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Sharon Worcester is an award-winning medical journalist for MDedge News. She has been with the company since 1996, first as the Southeast Bureau Chief (1996-2009) when the company was known as International Medical News Group, then as a freelance writer (2010-2015) before returning as a reporter in 2015. She previously worked as a daily newspaper reporter covering health and local government. Sharon currently reports primarily on oncology and hematology. She has a BA from Eckerd College and an MA in Mass Communication/Print Journalism from the University of Florida. Connect with her via LinkedIn and follow her on twitter @SW_MedReporter.
ACOG: Long-term Low-dose Vaginal Estrogen Poses No Apparent Cancer Risk
SAN FRANCISCO – The use of unopposed topical vaginal estrogen is not associated with an increased risk of endometrial hyperplasia or cancer, findings from a large database review suggest.
Yearly disease incidence between 2006 and 2012 among women aged 46 years or older from the Kaiser Permanente Northern California membership database did not differ significantly by number of dispensed vaginal estrogen prescriptions over a 3-year period, Dr. Kathryn M. Gunnison reported at the annual meeting of the American College of Obstetricians and Gynecologists.
Yearly incidence per 10,000 women was 1.86-18.23 in those who received four or more prescriptions, 7.29-15.01 in those who received one to three prescriptions, and 8.74-10.86 in those who received no prescriptions, said Dr. Gunnison of Kaiser Permanente Medical Center, Santa Clara, Calif.
The overall incidence rates in the groups, respectively, were 9.96, 10.25, and 9.96 per 10,000 women, she said.
Dr. Gunnison and her colleagues used ICD-9 codes and the Kaiser Permanente Northern California Cancer Registry to identify the first date of endometrial hyperplasia or cancer in the yearly population, and pharmacy records were reviewed to identify dispensed vaginal estrogen prescriptions in the 3 years prior to diagnosis of endometrial hyperplasia or cancer; those exposed within 2 years prior to diagnosis were excluded, as were those who used systemic estrogen.
Between 450,000 and 530,000 women met the selection criteria for each year during the study period, and the use of vaginal estrogen increased slightly over the study period. Between 26,000 and 34,000 women filled one to three prescriptions during the study years, and between 9,300 and 23,000 filled four or more prescriptions.
The overall annual incidence of endometrial hyperplasia or cancer increased over the study period, which is consistent with national data. The incidence rose from 8.96 per 10,000 women in 2006 to 10.56 per 10,000 women in 2012, but did not differ significantly by number of prescriptions filled.
“So we think our data suggest that the use of unopposed topical vaginal estrogen is not associated with an increased risk for endometrial hyperplasia or cancer over a 3-year period. However, further studies are needed,” Dr. Gunnison said, noting that the current study is limited by the retrospective, descriptive study design, and by the fact that the estrogen delivery method was not examined. The study also did not control for potential confounders.
Despite these limitations, it is the first study to look at vaginal estrogen use for more than 1 year, she said.
The findings are encouraging, she said, since many women choose low-dose topical vaginal estrogen because of concerns about potential adverse effects from systemic estrogen.
Dr. Gunnison reported having no financial disclosures.
SAN FRANCISCO – The use of unopposed topical vaginal estrogen is not associated with an increased risk of endometrial hyperplasia or cancer, findings from a large database review suggest.
Yearly disease incidence between 2006 and 2012 among women aged 46 years or older from the Kaiser Permanente Northern California membership database did not differ significantly by number of dispensed vaginal estrogen prescriptions over a 3-year period, Dr. Kathryn M. Gunnison reported at the annual meeting of the American College of Obstetricians and Gynecologists.
Yearly incidence per 10,000 women was 1.86-18.23 in those who received four or more prescriptions, 7.29-15.01 in those who received one to three prescriptions, and 8.74-10.86 in those who received no prescriptions, said Dr. Gunnison of Kaiser Permanente Medical Center, Santa Clara, Calif.
The overall incidence rates in the groups, respectively, were 9.96, 10.25, and 9.96 per 10,000 women, she said.
Dr. Gunnison and her colleagues used ICD-9 codes and the Kaiser Permanente Northern California Cancer Registry to identify the first date of endometrial hyperplasia or cancer in the yearly population, and pharmacy records were reviewed to identify dispensed vaginal estrogen prescriptions in the 3 years prior to diagnosis of endometrial hyperplasia or cancer; those exposed within 2 years prior to diagnosis were excluded, as were those who used systemic estrogen.
Between 450,000 and 530,000 women met the selection criteria for each year during the study period, and the use of vaginal estrogen increased slightly over the study period. Between 26,000 and 34,000 women filled one to three prescriptions during the study years, and between 9,300 and 23,000 filled four or more prescriptions.
The overall annual incidence of endometrial hyperplasia or cancer increased over the study period, which is consistent with national data. The incidence rose from 8.96 per 10,000 women in 2006 to 10.56 per 10,000 women in 2012, but did not differ significantly by number of prescriptions filled.
“So we think our data suggest that the use of unopposed topical vaginal estrogen is not associated with an increased risk for endometrial hyperplasia or cancer over a 3-year period. However, further studies are needed,” Dr. Gunnison said, noting that the current study is limited by the retrospective, descriptive study design, and by the fact that the estrogen delivery method was not examined. The study also did not control for potential confounders.
Despite these limitations, it is the first study to look at vaginal estrogen use for more than 1 year, she said.
The findings are encouraging, she said, since many women choose low-dose topical vaginal estrogen because of concerns about potential adverse effects from systemic estrogen.
Dr. Gunnison reported having no financial disclosures.
SAN FRANCISCO – The use of unopposed topical vaginal estrogen is not associated with an increased risk of endometrial hyperplasia or cancer, findings from a large database review suggest.
Yearly disease incidence between 2006 and 2012 among women aged 46 years or older from the Kaiser Permanente Northern California membership database did not differ significantly by number of dispensed vaginal estrogen prescriptions over a 3-year period, Dr. Kathryn M. Gunnison reported at the annual meeting of the American College of Obstetricians and Gynecologists.
Yearly incidence per 10,000 women was 1.86-18.23 in those who received four or more prescriptions, 7.29-15.01 in those who received one to three prescriptions, and 8.74-10.86 in those who received no prescriptions, said Dr. Gunnison of Kaiser Permanente Medical Center, Santa Clara, Calif.
The overall incidence rates in the groups, respectively, were 9.96, 10.25, and 9.96 per 10,000 women, she said.
Dr. Gunnison and her colleagues used ICD-9 codes and the Kaiser Permanente Northern California Cancer Registry to identify the first date of endometrial hyperplasia or cancer in the yearly population, and pharmacy records were reviewed to identify dispensed vaginal estrogen prescriptions in the 3 years prior to diagnosis of endometrial hyperplasia or cancer; those exposed within 2 years prior to diagnosis were excluded, as were those who used systemic estrogen.
Between 450,000 and 530,000 women met the selection criteria for each year during the study period, and the use of vaginal estrogen increased slightly over the study period. Between 26,000 and 34,000 women filled one to three prescriptions during the study years, and between 9,300 and 23,000 filled four or more prescriptions.
The overall annual incidence of endometrial hyperplasia or cancer increased over the study period, which is consistent with national data. The incidence rose from 8.96 per 10,000 women in 2006 to 10.56 per 10,000 women in 2012, but did not differ significantly by number of prescriptions filled.
“So we think our data suggest that the use of unopposed topical vaginal estrogen is not associated with an increased risk for endometrial hyperplasia or cancer over a 3-year period. However, further studies are needed,” Dr. Gunnison said, noting that the current study is limited by the retrospective, descriptive study design, and by the fact that the estrogen delivery method was not examined. The study also did not control for potential confounders.
Despite these limitations, it is the first study to look at vaginal estrogen use for more than 1 year, she said.
The findings are encouraging, she said, since many women choose low-dose topical vaginal estrogen because of concerns about potential adverse effects from systemic estrogen.
Dr. Gunnison reported having no financial disclosures.
AT ACOG 2015
ACOG: Long-term low-dose vaginal estrogen poses no apparent cancer risk
SAN FRANCISCO – The use of unopposed topical vaginal estrogen is not associated with an increased risk of endometrial hyperplasia or cancer, findings from a large database review suggest.
Yearly disease incidence between 2006 and 2012 among women aged 46 years or older from the Kaiser Permanente Northern California membership database did not differ significantly by number of dispensed vaginal estrogen prescriptions over a 3-year period, Dr. Kathryn M. Gunnison reported at the annual meeting of the American College of Obstetricians and Gynecologists.
Yearly incidence per 10,000 women was 1.86-18.23 in those who received four or more prescriptions, 7.29-15.01 in those who received one to three prescriptions, and 8.74-10.86 in those who received no prescriptions, said Dr. Gunnison of Kaiser Permanente Medical Center, Santa Clara, Calif.
The overall incidence rates in the groups, respectively, were 9.96, 10.25, and 9.96 per 10,000 women, she said.
Dr. Gunnison and her colleagues used ICD-9 codes and the Kaiser Permanente Northern California Cancer Registry to identify the first date of endometrial hyperplasia or cancer in the yearly population, and pharmacy records were reviewed to identify dispensed vaginal estrogen prescriptions in the 3 years prior to diagnosis of endometrial hyperplasia or cancer; those exposed within 2 years prior to diagnosis were excluded, as were those who used systemic estrogen.
Between 450,000 and 530,000 women met the selection criteria for each year during the study period, and the use of vaginal estrogen increased slightly over the study period. Between 26,000 and 34,000 women filled one to three prescriptions during the study years, and between 9,300 and 23,000 filled four or more prescriptions.
The overall annual incidence of endometrial hyperplasia or cancer increased over the study period, which is consistent with national data. The incidence rose from 8.96 per 10,000 women in 2006 to 10.56 per 10,000 women in 2012, but did not differ significantly by number of prescriptions filled.
“So we think our data suggest that the use of unopposed topical vaginal estrogen is not associated with an increased risk for endometrial hyperplasia or cancer over a 3-year period. However, further studies are needed,” Dr. Gunnison said, noting that the current study is limited by the retrospective, descriptive study design, and by the fact that the estrogen delivery method was not examined. The study also did not control for potential confounders.
Despite these limitations, it is the first study to look at vaginal estrogen use for more than 1 year, she said.
The findings are encouraging, she said, since many women choose low-dose topical vaginal estrogen because of concerns about potential adverse effects from systemic estrogen.
Dr. Gunnison reported having no financial disclosures.
SAN FRANCISCO – The use of unopposed topical vaginal estrogen is not associated with an increased risk of endometrial hyperplasia or cancer, findings from a large database review suggest.
Yearly disease incidence between 2006 and 2012 among women aged 46 years or older from the Kaiser Permanente Northern California membership database did not differ significantly by number of dispensed vaginal estrogen prescriptions over a 3-year period, Dr. Kathryn M. Gunnison reported at the annual meeting of the American College of Obstetricians and Gynecologists.
Yearly incidence per 10,000 women was 1.86-18.23 in those who received four or more prescriptions, 7.29-15.01 in those who received one to three prescriptions, and 8.74-10.86 in those who received no prescriptions, said Dr. Gunnison of Kaiser Permanente Medical Center, Santa Clara, Calif.
The overall incidence rates in the groups, respectively, were 9.96, 10.25, and 9.96 per 10,000 women, she said.
Dr. Gunnison and her colleagues used ICD-9 codes and the Kaiser Permanente Northern California Cancer Registry to identify the first date of endometrial hyperplasia or cancer in the yearly population, and pharmacy records were reviewed to identify dispensed vaginal estrogen prescriptions in the 3 years prior to diagnosis of endometrial hyperplasia or cancer; those exposed within 2 years prior to diagnosis were excluded, as were those who used systemic estrogen.
