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• 8 March - International Women's Day
• A Call for More Gender Specific Research
• Pelvic Organ Prolapse - A Common Condition
• Post Partum Haemorrhage - One of the Leading Causes of Maternal Death from Childbirth
• Chronic Pelvic Pain - A Disorder Affecting Millions of Women

The text of this edition of Medical Technology Focus was kindly provided by Cook Women's Health.

8 March - International Women's Day

International Women's Day is celebrated on 8 March, an occasion when women from all continents, often divided by ethnic, linguistic, cultural, economic and political differences, come together to celebrate. Today, women are more informed, and a focus on female specific healthcare from the medical community, is giving more women the opportunity to make informative choices regarding their health and treatment.

However, there is a long way to go. There has been a lot of discussion of late on the lack of female specific research and tailored product development in healthcare. The Journal of the Royal Society for Medicine published an article earlier this year looking at the importance of introducing legislation with gender specific research and clinical trials in mind. It is claimed that the exclusion of women from clinical trials and other associated medical research is potentially putting the health of millions of women at risk.

A Call for More Gender Specific Research

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. These women often lived with painful conditions for years without reporting them to their healthcare practitioner.

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' 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 medical technology companies 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, post partum haemorrhage, pelvic organ prolapse and chronic pelvic pain.

Pelvic Organ Prolapse - A Common Condition

Pelvic Organ Prolapse (POP) is a common condition, particularly among older women and those who have had more than one natural birth. It's 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 percent of women on the waiting list for major gynaecological surgery^[1].

POP occurs when the pelvic floor muscles become weak or damaged and can no longer support the pelvic organs. The womb (uterus) is the only organ that actually falls into the vagina. When the bladder and bowel slip out of place, they push up against the walls of the vagina. While prolapse is not considered a life threatening condition, it may cause a great deal of discomfort and distress.

Pelvic floor prolapse is classified into five categories:

• Anterior wall prolapse (cystocele) occurs when the bladder drops from its normal position into the vagina.
• Posterior wall prolapse (rectocele) occurs when the rectum protrudes into or out of the vagina.
• An enterocele occurs high in the back of the vagina, allowing the small intestine to protrude into the vagina. In severe cases, the protrusion may be seen or felt outside the vagina.
• A vaginal vault prolapse occurs when the tissue, which attaches the top of the vagina to the pelvic sidewall, is torn. This causes the top of the vagina to drop, which in turn causes the front and the back of the vagina to drop.
• A uterine prolapse occurs when the uterus drops either by itself or as a result of the prolapse from a different part of the vagina^[2].

Symptoms that women might encounter

The pelvic organs are kept in place by the muscles and connective tissues of the pelvis (pelvic diaphragm). The vagina of an adult woman is normally a round-topped, muscular tube that supports other pelvic organs. When the pelvic muscles and tissues are stretched or damaged, most commonly by pregnancy and childbirth, they lose their ability to support the organs. Prolapse can be partial or severe and mild genital prolapse may be asymptomatic. But generally, those 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^[3].

A number of treatment options are available

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 - will not cure or reverse prolapse, but may reduce existing symptoms or help prevent prolapse, including:
• Estrogen therapy;
• Hormone replacement therapy.

Surgery is widely considered to be the best treatment for POP - about 85 percent of the patients who have surgery performed have no recurrence of the condition^[4].

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 material used in repair operations is synthetics. Whilst this has been used for a long period of time, it can be rejected by the body and could eventually cause erosion. It also has a negative impact on sexual health in sexually active women.
• Cross-link biomaterials: This is the most controversial material; it is a biomaterial, which is embalmed with a chemical, which stabilises the tissue so that it does not degrade. The material does not incorporate into tissue, causing it to come loose from existing tissue. The material can create stiffness and infection and it often needs to be removed as it frequently calcifies (turns into bone).
• Biomaterials: The new entrant to the market is natural or bio-materials. Biomaterial in itself does not provide a building block for soft-tissue to structure around, and disintegrates in time. Many leading organisations have attempted to develop a material that would provide women with a natural alternative. A new advanced material has recently been launched that aids the growth of strong, biocompatible tissue. As healing occurs, the material is incorporated, leaving behind strong, fully vascularised tissue. The risk of complications generally associated with synthetic or cross-link 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 that might help women prevent prolapse

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

• 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.

Post Partum Haemorrhage - One of the Leading Causes of Maternal Death from Childbirth

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 percent of, or an estimated 127,000, maternal deaths annually. Post Partum Haemorrhage (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^[5]. 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 vaginal bleeding following delivery and is described as primary (loss of blood estimated to be more than 500ml within 24 hours of delivery) and secondary (abnormal bleeding from 24 hours after delivery until 6 weeks after). Symptoms usually include continuous bleeding, with loss of more than 1000ml of blood, which fails to stop after the delivery of the placenta.

The most common causes of PPH

The main risk for PPH due to uterine atony (failure of the uterus to contract properly after delivery) includes a large fetus, multiple fetuses 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 6 weeks postpartum. Atony and retained placenta make up 80 percent of all cases, lacerations comprise the bulk of the other 20 percent^[6].

