[Women "healthcare" and obstetrics - "thoughts of farewell"]. / Frauen -- "Heilkunde" und Geburtshilfe -- Gedanken zum Abschied.

Medicine, and so within also gynecology and obstetrics is shaped in the process of the last decade by changes of interaction between female-patient and physician in "Arbeitszeitgesetz" (law upon daily working time), the introduction of payment-system an case by case based lump-sums and intrusion (interference) of the political administration into autonomy of medical faculties. The contribution concerns with these prevailing economical required changes, interacting and beyond inter-disciplinarity. The progress in medicine by research is causing potential capacity and secondary costs explosion. Including financing of health service and decisive determinants: the demographic development of society, the change in working sphere and particularly law-dominated prenatal-medicine. This, future of medicine determining political, ethical and legal challenge must be accepted by medical professions. Solutions are pointed out.

[Contraception in young adolescents]. / Schwangerschaftspravention bei jungen Patientinnen.

The continuing increase in teenage pregnancies and abortions calls for more effective sex education on the one hand, including a detailed explication of the (perfectly normal) changes an adolescent body is undergoing, but we also need to understand the way teenagers actually do use contraceptives. Modern contraception for teenagers should not cause any side effects and its efficacy must not be linked to compliance. Gynaecologists must acquaint themselves with the laws covering the prescription of contraceptives to adolescents. Whether hormonal contraceptives for men are also suitable for teenage boys remains to be seen. Advising mentally or physically handicapped teen-agers or those with chronic diseases on their contraceptive options is particularly challenging. Adolescents are more prone to contract HPV infections and thus need to be screened, counselled and told about the association between HPV and cervical dysplasia.

Crash emergency cesarean section: decision-to-delivery interval under 30 min and its effect on Apgar and umbilical artery pH.

PURPOSE: The objective of this study was to investigate the effect of decision-to-delivery interval of crash emergency cesarean section on Apgar and umbilical artery pH in a level-3 university hospital. MATERIALS AND METHODS: In a retrospective analysis, all women undergoing "crash" emergency cesarean section were evaluated. Emergency cesarean sections were performed in the delivery room. Data relating to indication, Apgar score, arterial cord pH, and time intervals between decision-to-deliver and actual delivery were collected retrospectively. RESULTS: All 109 crash emergency cesarean sections were performed within a decision-to-delivery time of 30 min. The median (with 10-90th percentile) time was 10 min (5-19). Thirty-three (30.3%) of the emergency cesarean sections had a gestational age below 32 weeks and 60 (55%) below 37 weeks. An abnormal fetal heart rate pattern was noted in most of the cases (91%). Prolapsed cord (21%) and placental abruption (20%) were the most frequent reasons for emergency cesarean section but in one-fourth (25.7%) no morphological reason could be identified. Very short decision-to-delivery times below 20 min were inversely correlated to fetal outcome, i.e., lower umbilical blood pH and Apgar scores (P < 0.01). CONCLUSION: The 30-min standard for the decision-to-delivery time interval set by Anglo-American countries may be a feasible guideline at least for level-3 hospitals. The 20-min interval set by the German Society of Gynecology and Obstetrics could not be achieved in all cases. The positive effect of very short intervals on neonatal outcome still needs to be proven.

[Contraception and proception--competence of the gynaecologist in the planning of a woman's life]. / Kontra- und Prozeption--Zur Kompetenz des Frauenarztes/der Frauenärztin bei der Lebensplanung der Frau.

Contra- and proception provoke different answers in our country and culture than globally speaking, particularly regarding non-industrialized nations. Contraception should be viewed as a means of preventive medicine, especially as a means of avoiding the psychosocial emergency of an unwanted pregnancy and potentially subsequent pregnancy termination. In this light, contraceptive counselling to teenagers is of particular importance. Reliable contraception does not cause a change of morals but supports and facilitates lifestyle and provides security. This aspect interacts closely with social and family politics. The integration of contraception into a woman's concept of life is decidedly dependent on these circumstances. The gynaecologist is a participant in the development of this concept, particularly for women who initially practice contraception, often in pursuit of a professional career, and later--often too late or perhaps never--bear an only child with maximal intention or potentially even after assisted reproductive medical intervention. The initially desired infertility frequently turns into the unfulfilled desire to bear children. The issues at hand are innovative social and sexual pedagogics that eliminate the separation between career and family. In the awareness of this pedagogic task, gynaecologists participate in the design of a woman's life concept as well as in the demographic change of society.