Between 450,000 and 530,000 women met the selection criteria for each year during the study period, and the use of vaginal estrogen increased slightly over the study period. Between 26,000 and 34,000 women filled one to three prescriptions during the study years, and between 9,300 and 23,000 filled four or more prescriptions.
The overall annual incidence of endometrial hyperplasia or cancer increased over the study period, which is consistent with national data. The incidence rose from 8.96 per 10,000 women in 2006 to 10.56 per 10,000 women in 2012, but did not differ significantly by number of prescriptions filled.
“So we think our data suggest that the use of unopposed topical vaginal estrogen is not associated with an increased risk for endometrial hyperplasia or cancer over a 3-year period. However, further studies are needed,” Dr. Gunnison said, noting that the current study is limited by the retrospective, descriptive study design, and by the fact that the estrogen delivery method was not examined. The study also did not control for potential confounders.
Despite these limitations, it is the first study to look at vaginal estrogen use for more than 1 year, she said.
The findings are encouraging, she said, since many women choose low-dose topical vaginal estrogen because of concerns about potential adverse effects from systemic estrogen.
Dr. Gunnison reported having no financial disclosures.
SAN FRANCISCO – The use of unopposed topical vaginal estrogen is not associated with an increased risk of endometrial hyperplasia or cancer, findings from a large database review suggest.
Yearly disease incidence between 2006 and 2012 among women aged 46 years or older from the Kaiser Permanente Northern California membership database did not differ significantly by number of dispensed vaginal estrogen prescriptions over a 3-year period, Dr. Kathryn M. Gunnison reported at the annual meeting of the American College of Obstetricians and Gynecologists.
Yearly incidence per 10,000 women was 1.86-18.23 in those who received four or more prescriptions, 7.29-15.01 in those who received one to three prescriptions, and 8.74-10.86 in those who received no prescriptions, said Dr. Gunnison of Kaiser Permanente Medical Center, Santa Clara, Calif.
The overall incidence rates in the groups, respectively, were 9.96, 10.25, and 9.96 per 10,000 women, she said.
Dr. Gunnison and her colleagues used ICD-9 codes and the Kaiser Permanente Northern California Cancer Registry to identify the first date of endometrial hyperplasia or cancer in the yearly population, and pharmacy records were reviewed to identify dispensed vaginal estrogen prescriptions in the 3 years prior to diagnosis of endometrial hyperplasia or cancer; those exposed within 2 years prior to diagnosis were excluded, as were those who used systemic estrogen.
Between 450,000 and 530,000 women met the selection criteria for each year during the study period, and the use of vaginal estrogen increased slightly over the study period. Between 26,000 and 34,000 women filled one to three prescriptions during the study years, and between 9,300 and 23,000 filled four or more prescriptions.
The overall annual incidence of endometrial hyperplasia or cancer increased over the study period, which is consistent with national data. The incidence rose from 8.96 per 10,000 women in 2006 to 10.56 per 10,000 women in 2012, but did not differ significantly by number of prescriptions filled.
“So we think our data suggest that the use of unopposed topical vaginal estrogen is not associated with an increased risk for endometrial hyperplasia or cancer over a 3-year period. However, further studies are needed,” Dr. Gunnison said, noting that the current study is limited by the retrospective, descriptive study design, and by the fact that the estrogen delivery method was not examined. The study also did not control for potential confounders.
Despite these limitations, it is the first study to look at vaginal estrogen use for more than 1 year, she said.
The findings are encouraging, she said, since many women choose low-dose topical vaginal estrogen because of concerns about potential adverse effects from systemic estrogen.
Dr. Gunnison reported having no financial disclosures.
AT ACOG 2015
Key clinical point: Topical vaginal estrogen does not appear to increase the risk of endometrial hyperplasia or cancer.
Major finding: The overall incidence of endometrial hyperplasia or cancer was 9.96, 10.25, and 9.96 per 10,000 women who filled four or more, one to three, or no vaginal estrogen prescriptions, respectively.
Data source: A large health system database including more than 500,000 women.
Disclosures: Dr. Gunnison reported having no financial disclosures.
Mobile apps: Powerful untapped family planning resource?
SAN FRANCISCO – A review of 160 mobile applications yielded only a small number with comprehensive and medically accurate birth control information, but these apps could be a useful resource for patients, according to Angel Robinson.
Of the apps reviewed, 16 were targeted toward health care providers and 144 were targeted toward patients. Only 20 of the 144 had comprehensive information about multiple birth control methods, Ms. Robinson, a third-year medical student at the University of California, Los Angeles, reported in a poster at the annual meeting of the American College of Obstetricians and Gynecologists.
She and her colleagues featured a few of the better quality apps in their poster, including:
Mayo Clinic About Birth Control: Options for You (cost: $1.99)
Plan A Birth Control (free)
Pregnancy prevention, birth control techniques ($0.99)
My Sex Doctor Plus ($0.99)
Sexual Health Guide (free)
These apps provide information about the various types of birth control available, as well as information about selecting the most appropriate method, Ms. Robinson said. Interactive features allow consumers to input personal health and other information to identify the best options.
Given that 90% of Americans use mobile phones, 58% have a smartphone, and half of those smartphone owners have used their phones to download apps, it follows that health-related apps could have broad appeal and utility; this may be particularly true for younger patients who are tech savvy and comfortable using apps, Ms. Robinson said.
Apps are also an attractive patient resource because they eliminate barriers that can interfere with communication of sexual and reproductive health information, but studies regarding the accuracy of the content of apps related to contraception and family planning have been lacking, she said.
For this study, Ms. Robinson and her colleagues searched the iOS mobile platform using numerous key words related to contraception and family planning between June and July of 2014. Several themes that emerged among the 144 patient-targeted apps were cycle tracking (40 apps), birth control reminders (26 apps), games (16 apps), family planning locators (22 apps), and sexual health information (40 apps).
“Mobile applications may be a powerful untapped patient information and referral resource,” Ms. Robinson and her colleagues wrote. “While mobile applications are an increasingly utilized means of accessing health and medical information, accurate and comprehensive information about contraception and family planning is not easily available for women who seek it through such applications.”
The quality apps that are available, however, could prove to be a useful adjunct to clinical care, she said, adding that additional studies are needed to identify the usefulness of such applications for that purpose.
The investigators reported having no financial disclosures.
SAN FRANCISCO – A review of 160 mobile applications yielded only a small number with comprehensive and medically accurate birth control information, but these apps could be a useful resource for patients, according to Angel Robinson.
Of the apps reviewed, 16 were targeted toward health care providers and 144 were targeted toward patients. Only 20 of the 144 had comprehensive information about multiple birth control methods, Ms. Robinson, a third-year medical student at the University of California, Los Angeles, reported in a poster at the annual meeting of the American College of Obstetricians and Gynecologists.
She and her colleagues featured a few of the better quality apps in their poster, including:
Mayo Clinic About Birth Control: Options for You (cost: $1.99)
Plan A Birth Control (free)
Pregnancy prevention, birth control techniques ($0.99)
My Sex Doctor Plus ($0.99)
Sexual Health Guide (free)
These apps provide information about the various types of birth control available, as well as information about selecting the most appropriate method, Ms. Robinson said. Interactive features allow consumers to input personal health and other information to identify the best options.
Given that 90% of Americans use mobile phones, 58% have a smartphone, and half of those smartphone owners have used their phones to download apps, it follows that health-related apps could have broad appeal and utility; this may be particularly true for younger patients who are tech savvy and comfortable using apps, Ms. Robinson said.
Apps are also an attractive patient resource because they eliminate barriers that can interfere with communication of sexual and reproductive health information, but studies regarding the accuracy of the content of apps related to contraception and family planning have been lacking, she said.
For this study, Ms. Robinson and her colleagues searched the iOS mobile platform using numerous key words related to contraception and family planning between June and July of 2014. Several themes that emerged among the 144 patient-targeted apps were cycle tracking (40 apps), birth control reminders (26 apps), games (16 apps), family planning locators (22 apps), and sexual health information (40 apps).
“Mobile applications may be a powerful untapped patient information and referral resource,” Ms. Robinson and her colleagues wrote. “While mobile applications are an increasingly utilized means of accessing health and medical information, accurate and comprehensive information about contraception and family planning is not easily available for women who seek it through such applications.”
The quality apps that are available, however, could prove to be a useful adjunct to clinical care, she said, adding that additional studies are needed to identify the usefulness of such applications for that purpose.
The investigators reported having no financial disclosures.
SAN FRANCISCO – A review of 160 mobile applications yielded only a small number with comprehensive and medically accurate birth control information, but these apps could be a useful resource for patients, according to Angel Robinson.
Of the apps reviewed, 16 were targeted toward health care providers and 144 were targeted toward patients. Only 20 of the 144 had comprehensive information about multiple birth control methods, Ms. Robinson, a third-year medical student at the University of California, Los Angeles, reported in a poster at the annual meeting of the American College of Obstetricians and Gynecologists.
She and her colleagues featured a few of the better quality apps in their poster, including:
Mayo Clinic About Birth Control: Options for You (cost: $1.99)
Plan A Birth Control (free)
Pregnancy prevention, birth control techniques ($0.99)
My Sex Doctor Plus ($0.99)
Sexual Health Guide (free)
These apps provide information about the various types of birth control available, as well as information about selecting the most appropriate method, Ms. Robinson said. Interactive features allow consumers to input personal health and other information to identify the best options.
Given that 90% of Americans use mobile phones, 58% have a smartphone, and half of those smartphone owners have used their phones to download apps, it follows that health-related apps could have broad appeal and utility; this may be particularly true for younger patients who are tech savvy and comfortable using apps, Ms. Robinson said.
Apps are also an attractive patient resource because they eliminate barriers that can interfere with communication of sexual and reproductive health information, but studies regarding the accuracy of the content of apps related to contraception and family planning have been lacking, she said.
For this study, Ms. Robinson and her colleagues searched the iOS mobile platform using numerous key words related to contraception and family planning between June and July of 2014. Several themes that emerged among the 144 patient-targeted apps were cycle tracking (40 apps), birth control reminders (26 apps), games (16 apps), family planning locators (22 apps), and sexual health information (40 apps).
“Mobile applications may be a powerful untapped patient information and referral resource,” Ms. Robinson and her colleagues wrote. “While mobile applications are an increasingly utilized means of accessing health and medical information, accurate and comprehensive information about contraception and family planning is not easily available for women who seek it through such applications.”
The quality apps that are available, however, could prove to be a useful adjunct to clinical care, she said, adding that additional studies are needed to identify the usefulness of such applications for that purpose.
The investigators reported having no financial disclosures.
AT ACOG 2015
Key clinical point: Comprehensive and accurate contraception and family planning apps are scarce, but could be a useful resource.
Major finding: Twenty of 144 identified contraceptive and family planning apps provided comprehensive and accurate information for patients.
Data source: A review of available contraceptive and family planning apps.
Disclosures: The investigators reported having no financial disclosures.
ATS: Study confirms strong association between sleep apnea, depression
DENVER – Men with previously undiagnosed severe obstructive sleep apnea and excessive daytime sleepiness have a more than four-fold increase in the risk of depression, compared with those without either condition, according to findings from a population-based cohort study.
Those with both severe obstructive sleep apnea (OSA) and excessive daytime sleepiness (EDS) also have a 3.5 times greater risk of depression than do those with either OSA or EDS alone, Carol Lang, Ph.D., reported during a press briefing at an international conference of the American Thoracic Society.
The findings have important implications for clinicians treating patients with depression; clinicians should recognize the risk of OSA in men with depression, and should screen those presenting with OSA – regardless of whether sleepiness is present, said Dr. Lang of the University of Adelaide, Australia.
