Women's Health Action Selections from Women's Health Watch April 1997

Women's Health Watch

edited by Sandra Coney

Selected articles from Women's Health Watch newsletters in April 1997

Contents

Issue 40 March - April 1997

Records to be kept 10 years
Doctors poised to water down accountability law
Once a caesarean, always a caesarean, no longer valid
Endometrial cancer and HRT
Depression and menopause
Survey on breast cancer surgery gives disturbing results

Records to be kept for 10 years

In November 1996 the Government approved the Health (Retention of Health Information) Regulations 1996 which came into force on 1 January 1997.

These require health care providers to retain medical records for at least 10 years from the last date of treatment or care. After that it is lawful to destroy them, although the records are able to be transferred to another provider.

Copies of the regulations are available from Bennetts Government bookshops.

Doctors poised to water down accountability law

The public has until 9 May 1997 to comment on a new bill which will make it harder to convict doctors of medical manslaughter. The Crimes Amendment Bill (No 5) raises the test for medical manslaughter to:

'a major departure from the standard of care expected of a reasonable person' while performing dangerous acts including surgical and medical treatment.

The new words are 'a major departure'. This means that grossly negligent and reckless behaviour would have to be proved for the police to succeed in gaining a conviction. Critics have commented that under this test most former convictions for medical manslaughter would have failed, including the cases brought against surgeon Keith Ramstead.

The new legislation covers doctors who come under Sections 155 and 156 of the existing act. These sections say that people performing dangerous tasks must use 'reasonable knowledge, skill, and care' and take 'reasonable precautions to avoid suchdanger'.

In the past these provisions have been used against such persons as airline pilots, drivers of motor vehicles, the driver of a power boat, users of firearms, the user of a cutting tool that caught fire, a property owner with regard to the failure to fence a pool, and a bungy jump operator. Other people who typically carry our dangerous tasks are adventure park ride operators, white water raft operators, operators of ski lifts, lift operators etc.

Recently, charges were laid against a jet skier who allegedly killed a swimmer in Wellington using Section 156 as well as -Sections 160 (2b), 171, and 177.

Under the new law all these people would have to be grossly negligent before a charge would succeed.

The law does not introduce any lesser charges to modify the 1' effect of raising the test for manslaughter. For example, it would have been possible to introduce charges such as exist for motor vehicle drivers, eg the equivalent of dangerous driving causing death.

If the new law is passed, health professionals (along with airline pilots etc) will not face any charge unless they have been recklessly negligent.

Send submissions to Justice and Law Reform Committee, Parliament Buildings, Wellington. They usually ask for 20 copies. The Bill is available from Bennett's book stores.

Once a caesarean, always a caesarean, no longer valid

Trial of labour is acceptable after an initial caesarean section, according to a recent study in the New England Journal of Medicine. The study compared two groups: the first had a trial of labour, the second elective caesarean section. Complications were uncommon in both groups, but major complications (rupture of the uterus, hysterectomy) occurred in 1.3% and were twice as common in the trial of labour group. The incidence of hysterectomy was 0.2% in both groups, suggesting that other factors beside the trial of labour influenced the decision to remove the uterus. Eight women in the trial of labour group who had uterine ruptures did not have hysterectomies.

Perinatal deaths were similar but slightly higher in the trial of labour group (9 vs 5 per 10001ive births).

Complications were highest in women undergoing elective caesareans who had gone through at least three prior deliveries.

The paper makes the obvious point that avoiding caesareans sections in the first place would be the greatest help in avoiding complications in subsequent pregnancies. Despite the concern caesarean sections rates continue to be high in many hospitals, including New Zealand maternity facilities.
Ref: NEJM 1996; 335: 735-6

Endometrial cancer and HRT

While it is well known that unopposed oestrogen increases the risk of cancer of the endometrium in postmenopausal women, it has long been claimed that the addition of progestogen for around 13 days cancels the risk. It has also often been claimed that women on combined HRT have a lower risk of this cancer than women not using HRT at all.

But a new study contradicts this. It found that long-term users of combined therapy does have an increased risk, although the finding needs to be confirmed. The increased risk was less than that found with unopposed oestrogen.

The case-control study relied on women's recall of the type of therapy they had used, but the researchers comment that other studies have found that women's memories are consistent with their medical records.

The study found that under five years, women who used combined therapy were not at increased risk compared to non--users unless the progestogen was added for fewer than 10 days each month, when they ran three times the risk compared to women who had never used hormones.

But for longer than five years, use of combined therapy, even when progestogen is added for more than ten days a month, had double the risk of endometrial cancer. For women with less than 10 days progestogen, the risk was four times greater.
Ref: Lancet; 1997:349: 458-61

Depression and menopause

It is commonly claimed that depression and menopause go hand and hand, but a recent critical review of the literature showed that there is no evidence behind this assertion.

