, but it may reduce existing symptoms or help prevent prolapse. Possibilities include oestrogen therapy and hormone replacement therapy. Surgery is widely considered to be the best treatment for POP. About 85% of the patients who have surgery performed have no recurrence of the condition.3 If surgery is the only option, there are some important differences between the materials that are currently used to repair prolapse. These include:
• Synthetic materials: currently, the most popular materials used in repair operations are synthetics. While these have long been used, they can be rejected by the body and could eventually cause erosion. They also have a negative impact on sexual health in sexually active women.
• Cross-linked biomaterials: these are biomaterials that are chemically treated to stabilise the tissue to prevent it from degrading. Crosslinking reduces the likelihood of antigenic or immunogenic reactions while rendering the material leather-like for better handling. The material can create stiffness and infection and it often needs to be removed as it frequently calcifies.
• Natural biomaterials: the new entrant to the market is natural or non-crosslinked biomaterial. These materials provide a building block for soft-tissue to structure around, and gradually disintegrate in time. Many leading organisations have attempted to develop a material that would provide women with a natural alternative. Cook Women’s Health last year launched the first of its kind: Surgisis ES Soft-Tissue Graft, a material that aids the growth of strong, biocompatible tissue. As healing occurs, the biomaterial is incorporated, leaving behind strong, fully vascularised tissue. The risk of complications generally associated with synthetic or cross-linked materials is minimised.

Possible complications of pelvic reconstructive surgery include urinary tract infection, temporary or permanent incontinence, infection, bleeding and – rarely – damage to the urinary tract that requires additional corrective surgery. Some women may develop chronic irritation or pain during intercourse from a suture or scar tissue.

Lifestyle changes

Many women are able to adjust their lifestyle habits with positive impact on the condition. Measures include:

• Eating high-fibre foods to prevent constipation.
• Cutting down on caffeine, which acts as a diuretic, causing frequent urination.
• Achieving and maintaining a healthy weight.
• Avoiding activities, such as heavy lifting, that stress pelvic muscles.
• Doing pelvic floor (Kegel) exercises every day to tighten and strengthen pelvic muscles.

POSTPARTUM HAEMORRHAGE (PPH)

The risk of maternal death from childbirth represents one of the greatest risks in global health. Obstetric haemorrhage is the world’s leading cause of maternal mortality, causing at least 25%, or an estimated 127,000 maternal deaths annually. PPH is the most common type of obstetric haemorrhage and accounts for the majority of the 14 million cases of obstetric haemorrhage that occur each year.4 Although various management measures are available to treat the haemorrhage, many of these options may still lead to hysterectomy or a separate surgical procedure.

PPH is defined as excessive uterine bleeding following delivery of the foetus and placenta and is described as primary (loss of blood estimated to be more than 500 ml within 24 hours of delivery) and secondary (abnormal bleeding from 24 hours after delivery until six weeks after). Symptoms usually include continuous bleeding, with loss of more than 1,000 ml of blood, which fails to stop after the delivery of the placenta.

Common causes

The main risk for PPH due to uterine atony (failure of the uterus to contract properly after delivery) includes a large foetus, multiple foetuses or too much amniotic fluid (hydramnios). Retained fragments of the placenta, infection, and trophoblastic tumours can all produce delayed or secondary PPH, defined as haemorrhage after the first 24 hours but less than six weeks postpartum. Atony and retained placenta make up 80% of all cases; lacerations comprise the bulk of the other 20%.5

PPH may also be the result of placenta praevia, described by the Royal College of Obstetricians and Gynaecologists as “a condition in pregnancy where the placenta is too low in the womb and covers all or part of the entrance (the cervix).” Placenta praevia is serious and requires prompt care. PPH is very unpredictable. Up to 90% of women who experience it have no identifiable risk factors.

Treatment and prevention

Various management measures are utilised for control of bleeding, including uterine packing, manual compression, embolisation (the insertion of a substance through a catheter into a blood vessel to restrict blood flow) and hysterectomy. The ideal choice for management of postpartum haemorrhage will include easy administration and removal, control of capillary/venous bleeding and surface oozing, ability to gauge success of treatment in real time, and the avoidance of hysterectomy to preserve the patient’s reproductive potential.

Hysterectomy can be an undesirable action to take and it is usually only undertaken when other traditional measures to stop haemorrhage fail. Uterine packing has been used successfully in many cases to conservatively manage postpartum bleeding. However, removing such packing can sometimes require a separate surgical procedure to dilate and extract the materials. Therefore packing sometimes falls short of an ideal treatment option.

Active management of the third stage of labour (delivery of the placenta) can prevent 60% of uterine atony and is an evidence-based, feasible, low-cost intervention. Other preventative measures include reducing the incidence of prolonged labour (through monitoring and timely intervention, when needed) and minimising the trauma associated with instrumental delivery.

Physicians are also now able to navigate around conditions such as uterine atony and placenta previa with devices designed to address these specific conditions, effectively limiting additional risks. The Bakri postpartum balloon (Cook Women’s Health, Spencer, Indiana, USA) is one such device that offers healthcare providers and their patients a potentially lifesaving device to aid in the treatment of postpartum bleeding. In a statement issued in the International Journal of Gynaecology and Obstetrics, the International Federation of Gynaecology and Obstetrics (FIGO) along with the International Confederation of Midwives (ICM) cited the use of the Bakri postpartum balloon to illustrate the importance of using balloon tamponade as a primary support tool to treat postpartum haemorrhage.

