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Women's Health Update

edited by Sandra Coney

 

 

Women's Health Update Vol 6 no 1 - 4 2002 - 2003

Contents

vol 6 no 1 April 2002

vol 6 no 2 July 2002

vol 6 no 3 October 2002

vol 6 no 4 January 2003

Will vaccination end cervical screening?

Sandra Coney reports on recent advances in the development of a vaccine against cervical cancer and the New Zealand connection in ongoing research.

For over two decades it has been known that five particular strains of human papilloma virus (HPV) are closely associated with cervical cancer. HPV-16 is one of the main culprits - this strain is present in half of all cases of cervical cancer. About 20 percent of adults are infected with HPV-16.
The recent breakthrough was announced by US researchers, led by Dr Laura Koutsky of the University of Washington in Seattle. They reported in the New England Journal of Medicine that vaccination reduced the incidence of both HPV-16 infection and HPV-16 related cervical intraepithelial neoplasia (CIN). (see below) They predicted that Œimmunising HPV-16 negative women may eventually reduce the incidence of cervical cancer.ı
The researchers hope that the vaccine will eventually cover other HPV sub-types, especially 18, which together with 16, accounts for 70 percent of cervical cancer cases for which the viral aetiology is known. It will hopefully also cover types 6 and 11 which are responsible for the majority of cases of genital warts.
In an editorial accompanying the paper, Dr Christopher Crum of the Brigham and Womenıs Hospital in Boston elaborated on the potential of the discovery. ŒThe HPV-16 vaccine not only prevents the disease from developing, but also prevents its causative agent from residing in the genital tract where it can infect new sexual partners. If women were vaccinated against these five types of HPV before they became sexually active, there should be a reduction of at least 95 percent in the risk of cancer and a decline of 44 percent to 70 percent in the frequency of abnormal Papanicolaou smears attributable to HPV. Because the more pernicious cancers appear most often with HPV-16 and HPV-18, the level of protection from death due to cervical cancer could exceed 95 percent.ı This is the best possible scenario but one that may be difficult to achieve in practice. Dr Brian Cox, chair of the New Zealand Cancer Control Trust, cautions that Œit is a small trial, which needs to be confirmed. It is good news if it can be developed, but anyone already exposed to the virus will still need cervical screening.ı Unless the vaccine could protect against all the viral types associated with cervical cancer, vaccination would still need to be accompanied by regular cervical smear tests.
ŒIt depends on whether you want to simply protect women against cervical cancer or whether you want to eliminate the disease,ı says Dr Cox..ı The safety of women who are not vaccinated may be better protected by vaccinating men.ı
Eliminating HPV from the population will be difficult when it is not intended to vaccinate boys or men. Dr Sue Bagshaw, a Christchurch consultant in adolescent health, says the decision was made to promote the vaccine as a prevention for cancer, rather than sexually transmitted diseases, so that it is not obviously as relevant to the male sex. But without vaccination, men could infect unvaccinated women or other men. Some anal cancers are caused by the same viral types as cause cervical cancer.

The New Zealand connection
Two of the study sites for a multicentre, international extension of the HPV-16 study are in New Zealand. Dr Helen Roberts is leading the Auckland site which plans to enrol 200 women and Dr Sue Bagshaw the Christchurch site with 100 women to enrol. Internationally 5000 women will be enrolled. The vaccine being used aims to protect against HPV-16 but also 18, 6 and 11. Women who are enrolled are aged between 16 and 23 years and must have had at least one but less than five sexual partners, although they do not need to be sexually active during the study. The American principals were sensitive to potential accusations that an invitation to take part in the study might prompt women to initiate sex.
Enrolment began in July and the study will last four years. Participants will have 11 visits and three injections during that time. The study is looking at the safety of the vaccine ­ so far the main problem has been redness at the injection site ­ as well as acquisition of genital warts, HPV or cervical cancer precursors.
Although Dr Roberts emphasises that the trials have a long way to go, she sees a time when the vaccine could help in reducing the incidence of cervical cancer. ŒA decade hence, it could well be something thatıs offered to young women when weıre giving their rubella injections, before they are sexually active.ı
That may need to be around the age of 11 as a third of New Zealand girls have sex before the age of 16.
Dr Bagshaw agrees that informed consent will be an issue: ŒSome 11-year-olds will have the maturity to cope, but for others it would be difficult.ı
Many questions are raised by the study. How long will immunity from a single set of injections last? What if a woman doesnıt finish the course? How often will women need Œboosterı shots?
Even more vexed are questions which arise from the sociopolitical context around cervical cancer. Vaccination brings to the fore the issue of sexual transmission of HPV infection. Will there be resistance to a vaccine because of the behavioural implications of accepting it? Are there social implications of immunising girls and young women before they have had their first sexual partner?
While such questions are being addressed, conventional screening will still be the mainstay of protection against cervical cancer.

The cervical cancer vaccine study results

The double-blind study randomly assigned 2,392 women between 16 and 23 years old to receive three doses of placebo or an HPV-16 virus-like particle vaccine, and followed them for approximately 17 months. The primary end-point was persistent HPV-16 infection, defined as the detection of HPV-16 in samples at two or more visits. In the vaccine group, 99.7% developed anti-bodies to the virus. In the placebo group, the incidence of persistent HPV-16 infection was 3.8 per 100 woman-years compared to 0 in the vaccine group. All nine cases of HPV-16­related CIN occurred among placebo recipients.
Reference: NEJM 2002; 347:1645-51

