Betsy Bates

SAN FRANCISCO — Many myths surround polycystic ovary syndrome, according to two speakers at the Perspectives in Women's Health conference sponsored by OB.GYN. NEWS.

On hand to clear up some misconceptions were Dr. Anita L. Nelson, professor of obstetrics and gynecology at the University of California, Los Angeles, and medical director of women's health care programs at Harbor-UCLA Medical Center, and Dr. Paul S. Jellinger, professor of medicine on the voluntary faculty at the University of Miami and immediate past president of the American College of Endocrinology.

Among the myths about polycystic ovary syndrome (PCOS):

▸ PCOS is a rare disorder. In fact, PCOS is the most common metabolic disorder of young women, affecting 5%–10% of premenopausal women. Women with oligomenorrhea have a 90% likelihood of having PCOS. The condition is present in about a third of women with secondary amenorrhea and three-fourths of women with anovulatory infertility, Dr. Nelson said.

▸ Polycystic ovaries on ultrasound are diagnostic of PCOS. On ultrasound, the gross surface area of the ovary in a PCOS patient is doubled; the volume is increased nearly threefold, and each ovary contains 20–100 cystic follicles. The appearance of the PCOS ovary has been compared with a “black string of pearls,” reflecting follicles at the surface. But polycystic-appearing ovaries may occur because of chronic anovulation, regardless of the reason. They are seen in 100% of female-to-male transsexuals, 75% of anovulatory women, 14% of oral contraceptive users, 16%–23% of women with normal ovulation, and even children approaching puberty.

▸ Gonadotropin abnormalities are useful in diagnosing PCOS. Dr. Nelson said only 70%–75% of PCOS patients exhibit what were once considered telltale abnormalities, including higher-than-normal mean luteinizing hormone (LH), low or normal follicle-stimulating hormones (FSH), and an elevated LH/FSH ratio. The LH/FSH ratio is particularly useless as a test for PCOS because it goes up and down, she said.

▸ Insulin resistance is mostly a problem in overweight and obese women with PCOS. Although insulin resistance is a “very prominent feature” of PCOS, it is a selective resistance, Dr. Jellinger emphasized. “It is a unique form of insulin resistance because it occurs just as vigorously in nonoverweight individuals as in overweight individuals. It is weight independent to a large extent … [and] not always corrected with weight loss.”

▸ All PCOS patients with insulin resistance will develop diabetes. In fact, 80% of PCOS patients with insulin resistance have normal beta cells that are able to compensate for their selective insulin resistance. Although these patients are at a twofold increased risk of atherosclerosis and lipid and vascular abnormalities (versus a threefold elevated risk for PCOS patients who develop diabetes), they do not produce the signal of elevated blood sugar seen in patients with diabetes.

▸ Impaired glucose tolerance or type 2 diabetes risk are problems of older women with PCOS. Studies show that 30%–50% of obese women with PCOS will develop impaired glucose tolerance or type 2 diabetes by age 30. And since nonoverweight PCOS patients may have “rampant” insulin resistance, the American College of Endocrinology recommends screening every patient with PCOS at age 30 with a glucose challenge test, Dr. Jellinger said.

▸ The primary impact of PCOS on a woman's life has to do with fertility and physical appearance. Women with PCOS can have lifelong impairments of health and longevity because of their greatly increased risk of other manifestations of “insulin resistance syndrome,” including diabetes, hypertension, dyslipidemia, and atherosclerosis.

“It is not just an issue of infertility. It is not just an issue of acne and hirsutism. It's an issue of serious health consequences for life,” Dr. Jellinger said

SAN FRANCISCO — Many myths surround polycystic ovary syndrome, according to two speakers at the Perspectives in Women's Health conference sponsored by OB.GYN. NEWS.

On hand to clear up some misconceptions were Dr. Anita L. Nelson, professor of obstetrics and gynecology at the University of California, Los Angeles, and medical director of women's health care programs at Harbor-UCLA Medical Center, and Dr. Paul S. Jellinger, professor of medicine on the voluntary faculty at the University of Miami and immediate past president of the American College of Endocrinology.

Among the myths about polycystic ovary syndrome (PCOS):

▸ PCOS is a rare disorder. In fact, PCOS is the most common metabolic disorder of young women, affecting 5%–10% of premenopausal women. Women with oligomenorrhea have a 90% likelihood of having PCOS. The condition is present in about a third of women with secondary amenorrhea and three-fourths of women with anovulatory infertility, Dr. Nelson said.

▸ Polycystic ovaries on ultrasound are diagnostic of PCOS. On ultrasound, the gross surface area of the ovary in a PCOS patient is doubled; the volume is increased nearly threefold, and each ovary contains 20–100 cystic follicles. The appearance of the PCOS ovary has been compared with a “black string of pearls,” reflecting follicles at the surface. But polycystic-appearing ovaries may occur because of chronic anovulation, regardless of the reason. They are seen in 100% of female-to-male transsexuals, 75% of anovulatory women, 14% of oral contraceptive users, 16%–23% of women with normal ovulation, and even children approaching puberty.

▸ Gonadotropin abnormalities are useful in diagnosing PCOS. Dr. Nelson said only 70%–75% of PCOS patients exhibit what were once considered telltale abnormalities, including higher-than-normal mean luteinizing hormone (LH), low or normal follicle-stimulating hormones (FSH), and an elevated LH/FSH ratio. The LH/FSH ratio is particularly useless as a test for PCOS because it goes up and down, she said.

▸ Insulin resistance is mostly a problem in overweight and obese women with PCOS. Although insulin resistance is a “very prominent feature” of PCOS, it is a selective resistance, Dr. Jellinger emphasized. “It is a unique form of insulin resistance because it occurs just as vigorously in nonoverweight individuals as in overweight individuals. It is weight independent to a large extent … [and] not always corrected with weight loss.”

▸ All PCOS patients with insulin resistance will develop diabetes. In fact, 80% of PCOS patients with insulin resistance have normal beta cells that are able to compensate for their selective insulin resistance. Although these patients are at a twofold increased risk of atherosclerosis and lipid and vascular abnormalities (versus a threefold elevated risk for PCOS patients who develop diabetes), they do not produce the signal of elevated blood sugar seen in patients with diabetes.

▸ Impaired glucose tolerance or type 2 diabetes risk are problems of older women with PCOS. Studies show that 30%–50% of obese women with PCOS will develop impaired glucose tolerance or type 2 diabetes by age 30. And since nonoverweight PCOS patients may have “rampant” insulin resistance, the American College of Endocrinology recommends screening every patient with PCOS at age 30 with a glucose challenge test, Dr. Jellinger said.

▸ The primary impact of PCOS on a woman's life has to do with fertility and physical appearance. Women with PCOS can have lifelong impairments of health and longevity because of their greatly increased risk of other manifestations of “insulin resistance syndrome,” including diabetes, hypertension, dyslipidemia, and atherosclerosis.

“It is not just an issue of infertility. It is not just an issue of acne and hirsutism. It's an issue of serious health consequences for life,” Dr. Jellinger said

SAN FRANCISCO — Many myths surround polycystic ovary syndrome, according to two speakers at the Perspectives in Women's Health conference sponsored by OB.GYN. NEWS.

On hand to clear up some misconceptions were Dr. Anita L. Nelson, professor of obstetrics and gynecology at the University of California, Los Angeles, and medical director of women's health care programs at Harbor-UCLA Medical Center, and Dr. Paul S. Jellinger, professor of medicine on the voluntary faculty at the University of Miami and immediate past president of the American College of Endocrinology.

Among the myths about polycystic ovary syndrome (PCOS):

▸ PCOS is a rare disorder. In fact, PCOS is the most common metabolic disorder of young women, affecting 5%–10% of premenopausal women. Women with oligomenorrhea have a 90% likelihood of having PCOS. The condition is present in about a third of women with secondary amenorrhea and three-fourths of women with anovulatory infertility, Dr. Nelson said.

▸ Polycystic ovaries on ultrasound are diagnostic of PCOS. On ultrasound, the gross surface area of the ovary in a PCOS patient is doubled; the volume is increased nearly threefold, and each ovary contains 20–100 cystic follicles. The appearance of the PCOS ovary has been compared with a “black string of pearls,” reflecting follicles at the surface. But polycystic-appearing ovaries may occur because of chronic anovulation, regardless of the reason. They are seen in 100% of female-to-male transsexuals, 75% of anovulatory women, 14% of oral contraceptive users, 16%–23% of women with normal ovulation, and even children approaching puberty.

