Editor-in-Chief's introduction to ANZJOG 64 (5)

Welcome to the October issue of the Australian and New Zealand Journal of Obstetrics and Gynaecology.

This issue begins with an editorial by Joseph et al proposing whether the frequent delay between symptom onset and endometriosis diagnosis, referred to by Ellis and Wood as ‘a decade to wait’,¹ may be ‘worth waiting for’.² The authors argue that any plan to reduce this delay requires justification that it would improve clinical outcomes, and that a lesion-based or disease-based approach to the management of pelvic pain is not necessarily superior to empiric symptom-based medical management which can be initiated without invasive diagnostic procedures. Further, they express concern about the inequity of access to particular pharmacotherapies, with both Australian and New Zealand funding bodies limiting subsidised treatments to women with proven endometriosis and not others with either unconfirmed or endometriosis-negative persistent pelvic pain. Finally, they argue that efforts to reduce the diagnostic delay may lead to further surgical intervention given that younger age at first surgery is the strongest predictor for repeat endometriosis surgery and that this may have a compound resource burden.

Unsurprisingly for this controversial topic, this editorial provoked comment from other clinicians, also with substantial expertise in the management of endometriosis. Mallinder et al argue against the assumptions made by Joseph et al, suggesting that endometriosis is an inhomogeneous condition, that it has clinical relevance beyond pelvic pain, that deep vs superficial endometriosis have importantly different natural histories that respond differently to surgical treatment, and that medications subsidies for endometriosis and persistent pelvic pain are appropriate given the evidence base for their use.³

Endometriosis and persistent pelvic pain are common conditions with substantial impact on quality of life and large socioeconomic burden. The Australian Government-funded RANZCOG Endometriosis Guideline is currently being revised and will be published in 2025, aiming to improve the evidence-based management of this condition and to identify gaps in knowledge which should be the target of future research. Persistent pelvic pain, either in association with or in the absence of endometriosis lesions, also requires clear evidence-based management guidelines which are currently lacking.

This issue of ANZJOG provides more useful clinical guidance. For clinicians managing the challenging entity of recurrent miscarriage, Suker et al present the Australian Recurrent Pregnancy Loss Clinical Management Guideline 2024.^{4, 5} These guidelines will be valuable to those who work in this field where there has been much debate about the significance of associated immune and thrombotic disorders and a large number of proposed therapies, often with a heterogeneous and conflicting evidence base. In addition, Sweeting et al present their findings from the Australasian Diabetes in Pregnancy Society's TOBOGM Summit,⁶ a step toward revision of the 2014 consensus guidelines for the diagnosis of hyperglycaemia in pregnancy.

Subasinghe et al present their work on developing and evaluating a core indicator set for preconception health.⁷ The authors found that different indicators are collected in each Australian health jurisdiction, with no jurisdiction collecting adequate indicator information, particularly in sociodemographic variables. They call for nationally consistent data collection to enable quality linkage research and assessment of the quality of preconception health care with the aim of improving maternal, perinatal, and early childhood health outcomes.

In other obstetric topics, Sadler et al present their survey of obstetricians' views of the use of the FetalPillow® device in clinical practice and research.⁸ This study is valuable in shaping further research of this device in light of the recent retraction of the dominant clinical trial assessment which has substantially altered the evidence base. Rogers et al describe the implementation of a whole exome sequencing approach to prenatal investigation of structural fetal anomalies.⁹ They found that this approach yielded diagnostic findings in 35% of tested pregnancies with a clinically viable turn-around time of 12 days. The authors describe the important features of such a diagnostic program and how it might be implementable in other centres. Hofstee et al present their evaluation of pregnancy outcomes in women exposed to COVID-19 lockdown measures in rural New South Wales.¹⁰ They found variable impacts, with reductions in antenatal complications such as gestational diabetes and hypertensive disorders of pregnancy and in neonatal nursery admission, but an increase in peripartum complications such as suspected intrapartum fetal compromise and postpartum haemorrhage. These findings reinforce the varying impact of complex social interventions upon pregnancy outcomes.

In gynaecology topics, Eden provides an overview of the impact of hormonal contraception and menopausal hormone therapy upon breast cancer risk.¹¹ The lack of a large observed effect of exogenous hormones on breast cancer risk suggests mechanisms other than circulating oestrogen and progesterone levels, and the author provides evidence that local breast fat and tumour oestrogen production is the dominant mitogen in breast cancer development. Nash and Saidi present their single-centre study of outpatient hysteroscopy.¹² In their cohort of almost 500 women, they found a high level of patient acceptability and likely substantial cost savings of outpatient hysteroscopy over traditional hysteroscopy under general anaesthesia. In particular, they found that patient age and body mass index did not impact outpatient hysteroscopy success rates. Joseph et al present their study of longer-term quality of life outcomes of a small-group multidisciplinary pain self-management program in women with persistent pelvic pain.¹³ They found that the initial improvement observed with the six-week treatment program was sustained at 12 months of follow-up. Kyaw et al present their study of percutaneous tibial nerve stimulation for the treatment of overactive bladder.¹⁴ They found comparable results to previous studies of this technique, suggesting that this treatment is safe and effective but requires further assessment to develop a standardised protocol.

I trust that you will find these and the remaining articles in this issue interesting and useful in your clinical practice. Thank you for your support of ANZJOG.

The author reports no conflicts of interest.