Smoking and breast cancer risk

Smoking has previously been excluded as a risk factor for breast cancer but new research throws that belief into doubt.
A Canadian study found that the risk of breast cancer was 70% higher, compared with age-matched controls, in women who had ever been pregnant and who started to smoke within five years of their first period. Women who had never been pregnant and who smoked heavily showed a seven-fold increased risk of breast cancer.
The effect of cigarette smoking on the risk of breast cancer depends on womenıs age when they start smoking. The researchers concluded that breast tissue is most sensitive to cigarette smoke carcinogens during puberty when breast cells are growing rapidly or in women who have never been pregnant, as their breast cells never completely differentiate.
The study sent questionnaires to all women under 75 diagnosed with breast cancer in the year to 30 June 1989 and listed on the British Columbia cancer registry. They were compared with randomly selected controls with no history of breast cancer. They answered questions on smoking, alcohol con-sumption, age at menarche, pregnancy, breastfeeding, use of contraception and HRT, family history of breast cancer and lifetime occupation history.
In contrast, postmenopausal women whose weight increased after 18 and who started to smoke after a first full-term pregnancy had a significantly lower risk of breast cancer. This may be because high levels of oestrogen are associated with risk of breast cancer; weight gain increases production and cigarette smoke compounds reduce it.

Reference: Lancet 2002; 360: 1044-9; BMJ 2002;325:793

Have your say on an Action Plan for New Zealand women

A new Ministry of Womenıs Affairs initiative is an opportunity for women to set priorities for action to improve the status of New Zealand women. Over 300 woman attended the launch of the development of an action plan for women, held in Wellington in early December. Womenıs Affairs Minister Ruth Dyson released a discussion document, Towards an Action Plan for New Zealand Women, about which New Zealand women will have their say over the next three months.
The document is based on previous consultations with women and womenıs organisations, work of various government departments, consultations on the 5th CEDAW report and advice of Te Korowai Wahine, a Maori group that advises womenıs affairs.
Three key themes for women are highlighted in the discussion document:

  • economic sustainability, including adequacy of income, access to education and paid employment, employment outcomes
  • balancing work, family and community responsibilities, including caring for children and other dependants and building strong communities
  • general well-being, including health, safety from violence, adequate housing, and special needs of different groups of women.

The plan will identify a clear vision, set of goals and framework for action to improve womenıs lives. The Ministry is seeking agreement on priorities. The Ministryıs planned womenıs health strategy will now become part of the overall Action Plan.
At the launch Ruth Dyson noted that Œin spite of the progress we have made over past years, the future continues to pose challenges for New Zealand women. There are still inequalities between women and menŠand between different groups of women. We need to recognise them. We need to recognise the special place and role of Maori women, as tangata whenua and as the heart and soul of their whanau, hapu and iwi.ı
The Ministry of Womenıs Affairs is working with the National Council of Women and Maori Womenıs Welfare League to develop a consultation process and run meetings on the discussion document around the country in February and March.

How can you take part?

You can:

  • Get a copy of the discussion document: Towards an Action Plan for New Zealand Women. This is available in a summary or longer version. Online versions are at www.mwa.govt.nz
  • Get a consultation kit that provides information to help you set up a meeting.
  • Attend a meeting in your community in February and March. Details here.

How can you get information?
You can get information from the Ministry of Womenıs Affairs, PO Box 10049, Wellington, telephone (04) 470 6570, fax (04) 4706784, email action@mwa.govt.nz.

Launch of cancer control discussion document

On 5 December Health Minister Annette King released for consultation Towards a Cancer Control Strategy for New Zealand, a discussion document that will provide the basis for a New Zealand Cancer Control Strategy. The consultation process, to be held until mid-March 2003, aims to seek informed comment, highlight any gaps and identify which organisations should be actively involved in implementing the strategy. The final strategy is expected to be ready by June 2003.
The impetus for the strategy came from a National Cancer Control Workshop held in 1999 at which a wide range of participants including academics, Cancer Society, clinicians and others working in the cancer field and consumers unanimously endorsed the need for such a strategy. New Zealand lags behind other countries in not taking a coordinated approach to cancer control. Recent research released earlier this year showed that if Australian rates were applied to New Zealand, 200 fewer men and 600 fewer women would die from cancer each year.
Work on the discussion document has been gaining momentum since late last year when a Steering Group was formed to oversee development of the strategy following a commitment from the Minister of Health. The group is a partnership between the Ministry of Health and the New Zealand Cancer Control Trust which was set up with funding from the Cancer Society of New Zealand and the Child Cancer Foundation. So far the two agencies have invested nearly $500,000 in the strategy development process through their support of the Trust.
Earlier this year five Expert Working Groups were established to identify and recommend priorities for the strategy. The five groups covered prevention, screening and early detection, treatment, support and rehabilitation and palliative care.
Towards a Cancer Control Strategy for New Zealand will be distributed widely and will be posted on the Trust (www.cancercontrol.org.nz) and Ministry of Health (www.moh.govt.nz) websites. You can make written submissions or attend a consultation forum. These forums are likely to begin in early February and may continue until the end of March. A timetable and list of locations for the forums is being developed and will be posted on the Ministry and Trust websites.
Also on the Cancer Control Trust website are the membership of the Expert Working Groups and the Steering Group, along with Expert Working Group priorities for the strategy.

New advice limits HRT use

Sandra Coney outlines New Zealand responses to the results of the Womenıs Health Initiative study of long-term use of HRT.