▸ Gonadotropin abnormalities are useful in diagnosing PCOS. Dr. Nelson said only 70%–75% of PCOS patients exhibit what were once considered telltale abnormalities, including higher-than-normal mean luteinizing hormone (LH), low or normal follicle-stimulating hormones (FSH), and an elevated LH/FSH ratio. The LH/FSH ratio is particularly useless as a test for PCOS because it goes up and down, she said.

▸ Insulin resistance is mostly a problem in overweight and obese women with PCOS. Although insulin resistance is a “very prominent feature” of PCOS, it is a selective resistance, Dr. Jellinger emphasized. “It is a unique form of insulin resistance because it occurs just as vigorously in nonoverweight individuals as in overweight individuals. It is weight independent to a large extent … [and] not always corrected with weight loss.”

▸ All PCOS patients with insulin resistance will develop diabetes. In fact, 80% of PCOS patients with insulin resistance have normal beta cells that are able to compensate for their selective insulin resistance. Although these patients are at a twofold increased risk of atherosclerosis and lipid and vascular abnormalities (versus a threefold elevated risk for PCOS patients who develop diabetes), they do not produce the signal of elevated blood sugar seen in patients with diabetes.

▸ Impaired glucose tolerance or type 2 diabetes risk are problems of older women with PCOS. Studies show that 30%–50% of obese women with PCOS will develop impaired glucose tolerance or type 2 diabetes by age 30. And since nonoverweight PCOS patients may have “rampant” insulin resistance, the American College of Endocrinology recommends screening every patient with PCOS at age 30 with a glucose challenge test, Dr. Jellinger said.

▸ The primary impact of PCOS on a woman's life has to do with fertility and physical appearance. Women with PCOS can have lifelong impairments of health and longevity because of their greatly increased risk of other manifestations of “insulin resistance syndrome,” including diabetes, hypertension, dyslipidemia, and atherosclerosis.

“It is not just an issue of infertility. It is not just an issue of acne and hirsutism. It's an issue of serious health consequences for life,” Dr. Jellinger said

LAS VEGAS — Drinking red wine more than three times a week was associated with a 68% reduction in risk of significant colorectal neoplasia in a study of 1,625 people undergoing screening colonoscopy, New York researchers reported at the annual meeting of the American College of Gastroenterology.

Because such a reduction was not seen in white-wine drinkers, Dr. Joseph C. Anderson and his associates at the State University of New York at Stony Brook speculated that the high resveratrol content of red wine might explain the finding.

A multivariate analysis that controlled for smoking, age, and other potentially confounding factors explored differences in significant colorectal neoplasia (villous tissue, high-grade dysplasia, large tubular adenomas, or more than two adenomas of any size) in 68 regular white-wine drinkers, 176 regular red-wine drinkers, and 1,381 abstainers (or infrequent wine drinkers).

Significant neoplasia was found in 9.9% of the abstainer/low wine consumption group, 8.8% of regular white-wine drinkers, and 3.4% of regular red-wine drinkers, for a 68% reduction in risk among those who regularly drank red wine.

In a second study of 2,536 patients, the researchers found evidence of neoplasia in 17.4% of men who currently smoked, 8.5% of those who had never smoked, and 9.2% of low-exposure or historical smokers. Neoplasia was seen in 11.5% of women who currently smoked, 8.2% of those who had never smoked, and 6.4% of those who had a low or historical exposure to cigarettes.

Among current smokers, the odds ratio for having significant colorectal neoplasia was similar in men (1.92) and women (2.13).

Smoking may deserve consideration as a notable risk factor in screening guidelines, Dr. Anderson said.

LAS VEGAS — Drinking red wine more than three times a week was associated with a 68% reduction in risk of significant colorectal neoplasia in a study of 1,625 people undergoing screening colonoscopy, New York researchers reported at the annual meeting of the American College of Gastroenterology.

Because such a reduction was not seen in white-wine drinkers, Dr. Joseph C. Anderson and his associates at the State University of New York at Stony Brook speculated that the high resveratrol content of red wine might explain the finding.

A multivariate analysis that controlled for smoking, age, and other potentially confounding factors explored differences in significant colorectal neoplasia (villous tissue, high-grade dysplasia, large tubular adenomas, or more than two adenomas of any size) in 68 regular white-wine drinkers, 176 regular red-wine drinkers, and 1,381 abstainers (or infrequent wine drinkers).

Significant neoplasia was found in 9.9% of the abstainer/low wine consumption group, 8.8% of regular white-wine drinkers, and 3.4% of regular red-wine drinkers, for a 68% reduction in risk among those who regularly drank red wine.

In a second study of 2,536 patients, the researchers found evidence of neoplasia in 17.4% of men who currently smoked, 8.5% of those who had never smoked, and 9.2% of low-exposure or historical smokers. Neoplasia was seen in 11.5% of women who currently smoked, 8.2% of those who had never smoked, and 6.4% of those who had a low or historical exposure to cigarettes.

Among current smokers, the odds ratio for having significant colorectal neoplasia was similar in men (1.92) and women (2.13).

Smoking may deserve consideration as a notable risk factor in screening guidelines, Dr. Anderson said.

LAS VEGAS — Drinking red wine more than three times a week was associated with a 68% reduction in risk of significant colorectal neoplasia in a study of 1,625 people undergoing screening colonoscopy, New York researchers reported at the annual meeting of the American College of Gastroenterology.

Because such a reduction was not seen in white-wine drinkers, Dr. Joseph C. Anderson and his associates at the State University of New York at Stony Brook speculated that the high resveratrol content of red wine might explain the finding.

A multivariate analysis that controlled for smoking, age, and other potentially confounding factors explored differences in significant colorectal neoplasia (villous tissue, high-grade dysplasia, large tubular adenomas, or more than two adenomas of any size) in 68 regular white-wine drinkers, 176 regular red-wine drinkers, and 1,381 abstainers (or infrequent wine drinkers).

Significant neoplasia was found in 9.9% of the abstainer/low wine consumption group, 8.8% of regular white-wine drinkers, and 3.4% of regular red-wine drinkers, for a 68% reduction in risk among those who regularly drank red wine.

In a second study of 2,536 patients, the researchers found evidence of neoplasia in 17.4% of men who currently smoked, 8.5% of those who had never smoked, and 9.2% of low-exposure or historical smokers. Neoplasia was seen in 11.5% of women who currently smoked, 8.2% of those who had never smoked, and 6.4% of those who had a low or historical exposure to cigarettes.

Among current smokers, the odds ratio for having significant colorectal neoplasia was similar in men (1.92) and women (2.13).

Smoking may deserve consideration as a notable risk factor in screening guidelines, Dr. Anderson said.

LAS VEGAS — There's good news and bad news about the state of colorectal cancer screening, and both took center stage at the annual meeting of the American College of Gastroenterology.

First the good news: More Americans are being screened and having precancerous polyps removed. Age-adjusted rates of colon cancer fell from 42.81 per 100,000 in 1988–1990 to 38.59 per 100,000 during 2000–2002, according to the Nationwide Inpatient Sample (NIS), reported Dr. Mazen M. Jamal and Dr. Eugene J. Yoon of the Long Beach (Calif.) Veterans Affairs Medical Center and the University of California, Irvine, Medical Center.

Similar trends were seen in the Surveillance Epidemiology and End Result (SEER) database during the same time period, the authors noted.

“This may be the first sign that we're making an impact,” said Dr. Mark B. Pochapin, chief of gastrointestinal endoscopy at Cornell University/New York-Presbyterian Hospital, New York, speaking at a press briefing at the meeting.

More good news came from the Clinical Outcomes Research Initiative (CORI), an ongoing study of 75 representative U.S. gastroenterology practices serving 600,000 patients. Dr. David Lieberman, chief of gastroenterology at Oregon Health and Science University, Portland, announced CORI results showing that in 2005, 30.7% of colonoscopies performed in “real-life clinical practice” were for screening, vs. 9.7% in 2000–2002. “Clearly this shows a dramatic change in the use of colonoscopy in just over a few years,” he said.

“Overall, it appears that we are finally approaching 50% of patients who are age-eligible receiving at least some form of colon cancer screening,” Dr. Lieberman continued. “This is not as good as we would like—the rate is 70% for mammography—but it is an upward trend.”