Study subjects were 1,875 community dwelling Australian men aged 35-83 years who were assessed for depression using the Beck Depression Inventory/Centre for Epidemiological Studies Depression Scale (CES-D) at two times points about 5 years apart. A random sample of 857 men without previously diagnosed OSA underwent at-home polysomnography and completed the Epworth Sleepiness Scale questionnaire, and 1,660 men without depression at baseline were included in the analysis of incident depression.
Previously undiagnosed mild-to-moderate and severe OSA were associated with depression prevalence (adjusted odds ratio 2.1), and this was true even after adjusting for confounders and EDS.
EDS also was associated with depression (adjusted OR, 1.1). she said.
Patients with previously undiagnosed OSA and EDS had greater odds of depression than did those without OSA and EDS (OR, 4.2), and had greater odds of depression than did those with either condition alone (OR, 3.5).
Further, previously diagnosed OSA and previously undiagnosed severe OSA at follow-up were significantly associated with depression onset over a 5-year period (OR, 2.1 and 2.9, respectively), Dr. Lang said.
The findings support those of prior studies that have demonstrated a link between sleep apnea and depression.
As many as 22% of those with OSA also have clinically significant depressive symptoms, compared with 5% of the general population. Daytime sleepiness can occur in those with OSA, but not everyone with OSA reports daytime sleepiness, she said, noting that few prior studies have looked at the relationship between OSA and depression in a community-based population.
“Our study, in a large community-based sample of men, confirms a strong relationship even after adjustment for a number of other potential risk factors,” she said.
The mechanisms underlying the association remain unclear, but it may be that many of the symptoms of and risk factors for OSA and depression overlap.
“Sleep apnea is also associated with lower oxygen levels in the body, and this causes a range of physiological consequences, including altered inflammatory responses, hormonal stimulation, as well as neurological changes in the brain that just happen to be in the same region of the brain that might actually impact depression, feelings of guilt, worthlessness, and suicidal tendencies,” she said.
The message to clinicians based on these findings is that patients who present with symptoms of either OSA or depression should be screened for both.
“Often, I think, when people present with depression, it’s easy to just assume the sleep problems are related to the depression itself ... but there may actually be benefit for the patient if both are investigated and treated,” she concluded.
Dr. Mihaela Teodorescu of the University of Wisconsin, Madison, who moderated the press conference, added that additional data exist to suggest that sleep apnea leads to “more severe, and actually refractory depression,” and further stressed that lack of awareness of the association can be harmful for patients.
“These people just get more antidepressants, including benzodiazepines, which are really detrimental for the obstructive sleep apnea pathogenesis, worsening depression. So it’s very important for the community to be aware about sleep apnea as a potential aggravator and contributor to depression,” she said.
Dr. Lang reported having no relevant financial disclosures.
DENVER – Men with previously undiagnosed severe obstructive sleep apnea and excessive daytime sleepiness have a more than four-fold increase in the risk of depression, compared with those without either condition, according to findings from a population-based cohort study.
Those with both severe obstructive sleep apnea (OSA) and excessive daytime sleepiness (EDS) also have a 3.5 times greater risk of depression than do those with either OSA or EDS alone, Carol Lang, Ph.D., reported during a press briefing at an international conference of the American Thoracic Society.
The findings have important implications for clinicians treating patients with depression; clinicians should recognize the risk of OSA in men with depression, and should screen those presenting with OSA – regardless of whether sleepiness is present, said Dr. Lang of the University of Adelaide, Australia.
Study subjects were 1,875 community dwelling Australian men aged 35-83 years who were assessed for depression using the Beck Depression Inventory/Centre for Epidemiological Studies Depression Scale (CES-D) at two times points about 5 years apart. A random sample of 857 men without previously diagnosed OSA underwent at-home polysomnography and completed the Epworth Sleepiness Scale questionnaire, and 1,660 men without depression at baseline were included in the analysis of incident depression.
Previously undiagnosed mild-to-moderate and severe OSA were associated with depression prevalence (adjusted odds ratio 2.1), and this was true even after adjusting for confounders and EDS.
EDS also was associated with depression (adjusted OR, 1.1). she said.
Patients with previously undiagnosed OSA and EDS had greater odds of depression than did those without OSA and EDS (OR, 4.2), and had greater odds of depression than did those with either condition alone (OR, 3.5).
Further, previously diagnosed OSA and previously undiagnosed severe OSA at follow-up were significantly associated with depression onset over a 5-year period (OR, 2.1 and 2.9, respectively), Dr. Lang said.
The findings support those of prior studies that have demonstrated a link between sleep apnea and depression.
As many as 22% of those with OSA also have clinically significant depressive symptoms, compared with 5% of the general population. Daytime sleepiness can occur in those with OSA, but not everyone with OSA reports daytime sleepiness, she said, noting that few prior studies have looked at the relationship between OSA and depression in a community-based population.
“Our study, in a large community-based sample of men, confirms a strong relationship even after adjustment for a number of other potential risk factors,” she said.
The mechanisms underlying the association remain unclear, but it may be that many of the symptoms of and risk factors for OSA and depression overlap.
“Sleep apnea is also associated with lower oxygen levels in the body, and this causes a range of physiological consequences, including altered inflammatory responses, hormonal stimulation, as well as neurological changes in the brain that just happen to be in the same region of the brain that might actually impact depression, feelings of guilt, worthlessness, and suicidal tendencies,” she said.
The message to clinicians based on these findings is that patients who present with symptoms of either OSA or depression should be screened for both.
“Often, I think, when people present with depression, it’s easy to just assume the sleep problems are related to the depression itself ... but there may actually be benefit for the patient if both are investigated and treated,” she concluded.
Dr. Mihaela Teodorescu of the University of Wisconsin, Madison, who moderated the press conference, added that additional data exist to suggest that sleep apnea leads to “more severe, and actually refractory depression,” and further stressed that lack of awareness of the association can be harmful for patients.
“These people just get more antidepressants, including benzodiazepines, which are really detrimental for the obstructive sleep apnea pathogenesis, worsening depression. So it’s very important for the community to be aware about sleep apnea as a potential aggravator and contributor to depression,” she said.
Dr. Lang reported having no relevant financial disclosures.
DENVER – Men with previously undiagnosed severe obstructive sleep apnea and excessive daytime sleepiness have a more than four-fold increase in the risk of depression, compared with those without either condition, according to findings from a population-based cohort study.
Those with both severe obstructive sleep apnea (OSA) and excessive daytime sleepiness (EDS) also have a 3.5 times greater risk of depression than do those with either OSA or EDS alone, Carol Lang, Ph.D., reported during a press briefing at an international conference of the American Thoracic Society.
The findings have important implications for clinicians treating patients with depression; clinicians should recognize the risk of OSA in men with depression, and should screen those presenting with OSA – regardless of whether sleepiness is present, said Dr. Lang of the University of Adelaide, Australia.
Study subjects were 1,875 community dwelling Australian men aged 35-83 years who were assessed for depression using the Beck Depression Inventory/Centre for Epidemiological Studies Depression Scale (CES-D) at two times points about 5 years apart. A random sample of 857 men without previously diagnosed OSA underwent at-home polysomnography and completed the Epworth Sleepiness Scale questionnaire, and 1,660 men without depression at baseline were included in the analysis of incident depression.
Previously undiagnosed mild-to-moderate and severe OSA were associated with depression prevalence (adjusted odds ratio 2.1), and this was true even after adjusting for confounders and EDS.
EDS also was associated with depression (adjusted OR, 1.1). she said.
Patients with previously undiagnosed OSA and EDS had greater odds of depression than did those without OSA and EDS (OR, 4.2), and had greater odds of depression than did those with either condition alone (OR, 3.5).
Further, previously diagnosed OSA and previously undiagnosed severe OSA at follow-up were significantly associated with depression onset over a 5-year period (OR, 2.1 and 2.9, respectively), Dr. Lang said.
The findings support those of prior studies that have demonstrated a link between sleep apnea and depression.
As many as 22% of those with OSA also have clinically significant depressive symptoms, compared with 5% of the general population. Daytime sleepiness can occur in those with OSA, but not everyone with OSA reports daytime sleepiness, she said, noting that few prior studies have looked at the relationship between OSA and depression in a community-based population.
“Our study, in a large community-based sample of men, confirms a strong relationship even after adjustment for a number of other potential risk factors,” she said.
The mechanisms underlying the association remain unclear, but it may be that many of the symptoms of and risk factors for OSA and depression overlap.
“Sleep apnea is also associated with lower oxygen levels in the body, and this causes a range of physiological consequences, including altered inflammatory responses, hormonal stimulation, as well as neurological changes in the brain that just happen to be in the same region of the brain that might actually impact depression, feelings of guilt, worthlessness, and suicidal tendencies,” she said.
The message to clinicians based on these findings is that patients who present with symptoms of either OSA or depression should be screened for both.
“Often, I think, when people present with depression, it’s easy to just assume the sleep problems are related to the depression itself ... but there may actually be benefit for the patient if both are investigated and treated,” she concluded.
Dr. Mihaela Teodorescu of the University of Wisconsin, Madison, who moderated the press conference, added that additional data exist to suggest that sleep apnea leads to “more severe, and actually refractory depression,” and further stressed that lack of awareness of the association can be harmful for patients.
“These people just get more antidepressants, including benzodiazepines, which are really detrimental for the obstructive sleep apnea pathogenesis, worsening depression. So it’s very important for the community to be aware about sleep apnea as a potential aggravator and contributor to depression,” she said.
Dr. Lang reported having no relevant financial disclosures.
AT ATS 2015
Key clinical point: Patients who present for OSA or depression should be screened for both.
Major finding: Patients with previously undiagnosed OSA and EDS had greater odds of depression than did those without OSA and EDS (OR, 4.2).
Data source: A population-based cohort study of 1,875 men.
Disclosures: Dr. Lang reported having no relevant financial disclosures.
ACOG: Immediate postpartum IUD the ‘next big thing’
SAN FRANCISCO – Immediate postpartum intrauterine device placement offers multiple advantages, and is generally safe and effective for preventing rapid repeat pregnancy, according to Dr. Eve Espey.
“I personally think that the postpartum IUD is the next big thing,” she said during a clinical seminar on contraception at the annual meeting of the American College of Obstetricians and Gynecologists.
The biggest barrier to immediate postpartum IUD insertion is payment. In most states, IUD placement can’t be split out from the global fee for delivery, but that is steadily changing, said Dr. Espey, chair of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque.
There are now 11 states where Medicaid has agreed to split out postpartum placement of IUDs or contraceptive implants from the global fee for delivery, she said. The 11 states are Alabama, Colorado, Georgia, Iowa, Louisiana, Maryland, Montana, New Mexico, New York, Oklahoma, and South Carolina.
“We are fortunate in New Mexico to be one of those states, so we now have IUDs and implants available for postpartum women,” she said.
If placing an IUD at the time of delivery, Dr. Espey said insertion should occur as soon as possible since data suggest that insertion within 10 minutes of expulsion of the placenta or at the time of cesarean delivery is associated with a lower rate of IUD expulsion, compared with insertion that occurs after 10 minutes.
“We actually have not had difficulty getting them in within 10 minutes, but we give a 30-minute window,” she said, noting that the definitive study on the expulsion rate of IUDs has not yet been done, but that estimates range from 10% to 40%.
“But I think that the public health impact is such that, even if there is a high expulsion rate, it will still be worthwhile to place IUDs immediately, because of the multiple advantages,” she said.
In addition to knowing that the woman is not pregnant at the time of placement, advantages include the fact that postpartum women are “quite motivated to utilize a contraceptive method right after having a baby,” the patient and physician are already in the same place at the same time, and the procedure is relatively simple.
The prevention of rapid repeat pregnancy – within 18 months of delivery – is another major advantage to immediate postpartum insertions. About a third of pregnancies are rapid repeat pregnancies, Dr. Espey said.