Long-term use of combined hormone replacement therapy is not recom-mended, says new advice from the New Zealand Guidelines Group HRT working party. The updated advice reflects the findings of the Womenıs Health Initiative study in the US, which was stopped early in July. Women using oestrogen plus progestogen therapy had an increased risk of breast cancer, blood clots, stroke and coronary heart disease (CHD) and these risks outweighed the benefits of fracture reduction and reduced risk of colorectal cancer (see box below).
The advice says there may be limited circumstances where long-term use may be considered, such as women at high risk of osteoporosis who cannot tolerate other medications and who are at low risk for heart disease. Any women contemplating combined HRT should be fully informed of the risks.
Dr Helen Roberts, chair of the HRT guideline group, says the advice was well received at the recent GP conference in Rotorua. ŒQuite a few GPs had picked up on the cardiovascular story from the guideline last year so they were not amazed. Mostly the response was that we are making sense.ı
Similar advice has been issued by the Ministry of Healthıs Medicines Adverse Reactions Committee (MARC). (See below). Medsafe has sent both the NZGG and MARC advice to all doctors, pharmacies and hospital specialists. MARC says there are few circumstances where HRT should be used for more than 3-4 years.
Medsafeıs Dr Stewart Jessamine says that the time limit was chosen Œbecause thatıs the break point where the risks of breast cancer increased to a point where the risks outweighed the benefits. That occured somewhere between three and five years.ı
Such a short timeframe would not be useful for preventing osteoporosis. Medsafe is now looking at whether it should change its HRT indications with regard to osteoporosis and will convene an expert panel. Prevention of heart disease was removed as an indication in 2001.
Both the MARC advice and that of the NZGG group state that combined HRT should only be used for troublesome hot flushes and night sweats that are disrupting a womanıs life. The NZGG groups says that women need to be informed that even short-term use is associated with an increased risk of blood clots, stroke and CHD.
WHI investigator Dr Deborah Grady says there is Œno completely safe period - the risks appeared pretty much right away.ı She says that in her own practice ŒI get them to try and quit once a year to see about symptoms, they might have disappeared.ı
Dr Roberts says that local GPs are seeing quite a few long-term users of HRT who are not sure why they are using it. GPs also report that some women are having a return of hot flushes when they try and stop. The New Zealand advice is that women coming off HRT should be advised to withdraw from it over a period of 6-12 weeks or even longer to avoid rebound flushes. If mild flushes reappear these may be self-limiting and disappear. The oestrogen-only arm of the WHI trial is continuing. Although the WHI investigators have written to women in the oestrogen-only group twice warning of more heart attacks and strokes in those receiving treatment, Dr Grady says ŒWe donıt know how oestrogen-only affects risks. There are 6,000 less women in that part of the trial, so it will take longer to collect events.ı
But the NZGG warns that there is existing evidence of increased risks of venous thromboembolism , breast cancer (after five years), and possibly ovarian cancer in women on oestrogen. Results of this arm of the WHI trial are due in 2005.

For further information about HRT

Advice on HRT from Medicines Adverse Reactions Committee of Ministry of Health

  • Combined HRT should normally be used only where menopausal symptoms are disruptive to the quality of life of the woman;
  • HRT should not be used for the primary or secondary prevention of coronary heart disease or stroke;
  • In most circumstances, the risks of long term treatment outweigh the benefits and combined HRT should not be used for longer than 3-4 years;
  • Oestrogen-only HRT increases the risk of breast cancer and venous thromboembolism to a similar extent as combined HRT;
  • All prospective and current users of HRT should be advised of the risks and benefits of oestrogen and progestogens;
  • The need for continued treatment with HRT should be reviewed at the womanıs next visit to her General Practitioner and thereafter on a yearly basis.
Adverse event
Relative Risk HRT vs placebo at 5.2 years (95%CI)
Change in number of adverse events per 10,000 women in one year
Breast cancer
1.26 (1.00-1.59)
8 extra
Heart disease
1.29 (1.02-1.63)
7 extra
Stroke
1.41 (1.07-1.85)
8 extra
Pulmonary embolism
2.13 (1.39-3.25)
8 extra
Colorectal cancer
0.63 (0.43-0.92)
6 fewer
Hip fracture
0.66 (0.45-0.98)
5 fewer

Warrior princess in stunning new role

Cordelia Lockett reports on the New Zealand campaign during World Breastfeeding Week.

When Women's Health Actionıs breastfeeding advocate Sian Burgess decided on Lucy Lawless to front the World Breastfeeding Week campaign in August, she was in for a bit of a shock. ŒI wanted a high-profile poster, so I thought, whoıs famous and is breastfeeding? I came up with a few names with Lucyıs as the biggest. But I didnıt realise quite how big! The response has been huge - from around New Zealand but also from Australia, the States, even Europe.ı
The classic madonna and child pose of Lucy Lawless breastfeeding her baby on the edge of a chair, exudes a Renaissance painterly beauty. But read the tagline below, ŒBreastfeeding - my best role everı and itıs utterly contemporary- bang in the middle of twenty-first century celebrity stardom.
The poster was distributed widely to maternity providers and other health professionals, secondary schools, DHBs, childcare centres and community groups.
While the response was largely positive, it provoked some controversy. A few people questioned the combination of breastfeeding and sexy sophistication.
ŒIt challenges the dominant media imagery of the breastı, explains Sian. ŒWe are saturated with sexual images of the breast on billboards, TV, in magazines, but here we have an image of a breast being used as nature intended it. Even just seeing a photo of breastfeeding is unusual in our culture and for every one breastfeeding image, there are 250 images of bottles and artificial feeding. In this environment a photo of a well-dressed woman breastfeeding her healthy, well-fed baby (and Xena the warrior princess whatıs more), is a political act.ı
During its development, the poster was pretested with members of the target audience (young women aged 15-35 years). Sian was delighted that the group had picked up on the intended messages, demonstrated in responses like - Œshe makes breastfeeding fashionableı, Œshe makes you think you donıt have to stay home to do itı and ıshe looks like sheıs enjoying it.ı Another part of the World Breast-feeding Week campaign infiltrated cafes and other public places young women go. Free postcards promoted the superiority of human milk for human babies and challenged the acceptance that cowsı milk formula is equivalent to breast milk.
But surely everyone knows breast is best these days?
ŒYes and noı says Sian. ŒThe benefits of breastfeeding are indisputable. But while 98% of pregnant women say they want to breastfeed, by the time the baby is six months old, only seven percent are exclusively or fully breastfeeding. The social deterrents are overwhelming. Currently there is insufficient support for women to continue to breastfeed.ı
Sian advocates a range of affirmative actions to change social attitudes towards breastfeeding including:

  • Extending Paid Parental Leave to at least six months to enable exclusive breastfeeding for that period.
  • Encouraging family friendly workplace practices, such as paid breastfeeding breaks, to enable women to continue breastfeeding when they return to work.
  • Promoting positive social attitudes towards women who breastfeed in public.
  • Creating a community where mothers are supported and encouraged to continue breastfeeding their infants beyond the first few weeks.