But there was bad news as well.

Dr. Lieberman noted that more than 50% of endoscopists are recommending more frequent surveillance than expert guidelines recommend for patients with a low recurrence risk, including those with small tubular adenomas.

This trend will “use up a lot of our resources,” and reduce the rate of gains being achieved by initial screening of appropriate candidates, he said.

In the meeting's Emily Couric lecture, Dr. Douglas Rex, professor of medicine at Indiana University, Indianapolis, spotlighted two of the key shortcomings of colonoscopy: injuries to patients, including perforations that occur during the removal of small polyps, and detection rates that are highly variable and operator-dependent.

Medicare population data show a perforation rate of 1 in 1,000 patients during screening colonoscopy.

Many experts for years have advocated use of cold techniques rather than use of hot snaring equipment or hot forceps to reduce this perforation rate, but “people really aren't listening,” Dr. Rex said.

The problem of variable detection rates could be targeted by moving toward improved technology such as wide-angle views and flexible endoscopes capable of viewing the back sides of folds within the colon. But individual endoscopists must get engaged in changing practice, he said.

Two recent studies found 4-fold to 10-fold differences in adenoma detection rates by experienced endoscopists in controlled studies, including one study performed at Dr. Rex's institution. These differences extend even to detection of large adenomas.

Individual endoscopists should begin tracking their own adenoma detection rates to see if they match or exceed a general prevalence figure of 25% in men and 15% in women over age 50 undergoing screening colonoscopy, he said.

“If those numbers are low, then the first thing to look at is probably withdrawal time, since withdrawal time in seven studies has been associated with adenoma detection rates,” he said. The ideal withdrawal time for maximum detection of adenomas is unknown, but current data suggest it should be at least 6–7 minutes.

LAS VEGAS — There's good news and bad news about the state of colorectal cancer screening, and both took center stage at the annual meeting of the American College of Gastroenterology.

First the good news: More Americans are being screened and having precancerous polyps removed. Age-adjusted rates of colon cancer fell from 42.81 per 100,000 in 1988–1990 to 38.59 per 100,000 during 2000–2002, according to the Nationwide Inpatient Sample (NIS), reported Dr. Mazen M. Jamal and Dr. Eugene J. Yoon of the Long Beach (Calif.) Veterans Affairs Medical Center and the University of California, Irvine, Medical Center.

Similar trends were seen in the Surveillance Epidemiology and End Result (SEER) database during the same time period, the authors noted.

“This may be the first sign that we're making an impact,” said Dr. Mark B. Pochapin, chief of gastrointestinal endoscopy at Cornell University/New York-Presbyterian Hospital, New York, speaking at a press briefing at the meeting.

More good news came from the Clinical Outcomes Research Initiative (CORI), an ongoing study of 75 representative U.S. gastroenterology practices serving 600,000 patients. Dr. David Lieberman, chief of gastroenterology at Oregon Health and Science University, Portland, announced CORI results showing that in 2005, 30.7% of colonoscopies performed in “real-life clinical practice” were for screening, vs. 9.7% in 2000–2002. “Clearly this shows a dramatic change in the use of colonoscopy in just over a few years,” he said.

“Overall, it appears that we are finally approaching 50% of patients who are age-eligible receiving at least some form of colon cancer screening,” Dr. Lieberman continued. “This is not as good as we would like—the rate is 70% for mammography—but it is an upward trend.”

But there was bad news as well.

Dr. Lieberman noted that more than 50% of endoscopists are recommending more frequent surveillance than expert guidelines recommend for patients with a low recurrence risk, including those with small tubular adenomas.

This trend will “use up a lot of our resources,” and reduce the rate of gains being achieved by initial screening of appropriate candidates, he said.

In the meeting's Emily Couric lecture, Dr. Douglas Rex, professor of medicine at Indiana University, Indianapolis, spotlighted two of the key shortcomings of colonoscopy: injuries to patients, including perforations that occur during the removal of small polyps, and detection rates that are highly variable and operator-dependent.

Medicare population data show a perforation rate of 1 in 1,000 patients during screening colonoscopy.

Many experts for years have advocated use of cold techniques rather than use of hot snaring equipment or hot forceps to reduce this perforation rate, but “people really aren't listening,” Dr. Rex said.

The problem of variable detection rates could be targeted by moving toward improved technology such as wide-angle views and flexible endoscopes capable of viewing the back sides of folds within the colon. But individual endoscopists must get engaged in changing practice, he said.

Two recent studies found 4-fold to 10-fold differences in adenoma detection rates by experienced endoscopists in controlled studies, including one study performed at Dr. Rex's institution. These differences extend even to detection of large adenomas.

Individual endoscopists should begin tracking their own adenoma detection rates to see if they match or exceed a general prevalence figure of 25% in men and 15% in women over age 50 undergoing screening colonoscopy, he said.

“If those numbers are low, then the first thing to look at is probably withdrawal time, since withdrawal time in seven studies has been associated with adenoma detection rates,” he said. The ideal withdrawal time for maximum detection of adenomas is unknown, but current data suggest it should be at least 6–7 minutes.

LAS VEGAS — There's good news and bad news about the state of colorectal cancer screening, and both took center stage at the annual meeting of the American College of Gastroenterology.

First the good news: More Americans are being screened and having precancerous polyps removed. Age-adjusted rates of colon cancer fell from 42.81 per 100,000 in 1988–1990 to 38.59 per 100,000 during 2000–2002, according to the Nationwide Inpatient Sample (NIS), reported Dr. Mazen M. Jamal and Dr. Eugene J. Yoon of the Long Beach (Calif.) Veterans Affairs Medical Center and the University of California, Irvine, Medical Center.

Similar trends were seen in the Surveillance Epidemiology and End Result (SEER) database during the same time period, the authors noted.

“This may be the first sign that we're making an impact,” said Dr. Mark B. Pochapin, chief of gastrointestinal endoscopy at Cornell University/New York-Presbyterian Hospital, New York, speaking at a press briefing at the meeting.

More good news came from the Clinical Outcomes Research Initiative (CORI), an ongoing study of 75 representative U.S. gastroenterology practices serving 600,000 patients. Dr. David Lieberman, chief of gastroenterology at Oregon Health and Science University, Portland, announced CORI results showing that in 2005, 30.7% of colonoscopies performed in “real-life clinical practice” were for screening, vs. 9.7% in 2000–2002. “Clearly this shows a dramatic change in the use of colonoscopy in just over a few years,” he said.

“Overall, it appears that we are finally approaching 50% of patients who are age-eligible receiving at least some form of colon cancer screening,” Dr. Lieberman continued. “This is not as good as we would like—the rate is 70% for mammography—but it is an upward trend.”

But there was bad news as well.

Dr. Lieberman noted that more than 50% of endoscopists are recommending more frequent surveillance than expert guidelines recommend for patients with a low recurrence risk, including those with small tubular adenomas.

This trend will “use up a lot of our resources,” and reduce the rate of gains being achieved by initial screening of appropriate candidates, he said.

In the meeting's Emily Couric lecture, Dr. Douglas Rex, professor of medicine at Indiana University, Indianapolis, spotlighted two of the key shortcomings of colonoscopy: injuries to patients, including perforations that occur during the removal of small polyps, and detection rates that are highly variable and operator-dependent.

Medicare population data show a perforation rate of 1 in 1,000 patients during screening colonoscopy.

Many experts for years have advocated use of cold techniques rather than use of hot snaring equipment or hot forceps to reduce this perforation rate, but “people really aren't listening,” Dr. Rex said.

The problem of variable detection rates could be targeted by moving toward improved technology such as wide-angle views and flexible endoscopes capable of viewing the back sides of folds within the colon. But individual endoscopists must get engaged in changing practice, he said.

Two recent studies found 4-fold to 10-fold differences in adenoma detection rates by experienced endoscopists in controlled studies, including one study performed at Dr. Rex's institution. These differences extend even to detection of large adenomas.

Individual endoscopists should begin tracking their own adenoma detection rates to see if they match or exceed a general prevalence figure of 25% in men and 15% in women over age 50 undergoing screening colonoscopy, he said.

“If those numbers are low, then the first thing to look at is probably withdrawal time, since withdrawal time in seven studies has been associated with adenoma detection rates,” he said. The ideal withdrawal time for maximum detection of adenomas is unknown, but current data suggest it should be at least 6–7 minutes.