“So again, a postpartum IUD or a postpartum implant may really have the power to reduce those rapid repeat pregnancies,” Dr Espey said.
The disadvantages are few, she said, as are the contraindications, which include infection and postpartum hemorrhage.
As for safety, Dr. Espey said reasonable evidence suggests that IUDs – in contrast with hormonal contraceptives, and despite the fact that there is hormone in the levonorgestrel IUD – have no impact on cardiovascular risk or venous thromboembolism risk, and likely no impact on breastfeeding.
Postpartum IUD insertion isn’t difficult, but the postpartum uterus does pose some unique challenges, most notably the angle.
Insertion can be performed manually, or by using ring forceps or an inserter. However, an inserter is not recommended because of the difficulty with the angle in postpartum cases.
Dr. Espey recommended using ring forceps to grasp the IUD on the bias to allow the string to remain free. Long ring forceps are particularly helpful for postpartum cases, but standard ring forceps also work, she said.
“We typically will place the posterior blade of a [Graves] speculum in the posterior vagina, exert downward traction, identify the anterior cervix, and grasp the anterior cervix with the ring forceps,” she said.
The only setup needed involves the Graves speculum and two ring forceps, she added.
The speculum spreads the walls of the vagina to allow insertion without the IUD touching the vaginal walls. The IUD can be held in the down direction upon insertion to help prevent its touching the vaginal walls, then turned to provide the correct orientation all the way up to the fundus, she explained.
Ultrasound guidance may be useful and reassuring for those learning the procedure, but generally won’t be required once the physician gains experience in postpartum IUD placement, she added.
Interest in postpartum IUD placement is currently low and will likely remain that way until payment is more widespread, Dr. Espey said. But she recommended that physicians seek out training opportunities because payment is coming.
“We’ve been doing this for a year and a half. I think it is a really patient centered way to approach IUD insertion, so I would highly recommend being abreast of what’s going on in your state relative to reimbursement for postpartum IUD insertion,” she said.
Dr. Espey reported having no financial disclosures. She is a member of the Ob.Gyn. News editorial advisory board.
SAN FRANCISCO – Immediate postpartum intrauterine device placement offers multiple advantages, and is generally safe and effective for preventing rapid repeat pregnancy, according to Dr. Eve Espey.
“I personally think that the postpartum IUD is the next big thing,” she said during a clinical seminar on contraception at the annual meeting of the American College of Obstetricians and Gynecologists.
The biggest barrier to immediate postpartum IUD insertion is payment. In most states, IUD placement can’t be split out from the global fee for delivery, but that is steadily changing, said Dr. Espey, chair of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque.
There are now 11 states where Medicaid has agreed to split out postpartum placement of IUDs or contraceptive implants from the global fee for delivery, she said. The 11 states are Alabama, Colorado, Georgia, Iowa, Louisiana, Maryland, Montana, New Mexico, New York, Oklahoma, and South Carolina.
“We are fortunate in New Mexico to be one of those states, so we now have IUDs and implants available for postpartum women,” she said.
If placing an IUD at the time of delivery, Dr. Espey said insertion should occur as soon as possible since data suggest that insertion within 10 minutes of expulsion of the placenta or at the time of cesarean delivery is associated with a lower rate of IUD expulsion, compared with insertion that occurs after 10 minutes.
“We actually have not had difficulty getting them in within 10 minutes, but we give a 30-minute window,” she said, noting that the definitive study on the expulsion rate of IUDs has not yet been done, but that estimates range from 10% to 40%.
“But I think that the public health impact is such that, even if there is a high expulsion rate, it will still be worthwhile to place IUDs immediately, because of the multiple advantages,” she said.
In addition to knowing that the woman is not pregnant at the time of placement, advantages include the fact that postpartum women are “quite motivated to utilize a contraceptive method right after having a baby,” the patient and physician are already in the same place at the same time, and the procedure is relatively simple.
The prevention of rapid repeat pregnancy – within 18 months of delivery – is another major advantage to immediate postpartum insertions. About a third of pregnancies are rapid repeat pregnancies, Dr. Espey said.
“So again, a postpartum IUD or a postpartum implant may really have the power to reduce those rapid repeat pregnancies,” Dr Espey said.
The disadvantages are few, she said, as are the contraindications, which include infection and postpartum hemorrhage.
As for safety, Dr. Espey said reasonable evidence suggests that IUDs – in contrast with hormonal contraceptives, and despite the fact that there is hormone in the levonorgestrel IUD – have no impact on cardiovascular risk or venous thromboembolism risk, and likely no impact on breastfeeding.
Postpartum IUD insertion isn’t difficult, but the postpartum uterus does pose some unique challenges, most notably the angle.
Insertion can be performed manually, or by using ring forceps or an inserter. However, an inserter is not recommended because of the difficulty with the angle in postpartum cases.
Dr. Espey recommended using ring forceps to grasp the IUD on the bias to allow the string to remain free. Long ring forceps are particularly helpful for postpartum cases, but standard ring forceps also work, she said.
“We typically will place the posterior blade of a [Graves] speculum in the posterior vagina, exert downward traction, identify the anterior cervix, and grasp the anterior cervix with the ring forceps,” she said.
The only setup needed involves the Graves speculum and two ring forceps, she added.
The speculum spreads the walls of the vagina to allow insertion without the IUD touching the vaginal walls. The IUD can be held in the down direction upon insertion to help prevent its touching the vaginal walls, then turned to provide the correct orientation all the way up to the fundus, she explained.
Ultrasound guidance may be useful and reassuring for those learning the procedure, but generally won’t be required once the physician gains experience in postpartum IUD placement, she added.
Interest in postpartum IUD placement is currently low and will likely remain that way until payment is more widespread, Dr. Espey said. But she recommended that physicians seek out training opportunities because payment is coming.
“We’ve been doing this for a year and a half. I think it is a really patient centered way to approach IUD insertion, so I would highly recommend being abreast of what’s going on in your state relative to reimbursement for postpartum IUD insertion,” she said.
Dr. Espey reported having no financial disclosures. She is a member of the Ob.Gyn. News editorial advisory board.
SAN FRANCISCO – Immediate postpartum intrauterine device placement offers multiple advantages, and is generally safe and effective for preventing rapid repeat pregnancy, according to Dr. Eve Espey.
“I personally think that the postpartum IUD is the next big thing,” she said during a clinical seminar on contraception at the annual meeting of the American College of Obstetricians and Gynecologists.
The biggest barrier to immediate postpartum IUD insertion is payment. In most states, IUD placement can’t be split out from the global fee for delivery, but that is steadily changing, said Dr. Espey, chair of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque.
There are now 11 states where Medicaid has agreed to split out postpartum placement of IUDs or contraceptive implants from the global fee for delivery, she said. The 11 states are Alabama, Colorado, Georgia, Iowa, Louisiana, Maryland, Montana, New Mexico, New York, Oklahoma, and South Carolina.
“We are fortunate in New Mexico to be one of those states, so we now have IUDs and implants available for postpartum women,” she said.
If placing an IUD at the time of delivery, Dr. Espey said insertion should occur as soon as possible since data suggest that insertion within 10 minutes of expulsion of the placenta or at the time of cesarean delivery is associated with a lower rate of IUD expulsion, compared with insertion that occurs after 10 minutes.
“We actually have not had difficulty getting them in within 10 minutes, but we give a 30-minute window,” she said, noting that the definitive study on the expulsion rate of IUDs has not yet been done, but that estimates range from 10% to 40%.
“But I think that the public health impact is such that, even if there is a high expulsion rate, it will still be worthwhile to place IUDs immediately, because of the multiple advantages,” she said.
In addition to knowing that the woman is not pregnant at the time of placement, advantages include the fact that postpartum women are “quite motivated to utilize a contraceptive method right after having a baby,” the patient and physician are already in the same place at the same time, and the procedure is relatively simple.
The prevention of rapid repeat pregnancy – within 18 months of delivery – is another major advantage to immediate postpartum insertions. About a third of pregnancies are rapid repeat pregnancies, Dr. Espey said.
“So again, a postpartum IUD or a postpartum implant may really have the power to reduce those rapid repeat pregnancies,” Dr Espey said.
The disadvantages are few, she said, as are the contraindications, which include infection and postpartum hemorrhage.
As for safety, Dr. Espey said reasonable evidence suggests that IUDs – in contrast with hormonal contraceptives, and despite the fact that there is hormone in the levonorgestrel IUD – have no impact on cardiovascular risk or venous thromboembolism risk, and likely no impact on breastfeeding.
Postpartum IUD insertion isn’t difficult, but the postpartum uterus does pose some unique challenges, most notably the angle.
Insertion can be performed manually, or by using ring forceps or an inserter. However, an inserter is not recommended because of the difficulty with the angle in postpartum cases.
Dr. Espey recommended using ring forceps to grasp the IUD on the bias to allow the string to remain free. Long ring forceps are particularly helpful for postpartum cases, but standard ring forceps also work, she said.
“We typically will place the posterior blade of a [Graves] speculum in the posterior vagina, exert downward traction, identify the anterior cervix, and grasp the anterior cervix with the ring forceps,” she said.
The only setup needed involves the Graves speculum and two ring forceps, she added.
The speculum spreads the walls of the vagina to allow insertion without the IUD touching the vaginal walls. The IUD can be held in the down direction upon insertion to help prevent its touching the vaginal walls, then turned to provide the correct orientation all the way up to the fundus, she explained.
Ultrasound guidance may be useful and reassuring for those learning the procedure, but generally won’t be required once the physician gains experience in postpartum IUD placement, she added.
Interest in postpartum IUD placement is currently low and will likely remain that way until payment is more widespread, Dr. Espey said. But she recommended that physicians seek out training opportunities because payment is coming.
“We’ve been doing this for a year and a half. I think it is a really patient centered way to approach IUD insertion, so I would highly recommend being abreast of what’s going on in your state relative to reimbursement for postpartum IUD insertion,” she said.
Dr. Espey reported having no financial disclosures. She is a member of the Ob.Gyn. News editorial advisory board.
EXPERT ANALYSIS FROM THE ACOG ANNUAL CLINICAL MEETING
ACOG: Survey finds few have experience in third-trimester terminations
SAN FRANCISCO – A minority of abortion providers who participated in a recent survey have knowledge of and experience with third-trimester terminations in cases involving lethal fetal anomalies.
Of 112 respondents, 32 (29%) reported having a “good” foundation of knowledge regarding third-trimester pregnancy termination, and 21 (19%) reported participating in the care of women undergoing third-trimester terminations. The provision of such care was significantly associated with training-related factors and encounters with affected patients, Dr. Jessica Maria Atrio reported at the annual meeting of the American College of Obstetricians and Gynecologists.
“Lethal fetal anomalies are common ethically and emotionally challenging obstetric scenarios,” said Dr. Atrio of Montefiore Medical Center, New York, noting that birth defects account for 20% of infant mortality and are the leading cause of death among newborns.
Estimates regarding prevalence and outcomes in cases involving fetal anomalies, however, are not well established, due in part to inconsistent reporting across regions and states. But some women dealing with lethal and other fetal anomalies do request termination of their pregnancy. The diagnosis of a lethal fetal anomaly typically involves referral to a tertiary care facility and coordination among multiple providers involved with the testing, counseling, diagnostic, and interventional planning, according to Dr. Atrio.
If there is no reasonable likelihood of the fetus or infant surviving, termination of the pregnancy should be offered for the safety and well being of the woman, Dr. Atrio said, adding that “in collaborative practice environments, family planning fellowship affiliates and abortion providers may be solicited for their insight regarding expeditious evacuation of the gravid uterus.”
“However, third-trimester termination of pregnancy is not part of the required curriculum in the family planning fellowship,” she said.