[Must the postgraduate medical training for specialists of gynecology and obstetrics be reconsidered?]. / Muss die Weiterbildung zum Facharzt Gynäkologie und Geburtshilfe in der Schweiz überdacht werden?

Our specialty is based on a 3-pillared concept. The professional political development again requires a discussion on the separation of 'nonoperating' and 'operating' specialists. In addition, the future model of the 'gynecologist as family doctor for women' becomes an interesting topic. The guidelines for the proceedings in the case of suspect and positive cytological smears of the cervix have been revised with regard to the Bethesda nomenclature and will be published this year.

Primary cervical cancer screening by self-sampling of human papillomavirus DNA in internal medicine outpatient clinics.

BACKGROUND: We determined whether testing of self-collected vaginal swabs for human papillomavirus (HPV) DNA can be used to screen for cervical disease within internal medicine outpatient clinics. PATIENTS AND METHODS: In this prospective study, 560 patients visiting two referral outpatient clinics for internal medicine were asked to take an HPV self-sample. Acceptability of self sampling, HPV prevalence and cervical intraepithelial neoplasia (CIN) detection rate were evaluated. RESULTS: 435 women (78%) performed HPV self-sampling; 1.5% considered self-sampling to be difficult. 134 women (31%) tested positive for high-risk type of HPV. There were significant differences between HPV-positive and -negative women with respect to the following: mean age (42 versus 46 years), number of women aged <16 years at first coitus (35% versus 23%) and history of drug abuse (8.3% versus 2.6%). Colposcopy could be performed for 70 HPV positive women: CIN 1-3 was identified in 24%. Two of 52 women with HPV-negative results undergoing colposcopy had biopsy-confirmed CIN 1. Test performance for detection of CIN 2-3 after correction for verification bias: sensitivity, 100%; specificity, 71%; negative predictive value, 100%; positive predictive value, 10%. HPV persistence was associated with a 5.7-fold risk of CIN 2-3 detection at follow-up. CONCLUSIONS: Self-assessment for HPV DNA is an easy, feasible and well-accepted method for HPV testing and for cervical cancer screening in internal medicine outpatient clinics.

[Current debate on hormone replacement therapy]. / Aktuelle Kontroverse der Hormonersatztherapie.

The American Women's Health Initiative Study was stopped 2 years ago. Last year the British One Million Women Study was published. Both studies led to a critical discussion of hormone replacement therapy. Since then media, scientists and physicians have been discussing pros and cons. There is no agreement so far, but the German Senology Society and the German Society for Gynecology and Obstetrics declared their positions on this issue. The discussion focuses on the association between hormone replacement therapy and breast cancer. In vitro studies showed that estrogens stimulate the epithelium of the breast. Prolonged exposure to estrogens (e.g. early menarche and late onset of menopause) can promote breast cancer. Indications for hormone therapy are climacteric symptoms, prophylaxis of osteoporosis, improvement of cognitive functions as well as prophylaxis of dementia. These indications are discussed in the light of recent studies.

[Neoadjuvant therapy of breast cancer]. / Neoadjuvante Chemotherapie bei Mammakarzinom.

Whereas in the past primary systemic therapy (PST) was rather used for other tumor entities or was limited to the use in inoperable breast cancer, treatment of operable stages is being increasingly investigated. After the proof of equivalency between PST and adjuvant chemotherapy, numerous trials have been conducted. PST enables testing of in vivo chemosensitivity; thus, treatment can be monitored by tumor response. Insufficient responders can be switched to non-cross-resistant concepts to avoid administration of ineffective drugs and try to achieve improvement of survival for these patients. The reduction of tumor size not only increases the rate of breast-conserving therapy, but has predictive value for the further course of the disease. Especially pathohistological complete remission is a good surrogate marker for improved survival and the goal of modern protocols in the preoperative setting. Actively recruiting trials (e.g. trials of the AGO PREPARE and TECHNO) integrate modern concepts of treatment like dose-dense, dose-intensified, sequential therapy and tumor targeting with trastuzumab in PST. Eligible patients should be recruited in ongoing trials to further elucidate the role of PST in primary breast cancer. Evaluation of predictive factors and correlation of therapy response to the genetic profile of the tumor with modern technologies will allow improved selection of patients with increasingly tailored therapy.

[Preterm labour and risk factors]. / Frühgeburt und Risikofaktoren.

Infections, stress and haemorrhages are risk factors in the pathophysiology of preterm delivery. Genital infections can be diagnosed and treated, and thus the frequency of preterm labour is lowered. How psychosocial burdens which are also stress factors can be influenced remains uncertain.