SAN FRANCISCO — An office evaluation for incontinence and overactive bladder can begin with one simple screening question, and then a follow-up if the answer is yes, said Dr. Michael Moen, director of the division of urogynecology at Advocate Lutheran General Hospital in Park Ridge, Ill.

The first question is, “Do you have bladder problems that are troublesome, or do you ever leak urine?”

If the patient answers in the affirmative, rule out a urinary tract infection and perform a focused history and physical examination.

But don't forget to include one more key inquiry before you move on.

That question is whether she has nocturia, which points strongly in the direction of overactive bladder rather than stress incontinence.

“If you have overactive bladder, it doesn't take the evening off,” said Dr. Moen at Perspectives in Women's Health sponsored by OB.GYN. NEWS.

In contrast, urodynamic stress urinary incontinence is triggered by activity, not rest.

Many women will not volunteer the fact that they leak urine when they exercise, laugh, or cough, or that they rise four times a night to urinate—unless they're asked.

“They think it's part of aging or part of having children,” he said.

Although symptomatic pelvic organ prolapse may propel a woman to make an appointment, it may take significant lifestyle disruption or a profoundly embarrassing public episode of leakage to make women seek care for urinary incontinence, which affects 20%–55% of American women.

Dr. Moen targets four important areas in a review of pelvic symptoms:

▸ Anatomic function. Is there a bulge? A mass? Pressure?

▸ Urinary function. Does she void at intervals of less than 3 hours? Experience urgency? Rise more than twice a night to urinate? Leak with urge? Leak with laughing, coughing, or sneezing? Leak with exercise? Does she have difficulty voiding? Does she need to wear pads?

▸ Bowel function. Does she experience leakage? Constipation?

▸ Sexual function. Does she have pain with intercourse? Anatomic issues? Embarrassment or avoidance due to urinary issues?

Constipation is a surprisingly frequent concurrent issue, said Dr. Moen, occurring in at least 30% of patients he sees for any pelvic floor disorder. It is uncertain whether constipation causes or is caused by pelvic floor dysfunction, but it needs to be addressed.

“Some people think it is more normal to push and strain their insides out than to take fiber every day,” he said.

He frames the issue within the context of modern life and the American diet.

“I tell women it is virtually impossible to get enough usable fiber in their diet without consuming too many calories,” he said.

He suggests that supplements are the answer, not a medicine.

Before conducting an examination, Dr. Moen also brings up the possibility that a woman's quality of life may have been affected by her problems with incontinence or overactive bladder. Perhaps she has restricted her exercise, social activities, and travel. In line with several studies on an association with incontinence, she may be suffering from clinical depression.

The visual and physical examination are aimed at detecting urogenital atrophy, “one of the most overlooked and easily treated conditions in women,” and/or pelvic organ prolapse, he said.

A simple cough stress test approaches a 95%—98% sensitivity and specificity in identifying incontinence.

Neuromuscular function should be assessed by eliciting perineal sensations with a light touch near the anus and an assessment of pelvic muscle strength, facilitated by asking the patient to isolate and squeeze pelvic floor muscles while one of the physicians' fingers is inserted 3–4 cm into the vaginal canal.

In an examination of young, asymptomatic women, Dr. Moen and associates found that 20%—30% were unable to properly contract their pelvic floor muscles, with 10% “actually perform[ing] a Valsalva” maneuver and believing they were doing a Kegel contraction, said Dr. Moen.

“This is critical, because even if you don't suggest to them that they do these types of exercises, they're reading about them in Elle, Self, and Good Housekeeping.”

Doing Kegel exercises improperly can actually exacerbate pelvic floor weakness. On the other hand, proper use of the exercise as few as 30 times, 3 times a week, can be effective in preventing or improving symptoms of stress and urge incontinence.

If simple instruction does not work, physical therapy, perhaps including biofeedback, electrical stimulation, and electromagnetic therapy, may be very helpful in strengthening pelvic floor muscles.

Other potentially important therapeutic options for incontinence and/or overactive bladder may include medications, pessaries, and in 25% or fewer cases, eventual surgery if other measures fail.

The most important intervention, according to Dr. Moen, is bladder retraining.

“If you do nothing else, tell patients to go to the bathroom on schedule. They will get better,” he said.

If a woman estimates she is urinating every hour, he begins with that target, telling her to urinate each time the clock sweeps 12.

Next, the patient is instructed to begin to “outsmart her bladder,” by stretching the intervals to 2 hours, then 3 hours.

SAN FRANCISCO — An office evaluation for incontinence and overactive bladder can begin with one simple screening question, and then a follow-up if the answer is yes, said Dr. Michael Moen, director of the division of urogynecology at Advocate Lutheran General Hospital in Park Ridge, Ill.

The first question is, “Do you have bladder problems that are troublesome, or do you ever leak urine?”

If the patient answers in the affirmative, rule out a urinary tract infection and perform a focused history and physical examination.

But don't forget to include one more key inquiry before you move on.

That question is whether she has nocturia, which points strongly in the direction of overactive bladder rather than stress incontinence.

“If you have overactive bladder, it doesn't take the evening off,” said Dr. Moen at Perspectives in Women's Health sponsored by OB.GYN. NEWS.

In contrast, urodynamic stress urinary incontinence is triggered by activity, not rest.

Many women will not volunteer the fact that they leak urine when they exercise, laugh, or cough, or that they rise four times a night to urinate—unless they're asked.

“They think it's part of aging or part of having children,” he said.

Although symptomatic pelvic organ prolapse may propel a woman to make an appointment, it may take significant lifestyle disruption or a profoundly embarrassing public episode of leakage to make women seek care for urinary incontinence, which affects 20%–55% of American women.

Dr. Moen targets four important areas in a review of pelvic symptoms:

▸ Anatomic function. Is there a bulge? A mass? Pressure?

▸ Urinary function. Does she void at intervals of less than 3 hours? Experience urgency? Rise more than twice a night to urinate? Leak with urge? Leak with laughing, coughing, or sneezing? Leak with exercise? Does she have difficulty voiding? Does she need to wear pads?

▸ Bowel function. Does she experience leakage? Constipation?

▸ Sexual function. Does she have pain with intercourse? Anatomic issues? Embarrassment or avoidance due to urinary issues?

Constipation is a surprisingly frequent concurrent issue, said Dr. Moen, occurring in at least 30% of patients he sees for any pelvic floor disorder. It is uncertain whether constipation causes or is caused by pelvic floor dysfunction, but it needs to be addressed.

“Some people think it is more normal to push and strain their insides out than to take fiber every day,” he said.

He frames the issue within the context of modern life and the American diet.

“I tell women it is virtually impossible to get enough usable fiber in their diet without consuming too many calories,” he said.

He suggests that supplements are the answer, not a medicine.

Before conducting an examination, Dr. Moen also brings up the possibility that a woman's quality of life may have been affected by her problems with incontinence or overactive bladder. Perhaps she has restricted her exercise, social activities, and travel. In line with several studies on an association with incontinence, she may be suffering from clinical depression.

The visual and physical examination are aimed at detecting urogenital atrophy, “one of the most overlooked and easily treated conditions in women,” and/or pelvic organ prolapse, he said.

A simple cough stress test approaches a 95%—98% sensitivity and specificity in identifying incontinence.

Neuromuscular function should be assessed by eliciting perineal sensations with a light touch near the anus and an assessment of pelvic muscle strength, facilitated by asking the patient to isolate and squeeze pelvic floor muscles while one of the physicians' fingers is inserted 3–4 cm into the vaginal canal.

In an examination of young, asymptomatic women, Dr. Moen and associates found that 20%—30% were unable to properly contract their pelvic floor muscles, with 10% “actually perform[ing] a Valsalva” maneuver and believing they were doing a Kegel contraction, said Dr. Moen.

“This is critical, because even if you don't suggest to them that they do these types of exercises, they're reading about them in Elle, Self, and Good Housekeeping.”

Doing Kegel exercises improperly can actually exacerbate pelvic floor weakness. On the other hand, proper use of the exercise as few as 30 times, 3 times a week, can be effective in preventing or improving symptoms of stress and urge incontinence.

If simple instruction does not work, physical therapy, perhaps including biofeedback, electrical stimulation, and electromagnetic therapy, may be very helpful in strengthening pelvic floor muscles.