For this reason, the researchers designed a survey aimed at exploring the extent of knowledge and participation among U.S. abortion providers affiliated with family planning fellowship programs with respect to the care of women undergoing third-trimester pregnancy termination due to lethal fetal anomalies.
Most of the respondents to the electronically distributed survey were female abortion providers born in the late 1970s. About a third graduated from fellowship programs on the East Coast, a third from programs on the West Coast, and a third from programs distributed across the country. The vast majority (88%) were current academic faculty at teaching institutions in a clinical environment involving medical students or residents, but most did not have a family planning fellowship at their current academic home.
Age, gender, and type of abortion training were not significantly associated with provision of third-trimester termination for lethal fetal anomalies.
Of the 29% who reported having a good foundation of knowledge regarding the technical aspects and protocols used for third-trimester pregnancy termination, most said they learned during residency and through direct mentorship.
“This resonates with the classic edict of experiential learning, which is often involved in our canon of medical education: See one, do one, teach one,” Dr. Atrio said, adding that women who experience lethal fetal anomalies are vulnerable and deserve care that is informed by best practices and evidence-based protocols tailored to their clinical context.
One way to potentially improve access and knowledge regarding the care of these women is by expanding opportunities to involve trainees. The majority of survey respondents did express a desire to learn about the scope of care during their fellowship training, Dr. Atrio said.
“Enhancing collaborative care between various professionals such as gynecologists and obstetric providers may improve the quality of care offered to these vulnerable women,” she said.
Dr. Atrio reported having no financial disclosures.
SAN FRANCISCO – A minority of abortion providers who participated in a recent survey have knowledge of and experience with third-trimester terminations in cases involving lethal fetal anomalies.
Of 112 respondents, 32 (29%) reported having a “good” foundation of knowledge regarding third-trimester pregnancy termination, and 21 (19%) reported participating in the care of women undergoing third-trimester terminations. The provision of such care was significantly associated with training-related factors and encounters with affected patients, Dr. Jessica Maria Atrio reported at the annual meeting of the American College of Obstetricians and Gynecologists.
“Lethal fetal anomalies are common ethically and emotionally challenging obstetric scenarios,” said Dr. Atrio of Montefiore Medical Center, New York, noting that birth defects account for 20% of infant mortality and are the leading cause of death among newborns.
Estimates regarding prevalence and outcomes in cases involving fetal anomalies, however, are not well established, due in part to inconsistent reporting across regions and states. But some women dealing with lethal and other fetal anomalies do request termination of their pregnancy. The diagnosis of a lethal fetal anomaly typically involves referral to a tertiary care facility and coordination among multiple providers involved with the testing, counseling, diagnostic, and interventional planning, according to Dr. Atrio.
If there is no reasonable likelihood of the fetus or infant surviving, termination of the pregnancy should be offered for the safety and well being of the woman, Dr. Atrio said, adding that “in collaborative practice environments, family planning fellowship affiliates and abortion providers may be solicited for their insight regarding expeditious evacuation of the gravid uterus.”
“However, third-trimester termination of pregnancy is not part of the required curriculum in the family planning fellowship,” she said.
For this reason, the researchers designed a survey aimed at exploring the extent of knowledge and participation among U.S. abortion providers affiliated with family planning fellowship programs with respect to the care of women undergoing third-trimester pregnancy termination due to lethal fetal anomalies.
Most of the respondents to the electronically distributed survey were female abortion providers born in the late 1970s. About a third graduated from fellowship programs on the East Coast, a third from programs on the West Coast, and a third from programs distributed across the country. The vast majority (88%) were current academic faculty at teaching institutions in a clinical environment involving medical students or residents, but most did not have a family planning fellowship at their current academic home.
Age, gender, and type of abortion training were not significantly associated with provision of third-trimester termination for lethal fetal anomalies.
Of the 29% who reported having a good foundation of knowledge regarding the technical aspects and protocols used for third-trimester pregnancy termination, most said they learned during residency and through direct mentorship.
“This resonates with the classic edict of experiential learning, which is often involved in our canon of medical education: See one, do one, teach one,” Dr. Atrio said, adding that women who experience lethal fetal anomalies are vulnerable and deserve care that is informed by best practices and evidence-based protocols tailored to their clinical context.
One way to potentially improve access and knowledge regarding the care of these women is by expanding opportunities to involve trainees. The majority of survey respondents did express a desire to learn about the scope of care during their fellowship training, Dr. Atrio said.
“Enhancing collaborative care between various professionals such as gynecologists and obstetric providers may improve the quality of care offered to these vulnerable women,” she said.
Dr. Atrio reported having no financial disclosures.
SAN FRANCISCO – A minority of abortion providers who participated in a recent survey have knowledge of and experience with third-trimester terminations in cases involving lethal fetal anomalies.
Of 112 respondents, 32 (29%) reported having a “good” foundation of knowledge regarding third-trimester pregnancy termination, and 21 (19%) reported participating in the care of women undergoing third-trimester terminations. The provision of such care was significantly associated with training-related factors and encounters with affected patients, Dr. Jessica Maria Atrio reported at the annual meeting of the American College of Obstetricians and Gynecologists.
“Lethal fetal anomalies are common ethically and emotionally challenging obstetric scenarios,” said Dr. Atrio of Montefiore Medical Center, New York, noting that birth defects account for 20% of infant mortality and are the leading cause of death among newborns.
Estimates regarding prevalence and outcomes in cases involving fetal anomalies, however, are not well established, due in part to inconsistent reporting across regions and states. But some women dealing with lethal and other fetal anomalies do request termination of their pregnancy. The diagnosis of a lethal fetal anomaly typically involves referral to a tertiary care facility and coordination among multiple providers involved with the testing, counseling, diagnostic, and interventional planning, according to Dr. Atrio.
If there is no reasonable likelihood of the fetus or infant surviving, termination of the pregnancy should be offered for the safety and well being of the woman, Dr. Atrio said, adding that “in collaborative practice environments, family planning fellowship affiliates and abortion providers may be solicited for their insight regarding expeditious evacuation of the gravid uterus.”
“However, third-trimester termination of pregnancy is not part of the required curriculum in the family planning fellowship,” she said.
For this reason, the researchers designed a survey aimed at exploring the extent of knowledge and participation among U.S. abortion providers affiliated with family planning fellowship programs with respect to the care of women undergoing third-trimester pregnancy termination due to lethal fetal anomalies.
Most of the respondents to the electronically distributed survey were female abortion providers born in the late 1970s. About a third graduated from fellowship programs on the East Coast, a third from programs on the West Coast, and a third from programs distributed across the country. The vast majority (88%) were current academic faculty at teaching institutions in a clinical environment involving medical students or residents, but most did not have a family planning fellowship at their current academic home.
Age, gender, and type of abortion training were not significantly associated with provision of third-trimester termination for lethal fetal anomalies.
Of the 29% who reported having a good foundation of knowledge regarding the technical aspects and protocols used for third-trimester pregnancy termination, most said they learned during residency and through direct mentorship.
“This resonates with the classic edict of experiential learning, which is often involved in our canon of medical education: See one, do one, teach one,” Dr. Atrio said, adding that women who experience lethal fetal anomalies are vulnerable and deserve care that is informed by best practices and evidence-based protocols tailored to their clinical context.
One way to potentially improve access and knowledge regarding the care of these women is by expanding opportunities to involve trainees. The majority of survey respondents did express a desire to learn about the scope of care during their fellowship training, Dr. Atrio said.
“Enhancing collaborative care between various professionals such as gynecologists and obstetric providers may improve the quality of care offered to these vulnerable women,” she said.
Dr. Atrio reported having no financial disclosures.
AT THE ACOG ANNUAL CLINICAL MEETING
Key clinical point: Many abortion providers lack knowledge and experience in the third-trimester management of lethal fetal anomalies.
Major finding: In a survey of abortion providers, only 19% reported participating in the care of a woman undergoing a third-trimester termination.
Data source: A survey of 112 abortion providers affiliated with family planning fellowship programs.
Disclosures: Dr. Atrio reported having no financial disclosures.
NASPAG: Obesity raises unique contraceptive concerns in teens
ORLANDO – The data with respect to the effects of obesity on the efficacy of contraceptives in adolescents are limited, but the general consensus is that if efficacy is reduced, it isn’t by enough to make a real difference, according to Dr. Alene Toulany.
The effect of obesity is likely to be very small, and studies that have looked at pharmacokinetics in obesity have estimated that body weight accounts for only about 10%-20% of the variability of hormone levels, Dr. Toulany said at the North American Society for Pediatric and Adolescent Gynecology annual meeting.
“We know that this is within the normal range for individuals who are not obese, she said.
The concerns regarding efficacy in obese patients are understandable, as obesity increases the metabolic rate, increases clearance of hepatically metabolized drugs, increases circulating blood volume, and affects the absorption of contraceptive steroids through the adipose tissue, she said, adding that “it makes sense that the serum drug levels may be insufficient to maintain contraceptive effects, but the data are very limited and inconsistent.”
That’s not to say obesity isn’t a concern, added Dr. Toulany, an adolescent medicine specialist at the Hospital for Sick Children, Toronto, and the University of Toronto.
“Without fail, all of us will be seeing patients with obesity,” she said. The rate of adolescent obesity has quadrupled in the last 3 decades, increasing from 5% among those aged 12-19 years in 1980 to more than 20% now. A third are currently overweight or obese.
Further, sexually active obese women, regardless of age, are significantly less likely to use contraception, and obese teens are more likely to engage in risky sexual behaviors than are nonobese teens.
For these reasons, it is important to find the most effective contraceptive method, taking into account other risk factors and the likelihood of compliance, she said, noting that obesity is an independent risk factor for venous thromboembolism (VTE) and that studies suggest the risk is additive in users of estrogen-containing contraceptives.
However, she said, the benefits outweigh the risks of pregnancy in obesity – especially of unintended pregnancy.
The absolute risk of VTE in healthy women of reproductive age is small, and in adolescents it’s even smaller, she explained.
“The presence of risk factors for VTE should be taken into account when we see these youth in our clinics, but we can and should offer estrogen-containing contraceptives as long as there are no other risk factors,” she said.
Contraceptive options in young obese patients include:
• Intrauterine devices. There is no evidence that either copper IUDs or progestin-releasing IUDs have reduced efficacy in obese adolescents.
• Implants. These are highly effective in obese women, and even though the concentrations may be 30%-60% lower in obese women, they do remain above the contraceptive threshold for at least the first 3 years, Dr. Toulany said.
• Depot medroxyprogesterone acetate. There is some concern about weight gain with this injectable progestin-only contraceptive, particularly in those who are already obese, but it remains an option, as the levels do remain above what is needed to prevent ovulation. Interestingly, the persistence of ovulation suppression following discontinuation is different in obese women, and may be prolonged, compared with nonobese women; it is important to counsel patients about this, she said.
“So although randomized, controlled trials report no significant weight gain, we do agree with these observational studies that show that overweight and obese teens gain more weight with Depo-Provera than with oral contraceptives or with no contraceptives,” she said.
• Oral contraceptive pills. Although these may be less effective in obese adolescents, they remain an option and may be the best option in a given patient. Combined oral contraceptives are believed to be generally effective for pregnancy prevention, but “may be less forgiving of imperfect use,” and thus may not be the best choice in those who may have problems with adherence, for example.
The contraceptive patch is probably not a good option, because efficacy may be diminished as a result of absorption through the adipose tissues in those weighing more than 90 kg, Dr .Toulany said. Evidence is insufficient regarding the use of contraceptive rings in obese patients.
Bariatric surgery is increasingly being performed in adolescents, and this raises unique concerns with respect to contraception, Dr. Toulany said.
“We recommend discontinuing estrogen-containing contraceptives 1 month before surgery to reduce the risk of VTE postoperatively,” she said.