I asked Sian if she thought she might do something a bit more low-key for next yearıs campaign. ŒI want to do something even bigger and better next year - something really extraordinary. I just havenıt thought of it yet.ı

2002 World Breastfeeding Week (1-7 August)

The week is celebrated in more than 120 countries worldwide and launches the theme for the rest of the year. This yearıs World Breastfeeding Week theme - ŒHealthy Mothers, Healthy Babiesı - links breastfeeding with womenıs health.

Breastfeeding benefits for mothers include:

  • Significantly reduced risk of breast cancer
  • Reduced risk of the most common form of ovarian cancer
  • Contraceptive benefit for 6 months after childbirth (up to 98% if the mother is exclusively or fully breastfeeding, her periods have not returned and she has no spotting or bleeding)
  • Faster recovery from childbirth - less bleeding and less likelihood of anaemia
  • Quicker return to pre-pregnancy weight.

Celebrating Whaea

A new Maori language CD speaks about the powerful experiences of birth, breastfeeding and motherhood. Camille Guy talked to its creator, Ariana Tikao.

For Christchurch singer and composer, Ariana Tikao, the experiences of childbirth and motherhood were powerful and life-changing. ŒWhen I became pregnant I realized that there is a lot of expectation that life doesnıt change much,ı says Ariana. ŒThere is not much appreciation that motherhood is a job.ı
For Ariana and her partner Ross, motherhood deserved more honouring than that. When Ariana was first hapu (pregnant), they began to read and research Maori approaches to pregnancy and birth. As part of Maori kaupapa about birth, Ross learned an oriori or traditional chant, spoken at the moment of birth. Oriori (lullaby) refers to the genre of waiata for birth.
Ariana found an oriori written by Keri Kaa. ŒIt contains lovely images about talking to the baby as it is being born,ı says Ariana.
She wrote to Keri Kaa for permission to record the oriori for her album, Whaea ­ a term which means motherhood. The album explores a personal journey of identity (Mihi), love (Hoa Rakatira) and then various stages of welcoming a new babe into this world (Whaea, Oriori, Ukaipo and Whenua ki te Whenua). It contains a plea for women to stand up and be strong (E Hoa). The way Ariana puts it, Whaea acknowledges the goddesses in our culture that look after women.
ŒThe womb is the whare takata or house of the people,ı says Ariana. ŒSo there is a need to protect your body and the womb in particular. There is a challenge to the men to come on board, to help the women to fulfill the role of motherhood.ı
In the song, Ukaipo, the first verse addresses Papatuanuku, mother of the people and provider of sustenance. The second verse talks about breastfeeding and the power of breast milk as the best food for healthy children.
Whaea is Arianaıs first solo album. Musically it draws upon contemporary styles such as hip-hop and dub but with a strong emphasis on Maori chant and traditional sounds. It also features many taoka puoro, traditional Maori instruments, played by Richard Nunns.The album is entirely in te reo Maori. An accompanying booklet includes both the Maori lyrics and detailed explanations in English.
ŒI do want the thoughts to be accessible,ı says Ariana.
She and Ross speak Maori at home with daughter Matahana, three, and son, Tama-te-ra, 17 months. Her strong family life continues to inspire music.
One of the songs on Whaea, Whenua ki te Whenua, has been chosen for a compilation of Australasian music. Whenua was inspired by the burial of the childrenıs placentas on old family land at Banks Peninsula.
Now 31, Ariana came to music through writing and experience in choirs and cultural groups. In 1993 she was one of the founders of the all women group Pounamu.
Whaea can be purchased in music stores or ordered through the website www.maorimusic.com

New appointments for screening programmes

The current chief executive of the National Health Committee, Dr Ashley Bloomfield, has been appointed to the position of Public Health Leader for Screening Programmes. Dr Hazel Lewis has been appointed to the position of Clinical Leader for the National Cervical Screening Programme while Dr Madeleine Wall has been appointed Clinical Leader for BreastScreen Aotearoa. All three roles are newly established positions.
A clinical head of the National Screening Unit was recommended in the report of the Gisborne Inquiry. Dr Bloomfield will work alongside Karen Mitchell, the manager of the NSU.
The two clinical leader positions were recommended by Dr Euphemia McGoogan, the Scottish cytopathologist who is providing periodic external review of progress in implementing the Gisborne recommendations.
Dr Ashley Bloomfield is a public health physician with hospital and general practice clinical experience. Before taking up the NHC position he was Executive Director of the New Zealand Guidelines Group.
Dr Hazel Lewis is a public health physician with a special interest in womenıs health, in particular sexual and reproductive health, and has worked in both the provider and policy areas. She currently holds the position of National Advisor, Public Health for the New Zealand Family Planning Association.
Dr Madeleine Wall is of Te Rarawa, Te Aupouri and Ngati Maru descent. She is a radiologist and has been Clinical Director for BreastScreen Central since the start of the programme in December 1998.