Other potentially important therapeutic options for incontinence and/or overactive bladder may include medications, pessaries, and in 25% or fewer cases, eventual surgery if other measures fail.

The most important intervention, according to Dr. Moen, is bladder retraining.

“If you do nothing else, tell patients to go to the bathroom on schedule. They will get better,” he said.

If a woman estimates she is urinating every hour, he begins with that target, telling her to urinate each time the clock sweeps 12.

Next, the patient is instructed to begin to “outsmart her bladder,” by stretching the intervals to 2 hours, then 3 hours.

SAN FRANCISCO — An office evaluation for incontinence and overactive bladder can begin with one simple screening question, and then a follow-up if the answer is yes, said Dr. Michael Moen, director of the division of urogynecology at Advocate Lutheran General Hospital in Park Ridge, Ill.

The first question is, “Do you have bladder problems that are troublesome, or do you ever leak urine?”

If the patient answers in the affirmative, rule out a urinary tract infection and perform a focused history and physical examination.

But don't forget to include one more key inquiry before you move on.

That question is whether she has nocturia, which points strongly in the direction of overactive bladder rather than stress incontinence.

“If you have overactive bladder, it doesn't take the evening off,” said Dr. Moen at Perspectives in Women's Health sponsored by OB.GYN. NEWS.

In contrast, urodynamic stress urinary incontinence is triggered by activity, not rest.

Many women will not volunteer the fact that they leak urine when they exercise, laugh, or cough, or that they rise four times a night to urinate—unless they're asked.

“They think it's part of aging or part of having children,” he said.

Although symptomatic pelvic organ prolapse may propel a woman to make an appointment, it may take significant lifestyle disruption or a profoundly embarrassing public episode of leakage to make women seek care for urinary incontinence, which affects 20%–55% of American women.

Dr. Moen targets four important areas in a review of pelvic symptoms:

▸ Anatomic function. Is there a bulge? A mass? Pressure?

▸ Urinary function. Does she void at intervals of less than 3 hours? Experience urgency? Rise more than twice a night to urinate? Leak with urge? Leak with laughing, coughing, or sneezing? Leak with exercise? Does she have difficulty voiding? Does she need to wear pads?

▸ Bowel function. Does she experience leakage? Constipation?

▸ Sexual function. Does she have pain with intercourse? Anatomic issues? Embarrassment or avoidance due to urinary issues?

Constipation is a surprisingly frequent concurrent issue, said Dr. Moen, occurring in at least 30% of patients he sees for any pelvic floor disorder. It is uncertain whether constipation causes or is caused by pelvic floor dysfunction, but it needs to be addressed.

“Some people think it is more normal to push and strain their insides out than to take fiber every day,” he said.

He frames the issue within the context of modern life and the American diet.

“I tell women it is virtually impossible to get enough usable fiber in their diet without consuming too many calories,” he said.

He suggests that supplements are the answer, not a medicine.

Before conducting an examination, Dr. Moen also brings up the possibility that a woman's quality of life may have been affected by her problems with incontinence or overactive bladder. Perhaps she has restricted her exercise, social activities, and travel. In line with several studies on an association with incontinence, she may be suffering from clinical depression.

The visual and physical examination are aimed at detecting urogenital atrophy, “one of the most overlooked and easily treated conditions in women,” and/or pelvic organ prolapse, he said.

A simple cough stress test approaches a 95%—98% sensitivity and specificity in identifying incontinence.

Neuromuscular function should be assessed by eliciting perineal sensations with a light touch near the anus and an assessment of pelvic muscle strength, facilitated by asking the patient to isolate and squeeze pelvic floor muscles while one of the physicians' fingers is inserted 3–4 cm into the vaginal canal.

In an examination of young, asymptomatic women, Dr. Moen and associates found that 20%—30% were unable to properly contract their pelvic floor muscles, with 10% “actually perform[ing] a Valsalva” maneuver and believing they were doing a Kegel contraction, said Dr. Moen.

“This is critical, because even if you don't suggest to them that they do these types of exercises, they're reading about them in Elle, Self, and Good Housekeeping.”

Doing Kegel exercises improperly can actually exacerbate pelvic floor weakness. On the other hand, proper use of the exercise as few as 30 times, 3 times a week, can be effective in preventing or improving symptoms of stress and urge incontinence.

If simple instruction does not work, physical therapy, perhaps including biofeedback, electrical stimulation, and electromagnetic therapy, may be very helpful in strengthening pelvic floor muscles.

Other potentially important therapeutic options for incontinence and/or overactive bladder may include medications, pessaries, and in 25% or fewer cases, eventual surgery if other measures fail.

The most important intervention, according to Dr. Moen, is bladder retraining.

“If you do nothing else, tell patients to go to the bathroom on schedule. They will get better,” he said.

If a woman estimates she is urinating every hour, he begins with that target, telling her to urinate each time the clock sweeps 12.

Next, the patient is instructed to begin to “outsmart her bladder,” by stretching the intervals to 2 hours, then 3 hours.

SAN FRANCISCO — The “fast and furious” increase in obesity in the United States and a correlative rise in the incidence of gestational diabetes justify aggressive screening of pregnant women for the disorder, Dr. E. Albert Reece said at Perspectives in Women's Health sponsored by OB.GYN. NEWS.

“The numbers are quite staggering,” said Dr. Reece, dean of the school of medicine and vice president of medical affairs at the University of Maryland, Baltimore.

Fifteen years ago, the incidence of gestational diabetes was 1%–3%. Today, it's 4%–8%, he said.

Screening is aimed at reducing the risk of perinatal loss, but it also confers what Dr. Reece termed “fringe benefits,” namely, reducing the risk of fetal macrosomia, operative delivery, birth trauma, and metabolic derangements in the neonate.

Screening raises awareness of the long-term possibility of type II diabetes arising in the mother and, years later, the offspring.

“Diabetes begets diabetes,” said Dr. Reece, who advocates screening every pregnant woman for gestational diabetes at least once during pregnancy.

The tradition of screening at 24–28 weeks' gestation is “entirely arbitrary”—chosen by convention to pick up 85% of cases while there is still time in the pregnancy to intervene.

However, clinicians should be aware that 15% of cases will be missed by screening at that time point.

“If you are very suspicious, due to habitus or history, repeat it at 33–34 weeks,” he advised.

Choosing which test to use can be important, according to Dr. Reece.

Intravenous glucose tolerance testing is nonphysiologic, failing to simulate the normal process of glucose disposal, and therefore useless, he said.

Random blood glucose value testing isn't much better, since it is an insensitive test. “It should be used only when nothing else is available,” he said. “It is better than nothing at all.”

Capillary whole blood glucose testing uses a pinprick to obtain blood that is analyzed by a portable meter. It is convenient and cost-effective, but the meter should be calibrated regularly with results obtained in a hospital laboratory to ensure its accuracy.

Most common, of course, are fasting oral glucose tolerance tests.

These tests are most accurate when the pancreas is adequately primed prior to a 3-hour glucose tolerance test. This cannot always be ensured when people skip meals or follow unusual diets, said Dr. Reece.

That's why he advises patients to eat two to three slices of bread with each meal for 3 days before the test, which involves drinking a glucose solution and having blood drawn 1 hour later.

Nicotine, caffeine, many drugs, bed rest, and exertion may also interfere with test results.

If a patient vomits Glucola, the standard glucose solution used in fasting oral glucose tolerance testing, a culinary glucose polymer, Polycose, can be used instead, said Dr. Reece.

Even more palatable for some women is the jelly bean test, standardized by Boyd and associates and found to be “incredibly consistent” with Glucola in terms of sensitivity and specificity, and positive predictive value.

However, that accuracy is ensured only if one uses the exact protocol described by Boyd or one later tested by Lamar and colleagues: 18 or 26 Brach's jelly beans, with blood drawn 1, 2, and 3 hours later (Am. J. Obstet. Gynecol. 1995;173:1889–92 and Am. J. Obstet. Gynecol. 1999;181[5 pt. 1]:1154–7).

Two relatively new methods—glycohemoglobin A₁ and a fructosamine-based test—are too insensitive to be used in screening for gestational diabetes, Dr. Reece said.

A breakfast tolerance test involving a specific 600-kcal meal before the blood draw achieves a sensitivity of 75% and specificity of 95% if a 120-mg/dL value is used, and a sensitivity of 96% and specificity of 74% if a threshold is set at 100 mg/dL. It's acceptable, but “cumbersome” to adjust the thresholds, he said.