After bariatric surgery, those who undergo a restrictive procedure such as gastric banding or a gastric sleeve procedure that reduces the volume of the stomach can use oral contraceptives, but postsurgery vomiting and diarrhea could increase the risk of complications. In those who undergo surgery using a technique that involves a significant malabsorption component, such as Roux-en-Y gastric bypass, nonoral contraceptives are the best option.
“Most patients going for bariatric surgery have an IUD inserted at the time of surgery, and that’s what we would recommend,” Dr. Toulany said.
She reported having no relevant financial disclosures.
ORLANDO – The data with respect to the effects of obesity on the efficacy of contraceptives in adolescents are limited, but the general consensus is that if efficacy is reduced, it isn’t by enough to make a real difference, according to Dr. Alene Toulany.
The effect of obesity is likely to be very small, and studies that have looked at pharmacokinetics in obesity have estimated that body weight accounts for only about 10%-20% of the variability of hormone levels, Dr. Toulany said at the North American Society for Pediatric and Adolescent Gynecology annual meeting.
“We know that this is within the normal range for individuals who are not obese, she said.
The concerns regarding efficacy in obese patients are understandable, as obesity increases the metabolic rate, increases clearance of hepatically metabolized drugs, increases circulating blood volume, and affects the absorption of contraceptive steroids through the adipose tissue, she said, adding that “it makes sense that the serum drug levels may be insufficient to maintain contraceptive effects, but the data are very limited and inconsistent.”
That’s not to say obesity isn’t a concern, added Dr. Toulany, an adolescent medicine specialist at the Hospital for Sick Children, Toronto, and the University of Toronto.
“Without fail, all of us will be seeing patients with obesity,” she said. The rate of adolescent obesity has quadrupled in the last 3 decades, increasing from 5% among those aged 12-19 years in 1980 to more than 20% now. A third are currently overweight or obese.
Further, sexually active obese women, regardless of age, are significantly less likely to use contraception, and obese teens are more likely to engage in risky sexual behaviors than are nonobese teens.
For these reasons, it is important to find the most effective contraceptive method, taking into account other risk factors and the likelihood of compliance, she said, noting that obesity is an independent risk factor for venous thromboembolism (VTE) and that studies suggest the risk is additive in users of estrogen-containing contraceptives.
However, she said, the benefits outweigh the risks of pregnancy in obesity – especially of unintended pregnancy.
The absolute risk of VTE in healthy women of reproductive age is small, and in adolescents it’s even smaller, she explained.
“The presence of risk factors for VTE should be taken into account when we see these youth in our clinics, but we can and should offer estrogen-containing contraceptives as long as there are no other risk factors,” she said.
Contraceptive options in young obese patients include:
• Intrauterine devices. There is no evidence that either copper IUDs or progestin-releasing IUDs have reduced efficacy in obese adolescents.
• Implants. These are highly effective in obese women, and even though the concentrations may be 30%-60% lower in obese women, they do remain above the contraceptive threshold for at least the first 3 years, Dr. Toulany said.
• Depot medroxyprogesterone acetate. There is some concern about weight gain with this injectable progestin-only contraceptive, particularly in those who are already obese, but it remains an option, as the levels do remain above what is needed to prevent ovulation. Interestingly, the persistence of ovulation suppression following discontinuation is different in obese women, and may be prolonged, compared with nonobese women; it is important to counsel patients about this, she said.
“So although randomized, controlled trials report no significant weight gain, we do agree with these observational studies that show that overweight and obese teens gain more weight with Depo-Provera than with oral contraceptives or with no contraceptives,” she said.
• Oral contraceptive pills. Although these may be less effective in obese adolescents, they remain an option and may be the best option in a given patient. Combined oral contraceptives are believed to be generally effective for pregnancy prevention, but “may be less forgiving of imperfect use,” and thus may not be the best choice in those who may have problems with adherence, for example.
The contraceptive patch is probably not a good option, because efficacy may be diminished as a result of absorption through the adipose tissues in those weighing more than 90 kg, Dr .Toulany said. Evidence is insufficient regarding the use of contraceptive rings in obese patients.
Bariatric surgery is increasingly being performed in adolescents, and this raises unique concerns with respect to contraception, Dr. Toulany said.
“We recommend discontinuing estrogen-containing contraceptives 1 month before surgery to reduce the risk of VTE postoperatively,” she said.
After bariatric surgery, those who undergo a restrictive procedure such as gastric banding or a gastric sleeve procedure that reduces the volume of the stomach can use oral contraceptives, but postsurgery vomiting and diarrhea could increase the risk of complications. In those who undergo surgery using a technique that involves a significant malabsorption component, such as Roux-en-Y gastric bypass, nonoral contraceptives are the best option.
“Most patients going for bariatric surgery have an IUD inserted at the time of surgery, and that’s what we would recommend,” Dr. Toulany said.
She reported having no relevant financial disclosures.
ORLANDO – The data with respect to the effects of obesity on the efficacy of contraceptives in adolescents are limited, but the general consensus is that if efficacy is reduced, it isn’t by enough to make a real difference, according to Dr. Alene Toulany.
The effect of obesity is likely to be very small, and studies that have looked at pharmacokinetics in obesity have estimated that body weight accounts for only about 10%-20% of the variability of hormone levels, Dr. Toulany said at the North American Society for Pediatric and Adolescent Gynecology annual meeting.
“We know that this is within the normal range for individuals who are not obese, she said.
The concerns regarding efficacy in obese patients are understandable, as obesity increases the metabolic rate, increases clearance of hepatically metabolized drugs, increases circulating blood volume, and affects the absorption of contraceptive steroids through the adipose tissue, she said, adding that “it makes sense that the serum drug levels may be insufficient to maintain contraceptive effects, but the data are very limited and inconsistent.”
That’s not to say obesity isn’t a concern, added Dr. Toulany, an adolescent medicine specialist at the Hospital for Sick Children, Toronto, and the University of Toronto.
“Without fail, all of us will be seeing patients with obesity,” she said. The rate of adolescent obesity has quadrupled in the last 3 decades, increasing from 5% among those aged 12-19 years in 1980 to more than 20% now. A third are currently overweight or obese.
Further, sexually active obese women, regardless of age, are significantly less likely to use contraception, and obese teens are more likely to engage in risky sexual behaviors than are nonobese teens.
For these reasons, it is important to find the most effective contraceptive method, taking into account other risk factors and the likelihood of compliance, she said, noting that obesity is an independent risk factor for venous thromboembolism (VTE) and that studies suggest the risk is additive in users of estrogen-containing contraceptives.
However, she said, the benefits outweigh the risks of pregnancy in obesity – especially of unintended pregnancy.
The absolute risk of VTE in healthy women of reproductive age is small, and in adolescents it’s even smaller, she explained.
“The presence of risk factors for VTE should be taken into account when we see these youth in our clinics, but we can and should offer estrogen-containing contraceptives as long as there are no other risk factors,” she said.
Contraceptive options in young obese patients include:
• Intrauterine devices. There is no evidence that either copper IUDs or progestin-releasing IUDs have reduced efficacy in obese adolescents.
• Implants. These are highly effective in obese women, and even though the concentrations may be 30%-60% lower in obese women, they do remain above the contraceptive threshold for at least the first 3 years, Dr. Toulany said.
• Depot medroxyprogesterone acetate. There is some concern about weight gain with this injectable progestin-only contraceptive, particularly in those who are already obese, but it remains an option, as the levels do remain above what is needed to prevent ovulation. Interestingly, the persistence of ovulation suppression following discontinuation is different in obese women, and may be prolonged, compared with nonobese women; it is important to counsel patients about this, she said.
“So although randomized, controlled trials report no significant weight gain, we do agree with these observational studies that show that overweight and obese teens gain more weight with Depo-Provera than with oral contraceptives or with no contraceptives,” she said.
• Oral contraceptive pills. Although these may be less effective in obese adolescents, they remain an option and may be the best option in a given patient. Combined oral contraceptives are believed to be generally effective for pregnancy prevention, but “may be less forgiving of imperfect use,” and thus may not be the best choice in those who may have problems with adherence, for example.
The contraceptive patch is probably not a good option, because efficacy may be diminished as a result of absorption through the adipose tissues in those weighing more than 90 kg, Dr .Toulany said. Evidence is insufficient regarding the use of contraceptive rings in obese patients.
Bariatric surgery is increasingly being performed in adolescents, and this raises unique concerns with respect to contraception, Dr. Toulany said.
“We recommend discontinuing estrogen-containing contraceptives 1 month before surgery to reduce the risk of VTE postoperatively,” she said.
After bariatric surgery, those who undergo a restrictive procedure such as gastric banding or a gastric sleeve procedure that reduces the volume of the stomach can use oral contraceptives, but postsurgery vomiting and diarrhea could increase the risk of complications. In those who undergo surgery using a technique that involves a significant malabsorption component, such as Roux-en-Y gastric bypass, nonoral contraceptives are the best option.
“Most patients going for bariatric surgery have an IUD inserted at the time of surgery, and that’s what we would recommend,” Dr. Toulany said.
She reported having no relevant financial disclosures.
EXPERT ANALYSIS FROM THE NASPAG ANNUAL MEETING
Allis clamp, nitrous oxide improve patient experience during IUD insertion
SAN FRANCISCO – A suitable and effective method for relieving pain among women undergoing intrauterine device insertion has eluded investigators, but the search has not been in vain.
Findings from two studies presented at the annual meeting of the American College of Obstetricians and Gynecologists may have failed to demonstrate clearcut improvements in pain management, but they did show improvement in other aspects of the patient experience.
In one randomized controlled study, use of an Allis clamp to stabilize the uterus during device placement failed to improve pain when compared with the use of a single-tooth tenaculum, but Allis clamp use was associated with a reduced risk of bleeding requiring intervention, Dr. Lee Taylor Johnson reported at the meeting.
Pain scores at the time of placement as measured using a 100-mm visual analog scale were 23.5 mm in 38 patients randomized to undergo placement using an Allis clamp, and 31.5 mm in 40 patients who underwent placement using the tenaculum. The scores at 10 minutes were 4.5 mm and 9 mm, respectively. The scores did not differ significantly between the groups.
However, the tenaculum group required more interventions to stop bleeding with pressure or cauterization (15 patients vs. 1 patient in the Allis clamp group), said Dr. Johnson, who conducted the research with colleagues at the Carilion Clinic Residency Gynecology Clinic in Roanoke, Va. She is now at the Tuba City Healthcare Corporation in Tuba City, Ariz.
Patients included in the study were at least 18 years old and were enrolled between September 2012 and November 2013. The study is the first to compare the effects of different instruments on pain during IUD placement, although multiple studies have looked at other ways to reduce pain, she noted.
“They have looked at NSAIDs, paracervical blocks, lidocaine gel, misoprostol, and nitroglycerin. In 2009 a Cochrane Database Review noted that no interventions that have been properly evaluated reduce pain during or after IUD insertion,” Dr. Johnson said.
Based on the current findings, providers should consider using an Allis clamp during IUD placement to decrease the risk of cervical bleeding following the procedure, she said.
In another study, Dr. Lauren D. Thaxton, of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque, found that the use of nitrous oxide improved satisfaction with pain management.
The mean pain score among 40 women in the randomized double-blind study who were treated with 50/50 nitrous oxide and oxygen at the time of IUD insertion was 54 mm on a 100 mm visual analog scale, which was not significantly different from the mean of 55 mm in women who received only oxygen. However, satisfaction with pain management, as measured on a 5-point Likert scale, was significantly greater in the nitrous oxide group, she said.
The study included nulliparous women aged 13-45 years.
Nitrous oxide is relatively inexpensive and has few side effects, which are rapidly reversible with 100% oxygen, making it a feasible approach to improving the experience of IUD insertion for many women, according to Dr. Thaxton.