Ninety-four articles from 30 years of research were traced using Medline and other methods. After exclusion and inclusion criteria had been applied there were 43 epidemiological primary research papers, which were evaluated for causality.

Using these criteria the researcher concluded that menopause had not been demonstrated to cause depression.

Commenting on this study in an editorial in the British Medical Journal, clinical psychologist Myra Hunter noted that a number of prospective studies have shown that psychosocial factors, rather than menopause itself, have been shown to be the main predictors of depression occurring during the menopause. These include past depression, socioeconomic status, stressful life events such as bereavements, and negative beliefs about the menopause. The menopause seems to have a negative effect on women who previously believed that menopause brought a whole host of physical and emotional problems. There is a fairly clear consensus, she said, that oestrogen status is not linked to depression.

Attributing depression at the menopause to menopause is 'overly simplistic and usually unjustified'. When women seek help for depression during the menopause, a number of possible causes should be explored such as stresses and conflicts, lack of social support, ill health, as well as severe vasomotor symptoms which can cause sleeplessness. Concerns about aging and loss of youth also need to be addressed.
Ref: BMJ 1996; 313: 1229-32; BMJ 1996; 313: 1217-8

Survey on breast cancer surgery gives disturbing results

A recent study of breast cancer in New Zealand found that there was general agreement about the best treatments among breast surgeons, and little regional difference in treatments offered, although surgeons in the northern region were under--represented in the study (the study response rate was 60%, but it was lowest in the Northern RHA region). Despite this gen-erally reassuring result, some disturbing attitudes were revealed.

Wen mastectomy was performed, surgeons were asked whether they discussed the possibility of reconstruction. 28% said they would 'in every case', 39% 'in most cases', and 33% in some cases'. Reasons for not discussing reconstruction included: did not believe reconstruction was advisable (8), limitations on time (7), and cost/accessibility (1). Of the 75 who said they would discuss reconstruction, the following are the criteria surgeons would use in offering this procedure: stage of the disease (50), age of the patient (47), patient's reaction to mastectomy (46), time since surgery (21), size of patient's breasts (20), patient preferences (13), and patient cohabits with partner (7).

In other words, sweeping value judgements were made by surgeons on behalf of their patients. Surgeons assumed that older women, and women with small breasts could live without a breast, while women not in a relationship, or even simply not Iiving with a partner, were judged to not need a second breast. Breasts, it seems, exist more for partner and public needs than the woman's own.
Ref: NZMJ 1997; 110: 53-56