“I've never used it.”

A diagnosis of gestational diabetes is generally reserved for patients who have at least two abnormal oral glucose tolerance tests. Research suggests, however, that potential adverse pregnancy outcomes can occur with just one abnormal result, reflecting impaired glucose metabolism.

Dr. Reece believes one abnormal test warrants at least dietary therapy and retesting, while two abnormal tests during pregnancy may require more aggressive interventions, including oral glucose therapy and possibly insulin.

SAN FRANCISCO — The “fast and furious” increase in obesity in the United States and a correlative rise in the incidence of gestational diabetes justify aggressive screening of pregnant women for the disorder, Dr. E. Albert Reece said at Perspectives in Women's Health sponsored by OB.GYN. NEWS.

“The numbers are quite staggering,” said Dr. Reece, dean of the school of medicine and vice president of medical affairs at the University of Maryland, Baltimore.

Fifteen years ago, the incidence of gestational diabetes was 1%–3%. Today, it's 4%–8%, he said.

Screening is aimed at reducing the risk of perinatal loss, but it also confers what Dr. Reece termed “fringe benefits,” namely, reducing the risk of fetal macrosomia, operative delivery, birth trauma, and metabolic derangements in the neonate.

Screening raises awareness of the long-term possibility of type II diabetes arising in the mother and, years later, the offspring.

“Diabetes begets diabetes,” said Dr. Reece, who advocates screening every pregnant woman for gestational diabetes at least once during pregnancy.

The tradition of screening at 24–28 weeks' gestation is “entirely arbitrary”—chosen by convention to pick up 85% of cases while there is still time in the pregnancy to intervene.

However, clinicians should be aware that 15% of cases will be missed by screening at that time point.

“If you are very suspicious, due to habitus or history, repeat it at 33–34 weeks,” he advised.

Choosing which test to use can be important, according to Dr. Reece.

Intravenous glucose tolerance testing is nonphysiologic, failing to simulate the normal process of glucose disposal, and therefore useless, he said.

Random blood glucose value testing isn't much better, since it is an insensitive test. “It should be used only when nothing else is available,” he said. “It is better than nothing at all.”

Capillary whole blood glucose testing uses a pinprick to obtain blood that is analyzed by a portable meter. It is convenient and cost-effective, but the meter should be calibrated regularly with results obtained in a hospital laboratory to ensure its accuracy.

Most common, of course, are fasting oral glucose tolerance tests.

These tests are most accurate when the pancreas is adequately primed prior to a 3-hour glucose tolerance test. This cannot always be ensured when people skip meals or follow unusual diets, said Dr. Reece.

That's why he advises patients to eat two to three slices of bread with each meal for 3 days before the test, which involves drinking a glucose solution and having blood drawn 1 hour later.

Nicotine, caffeine, many drugs, bed rest, and exertion may also interfere with test results.

If a patient vomits Glucola, the standard glucose solution used in fasting oral glucose tolerance testing, a culinary glucose polymer, Polycose, can be used instead, said Dr. Reece.

Even more palatable for some women is the jelly bean test, standardized by Boyd and associates and found to be “incredibly consistent” with Glucola in terms of sensitivity and specificity, and positive predictive value.

However, that accuracy is ensured only if one uses the exact protocol described by Boyd or one later tested by Lamar and colleagues: 18 or 26 Brach's jelly beans, with blood drawn 1, 2, and 3 hours later (Am. J. Obstet. Gynecol. 1995;173:1889–92 and Am. J. Obstet. Gynecol. 1999;181[5 pt. 1]:1154–7).

Two relatively new methods—glycohemoglobin A₁ and a fructosamine-based test—are too insensitive to be used in screening for gestational diabetes, Dr. Reece said.

A breakfast tolerance test involving a specific 600-kcal meal before the blood draw achieves a sensitivity of 75% and specificity of 95% if a 120-mg/dL value is used, and a sensitivity of 96% and specificity of 74% if a threshold is set at 100 mg/dL. It's acceptable, but “cumbersome” to adjust the thresholds, he said.

“I've never used it.”

A diagnosis of gestational diabetes is generally reserved for patients who have at least two abnormal oral glucose tolerance tests. Research suggests, however, that potential adverse pregnancy outcomes can occur with just one abnormal result, reflecting impaired glucose metabolism.

Dr. Reece believes one abnormal test warrants at least dietary therapy and retesting, while two abnormal tests during pregnancy may require more aggressive interventions, including oral glucose therapy and possibly insulin.

SAN FRANCISCO — The “fast and furious” increase in obesity in the United States and a correlative rise in the incidence of gestational diabetes justify aggressive screening of pregnant women for the disorder, Dr. E. Albert Reece said at Perspectives in Women's Health sponsored by OB.GYN. NEWS.

“The numbers are quite staggering,” said Dr. Reece, dean of the school of medicine and vice president of medical affairs at the University of Maryland, Baltimore.

Fifteen years ago, the incidence of gestational diabetes was 1%–3%. Today, it's 4%–8%, he said.

Screening is aimed at reducing the risk of perinatal loss, but it also confers what Dr. Reece termed “fringe benefits,” namely, reducing the risk of fetal macrosomia, operative delivery, birth trauma, and metabolic derangements in the neonate.

Screening raises awareness of the long-term possibility of type II diabetes arising in the mother and, years later, the offspring.

“Diabetes begets diabetes,” said Dr. Reece, who advocates screening every pregnant woman for gestational diabetes at least once during pregnancy.

The tradition of screening at 24–28 weeks' gestation is “entirely arbitrary”—chosen by convention to pick up 85% of cases while there is still time in the pregnancy to intervene.

However, clinicians should be aware that 15% of cases will be missed by screening at that time point.

“If you are very suspicious, due to habitus or history, repeat it at 33–34 weeks,” he advised.

Choosing which test to use can be important, according to Dr. Reece.

Intravenous glucose tolerance testing is nonphysiologic, failing to simulate the normal process of glucose disposal, and therefore useless, he said.

Random blood glucose value testing isn't much better, since it is an insensitive test. “It should be used only when nothing else is available,” he said. “It is better than nothing at all.”

Capillary whole blood glucose testing uses a pinprick to obtain blood that is analyzed by a portable meter. It is convenient and cost-effective, but the meter should be calibrated regularly with results obtained in a hospital laboratory to ensure its accuracy.

Most common, of course, are fasting oral glucose tolerance tests.

These tests are most accurate when the pancreas is adequately primed prior to a 3-hour glucose tolerance test. This cannot always be ensured when people skip meals or follow unusual diets, said Dr. Reece.

That's why he advises patients to eat two to three slices of bread with each meal for 3 days before the test, which involves drinking a glucose solution and having blood drawn 1 hour later.

Nicotine, caffeine, many drugs, bed rest, and exertion may also interfere with test results.

If a patient vomits Glucola, the standard glucose solution used in fasting oral glucose tolerance testing, a culinary glucose polymer, Polycose, can be used instead, said Dr. Reece.

Even more palatable for some women is the jelly bean test, standardized by Boyd and associates and found to be “incredibly consistent” with Glucola in terms of sensitivity and specificity, and positive predictive value.

However, that accuracy is ensured only if one uses the exact protocol described by Boyd or one later tested by Lamar and colleagues: 18 or 26 Brach's jelly beans, with blood drawn 1, 2, and 3 hours later (Am. J. Obstet. Gynecol. 1995;173:1889–92 and Am. J. Obstet. Gynecol. 1999;181[5 pt. 1]:1154–7).

Two relatively new methods—glycohemoglobin A₁ and a fructosamine-based test—are too insensitive to be used in screening for gestational diabetes, Dr. Reece said.

A breakfast tolerance test involving a specific 600-kcal meal before the blood draw achieves a sensitivity of 75% and specificity of 95% if a 120-mg/dL value is used, and a sensitivity of 96% and specificity of 74% if a threshold is set at 100 mg/dL. It's acceptable, but “cumbersome” to adjust the thresholds, he said.

“I've never used it.”

A diagnosis of gestational diabetes is generally reserved for patients who have at least two abnormal oral glucose tolerance tests. Research suggests, however, that potential adverse pregnancy outcomes can occur with just one abnormal result, reflecting impaired glucose metabolism.