In fact, women in the study reported being willing to pay $20 to $50 out of pocket for nitrous oxide administration at the time of IUD insertion, Dr. Thaxton said.
In a video interview, she speculated that the amnestic and anxiolytic effects of nitrous oxide may play a role in the higher satisfaction scores, and that higher dosing could contribute to better pain relief.
Dr. Rameet H. Singh, also of the University of New Mexico and the principle investigator for the study, said that it only takes about 1 minute to administer 50/50 nitrous oxide and oxygen, and about 90 seconds to achieve 70/30 concentration, so the process doesn’t substantially prolong the insertion process.
Both Dr. Johnson and Dr. Thaxton reported having no financial disclosures. Dr. Singh reported receiving an honorarium for authoring an article on long-acting reversible contraception.
SAN FRANCISCO – A suitable and effective method for relieving pain among women undergoing intrauterine device insertion has eluded investigators, but the search has not been in vain.
Findings from two studies presented at the annual meeting of the American College of Obstetricians and Gynecologists may have failed to demonstrate clearcut improvements in pain management, but they did show improvement in other aspects of the patient experience.
In one randomized controlled study, use of an Allis clamp to stabilize the uterus during device placement failed to improve pain when compared with the use of a single-tooth tenaculum, but Allis clamp use was associated with a reduced risk of bleeding requiring intervention, Dr. Lee Taylor Johnson reported at the meeting.
Pain scores at the time of placement as measured using a 100-mm visual analog scale were 23.5 mm in 38 patients randomized to undergo placement using an Allis clamp, and 31.5 mm in 40 patients who underwent placement using the tenaculum. The scores at 10 minutes were 4.5 mm and 9 mm, respectively. The scores did not differ significantly between the groups.
However, the tenaculum group required more interventions to stop bleeding with pressure or cauterization (15 patients vs. 1 patient in the Allis clamp group), said Dr. Johnson, who conducted the research with colleagues at the Carilion Clinic Residency Gynecology Clinic in Roanoke, Va. She is now at the Tuba City Healthcare Corporation in Tuba City, Ariz.
Patients included in the study were at least 18 years old and were enrolled between September 2012 and November 2013. The study is the first to compare the effects of different instruments on pain during IUD placement, although multiple studies have looked at other ways to reduce pain, she noted.
“They have looked at NSAIDs, paracervical blocks, lidocaine gel, misoprostol, and nitroglycerin. In 2009 a Cochrane Database Review noted that no interventions that have been properly evaluated reduce pain during or after IUD insertion,” Dr. Johnson said.
Based on the current findings, providers should consider using an Allis clamp during IUD placement to decrease the risk of cervical bleeding following the procedure, she said.
In another study, Dr. Lauren D. Thaxton, of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque, found that the use of nitrous oxide improved satisfaction with pain management.
The mean pain score among 40 women in the randomized double-blind study who were treated with 50/50 nitrous oxide and oxygen at the time of IUD insertion was 54 mm on a 100 mm visual analog scale, which was not significantly different from the mean of 55 mm in women who received only oxygen. However, satisfaction with pain management, as measured on a 5-point Likert scale, was significantly greater in the nitrous oxide group, she said.
The study included nulliparous women aged 13-45 years.
Nitrous oxide is relatively inexpensive and has few side effects, which are rapidly reversible with 100% oxygen, making it a feasible approach to improving the experience of IUD insertion for many women, according to Dr. Thaxton.
In fact, women in the study reported being willing to pay $20 to $50 out of pocket for nitrous oxide administration at the time of IUD insertion, Dr. Thaxton said.
In a video interview, she speculated that the amnestic and anxiolytic effects of nitrous oxide may play a role in the higher satisfaction scores, and that higher dosing could contribute to better pain relief.
Dr. Rameet H. Singh, also of the University of New Mexico and the principle investigator for the study, said that it only takes about 1 minute to administer 50/50 nitrous oxide and oxygen, and about 90 seconds to achieve 70/30 concentration, so the process doesn’t substantially prolong the insertion process.
Both Dr. Johnson and Dr. Thaxton reported having no financial disclosures. Dr. Singh reported receiving an honorarium for authoring an article on long-acting reversible contraception.
SAN FRANCISCO – A suitable and effective method for relieving pain among women undergoing intrauterine device insertion has eluded investigators, but the search has not been in vain.
Findings from two studies presented at the annual meeting of the American College of Obstetricians and Gynecologists may have failed to demonstrate clearcut improvements in pain management, but they did show improvement in other aspects of the patient experience.
In one randomized controlled study, use of an Allis clamp to stabilize the uterus during device placement failed to improve pain when compared with the use of a single-tooth tenaculum, but Allis clamp use was associated with a reduced risk of bleeding requiring intervention, Dr. Lee Taylor Johnson reported at the meeting.
Pain scores at the time of placement as measured using a 100-mm visual analog scale were 23.5 mm in 38 patients randomized to undergo placement using an Allis clamp, and 31.5 mm in 40 patients who underwent placement using the tenaculum. The scores at 10 minutes were 4.5 mm and 9 mm, respectively. The scores did not differ significantly between the groups.
However, the tenaculum group required more interventions to stop bleeding with pressure or cauterization (15 patients vs. 1 patient in the Allis clamp group), said Dr. Johnson, who conducted the research with colleagues at the Carilion Clinic Residency Gynecology Clinic in Roanoke, Va. She is now at the Tuba City Healthcare Corporation in Tuba City, Ariz.
Patients included in the study were at least 18 years old and were enrolled between September 2012 and November 2013. The study is the first to compare the effects of different instruments on pain during IUD placement, although multiple studies have looked at other ways to reduce pain, she noted.
“They have looked at NSAIDs, paracervical blocks, lidocaine gel, misoprostol, and nitroglycerin. In 2009 a Cochrane Database Review noted that no interventions that have been properly evaluated reduce pain during or after IUD insertion,” Dr. Johnson said.
Based on the current findings, providers should consider using an Allis clamp during IUD placement to decrease the risk of cervical bleeding following the procedure, she said.
In another study, Dr. Lauren D. Thaxton, of the department of obstetrics and gynecology at the University of New Mexico, Albuquerque, found that the use of nitrous oxide improved satisfaction with pain management.
The mean pain score among 40 women in the randomized double-blind study who were treated with 50/50 nitrous oxide and oxygen at the time of IUD insertion was 54 mm on a 100 mm visual analog scale, which was not significantly different from the mean of 55 mm in women who received only oxygen. However, satisfaction with pain management, as measured on a 5-point Likert scale, was significantly greater in the nitrous oxide group, she said.
The study included nulliparous women aged 13-45 years.
Nitrous oxide is relatively inexpensive and has few side effects, which are rapidly reversible with 100% oxygen, making it a feasible approach to improving the experience of IUD insertion for many women, according to Dr. Thaxton.
In fact, women in the study reported being willing to pay $20 to $50 out of pocket for nitrous oxide administration at the time of IUD insertion, Dr. Thaxton said.
In a video interview, she speculated that the amnestic and anxiolytic effects of nitrous oxide may play a role in the higher satisfaction scores, and that higher dosing could contribute to better pain relief.
Dr. Rameet H. Singh, also of the University of New Mexico and the principle investigator for the study, said that it only takes about 1 minute to administer 50/50 nitrous oxide and oxygen, and about 90 seconds to achieve 70/30 concentration, so the process doesn’t substantially prolong the insertion process.
Both Dr. Johnson and Dr. Thaxton reported having no financial disclosures. Dr. Singh reported receiving an honorarium for authoring an article on long-acting reversible contraception.
AT THE ACOG ANNUAL CLINICAL MEETING
ACOG: Practice and referral patterns may affect occult uterine sarcoma risk post hysterectomy
SAN FRANCISCO – Occult uterine sarcoma occurred in less than 0.1% of more than 10,000 hysterectomies performed at a large hospital system between 2000 and 2014 for presumed benign gynecologic indications.
Of 10,083 patients who underwent such hysterectomies at University of Texas Southwestern Medical Center hospitals during the study period, 9 were found to have uterine sarcoma (overall rate of 8.9 per 10,000), including 5 with leiomyosarcoma (rate of 4.96 per 10,000) and 2 each with endometrial stromal sarcoma and uterine adenosarcoma (rate of 1.98 per 10,000 for each) Dr. Ken Yu Lin reported at the annual meeting of the American College of Obstetricians and Gynecologists.
The patients’ median age at diagnosis was 39 years, and their median body mass index was 27 kg/m2. Six had prior hormonal therapy, and three reported responding to leuprolide, including two who experienced decreased bleeding, and one who experienced uterine mass size reduction. None had a history of tamoxifen use or pelvic radiation exposure, and one had rapid uterine enlargement and was found to have leiomyosarcoma.
At a median follow-up of 48 months, one had died, one had a recurrence of endometrial stromal sarcoma, and seven were alive with no evidence of disease, Dr. Lin said.
Leiomyomas were associated with significantly larger uterine size (mean weight of 3,500 g), compared with endometrial stromal sarcoma and adenosarcoma, he noted.
Four of five patients with leiomyoma underwent a biopsy prior to surgery, and the results were normal. One underwent manual morcellation during abdominal hysterectomy because of large mass size, but power morcellation was not used in any patient.
The 0.1% frequency of uterine sarcoma in patients undergoing hysterectomy for a benign condition was lower than the frequency in previously reported studies and pooled analyses, Dr. Lin said.
The patients were women who underwent hysterectomy for benign conditions – abnormal bleeding in 78% of cases and leiomyoma in 56% of cases. Five underwent total abdominal hysterectomy, three had a total vaginal hysterectomy, and one had a supracervical hysterectomy.
Occult uterine sarcoma was defined as uterine sarcoma on pathology postoperatively in those with no preoperative suspicion of malignancy, Dr. Lin said.
Hysterectomy is one of the most common surgical procedures in the United States, and outcomes have improved thanks to minimally invasive procedures that require only small incisions.
However, small incisions lead to challenges with respect to the removal of large specimens, Dr. Lin said, adding that morcellation, which has been used to facilitate the removal of tissue in cases involving minimally invasive surgery, has come under scrutiny because of concerns about its role in the dissemination of occult gynecologic malignancies, and particularly uterine sarcoma.
Central to this discussion is the question of the prevalence of occult sarcoma in the setting of hysterectomy for benign indications, he said, noting that the prevalence of occult sarcoma in women undergoing surgery for presumed uterine fibroids has been reported to be as high as 1 in 350 by some authors.
The findings suggest that “clinical practices and regional referral patterns may impact local rates of occult uterine sarcoma and should be considered during patient counseling and when developing clinical recommendations,” Dr Lin concluded.
Dr. Lin reported having no relevant disclosures.
SAN FRANCISCO – Occult uterine sarcoma occurred in less than 0.1% of more than 10,000 hysterectomies performed at a large hospital system between 2000 and 2014 for presumed benign gynecologic indications.
Of 10,083 patients who underwent such hysterectomies at University of Texas Southwestern Medical Center hospitals during the study period, 9 were found to have uterine sarcoma (overall rate of 8.9 per 10,000), including 5 with leiomyosarcoma (rate of 4.96 per 10,000) and 2 each with endometrial stromal sarcoma and uterine adenosarcoma (rate of 1.98 per 10,000 for each) Dr. Ken Yu Lin reported at the annual meeting of the American College of Obstetricians and Gynecologists.
The patients’ median age at diagnosis was 39 years, and their median body mass index was 27 kg/m2. Six had prior hormonal therapy, and three reported responding to leuprolide, including two who experienced decreased bleeding, and one who experienced uterine mass size reduction. None had a history of tamoxifen use or pelvic radiation exposure, and one had rapid uterine enlargement and was found to have leiomyosarcoma.