The use of the balloon also helps preserve the patient’s fertility by potentially limiting the need for a hysterectomy to stop the bleeding.

Although various other management measures are available to treat the haemorrhage, many of these options may still lead to hysterectomy or a separate surgical procedure.

CHRONIC PELVIC PAIN

Chronic pelvic pain affects 15% of women aged 18 to 50 and has a drastic negative impact on the quality of a woman’s life. It refers to any pain in the pelvic region that lasts six months or longer. It can be a symptom of another disease or it can be diagnosed as a condition in its own right. The ailment can be caused by a number of sources, including endometriosis, interstitial cystitis, pelvic injury and most often pelvic congestion syndrome. All of these causes are currently difficult to diagnose and treat because of the complicated design of the pelvis. Determining what is causing the discomfort may be one of medicine’s more puzzling and frustrating endeavours. Often pelvic pain is just the normal functioning of the reproductive or other organs. Other times pelvic pain may indicate a serious problem that needs urgent treatment.

Symptoms and causes

Chronic pelvic pain may have a combination of physical symptoms (pain, trouble sleeping, loss of appetite), psychological symptoms (depression), and changes in behaviour (change in relationships due to the physical and psychological problems). Chronic pelvic pain exhibits many different characteristics. Among the signs and symptoms are:

• Severe and steady pain.
• Pain that comes and goes (intermittent).
• Dull aching.
• Sharp pains or cramping.
• Pressure or heaviness deep within the pelvis.

In addition, women may have pain during intercourse, while having a bowel movement or even when sitting down. The pain may intensify after standing for long periods and may be relieved when lying down. The pain may be so bad that women miss work, cannot sleep and cannot exercise; it may vary from mild to severe, from annoying to disabling.6

One of the more common causes of chronic pelvic pain is endometriosis: a condition in which tissue from the uterine lining (endometrium) grows outside the uterus. The deposits of tissue respond to the menstrual cycle, just as the uterine lining does, thickening, breaking down and bleeding each month as hormone levels rise and fall. Because this happens outside the uterus, however, the blood and tissue cannot exit the body through the vagina and can become trapped in the abdomen, which can lead to painful cysts and adhesions.

Tension in the pelvic floor muscles, including spasm of the pelvic floor muscles, may also lead to recurring pelvic pain. Chronic pelvic inflammatory disease is another cause, which can occur if a longterm infection, often sexually transmitted, causes the fallopian tubes to scar and stick to the ovaries. Other conditions that can contribute to chronic pelvic pain include irritable bowel syndrome and interstitial cystitis (chronic inflammation of the bladder and frequent need to urinate).

Another condition, pelvic congestion syndrome may be caused by enlarged, varicose-type veins around the ovaries and pelvic area. Characteristics of the pelvic veins make them vulnerable to chronic dilation, which can lead to vascular congestion. Pelvic veins are thin-walled, unsupported and are attached relatively weakly to supporting tissue. As a result they may bulge, stretch and dilate causing discomfort and pain in the form of pelvic congestion, which has similar symptoms to varicose veins. The condition may be severe and can hinder an individual’s ability to walk and exercise, sleep, conduct chores and, in some cases, engage in activity at any level.

Options for treatment

Figuring out what is at the root of chronic pelvic pain often involves a process of elimination, since the numerous disorders mentioned above could be responsible.

Tests or examinations might include:

• Pelvic examination: this can reveal signs of infection, abnormal growths or tense pelvic floor muscles.
• Cultures: these can be checked for infection including sexually transmitted diseases.
• Laparoscopy: this can be used to check for abnormal tissues or signs of infection in the pelvis.
• Imaging studies: venography, abdominal X-rays, computerised tomography (CT) scans and magnetic resonance imaging (MRI) can be used for detecting possible sources of pain.

Once clinicians have isolated the cause of the pelvic pain, they have a number of pharmaceutical, non-invasive and surgical forms of treatment available. Women often find that they need to try a combination of treatment approaches before finding one that works for them.

Home prevention methods

One of the more frustrating aspects of chronic pain is that it can have significant impact on a woman’s daily life. Often, self-care techniques can ease at least some of the discomfort.

Relaxation, deep breathing and targeted stretching exercises for the pelvic region can help minimise bouts of pain when they occur. It is also important to receive emotional support. Chronic pain can trigger some intense, negative emotions, such as pain, grief and anger, which can affect a woman’s self-esteem and her relationships with others. Acknowledging and talking about these feelings is the first step toward emotional health. Stress management can also be an important step to good health. Getting too wound up and stressed over certain situations may exacerbate chronic pain. Effective stress management techniques not only help reduce stress levels, but may also have the indirect effect of easing stress-triggered pain.

CONCLUSION

The advancement of gender specific research, and the development of devices tailored to conditions affecting women, has been a step forward in improving quality of life for women worldwide. We hope that Women’s Day 2008 will mark even more progress.  

REFERENCES

1 Thakar R., Stanton S. Management of Genital Prolapse. BMJ; 324; 1258-1262.

2 Ibid.

3 www.mwri.magee.edu/urogyne/ prolapsetreatment.htm

4 www.pphprevention.org

5 www.patient.co.uk/showdoc/40000261/

6 www.mayoclinic.com/health/ chronic-pelvic-pain/DS00571

Christina Anné
Christina Anné is global business unit leader, Cook Women’s Health.