Dr. Reece believes one abnormal test warrants at least dietary therapy and retesting, while two abnormal tests during pregnancy may require more aggressive interventions, including oral glucose therapy and possibly insulin.

SAN FRANCISCO — Many myths surround polycystic ovary syndrome, according to two speakers at Perspectives in Women's Health, a meeting sponsored by OB.GYN. NEWS, a sister publication of FAMILY PRACTICE NEWS.

On hand to clear up some misconceptions were Dr. Anita L. Nelson, professor of obstetrics and gynecology at the University of California, Los Angeles, and medical director of women's health care programs at Harbor-UCLA Medical Center, and Dr. Paul S. Jellinger, professor of medicine on the voluntary faculty at the University of Miami and immediate past president of the American College of Endocrinology.

Among the myths about polycystic ovary syndrome (PCOS) that the two speakers discussed, were:

▸ PCOS is a rare disorder. In fact, PCOS is the most common metabolic disorder of young women, affecting 5%–10% of premenopausal women. Women with oligomenorrhea have a 90% likelihood of having PCOS. The condition is present in approximately a third of women with secondary amenorrhea and three-fourths of women with anovulatory infertility, Dr. Nelson said.

▸ Polycystic ovaries on ultrasound are diagnostic of PCOS. On ultrasound, the gross surface area of the ovary in a PCOS patient is doubled; the volume is increased nearly threefold, and each ovary contains 20–100 cystic follicles. The appearance of the PCOS ovary has been compared with a “black string of pearls,” reflecting follicles at the surface. But polycystic-appearing ovaries may occur because of chronic anovulation, regardless of the reason.

They are seen in 100% of female-to-male transsexuals, 75% of anovulatory women, 14% of oral contraceptive users, 16%–23% of women with normal ovulation, and even children approaching puberty.

▸ Gonadotropin abnormalities are useful in diagnosing PCOS. Dr. Nelson said only 70%–75% of PCOS patients exhibit what were once considered telltale abnormalities, including higher-than-normal mean luteinizing hormone (LH), low or normal follicle-stimulating hormones (FSH), and an elevated LH/FSH ratio. The LH/FSH ratio is particularly useless as a test for PCOS because it goes up and down, she said.

▸ Insulin resistance is mostly a problem in overweight and obese women with PCOS. Although insulin resistance is a “very prominent feature” of PCOS, it is a selective resistance, Dr. Jellinger emphasized.

“It is a unique form of insulin resistance because it occurs just as vigorously in nonoverweight individuals as in overweight individuals. It is weight independent to a large extent [and] not always corrected with weight loss.”

▸ All PCOS patients with insulin resistance will develop diabetes. In fact, 80% of PCOS patients with insulin resistance have normal beta cells that are able to compensate for their selective insulin resistance. Although these patients are at a twofold increased risk of atherosclerosis and lipid and vascular abnormalities (versus a threefold elevated risk for PCOS patients who develop diabetes), they do not produce the signal of elevated blood sugar seen in patients with diabetes.

▸ Impaired glucose tolerance or type 2 diabetes risk are problems of older women with PCOS. Studies show that 30%–50% of obese women with PCOS will develop impaired glucose tolerance or Type 2 diabetes by age 30. And since nonoverweight PCOS patients may have “rampant” insulin resistance, the American College of Endocrinology recommends screening every patient with PCOS at age 30 with a glucose challenge test, Dr. Jellinger said.

▸ The primary impact of PCOS on a woman's life has to do with fertility and physical appearance. Women with PCOS can have lifelong impairments of health and longevity because of their greatly increased risk of other manifestations of “insulin resistance syndrome,” including diabetes, hypertension, dyslipidemia, and atherosclerosis.

“It is not just an issue of infertility. It is not just an issue of acne and hirsutism. It's an issue of serious health consequences for life,” Dr. Jellinger said.

OB.GYN. NEWS is published by the International Medical News Group, a division of Elsevier.

SAN FRANCISCO — Many myths surround polycystic ovary syndrome, according to two speakers at Perspectives in Women's Health, a meeting sponsored by OB.GYN. NEWS, a sister publication of FAMILY PRACTICE NEWS.

On hand to clear up some misconceptions were Dr. Anita L. Nelson, professor of obstetrics and gynecology at the University of California, Los Angeles, and medical director of women's health care programs at Harbor-UCLA Medical Center, and Dr. Paul S. Jellinger, professor of medicine on the voluntary faculty at the University of Miami and immediate past president of the American College of Endocrinology.

Among the myths about polycystic ovary syndrome (PCOS) that the two speakers discussed, were:

▸ PCOS is a rare disorder. In fact, PCOS is the most common metabolic disorder of young women, affecting 5%–10% of premenopausal women. Women with oligomenorrhea have a 90% likelihood of having PCOS. The condition is present in approximately a third of women with secondary amenorrhea and three-fourths of women with anovulatory infertility, Dr. Nelson said.

▸ Polycystic ovaries on ultrasound are diagnostic of PCOS. On ultrasound, the gross surface area of the ovary in a PCOS patient is doubled; the volume is increased nearly threefold, and each ovary contains 20–100 cystic follicles. The appearance of the PCOS ovary has been compared with a “black string of pearls,” reflecting follicles at the surface. But polycystic-appearing ovaries may occur because of chronic anovulation, regardless of the reason.

They are seen in 100% of female-to-male transsexuals, 75% of anovulatory women, 14% of oral contraceptive users, 16%–23% of women with normal ovulation, and even children approaching puberty.

▸ Gonadotropin abnormalities are useful in diagnosing PCOS. Dr. Nelson said only 70%–75% of PCOS patients exhibit what were once considered telltale abnormalities, including higher-than-normal mean luteinizing hormone (LH), low or normal follicle-stimulating hormones (FSH), and an elevated LH/FSH ratio. The LH/FSH ratio is particularly useless as a test for PCOS because it goes up and down, she said.

▸ Insulin resistance is mostly a problem in overweight and obese women with PCOS. Although insulin resistance is a “very prominent feature” of PCOS, it is a selective resistance, Dr. Jellinger emphasized.

“It is a unique form of insulin resistance because it occurs just as vigorously in nonoverweight individuals as in overweight individuals. It is weight independent to a large extent [and] not always corrected with weight loss.”

▸ All PCOS patients with insulin resistance will develop diabetes. In fact, 80% of PCOS patients with insulin resistance have normal beta cells that are able to compensate for their selective insulin resistance. Although these patients are at a twofold increased risk of atherosclerosis and lipid and vascular abnormalities (versus a threefold elevated risk for PCOS patients who develop diabetes), they do not produce the signal of elevated blood sugar seen in patients with diabetes.

▸ Impaired glucose tolerance or type 2 diabetes risk are problems of older women with PCOS. Studies show that 30%–50% of obese women with PCOS will develop impaired glucose tolerance or Type 2 diabetes by age 30. And since nonoverweight PCOS patients may have “rampant” insulin resistance, the American College of Endocrinology recommends screening every patient with PCOS at age 30 with a glucose challenge test, Dr. Jellinger said.

▸ The primary impact of PCOS on a woman's life has to do with fertility and physical appearance. Women with PCOS can have lifelong impairments of health and longevity because of their greatly increased risk of other manifestations of “insulin resistance syndrome,” including diabetes, hypertension, dyslipidemia, and atherosclerosis.

“It is not just an issue of infertility. It is not just an issue of acne and hirsutism. It's an issue of serious health consequences for life,” Dr. Jellinger said.

OB.GYN. NEWS is published by the International Medical News Group, a division of Elsevier.

SAN FRANCISCO — Many myths surround polycystic ovary syndrome, according to two speakers at Perspectives in Women's Health, a meeting sponsored by OB.GYN. NEWS, a sister publication of FAMILY PRACTICE NEWS.

On hand to clear up some misconceptions were Dr. Anita L. Nelson, professor of obstetrics and gynecology at the University of California, Los Angeles, and medical director of women's health care programs at Harbor-UCLA Medical Center, and Dr. Paul S. Jellinger, professor of medicine on the voluntary faculty at the University of Miami and immediate past president of the American College of Endocrinology.

Among the myths about polycystic ovary syndrome (PCOS) that the two speakers discussed, were:

▸ PCOS is a rare disorder. In fact, PCOS is the most common metabolic disorder of young women, affecting 5%–10% of premenopausal women. Women with oligomenorrhea have a 90% likelihood of having PCOS. The condition is present in approximately a third of women with secondary amenorrhea and three-fourths of women with anovulatory infertility, Dr. Nelson said.