Womenıs voices shape action plan on violence

Jo Fitzpatrick reports on newly released research that uses womenıs experiences to develop strategies on ending abuse

Dr Jennifer Hand, principal researcher in a ground-breaking study of violence against women in New Zealand families, believes it is time for action: 'I believe we are at a point in New Zealand history where we are not only heartily sick of the violence around us but are prepared to do something about it.' The study, Free From Abuse: What women say and what can be done, is designed to provoke action.
The inspiration for Free From Abuse was the stories public health promotion workers heard from abused women and the agencies working with them. The women in the study had all made the journey away from abuse and they identified the elements that assisted and supported them as well as the things that got in their way.
ŒThis research builds on what has gone before to establish, in a systematic and scien-tific manner, the need for action and the direction that action should take, Œsays Dr Hand. ŒThe women at the heart of the research are our best guides to what should be done. They have shown us how we can better protect women in danger and assist them to recover.ı Maori, general and Pacific streams worked autonomously under one research umbrella, but research work and decisions were placed in the hands of women from the same culture as that being studied. Separate Maori and Pacific reports are available.
The author of "Te Whanau Korowai" the Maori stream was Hine Rauwhero (Tainui, Raukawa ki te Kaokaoroa) who was supported by both rural and urban organisations within her iwi. The poster "Te Kotahitanga o te Whakapapa" provides a pictorial image of the consequences of family violence and of actions which will rebuild the strength of whanau, hapu and iwi and build vitality through whakapapa connections.
The Pacific stream was led by Luisa Falanitule (Nuie). Posters for Pacific communities feature families and women of all ages living free from abuse.
The three streams are brought together in Free From Abuse: What women say and what can be done. Principal author, Jennifer Hand, has had overall responsibility for this first publication from the ŒFrom abuse to family strengthı research project - funded by the Health Research Council and conducted under the auspices of the Public Health Promotion Service of Auckland Healthcare Services.
Free From Abuse advocates a community and whole-government approach to the elimination of violence and, in particular, the abuse of women. A consistent and sustained campaign of debate, action and change is needed.
ŒThe aim of the research,ı says Dr Hand, Œis to shift the balance of responsibility from individual women to society as a whole.ı
Free From Abuse identified five key areas for action - material and financial support; the criminal justice system; the health sector; education and information; and the social environment. Recommendations are made in each area and deal with responsiveness and cultural relevance. They are addressed to the Government, NGOs, community and professional groups and to many government departments and agencies.

The full report is available on the Public Health website: http://www.akhealth.co.nz/akphp/Women_Healthfree_from_abuse.htm and on CD and in hard copy from: Public Health Promotion, Auckland DHB, PO Box 41 200, Auckland. Phone 09 845 0950, fax 09 845 0951. For more information email Dr Jennifer Hand: jennifer@adhb.govt.nz
The 20-page Maori report, and the 18-page Pacific report are available as stand alone publications.

The women in Free From Abuse identified the following areas for change:

  • Easy access to information on resources, rights and services available to women
  • For Maori, by Maori whanau-focused interventions and programmes
  • Refuge and referral services that emphasise cultural sensitivity and dignity
  • Family violence education in training programmes for health, social and community workers and police
  • Practical and emotional support from friends and whanau
  • Pacific women wanted better communication among family members and awareness and discussion of the issue in their communities.
  • Doctors and nurses to be trained in domestic violence issues and to ask patients if they are being abused
  • Public education campaigns that identify abuse and state clearly violence is wrong
  • Public information that explains the impact of psychological abuse and threatening behaviour
  • Prompt response by police at times of crisis and consistent enforcement of protection orders
  • Assistance with practical and mental preparation for leaving and separation
  • Faster resolution of legal challenges to property and custody rights
  • Adequate provision of material resources
  • Interactions with WINZ that demonstrate respect and acknowledge that women escaping violence are seeking help in a state of crisis and are experiencing high levels of fear and anxiety
  • A network of support available before and after separation
  • Practical, financial, counselling and social support of sufficient duration for recovery
  • Community acknowledgement of their grief, including an extension of the length of time it is socially acceptable to mourn losses
  • Assistance to reconnect to communities after they have separated.

Donıt start, do stop, for HRT?

Longer follow-up from the HERS study provides more bad news about hormone replacement therapy. After the first four years, HERS had shown an early increase in heart events in the study participants, women with coronary heart disease (CHD), but the effect levelled out at the end of the period. There was speculation that over a longer timeframe benefits might emerge, leading to the slogan ŒDonıt start, donıt stopı.
But after another average 2.7 years follow-up of some study participants, no benefit emerged in the study, called HERS II. There was also no reduction in strokes among users of HRT.
There had been some theorising that the women who had more CHD events in the first year of using HRT came from particular sub-groups with special risk factors, medication use or other factors. But HERS II found that even when sub-groups were looked at, the picture was the same. HRT did not lower the risk of CHD events.
A second HERS II study looked at non-cardiovascular diseases. It found that the risk of venous thromboembolism (VTE) in users of HRT doubled over 6.8 years and there was a 50 percent increase in biliary tract surgery. Trends in other disease outcomes were not favourable either. The women in the HRT group had more hip fractures and more of some cancers than the control group, though these results were not statistically significant. The study team called for more research to clarify this.
These poor results are being mirrored in early results from the Womenıs Health Initiative or WHI study, which is looking at whether HRT prevents disease in well postmenopausal women. Early results show increased risk of VTE, heart attacks and strokes among women on HRT. The HERS II results indicate that it is unlikely these risks will turn into benefits over the longer timeframe of the study.

References:
Grady, et al (2002) ŒCardiovascular disease outcomes during 6.8 years of hormone therapyı JAMA 288:49-57
Hulley, S, et al (2002) ŒNoncardiovascular disease outcomes during 6.8 years of hormone therapyı JAMA 288: 58-66 Petitti, D (2002) ŒHormone replacement therapy for preventionı JAMA 288: 99-101

Cervical cancer audit underway

The Cervical Cancer Audit recommended by the Gisborne Inquiry is now going out into the community to contact women. Penny St John reports.