[New developments in hormone replacement therapy]. / Neue Erkenntnisse in der Hormonersatztherapie.

Hormone replacement therapy with estrogen and progesterone does not appear to protect against Alzheimer's disease and does not improve cognitive functioning. Long-term administration of estrogen as monotherapy may be associated with an increased risk of ovarian cancer.

[Uterine fibroids--therapy from the point of view of the gynaecologist]. / Uterusmyome--Behandlungsoptionen aus der Sicht des Gynäkologen.

Uterine fibroids are the most common benign tumour affecting the female reproductive tract, 20% of all women older than 35 years are afflicted. Patients with fibroids tend to be asymptomatic, but fibroids may lead to meno-, metrorrhagia, hyper- and dysmenorrhoea and urination and defecation problems. If the fibroids do not cause any clinical symptoms and if there is no suspicion of a malignant tumor, there is no need for therapeutic intervention. Otherwise, besides the medical management with gestagenes and GnRH (gonadotropin-releasing hormone) analog, surgery represents the classical treatment. Hysterectomy is the common approach for women with completed family planning. For women who wish to conserve their fertility enucleation of the fibroids can be considered. These surgical procedures can be performed endoscopically or abdominally. Uterine artery embolisation, a radiological intervention, is less invasive and represents an interesting therapeutic alternative.

[The Gynecologic and Obstetric Review (Gynaekologisch-geburtshilfliche Rundschau) faces a new challenge!]. / Die "Gynäkologisch-geburtshilfliche Rundschau" steht vor einer neuen Herausforderung!

The Austrian Society of Gynecology and Obstetrics gave notice of organ membership and at the same time of the compulsory subscription to the Gynecologic and Obstetric Review/ Gynäkologisch-geburtshilfliche Rundschau in favor of a journal oriented more towards professional politics. Thus ends a long-standing international tradition. This also means a new challenge for the Gynecologic and Obstetric Review/Gynäkologisch-geburtshilfliche Rundschau.

[Child and adolescent gynecology. Introduction to the focal topic 'Child and adolescent gynecology']. / Kinder- und Jugendgynäkologie. Einführung zum Schwerpunkt <>.

Valuable knowledge from the subspecialty of child and adolescent gynecology is of considerable importance for the clinically active pediatrician and gynecologist. Focal topics such as sexual violence to children and young adults, undesired pregnancies and pregnancy termination should not only be made known in the media, but also to specialists, so that successful prevention and treatment can be carried out. Furthermore, endocrinological problems and genital malformations in adolescence should be detectable and treatable.

[Abnormalities of external and internal genitalia]. / Fehlbildungen des äusseren und inneren Genitales.

The gynecologic examination of the female genitalia of children and young adults belongs in the hands of specialists and should be performed in the appropriate environment. The most important task of such an examination is the distinction between true developmental anomalies and anatomical findings mimicking such anomalies. Even newborn females can be successfully examined without any large effort expenditure. In most cases, the external inspection of the vestibule is enough to reach a diagnosis. In other case scenarios, vaginoscopy and gynecological speculum examination may be necessary. Additional imaging studies include abdominal sonography and magnetic resonance imaging. Normal variations of a child's hymenal membrane, fusion of the labia minora, hymenal polyps and hypertrophy of the preputium of the clitoris are the entities most likely to be mistaken for real developmental malformations. The most important asymptomatic developmental anomaly of the vagina and the uterus is the Mayer-Rokitansky-Kuster-Hauser syndrome (uterine and vaginal agenesis). Developmental malformations, such as hymenal atresia, vaginal septum formation and Millerian anomalies in general, tend to be symptomatic, presenting with hematometra, hematocolpos or dysmenorrhea. The treatment of genital developmental anomalies is generally not difficult but requires the appropriate clinical and surgical expertise.

Cancer in pregnancy: maternal-fetal conflict.