At a median follow-up of 48 months, one had died, one had a recurrence of endometrial stromal sarcoma, and seven were alive with no evidence of disease, Dr. Lin said.
Leiomyomas were associated with significantly larger uterine size (mean weight of 3,500 g), compared with endometrial stromal sarcoma and adenosarcoma, he noted.
Four of five patients with leiomyoma underwent a biopsy prior to surgery, and the results were normal. One underwent manual morcellation during abdominal hysterectomy because of large mass size, but power morcellation was not used in any patient.
The 0.1% frequency of uterine sarcoma in patients undergoing hysterectomy for a benign condition was lower than the frequency in previously reported studies and pooled analyses, Dr. Lin said.
The patients were women who underwent hysterectomy for benign conditions – abnormal bleeding in 78% of cases and leiomyoma in 56% of cases. Five underwent total abdominal hysterectomy, three had a total vaginal hysterectomy, and one had a supracervical hysterectomy.
Occult uterine sarcoma was defined as uterine sarcoma on pathology postoperatively in those with no preoperative suspicion of malignancy, Dr. Lin said.
Hysterectomy is one of the most common surgical procedures in the United States, and outcomes have improved thanks to minimally invasive procedures that require only small incisions.
However, small incisions lead to challenges with respect to the removal of large specimens, Dr. Lin said, adding that morcellation, which has been used to facilitate the removal of tissue in cases involving minimally invasive surgery, has come under scrutiny because of concerns about its role in the dissemination of occult gynecologic malignancies, and particularly uterine sarcoma.
Central to this discussion is the question of the prevalence of occult sarcoma in the setting of hysterectomy for benign indications, he said, noting that the prevalence of occult sarcoma in women undergoing surgery for presumed uterine fibroids has been reported to be as high as 1 in 350 by some authors.
The findings suggest that “clinical practices and regional referral patterns may impact local rates of occult uterine sarcoma and should be considered during patient counseling and when developing clinical recommendations,” Dr Lin concluded.
Dr. Lin reported having no relevant disclosures.
SAN FRANCISCO – Occult uterine sarcoma occurred in less than 0.1% of more than 10,000 hysterectomies performed at a large hospital system between 2000 and 2014 for presumed benign gynecologic indications.
Of 10,083 patients who underwent such hysterectomies at University of Texas Southwestern Medical Center hospitals during the study period, 9 were found to have uterine sarcoma (overall rate of 8.9 per 10,000), including 5 with leiomyosarcoma (rate of 4.96 per 10,000) and 2 each with endometrial stromal sarcoma and uterine adenosarcoma (rate of 1.98 per 10,000 for each) Dr. Ken Yu Lin reported at the annual meeting of the American College of Obstetricians and Gynecologists.
The patients’ median age at diagnosis was 39 years, and their median body mass index was 27 kg/m2. Six had prior hormonal therapy, and three reported responding to leuprolide, including two who experienced decreased bleeding, and one who experienced uterine mass size reduction. None had a history of tamoxifen use or pelvic radiation exposure, and one had rapid uterine enlargement and was found to have leiomyosarcoma.
At a median follow-up of 48 months, one had died, one had a recurrence of endometrial stromal sarcoma, and seven were alive with no evidence of disease, Dr. Lin said.
Leiomyomas were associated with significantly larger uterine size (mean weight of 3,500 g), compared with endometrial stromal sarcoma and adenosarcoma, he noted.
Four of five patients with leiomyoma underwent a biopsy prior to surgery, and the results were normal. One underwent manual morcellation during abdominal hysterectomy because of large mass size, but power morcellation was not used in any patient.
The 0.1% frequency of uterine sarcoma in patients undergoing hysterectomy for a benign condition was lower than the frequency in previously reported studies and pooled analyses, Dr. Lin said.
The patients were women who underwent hysterectomy for benign conditions – abnormal bleeding in 78% of cases and leiomyoma in 56% of cases. Five underwent total abdominal hysterectomy, three had a total vaginal hysterectomy, and one had a supracervical hysterectomy.
Occult uterine sarcoma was defined as uterine sarcoma on pathology postoperatively in those with no preoperative suspicion of malignancy, Dr. Lin said.
Hysterectomy is one of the most common surgical procedures in the United States, and outcomes have improved thanks to minimally invasive procedures that require only small incisions.
However, small incisions lead to challenges with respect to the removal of large specimens, Dr. Lin said, adding that morcellation, which has been used to facilitate the removal of tissue in cases involving minimally invasive surgery, has come under scrutiny because of concerns about its role in the dissemination of occult gynecologic malignancies, and particularly uterine sarcoma.
Central to this discussion is the question of the prevalence of occult sarcoma in the setting of hysterectomy for benign indications, he said, noting that the prevalence of occult sarcoma in women undergoing surgery for presumed uterine fibroids has been reported to be as high as 1 in 350 by some authors.
The findings suggest that “clinical practices and regional referral patterns may impact local rates of occult uterine sarcoma and should be considered during patient counseling and when developing clinical recommendations,” Dr Lin concluded.
Dr. Lin reported having no relevant disclosures.
AT THE ACOG ANNUAL CLINICAL MEETING
Key clinical point: Consider local clinical practice and referral patterns when counseling patients about occult uterine sarcoma risk.
Major finding: Occult uterine sarcoma occurred in 0.1% of women undergoing hysterectomy for benign conditions.
Data source: A retrospective review of 10,083 hysterectomies.
Disclosures: Dr. Lin reported having no relevant disclosures.
ACOG: First-trimester smoking cessation reduces preterm birth risk by 24%
SAN FRANCISCO – The majority of pregnant teens who smoked in a large population-based cohort study continued smoking throughout pregnancy, and those teens had a higher rate of preterm birth than did those who quit at any time during pregnancy.
Those who quit in the first trimester, however, had the greatest reduction in the risk of preterm birth, Dr. Beth Moore reported during a poster session at the annual meeting of the American College of Obstetricians and Gynecologists.
The findings underscore the need to counsel teen mothers that smoking cessation at any point in pregnancy will reduce the risk for preterm birth, Dr. Moore said. “Targeted counseling and interventions should focus on early smoking cessation in this group of mothers who are at an inherently high risk of preterm birth, as it results in the most substantial risk reduction for delivering prior to 37 weeks.”
Of 96,599 teens who were included in the analysis, 31% smoked during the 3 months prior to conception. Of those, 6,508 (22%) quit during the first trimester, and 17,804 (about 60%) smoked throughout pregnancy. The remainder quit smoking during the second or third trimester, according to Dr. Moore, of the department of maternal-fetal medicine at the University of Cincinnati.
The baseline rate of preterm birth in the study cohort was 11%; the rate among those who smoked throughout pregnancy was 13%.
The risk of preterm birth was reduced by about 24% (odds ratio, 0.76) among those who quit smoking during the first trimester, and was reduced by about 12% (OR, 0.88) among those who quit at any point during pregnancy, she said.
Compared with older women, teens are already at increased risk of preterm birth, and smoking further increases that risk, Dr. Moore said.
To assess the effects of smoking cessation on preterm birth risk in teens, she and her colleagues retrospectively reviewed all non-anomalous singleton birth records in Ohio during the study period. Of the 1,003,532 eligible births recorded during that time, the 96,599 included in the current analysis were to those under age 20 years for whom smoking data were available.
The association between smoking cessation and preterm birth risk was assessed by logistic regression after adjusting for maternal race, Medicaid enrollment, and marital status.
The authors reported having no disclosures.
SAN FRANCISCO – The majority of pregnant teens who smoked in a large population-based cohort study continued smoking throughout pregnancy, and those teens had a higher rate of preterm birth than did those who quit at any time during pregnancy.
Those who quit in the first trimester, however, had the greatest reduction in the risk of preterm birth, Dr. Beth Moore reported during a poster session at the annual meeting of the American College of Obstetricians and Gynecologists.
The findings underscore the need to counsel teen mothers that smoking cessation at any point in pregnancy will reduce the risk for preterm birth, Dr. Moore said. “Targeted counseling and interventions should focus on early smoking cessation in this group of mothers who are at an inherently high risk of preterm birth, as it results in the most substantial risk reduction for delivering prior to 37 weeks.”
Of 96,599 teens who were included in the analysis, 31% smoked during the 3 months prior to conception. Of those, 6,508 (22%) quit during the first trimester, and 17,804 (about 60%) smoked throughout pregnancy. The remainder quit smoking during the second or third trimester, according to Dr. Moore, of the department of maternal-fetal medicine at the University of Cincinnati.
The baseline rate of preterm birth in the study cohort was 11%; the rate among those who smoked throughout pregnancy was 13%.
The risk of preterm birth was reduced by about 24% (odds ratio, 0.76) among those who quit smoking during the first trimester, and was reduced by about 12% (OR, 0.88) among those who quit at any point during pregnancy, she said.
Compared with older women, teens are already at increased risk of preterm birth, and smoking further increases that risk, Dr. Moore said.
To assess the effects of smoking cessation on preterm birth risk in teens, she and her colleagues retrospectively reviewed all non-anomalous singleton birth records in Ohio during the study period. Of the 1,003,532 eligible births recorded during that time, the 96,599 included in the current analysis were to those under age 20 years for whom smoking data were available.
The association between smoking cessation and preterm birth risk was assessed by logistic regression after adjusting for maternal race, Medicaid enrollment, and marital status.
The authors reported having no disclosures.
SAN FRANCISCO – The majority of pregnant teens who smoked in a large population-based cohort study continued smoking throughout pregnancy, and those teens had a higher rate of preterm birth than did those who quit at any time during pregnancy.
Those who quit in the first trimester, however, had the greatest reduction in the risk of preterm birth, Dr. Beth Moore reported during a poster session at the annual meeting of the American College of Obstetricians and Gynecologists.
The findings underscore the need to counsel teen mothers that smoking cessation at any point in pregnancy will reduce the risk for preterm birth, Dr. Moore said. “Targeted counseling and interventions should focus on early smoking cessation in this group of mothers who are at an inherently high risk of preterm birth, as it results in the most substantial risk reduction for delivering prior to 37 weeks.”
Of 96,599 teens who were included in the analysis, 31% smoked during the 3 months prior to conception. Of those, 6,508 (22%) quit during the first trimester, and 17,804 (about 60%) smoked throughout pregnancy. The remainder quit smoking during the second or third trimester, according to Dr. Moore, of the department of maternal-fetal medicine at the University of Cincinnati.
The baseline rate of preterm birth in the study cohort was 11%; the rate among those who smoked throughout pregnancy was 13%.
The risk of preterm birth was reduced by about 24% (odds ratio, 0.76) among those who quit smoking during the first trimester, and was reduced by about 12% (OR, 0.88) among those who quit at any point during pregnancy, she said.
Compared with older women, teens are already at increased risk of preterm birth, and smoking further increases that risk, Dr. Moore said.
To assess the effects of smoking cessation on preterm birth risk in teens, she and her colleagues retrospectively reviewed all non-anomalous singleton birth records in Ohio during the study period. Of the 1,003,532 eligible births recorded during that time, the 96,599 included in the current analysis were to those under age 20 years for whom smoking data were available.
The association between smoking cessation and preterm birth risk was assessed by logistic regression after adjusting for maternal race, Medicaid enrollment, and marital status.
The authors reported having no disclosures.
AT THE ACOG ANNUAL CLINICAL MEETING
Key clinical point: When it comes to quitting smoking, the earlier in teen pregnancy the better for reducing preterm birth.
Major finding: The risk of preterm birth was reduced by about 24% (OR, 0.76) among pregnant teens who quit smoking during the first trimester.
Data source: A retrospective cohort study of 96,599 teen births.
Disclosures: The investigators reported having no disclosures.