Rhondda Kerins gave up a position as director of midwifery at South Auckland Health to take up a six-month contract as a case coordinator for the cervical cancer audit. People from clinical research backgrounds and social workers also responded to the advert-isements calling for applicants to interview women with invasive cervical cancer. In fact there were 140 applic-ations for these positions, with many applicants saying they wanted to take part in something that was an important public service. In Rhondda Kerins' case, she felt cervical cancer is preventable and being involved in the audit would be an opportunity to make a difference.
The audit will initially involve interviews with about 350 women who developed invasive cervical cancer between 1 January 2000 and 30 September 2001. Another 200 women diagnosed with cervical cancer between 1 October 2001 and 30 September 2002 will be contacted between December 2002 and June 2003.
A Ministry of Health team as well as University of Auckland researchers aim to interview and review the clinical histories of these women. Project Manager Ruth Herbert is quick to point out the audit is not intended to be a review of individual cases, although it is possible the audit will find individual cases indicating inappropriate or inadequate practice. Ms Herbert says the aim is to come up with recommendations about ways of improving the cervical screening programme and she believes many women will want to contribute even though there may be no personal gain.
Another possible misconception is that the audit will signal whether the screening programme is safe and that it will give a definitive answer about the high-grade reporting rate, according to Ms Herbert. One of the problems is that even in the unlikely event of a 100 percent response rate from women, the numbers are still small in statistical terms, she says. She points out much larger numbers would be needed for definitive answers on matters such as New Zealandıs high-grade reporting rate.
ŒIt is more likely the audit will indicate lots of little flags on areas that will need further investigation.ı
The first stage of the audit process has involved reviewing the information on the National Cancer Registry to ensure the women being approached actually have invasive cervical cancer. The audit team will also write to clinicians and GPs of individual women to identify any particular circumstances the case coordinators should be sensitive to such as whether the woman is terminally ill. Women will then be contacted about the audit by the specialist who treated them, before the audit team makes any contact.
If a woman gives consent, the case coordinator will approach GPs, hospitals and private clinics involved in her case to access health records for the seven years before cervical cancer was diagnosed. Ms Herbert says only the audit team will look at these files and the files must relate to smears, gynaecological symptoms and follow-up eg colposcopy. Slides for the four years prior to diagnosis will be re-read by an independent Australian laboratory. Participants will be interviewed by phone or face to face and the woman will be informed if the audit team finds anything that affects her clinical care. The process will be rolled out with 25 women being approached at a time to avoid long time delays between the time of first contact and interview.
There has been a lot of pressure on the team to get the audit underway but Ms Herbert is adamant the audit needed time and careful planning so women from all ethnic groups would feel confident about taking part.
Planning has taken time because New Zealand is the first country to undertake such a comprehensive audit into cervical screening, Ms Herbert says. There was a lot of comment about the lack of audit at the Gisborne inquiry and Ms Herbert thought there would be many overseas examples to look at when planning the New Zealand audit. However she says searches have not revealed that any other country has done an audit of this magnitude.

Time line for audit

April 2001
Release of Report of Gisborne Inquiry

April 2002
Director of
Public Health Dr Colin Tukuitonga appointed to replace Dr Julia Peters on the audit.

May 2002
All ethics committees give approval for the audit

June 2002
The interview process starts with 350 women progressively contacted

December 2002
A further 200 women are progressively contacted

June 2003 Interim report released

2004
Full report completed

World Breastfeeding Week 1-7 August 2002

The theme is - Breastfeeding - healthy mothers, healthy babies - to acknowledge the links between breastfeeding and womenıs reproductive health.
This year World Breastfeeding Week will underscore the urgent need to protect, promote and support the health and wellbeing of mothers as well as to promote, protect and support the health and wellbeing of babies through breastfeeding.

Goals for World Breastfeeding Week 2002 are:

  • To reinstate breastfeeding as an integral part of womenıs reproductive cycle and health
  • To create awareness of womenıs right to humane and non-invasive birthing practices
  • To promote the Global Initiative for Mother Support (GIMS) for Breastfeeding as one way to strengthen the support for mothers

Womenıs Health Action will support a day long event on 1 August hosted by the Auckland Breastfeeding Network that will focus on breastfeeding visibility. The difficulty of breastfeeding in public is cited as one of the reasons women abandon breastfeeding.
 Accompanied by a string quartet, a group of breastfeeding mothers and their breastfed infants will travel by bus to venues in Auckland, such as -

The museum - ancientness

The zoo - to reinforce that this is what all mammals do with their young and that we are species-specific

The Royal Sun Alliance foyer - to link in with breastfeeding and work because most employees are also parents. To encourage employers to embrace the health benefits to babies and reduced sick leave for women of enabling paid breastfeeding breaks.

Manukau City Centre - because we will all need lunch and to link in with family and the reality of daily life.
Come along to any one of these events to support breastfeeding. Times in your local suburban newspaper.

Government bill on screening audits

The government recently released the Health (Screening Programmes) Amendment Bill, aimed at removing roadblocks to auditing screening programmes, such as the National Cervical Screening Programme.
The bill provides for women to be automatically enrolled on the programme. Smeartakers are required to tell women about the programme and women can prevent or cancel their enrolment by directly contacting the NCSP manager. Information about individual women on the NCSP Register and information held by labs will now be accessible for evaluators (people carrying out evaluation and audit of the programme).
The bill follows a discussion paper, which proposed that people carrying out audits could access personal health information held by GPs and others.
In response to submissions, consent will now be needed to accessing GP records, but no consent would be needed to access hospital records. If a woman cannot be found, or if she has died and her representative cannot be found, the Director-General has the power to authorise the release of her health information to programme evaluators.
No date has yet been set for submissions on the bill.