The occurrence of malignancies during pregnancy has increased over the last decades. They complicate approximately 1 per 1000 pregnancies. The most common malignancies associated with pregnancy include malignant melanoma, malignant lymphomas and leukemia, and cancer of the cervix, breast, ovary, colon and thyroid. Since it is impossible for prospective randomized clinical trials to be conducted in this field, relevant data have been generated from case reports and matched historical cohort studies in order to evaluate the treatment outcomes and the issues complicating the management of malignancy in the pregnant patient. There is almost always a conflict between optimal maternal therapy and fetal well-being. The maternal interest is for an immediate treatment of the recently diagnosed tumor. However, the optimal therapy, be it chemotherapy, radiotherapy or surgery, may impose great risks on the fetus. Consequently, either maternal or fetal health, or both, will be compromised. Therefore, both the pregnant patient and her physician are often in a dilemma as to the optimal course. On the basis of the medical facts, we discuss the issues raising potential ethical conflicts and present a practical ethical approach which may help to increase clarity in maternal-fetal conflicts. We review the available data informing the incidence and impact of the most common malignancies during pregnancy and their treatment on both the pregnant woman and her fetus. The optimal therapy for the tragic diagnosis of cancer in pregnancy requires a collaborative and interdisciplinary approach between gynecologists, oncologists, obstetricians, surgeons, neonatologists, psychologists, nursing staff and other disciplines. The purpose of this article is not to answer specific questions or to construct management schemes for specific tumors but to provide a framework for approaching some of these complex issues.

[Anti-aging or better aging: a contribution to the prevention of aging?]. / Anti-Aging oder "Better Aging"--Ein Beitrag zur Alterungsprävention?

Anti-aging wants to influence the quality of the second half of life so that chronic damage to health can also be prevented at a higher age with a good quality of life. Thus, molecular biological tests should become the basis for an individualized, preventive hormone therapy. In this context, the question arises whether for each woman in the menopause a risk profile of disturbances of hormone metabolism can already be recognized in her pattern of polymorphisms, although scientific evidence has been lacking until now. Even the topic of the adrenopause, which--among other features--is characterized by an age-specific, partial adrenal insufficiency, must not be neglected in the context of the problem of anti-aging.

Chemosensitivity testing in gynecologic oncology--dream or reality?

Cell culture and animal models have played an essential role in the research of new principles of therapy. Many methods for the individualized testing of therapy sensitivity and resistance have been developed, for example, the clonogenic assay. Presently, the ATP-TCA is commercially available as a testing kit. This review gives an overview of the tumor samples that were tested in the oncologic laboratory in the Department of Obstetrics and Gynecology, Munich Grosshadern between 1993 and 2001. All target parameters show a clear trend in favor of sequential, dose-intensified Epirubicin/Paclitaxel therapy. If this trend remains valid for the total number of patients, a significant impact of this new principle of therapy can be expected. By individualized planning of therapy with ATP-TCA testing, therapy in the individual patient could already be performed by the examination of sensitivity in the preoperative biopsy specimen.

[Science and law in assisted reproductive medicine -- two sides of the same token]. / Wissenschaft und Recht der Reproduktionsmedizin -- zwei Seiten einer Medaille.

The topic of assisted reproductive medicine (ART) illustrates the two-sidedness of all medical advances. It encompasses not only a responsibility for research, but also a responsibility to research. Current discussion revolves around the central question whether an all too strict interpretation of the German 'Embryonenschutzgesetz' (law to protect the embryo) with the resulting medical guidelines hinders the establishment of an ART practice corresponding to international standards. Current discussion, particularly in view of a new ART legislature in process, leaves the following topics open to debate: heterologous oocyte and sperm donations and a possible 'split' parenthood, the marital status of prospective couples and the serious clinical problem of multiple-gestation pregnancies. The technically feasible frequently surpasses what can or should ethically and legally be made possible.

[Primary hyperparathyroidism with persistent hypercalcemia in pregnancy]. / Primärer Hyperparathyreoidismus mit persistierender Hyperkalziämie in der Schwangerschaft.

Parathyroidectomy is effective in avoiding complications of primary hyperparathyroidism (pHPT) during pregnancy, because in about 90% of cases, it is caused by parathyroid adenomas. We present a case of severe pHPT during pregnancy of unknown etiology and without detectable parathyroid adenoma so that surgery was not a therapeutic option. The patient was a 29-year-old gravida 1 who presented with pHPT at 11 weeks of gestation. Although her serum calcium levels were elevated throughout pregnancy (>3.05 mmol/l; reference range: 2.05-2.65), a vigorous premature infant was delivered at 35 weeks of gestation. The infant received calcium intravenously, vitamin D(3) orally and was fed with raw human milk (low phosphorus) to prevent hypocalcemia. The baby did not develop clinical signs of hypocalcemia. Her initial parathyroid hormone level was suppressed (1.1 pg/ml; reference range: 15-65) and was normal at the age of 8 weeks. She was discharged from hospital at 14 days of life. Her physical, cognitive and motor development was normal through infancy and early childhood. In conclusion, pHPT during pregnancy does not necessarily lead to fetal or neonatal morbidity or mortality.