Thatcher's Thoughts Age related increase in uterine dysfunction during labor

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Index for entries posted 11/21/00:

Lower cholesterol -- lower dementia
Age related increase in uterine dysfunction during labor
Worrisome ovarian cysts

Lower cholesterol -- lower dementia
Title: Statins and the risk of dementia
Author: H. Jick, et al.
Address: Lexington, MA 
Source: The Lancet 356:1627-1631 (November) 2000 
Summary: It is estimated that dementia affects 10% of the population older than 65 years and vascular and lipid-related mechanisms are thought to have a role in the pathogenesis of Alzheimer's disease and vascular dementia. Thus, researchers conducted a study of the potential effect of HMG CoA (3 hydroxy-3menthylglutaryl-coenzyme A) reductase inhibitors (statins) and other lipid-lowering agents on dementia. The study population initially included 3 groups who were 50 years and older. Group 1 consisted of all individuals who had received lipid-lowering agents; group 2 included all individuals with a clinical diagnosis of untreated hyperlipidaemia; and group 3 was a randomly selected group of other individuals. From these three groups, all cases with a computer recorded clinical diagnosis of dementia were identified. Each case was matched with as many as four controls derived from the base population on age, sex, practice, and index date of case. Included in the study were 284 subjects with dementia and 1,080 controls. 13% of the controls had untreated hyperlipidaemia, 11% were prescribed statins, 7% other LLAs, and 69% had no hyperlipidaemia or LLA exposure. Researchers found that individuals 50 years and older who were prescribed statins had a substantially lower risk of developing dementia, independent of the presence or absence of untreated hyperlipidaemia or exposure to non-statin LLAs. However, the available data do not distinguish between Alzheimer's disease and other forms of dementia. 
Comment: This reminds me of a cartoon of a physician looking over his desk and telling a perimenopausal patient, "I'm going to take you off additives and put you on preservatives." An interesting comparison might be made with HRT. Both are needed because of our extended life expectancy and to help extend it. Both have benefits greater than the reason for which they are indicated. Both are associated with unwanted side-effects. It is too early to know the impact of lipid lowering agents on large populations over many years. The frontier of pharmaceutical research is drugs to acclimate our genetic predispositions into our 21st century lifestyle. 

Age related increase in uterine dysfunction during labor
Title: The relationship between maternal age and uterine dysfunction: A continuous effect throughout reproductive life 
Author: D. Main, et al. 
Address: San Francisco, CA
Source: American Journal of Obstetrics and Gynecology 183:1312-1320 (November) 2000 
Summary: This study was undertaken to determine whether there is a continuous effect of maternal age on uterine function. Using a comprehensive computerized database and medical record system, researchers identified 8496 low risk patients who were nulliparous and in spontaneous term labor with singleton fetuses in vertex presentation. Subjects were analyzed according to maternal age for measures of labor dysfunction and rates of operative delivery. The use of oxytocin, duration of second stage of labor, cesarean delivery, cesarean delivery for failure to progress and operative vaginal delivery rates were significantly increased with advancing maternal age. These increases appeared to be continuous functions beginning during the early 20s instead of a new phenomenon beginning after age 35. Researchers concluded that among nulliparous patients with uncomplicated labor there is a continuously increasing risk of uterine dysfunction related to maternal age. 
Comment: On analysis of a large number of studies on the adverse effects of aging on pregnancy and labor, there are three risks that seem to stand out as incontrovertible. There is an increased risk of spontaneous abortion / chromosomal abnormalities and there is an increased risk of C-section. Some have stated this is because of the increased incidence of fibroids and anatomic abnormalities. Others have proposed that there is a greater propensity for the obstetrician to intervene because of perceived risk. When both of these are excluded, C-section rates are still higher and seem to be related to uterine dysfunction. 

Worrisome ovarian cysts
Title: Worrisome ovarian cysts 
Author: W. Gotlieb, et al.
Address: Tel Hashomer, Israel 
Source: American Journal of Obstetrics and Gynecology 183:541-546 (September) 2000 
Summary: Researchers performed a retrospective analysis of ultrasonographic characteristics and CA 125 levels in 91 patients with ovarian tumors of borderline malignancy. In 75% of the patients, serous tumors of borderline malignancy were associated with elevated CA 125 levels, compared with 30% of mucinous tumors. In stage IA serous tumors, CA 125 was elevated in 35% of patients, compared with 89% of tumors that had spread beyond the ovary. Mucinous tumors were larger on ultrasonography than serous tumors. Mucinous tumors were also multilocular in half the patients and contained papillations in 40%. Serous tumors were multilocular in 30%, but presented with solid or papillary patterns in 78%. A resistance index of less than 0.4 was found in 36% of mucinous tumors and half the cases of serous tumors. In 13%, ultrasonographic traits were compatible with a simple cyst, including 1 patient with microinvasion and 1 patient with stage IIIB disease. Sensitivity of gray-scale ultrasonography was 87% that of CA 125 measurement was 62%, and that of flow was 55%. At least 1 diagnostic test result was abnormal in 93%, 2 were abnormal in 69%, and all 3 were abnormal in 21%. A high proportion of borderline tumors of the ovary, particularly of the serous type, were associated with elevated CA 125 levels and abnormal ultrasonographic characteristics, although some tumors presented as simple cysts. 
Comment: The great fear is that a cyst found on ultrasound is cancerous. While this is rare in the woman of reproductive age, it does occur. This study was particularly distressing because some of the borderline tumors and 2 cancers were associated with "simple cysts," i.e. those with a thin wall and none of the usual signs that raise suspicion. Persistent cysts should not be dismissed and a CA 125 seems to be a relatively good 2nd step. 

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