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	Women's Health Watch edited by Sandra Coney Selected articles from Women's Health Watch newsletters in April 1997 Contents Issue 40 March - April 1997 Records to be kept 10 years Doctors poised to water down accountability law Once a caesarean, always a caesarean, no longer valid Endometrial cancer and HRT Depression and menopause Survey on breast cancer surgery gives disturbing results Records to be kept for 10 years In November 1996 the Government approved the Health (Retention of Health Information) Regulations 1996 which came into force on 1 January 1997. These require health care providers to retain medical records for at least 10 years from the last date of treatment or care. After that it is lawful to destroy them, although the records are able to be transferred to another provider. Copies of the regulations are available from Bennetts Government bookshops. Doctors poised to water down accountability law The public has until 9 May 1997 to comment on a new bill which will make it harder to convict doctors of medical manslaughter. The Crimes Amendment Bill (No 5) raises the test for medical manslaughter to: 'a major departure from the standard of care expected of a reasonable person' while performing dangerous acts including surgical and medical treatment. The new words are 'a major departure'. This means that grossly negligent and reckless behaviour would have to be proved for the police to succeed in gaining a conviction. Critics have commented that under this test most former convictions for medical manslaughter would have failed, including the cases brought against surgeon Keith Ramstead. The new legislation covers doctors who come under Sections 155 and 156 of the existing act. These sections say that people performing dangerous tasks must use 'reasonable knowledge, skill, and care' and take 'reasonable precautions to avoid suchdanger'. In the past these provisions have been used against such persons as airline pilots, drivers of motor vehicles, the driver of a power boat, users of firearms, the user of a cutting tool that caught fire, a property owner with regard to the failure to fence a pool, and a bungy jump operator. Other people who typically carry our dangerous tasks are adventure park ride operators, white water raft operators, operators of ski lifts, lift operators etc. Recently, charges were laid against a jet skier who allegedly killed a swimmer in Wellington using Section 156 as well as -Sections 160 (2b), 171, and 177. Under the new law all these people would have to be grossly negligent before a charge would succeed. The law does not introduce any lesser charges to modify the 1' effect of raising the test for manslaughter. For example, it would have been possible to introduce charges such as exist for motor vehicle drivers, eg the equivalent of dangerous driving causing death. If the new law is passed, health professionals (along with airline pilots etc) will not face any charge unless they have been recklessly negligent. Send submissions to Justice and Law Reform Committee, Parliament Buildings, Wellington. They usually ask for 20 copies. The Bill is available from Bennett's book stores. Once a caesarean, always a caesarean, no longer valid Trial of labour is acceptable after an initial caesarean section, according to a recent study in the New England Journal of Medicine. The study compared two groups: the first had a trial of labour, the second elective caesarean section. Complications were uncommon in both groups, but major complications (rupture of the uterus, hysterectomy) occurred in 1.3% and were twice as common in the trial of labour group. The incidence of hysterectomy was 0.2% in both groups, suggesting that other factors beside the trial of labour influenced the decision to remove the uterus. Eight women in the trial of labour group who had uterine ruptures did not have hysterectomies. Perinatal deaths were similar but slightly higher in the trial of labour group (9 vs 5 per 10001ive births). Complications were highest in women undergoing elective caesareans who had gone through at least three prior deliveries. The paper makes the obvious point that avoiding caesareans sections in the first place would be the greatest help in avoiding complications in subsequent pregnancies. Despite the concern caesarean sections rates continue to be high in many hospitals, including New Zealand maternity facilities. Ref: NEJM 1996; 335: 735-6 Endometrial cancer and HRT While it is well known that unopposed oestrogen increases the risk of cancer of the endometrium in postmenopausal women, it has long been claimed that the addition of progestogen for around 13 days cancels the risk. It has also often been claimed that women on combined HRT have a lower risk of this cancer than women not using HRT at all. But a new study contradicts this. It found that long-term users of combined therapy does have an increased risk, although the finding needs to be confirmed. The increased risk was less than that found with unopposed oestrogen. The case-control study relied on women's recall of the type of therapy they had used, but the researchers comment that other studies have found that women's memories are consistent with their medical records. The study found that under five years, women who used combined therapy were not at increased risk compared to non--users unless the progestogen was added for fewer than 10 days each month, when they ran three times the risk compared to women who had never used hormones. But for longer than five years, use of combined therapy, even when progestogen is added for more than ten days a month, had double the risk of endometrial cancer. For women with less than 10 days progestogen, the risk was four times greater. Ref: Lancet; 1997:349: 458-61 Depression and menopause It is commonly claimed that depression and menopause go hand and hand, but a recent critical review of the literature showed that there is no evidence behind this assertion. Ninety-four articles from 30 years of research were traced using Medline and other methods. After exclusion and inclusion criteria had been applied there were 43 epidemiological primary research papers, which were evaluated for causality. Using these criteria the researcher concluded that menopause had not been demonstrated to cause depression. Commenting on this study in an editorial in the British Medical Journal, clinical psychologist Myra Hunter noted that a number of prospective studies have shown that psychosocial factors, rather than menopause itself, have been shown to be the main predictors of depression occurring during the menopause. These include past depression, socioeconomic status, stressful life events such as bereavements, and negative beliefs about the menopause. The menopause seems to have a negative effect on women who previously believed that menopause brought a whole host of physical and emotional problems. There is a fairly clear consensus, she said, that oestrogen status is not linked to depression. Attributing depression at the menopause to menopause is 'overly simplistic and usually unjustified'. When women seek help for depression during the menopause, a number of possible causes should be explored such as stresses and conflicts, lack of social support, ill health, as well as severe vasomotor symptoms which can cause sleeplessness. Concerns about aging and loss of youth also need to be addressed. Ref: BMJ 1996; 313: 1229-32; BMJ 1996; 313: 1217-8 Survey on breast cancer surgery gives disturbing results A recent study of breast cancer in New Zealand found that there was general agreement about the best treatments among breast surgeons, and little regional difference in treatments offered, although surgeons in the northern region were under--represented in the study (the study response rate was 60%, but it was lowest in the Northern RHA region). Despite this gen-erally reassuring result, some disturbing attitudes were revealed. Wen mastectomy was performed, surgeons were asked whether they discussed the possibility of reconstruction. 28% said they would 'in every case', 39% 'in most cases', and 33% in some cases'. Reasons for not discussing reconstruction included: did not believe reconstruction was advisable (8), limitations on time (7), and cost/accessibility (1). Of the 75 who said they would discuss reconstruction, the following are the criteria surgeons would use in offering this procedure: stage of the disease (50), age of the patient (47), patient's reaction to mastectomy (46), time since surgery (21), size of patient's breasts (20), patient preferences (13), and patient cohabits with partner (7). In other words, sweeping value judgements were made by surgeons on behalf of their patients. Surgeons assumed that older women, and women with small breasts could live without a breast, while women not in a relationship, or even simply not Iiving with a partner, were judged to not need a second breast. Breasts, it seems, exist more for partner and public needs than the woman's own. Ref: NZMJ 1997; 110: 53-56