Blood clots on Diane-35 & Estelle-35

Sandra Coney reports on the news that yet more forms of the contraceptive pill increase the risk of blood clots.
She's clear-skinned and pretty, and all because of Diane. That is the message to women conveyed in Schering's patient pamphlet for Diane, an acne treatment that also works as a contraceptive pill.
But in March the Ministry of Health's Medsafe revealed that the medication was not as benign as it had seemed. New research had confirmed that Diane, and its generic sister, Estelle (both containing the anti-androgen cyproterone), increased the risk of blood clots in users even more than third generation oral contraceptives. The risk is still small, but it's a risk that women need not take unless they need treatment for severe acne or another androgen-related disorder.
Earlier research had suggested this possibility, including a New Zealand study which found that two of 17 deaths of women using OCs who developed blood clots had been using Diane. But the numbers in the study were too small to come to a conclusion. A World Health Organisation study in 1995 had also raised a red flag, but once again the numbers were small.
The new British case-control study, using the UK General Practice Research Database, was published in the Lancet in late 2001. It confirmed the greater risk to women using cyproterone-containing OCs.
Medsafe says that the risk of a blood clot in women not using oral contraceptives is 5-10 in 100,000 woman-years. The risk is 3-4 times greater in users of second generation pills and 6-8 times greater in users of third generation pills. In women using Diane and Estelle, the UK study found the risk is probably over 8 times, or more than 80 per 100,000 woman-years. The study also concluded that this increase was not the result of women using these preparations being more obese, as has been suggested.
For reasons that are not clear, New Zealand's use of cyproterone-containing pills is unusually high compared to similar countries. New Zealand women are generally high users of oral contraceptives and as the third generation pill controversy showed, prescribers are quick, perhaps too quick, to use products new to the market.
About 25,000 young New Zealand women use oral contraceptives containing cyproterone, 90 percent of these Douglas Pharmaceuticals' Estelle, which is fully funded by Pharmac. Diane and Estelle enjoy a 10-12 percent share of the local oral contraceptive market.
Up to January 2001 the Centre for Adverse Reactions Monitoring had received 13 reports of venous thromboembolism in women using Diane. Ten of the women had had pulmonary emboli. The next month, in response to the studies suggesting the heightened risk, pills containing cyproterone were put on an intensive monitoring system requiring doctors to report adverse events. Up to November 2001 CARM received five more reports of pulmonary embolism. None of the 18 cases was fatal. Where the reasons for using the pills were known, 10 were for contraception, five for acne and two for irregular menstruation.

Medsafe warns doctors and women
In March, on the advice of the Medicines Adverse Reactions Committee, Medsafe wrote to all doctors advising them to review the cases of women on the pills, and in future to only prescribe cyproterone-containing pills to women with androgen-dependent disorders such as polycystic ovary syndrome, hirsutism, androgenic alopecia or severe acne. Says Medsafe's Stewart Jessamine:' We wanted to make it clear that they are not to be used as a contraceptive alone and they are not to be used for mild to moderate acne. They are only to be used in women with pronounced acne.'
It is not known how many women have been using Diane and Estelle for contraception alone. Dr Jessamine says that information is contained only in doctors' notes. He speculates that some women may have been transferred onto these pills following publicity about the blood clot risk on third generation pills, because they were perceived as safer as well as good for mild acne.

The advertising message to women
Both Schering and Douglas Pharmaceuticals have advertised their products widely, including to women. Apart from the US, New Zealand is the only country in the world to allow direct-to-consumer advertising of pharmaeutical products, and the tone of some Schering advertisements has caused concern.
'Restore the natural balance of your skin with Diane-35' is the banner on one advertisement in She, a local magazine for young women.
'Tried every skin treatment known to woman? Diane-35 is an effective solution for problem skin that is proven to be 93% effective…If you are sick of smearing stuff that dries, damages or adds a useless layer, your doctor can prescribe Diane-35 specifically to restore your skin's natural healthy balance.'
Put this way, say critics, it sounds as benign as a cosmetic. Local drug agencies were concerned, but concluded that the ads did not breach the regulations on such advertising.
Dr Jessamine says he had'personal unhappiness about an oral contraceptive being promoted for acne, but it was legal under the Medicines Act to do it. It had been approved for that indication.'
Family Planning clinics report a flood of calls from young women following the publicity. Medsafe has fielded questions from doctors as to why it no longer compares the risk of blood clots on the Pill with the risk during pregnancy.
Dr Jessamine explains that'the data around blood clots and pregnancy is very old. It was derived from a period when women were put to bed for 10 days after a birth. This may be what explains the risk of blood clots rather than the fact of the birth.'

Information for women is available in a leaflet, bulk copies of which are available from MOH, c/- Wickliffe Ltd, PO Box 932 Dunedin, fax 03 479 0979, phone 04 496 2277, email pubs@moh.govt.nz. The leaflet and all articles can be found on www.medsafe.govt.nz. The reference for the GPRD study is Vasilakis-Scaramozza C, Jick H. Lancet 2001; 358: 1427-29.

Crazy-making

When women say their men'drove them mad', is it just a flippant remark or does domestic violence drive some women crazy? Cordelia Lockett reports.
Debbie Hager set out to investigate a possible link between domestic violence and mental health as part of her Masters in Public Health. In-depth interviews with 10 women who had experienced partner abuse as well as mental health problems formed the core of Debbie Hager's research. She also interviewed 20 staff in agencies dealing with abused women - police, courts, domestic violence services, mental health services, independent psychiatrists and academics. The strongest theme to emerge from the research is that abuse, especially emotional abuse, does make women think they are crazy. As one woman summed up:'I think you can be as sane as anything… and repeated messages to you that really are damaging can make anybody crazy.'
Hager found that women living in situations who constantly have their perceptions denied, gradually lose the ability to trust their own sense of reality. Behaviours that are quite reasonable responses to living in intolerable situations can be interpreted as symptoms of mental illness, such as depression, anxiety disorders, post-traumatic stress disorder, obsessive-compulsive disorders and personality disorders.
Prescribed medication reinforces the idea that women are to blame for the abuse. Once on medication, they are less able to function and protect themselves from the abuse. Many of the women interviewed had had therapy to teach them how to cope with or minimise the abusive behaviour by placating their partners. Many had been sent back to their abusive partners to be'cared for'.
Hager identified a range of reasons why mental and other health providers don't ask women about abuse.'Some don't make the connection or they don't ask because they don't know what to do with the information. Others wouldn't want to bring it up in case it was too upsetting.'
Ms Hager believes a number of improvements need to be made in mental health services.'There are individual people out there doing great work, but there needs to be a standardised approach. Comprehensive screening for domestic violence is vital. Staff need training in asking women very specific questions about abuse and services need clear procedures for responding to disclosures of abuse. Once women have identified abuse, they need to be given the language to speak about their experience.'
Currently, women who experience violence at home and have mental health problems have no place to go for help. Ms Hager says that what abused women really need is not a diagnosis, but the time, safety and support to reconnect themselves and to regain faith in their perceptions of reality. This requires specialist refuge services that can cater both for women's need for sanctuary and their need for abatement of symptoms. Ms Hager is currently working to establish such a service for women.

