Cost-effectiveness analysis of AS04-adjuvanted human papillomavirus 16/18 vaccine compared with human papillomavirus 6/11/16/18 vaccine in the Philippines, with the new 2-dose schedule.

Cervical cancer (CC) is the second leading cause of cancer death among Filipino women. Human papillomavirus (HPV) vaccination protects against CC. Two vaccines (AS04-HPV-16/18 and 4vHPV) are approved in the Philippines; they were originally developed for a 3-dose (3D) administration and have recently been approved in a 2-dose schedule (2D). This study aims to evaluate the cost-effectiveness of HPV vaccination of 13-year-old Filipino girls, in addition to current screening, in the new 2D schedule. An existing static lifetime, one-year cycle Markov cohort model was adapted to the Philippine settings to simulate the natural history of low-risk and oncogenic HPV infection, the effects of screening and vaccination of a 13-year-old girls cohort vaccinated with either the 2D-AS04-HPV-16/18 or 2D-4vHPV assuming a 100% vaccination coverage. Incremental cost, quality-adjusted life year (QALY) and cost-effectiveness were derived from these estimates. Input data were obtained from published sources and Delphi panel, using country-specific data where possible. Sensitivity analyses were performed to assess the robustness of the model. The model estimated that 2D-AS04-HPV-16/18 prevented 986 additional CC cases and 399 CC deaths (undiscounted), as well as 555 increased QALY (discounted), and save 228.1 million Philippine pesos (PHP) compared with the 2D-4vHPV. In conclusion, AS04-HPV-16/18 is shown to be dominant over 4vHPV in the Philippines, with greater estimated health benefits and lower costs.

A rare case of concurrent prolapses of the vaginal vault and rectum / Philippine Journal of Obstetrics and Gynecology

Vaginal vault prolapse occurs in 0.2% to 1.0% of menopausal women with prior hysterectomy. Even rarer is the development of concurrent rectal prolapse seen in 0.03% to 0.1% of cases. This paper aimed to 1) present a rare case of concurrent prolapses of the vaginal vault and rectum in an 87-year old grandmultipara, 2) evaluate factors predisposing to vault prolapse and rectal prolapse and their manifestations, 3) introduce the new quantitative staging system of pelvic organ prolapse by the International Continence Society, 4) discuss the options of management, and 5) emphasize the need for multidisciplinary management approach. An 87-year old grandmultipara presented with two distinct prolapsing masses at the introitus and anus. Implicated factors such as prior hysterectomy, advanced age, multiple vaginal deliveries, menopausal state and history of heavy lifting were identified. Diagnosis was made clinically. The vaginal vault prolapse was categorized quantitatively according to the Pelvic Organ Prolapse Quantification System wherein she was diagnosed to be at stage IV C. Based on such stage, treatment options, both conservative and surgical, were discussed. She underwent perineal surgery for both lesions. Effective therapy for concurrent prolapses of vaginal vault and rectum requires in-depth knowledge of pelvic anatomy and physiology, a thorough physical examination, adequate preoperative planning and prudent selection of surgical procedures that will achieve the most anatomically complete repair that will prevent recurrence.

Diagnosing androgen insensitivity syndrome in the mid-adult life: Facing the dilemma of malignancy and sexual identity / Philippine Journal of Obstetrics and Gynecology

A 44-year old phenotypic female, married with primary amenorrhea presented with recurrent urinary tract infection and an incidental finding of a pelvo-abdomlnal mass.Ultrasonogram with doppler studies showed a huge pelvo-abdominal mass with rich intratumoral and peripheral color flow and low resistance index. No uterus or cervix was demonstrated. Tumor marker, CA-125 level, was elevated. Exploratory laparotomy confirmed the absence of the uterus and fallopian tubes. The left "ovary" was converted to a 16cm x 15cm x 12cm predominantly solid encapsulated mass. The capsule was smooth with a point of rupture measuring approximately 1 cm in diameter, exuding fresh blood. The right "ovary" was grossly normal measuring 3cm x 2cm x 2cm. Bilateral "oophorectomy", peritoneal fluid cytology, infracolic omentectomy with frozen section, were carried out. Histopathology of the left pelvic mass revealed testicular seminoma, while the right mass was consistent with an atrophic testis. Peritoneal fluid was positlve for malignant cells. Referral to a gynecologic oncologist was done for adjuvant radiation therapy. With the late realization of her being genetically male,psychological therapy and genetic counseling were advised.