PPH is very unpredictable; up to 90 percent of women who experience it have no identifiable risk factors.

Treatment and prevention of PPH

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 stop haemorrhaging) and hysterectomy. The ideal choice for a patient's post partum haemorrhage will include easily administered and removed, 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 measure to stop haemorrhage fail. Uterine packing has been used successfully in many cases to conservatively manage post partum 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 can prevent 60 percent 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 with devices designed to address these specific conditions, eliminating additional risks. One innovating medical technology manufacturer has developed a post partum balloon that offers health care providers and their patients a potentially lifesaving device to aid in the treatment of postpartum bleeding. It has also proven to be an effective management device for postpartum uterine haemorrhage. The use of the balloon 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 - A Disorder Affecting Millions of Women

Chronic pelvic pain affects 15 percent of women ages 18-50 and has a drastic negative impact on the quality of a woman's life. Chronic pelvic pain refers to any pain in your 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 endometrioses, 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 and determining what's causing the discomfort may be one of medicine's more puzzling and frustrating endeavours. 61 percent of women who experience chronic pelvic pain at some time during their lives never receive a specific diagnosis for their symptoms. Many times 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.

Chronic pelvic pain symptoms and causes that women might encounter

Chronic pelvic pain can 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 your 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, can't sleep and can't exercise; it may vary from mild to severe, from annoying to disabling^[7].

Some of the more common causes of chronic pelvic pain include:

• Endiometriosis - 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 it happens outside the uterus, the blood and tissue can't 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, which includes spasm of the pelvic floor muscles, leads to recurring pelvic pain. Chronic pelvic inflammatory disease is another cause, which can occur if a long-term infection, often sexually transmitted, causes the fallopian tubes to scar and stick to the ovaries. Another condition, pelvic congestion syndrome may be caused by enlarged, varicose-type veins around the ovaries and pelvic area. 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).

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 is extremely severe and hinders an individual's ability to walk and exercise, sleep, conduct chores and in some cases activity at any level.

How to determine the cause and options available for treatment

Figuring out what's at the root of chronic pelvic pain often involves a process of elimination, since the numerous disorders mentioned above could be responsible. Test or exams might include:

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

Possible treatments for chronic pelvic pain include:

• Pain relievers - general over-the-counter pain remedies may provide relief;
• Hormone treatment - some pelvic pain is tied to the menstrual cycle and the hormones the body produces. Stopping ovulation by using birth control pills or other hormone medications may help control cyclic pelvic pain;
• Antidepressants - may manage many chronic pain syndromes as some have pain-relieving as well as antidepressant effects;
• Physical therapy - applications of heat and cold to the abdomen, stretching exercises, massage, or transcutaneous electrical nerve stimulation (TENS) therapy may improve your chronic pelvic pain;
• Counselling - if the pain is a psychological or social problem stemming from sexual abuse, a personality disorder, counselling can be helpful in relieving symptoms;
• Nerve separation (ablation) - sometimes the source of chronic pelvic pain is linked to the complex pathways in the nervous system and procedures to control the pain impulses sent to the pelvic region might reduce or stop the pain. Such procedures include removing (excising) the targeted nerves, injecting a medicine into the nerve to block its sensitivity, or using heat or a laser to destroy nerve tissue;
• Surgery - surgery is sometimes suggested to correct certain underlying problems. For instance, pelvic adhesions or endometriosis deposits can be removed through laparoscopic surgery. Hysterectomy may be an option for several different causes of pelvic pain

Women often find that they need to try a combination of treatment approaches before finding one that works for them.

A new approach to diagnosing and treating chronic pelvic pain

Advances in medical technology now enable a dynamic diagnosis of pelvic congestion in a matter of minutes and a fraction of the cost of other techniques. The device in question injects a water-soluble contrast medium into the uterine cavity and then into lining of the uterus to perform a pelvic venography. This provides physicians with a clear look at what is taking place within the pelvis. Physicians can then measure the amount of time it takes the fluid to travel through the pelvic veins. If the fluid is slow moving, that indicates a possible congestion. From this point physicians continue to track the amount of time it takes the fluid to travel - the longer this takes the higher the severity of congestion. This information allows physicians to fine tune diagnosis and determine the best treatment option for the patient based on the severity of their congestion.

At home prevention methods against chronic pelvic pain

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 their 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 the 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, have been major steps forward in improving quality of life for women world-wide. We hope that Women's Day 2008 will mark even more progress.

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[1] Thakar R, Stanton S; Management of Genital Prolapse. BMJ; 324; 1258-1262.
[2] GyneaCare Women's Health Solutions, POP Fact Sheet, http://www.gynecare.com/content/backgrounders/www.womenhealth.info/www.womenhealth.info/Pelvic_Prolapse_Fact_Sheet.pdf
[3] Thakar R, Stanton S; Management of Genital Prolapse. BMJ; 324; 1258-1262.
[4] http://www.mwri.magee.edu/urogyne/prolapsetreatment.htm
[5] http://www.pphprevention.org/
[6] http://www.patient.co.uk/showdoc/40000261/
[7] http://www.mayoclinic.com/health/chronic-pelvic-pain/DS00571