Reference:
He Drove Me Mad: an investigation into the relationship between domestic violence and mental illness (thesis). Deborah Mary Hager. For a copy of her paper,thesis or to arrange for her to talk to your group, contact Debbie Hager debbie.neil@paradise.net.nz

Mana Wahine & the necessity of kaupapa Maori

Jo Fitzpatrick reports on keynote presentations by Maori women at the Health Promotion Conference.
It was clear from the beginning that the Health Promotion Forum Conference was grounded in Aotearoa and that mana wahine are a significant force here. Two Maori women doctors described the historical impact of Pakeha settlement on Maori using descriptors (civilised, patronised, minimised, minoritised and colonised) and providing examples. Dr Papaarangi Reid (Te Rarawa) is director of the Eru Pomare Maori Health Research Centre at the Wellington School of Medicine and Health Sciences. Dr Fiona Cram (Ngati Kahungungu) is a Senior Research fellow at the International Research Institute for Maori and Indigenous Education at the University of Auckland, recently recognised as one of the six research Centres of Excellence in Aotearoa.
Dr Cram spoke about the introduction of Christianity and the social norm that assumed nuclear families. She argued that the Native (later Maori) Schools movement (1867 to 1969) was an exercise in assimilation and civilisation along Pakeha lines. All teaching was in English and daily routines commonly included inspections for kutu, doses of cod liver oil and cleanliness training including footbaths, showers and toothbrushing. Also common were'model' cottages for training Maori women in the fundamentals of good Pakeha housekeeping. Maori women were trained as nurses but training was conditional on them returning to their kainga. Throughout this period infant mortality rates and the poor health of Maori were a concern but the link between these and loss of land and identity was never acknowledged. Dr Reid examined the result of this history on the perception and misperception of Maori today. New Zealanders today see Maori as'other' and often have a romantic idea of Maori. There is a tendency to'blame the victim' or categorise Maori as'good Maori','bad Maori' or'real Maori' depending on what best suits the purpose at the time.
Dr Reid describes the dysfunction of current systems with the argument that population-based health statistics assess risk on a whole population basis and prescribe solutions for high-risk populations on the same basis. Assumptions based on the majority norm do not lead to effective solutions for high-risk groups. Dr Reid used Sudden Infant Death Syndrome as an example. There has been a reduction in SIDS rates, and many consider that these rates are now at an acceptable level, but Maori babies are still dying.
Dr Reid and Dr Cram both identify kaupapa Maori as the only viable tool for effective intervention. Dr Cram defines this as retrieving space for Maori voices and perspectives alongside a framework to explain kaupapa Maori to tauiwi. Dr Reid outlines elements essential to kaupapa Maori.
These are that Maori

  • must be brought from the margins to the centre
  • need to be able to articulate priorities and have them taken seriously
  • are entitled to intervention that is culturally safe and controlled by them
  • are able to provide a critical Maori analysis of society and health structures which is accepted as valid.

McGoogan report provides reality check on progress on cervical screening

The first six-monthly report on the National Cervical Screening Programme by independent reviewer Dr Euphemia McGoogan praised progress but highlighted a significant number of issues that still needed attention.'Despite very good progress in many areas, I have serious concerns about momentum in…specific areas,' she said.
She was disappointed that more progress had not been made with the retrospective audit of clinical histories of women with cervical cancer, though she praised the excellent work that had been done. She called for more resource to go into this area to finish the audit as quickly as possible.'I cannot accept that New Zealand women must wait until 2004 for reassurance that their NCSP is safe and effective,' she said. Since writing her report the audit protocol has gone to every ethics committee in the country, and an Auckland University team has signed on to provide academic epidemiological advice.
She had concerns too about the governance, management and manpower resource of the National Screening Unit. She believes the manager of the NSU lacks the authority and independence to run the unit as the report of the Gisborne Inquiry had stipulated. The present manager, while showing leadership and expertise, was not medically qualified, while staff did not report to the clinical director. Although the two currently worked well together, the smooth running of the NSU should not be dependent on personalities, she said.'There is a serious risk that the Clinical Director could be excluded from decision-making and the clinical input to the NSU sidelined.'
Dr McGoogan believes that there should be more experienced clinical input into the NSU and recommended that there should be Clinical Leads for both BreastScreen Aotearoa and NCSP as well as a Clinical Director of the NSU. She said addressing this was urgent.'If the current pressure continues, there is a major risk of'burn out' of the staff in post.'
Dr McGoogan made many other recommendations, finally warning that New Zealand should not be complacent about its screening coverage. As data is cleaned up it appears that under 70 percent of women across New Zealand are having regular cervical smears. There was a need to improve access for women and she highlighted the barrier of cost to some women in having smears.
Dr McGoogan was back in New Zealand in April to investigate progress for her second six-monthly report.
Dr McGoogan's report is available on www.csi.org.nz. A report by the Office of the Auditor-General that comes to similar conclusions is to be found at www.oag.govt.nz.