▸ Polycystic ovaries on ultrasound are diagnostic of PCOS. On ultrasound, the gross surface area of the ovary in a PCOS patient is doubled; the volume is increased nearly threefold, and each ovary contains 20–100 cystic follicles. The appearance of the PCOS ovary has been compared with a “black string of pearls,” reflecting follicles at the surface. But polycystic-appearing ovaries may occur because of chronic anovulation, regardless of the reason.

They are seen in 100% of female-to-male transsexuals, 75% of anovulatory women, 14% of oral contraceptive users, 16%–23% of women with normal ovulation, and even children approaching puberty.

▸ Gonadotropin abnormalities are useful in diagnosing PCOS. Dr. Nelson said only 70%–75% of PCOS patients exhibit what were once considered telltale abnormalities, including higher-than-normal mean luteinizing hormone (LH), low or normal follicle-stimulating hormones (FSH), and an elevated LH/FSH ratio. The LH/FSH ratio is particularly useless as a test for PCOS because it goes up and down, she said.

▸ Insulin resistance is mostly a problem in overweight and obese women with PCOS. Although insulin resistance is a “very prominent feature” of PCOS, it is a selective resistance, Dr. Jellinger emphasized.

“It is a unique form of insulin resistance because it occurs just as vigorously in nonoverweight individuals as in overweight individuals. It is weight independent to a large extent [and] not always corrected with weight loss.”

▸ All PCOS patients with insulin resistance will develop diabetes. In fact, 80% of PCOS patients with insulin resistance have normal beta cells that are able to compensate for their selective insulin resistance. Although these patients are at a twofold increased risk of atherosclerosis and lipid and vascular abnormalities (versus a threefold elevated risk for PCOS patients who develop diabetes), they do not produce the signal of elevated blood sugar seen in patients with diabetes.

▸ Impaired glucose tolerance or type 2 diabetes risk are problems of older women with PCOS. Studies show that 30%–50% of obese women with PCOS will develop impaired glucose tolerance or Type 2 diabetes by age 30. And since nonoverweight PCOS patients may have “rampant” insulin resistance, the American College of Endocrinology recommends screening every patient with PCOS at age 30 with a glucose challenge test, Dr. Jellinger said.

▸ The primary impact of PCOS on a woman's life has to do with fertility and physical appearance. Women with PCOS can have lifelong impairments of health and longevity because of their greatly increased risk of other manifestations of “insulin resistance syndrome,” including diabetes, hypertension, dyslipidemia, and atherosclerosis.

“It is not just an issue of infertility. It is not just an issue of acne and hirsutism. It's an issue of serious health consequences for life,” Dr. Jellinger said.

OB.GYN. NEWS is published by the International Medical News Group, a division of Elsevier.

LOS ANGELES — Eosinophilic esophagitis appears to be a different disease in adults than it is in children, sharing similar pathophysiologic features and perhaps an allergic etiology, but displaying a different pattern of symptoms, Dr. David A. Katzka said at the annual Digestive Disease Week.

“Certainly this is a new kid on the block, with many of us feeling this is a totally new disease,” said Dr. Katzka, director of the swallowing program at the University of Pennsylvania in Philadelphia.

It is generally agreed that eosinophilia is on the rise. Children with eosinophilic esophagitis complain of a “plethora” of symptoms, including nausea and vomiting, epigastric pain, heartburn, and dysphagia. “In adults, by far and away, the most dominant symptom is dysphagia,” Dr. Katzka stressed. “It may be intermittent. It may be catastrophic,” he said, noting that it has become a highly prevalent cause of food impaction, despite the fact the disease was only described in 1993.

At first believed to be a variant of gastroesophageal reflux disease (GERD), the disease is clearly a distinct entity with a genetic component in some families. On the other hand, many adults with the disease have GERD symptoms and some respond to aggressive acid suppression with proton pump inhibitors, making the connection between the two entities vexing.

In both children and adults, the diagnosis is pathologic and based on an ill-defined elevated rate of eosinophils found in a patchy pattern in the esophageal mucosa.

He emphasized the importance of taking multiple biopsies, since there may be 5 eosinophils per high-powered field in one spot, and “50 in another.”

Longitudinal furrows are very common findings on endoscopy in all age groups.

In addition, rings throughout the esophagus and strictures are commonly seen in adults (and less often, in children) even on radiographic films.

Eosinophilic abscesses, visualized as white specks, are seen in 17%–20% of children with the disease and are “almost pathopneumonic” in adults. The esophagus may have a “firm, woody feel,” he said.

Debate rages as to whether a person with a normal-appearing esophagus can have the disease. Dr. Katzka said he believes it is possible.

The peripheral eosinophil count is normal in about 90% of patients.

Although studies have not been done in adults to direct management, Dr. Katzka recommends RAST testing, patch testing, and skin testing to try to identify an allergen or combination of allergens that may be responsible. However, he warned of an “imprecise correlation between skin, blood, and esophageal findings” and said some adult patients do not respond to avoidance of known allergens.

The biggest problem is convincing patients to avoid foods that may be contributing to the condition.

In children, treatment with steroids, leukotriene inhibitors, and mast cell stabilizers have been shown effective.

In adults, “we're flying by the seat of our pants” in regard to treatment, he said.

He recommends a 2-month course of fluticasone propionate and possibly, maintenance with montelukast, noting that some specialists also suggest a 1− to 2− month course of proton pump inhibitors prior to performing a second endoscopy.

“We will treat these patients very aggressively for 2 months before thinking about dilation,” he said.

In children, eosinophilic esophagitis seems to stabilize and improve over time, while in adults, limited studies suggest it persists or worsens.

“One of our fears is that in adults, this is a progressive or static disease that has to be recognized and treated early.”

LOS ANGELES — Eosinophilic esophagitis appears to be a different disease in adults than it is in children, sharing similar pathophysiologic features and perhaps an allergic etiology, but displaying a different pattern of symptoms, Dr. David A. Katzka said at the annual Digestive Disease Week.

“Certainly this is a new kid on the block, with many of us feeling this is a totally new disease,” said Dr. Katzka, director of the swallowing program at the University of Pennsylvania in Philadelphia.

It is generally agreed that eosinophilia is on the rise. Children with eosinophilic esophagitis complain of a “plethora” of symptoms, including nausea and vomiting, epigastric pain, heartburn, and dysphagia. “In adults, by far and away, the most dominant symptom is dysphagia,” Dr. Katzka stressed. “It may be intermittent. It may be catastrophic,” he said, noting that it has become a highly prevalent cause of food impaction, despite the fact the disease was only described in 1993.

At first believed to be a variant of gastroesophageal reflux disease (GERD), the disease is clearly a distinct entity with a genetic component in some families. On the other hand, many adults with the disease have GERD symptoms and some respond to aggressive acid suppression with proton pump inhibitors, making the connection between the two entities vexing.

In both children and adults, the diagnosis is pathologic and based on an ill-defined elevated rate of eosinophils found in a patchy pattern in the esophageal mucosa.

He emphasized the importance of taking multiple biopsies, since there may be 5 eosinophils per high-powered field in one spot, and “50 in another.”

Longitudinal furrows are very common findings on endoscopy in all age groups.

In addition, rings throughout the esophagus and strictures are commonly seen in adults (and less often, in children) even on radiographic films.

Eosinophilic abscesses, visualized as white specks, are seen in 17%–20% of children with the disease and are “almost pathopneumonic” in adults. The esophagus may have a “firm, woody feel,” he said.

Debate rages as to whether a person with a normal-appearing esophagus can have the disease. Dr. Katzka said he believes it is possible.

The peripheral eosinophil count is normal in about 90% of patients.

Although studies have not been done in adults to direct management, Dr. Katzka recommends RAST testing, patch testing, and skin testing to try to identify an allergen or combination of allergens that may be responsible. However, he warned of an “imprecise correlation between skin, blood, and esophageal findings” and said some adult patients do not respond to avoidance of known allergens.

The biggest problem is convincing patients to avoid foods that may be contributing to the condition.

In children, treatment with steroids, leukotriene inhibitors, and mast cell stabilizers have been shown effective.

In adults, “we're flying by the seat of our pants” in regard to treatment, he said.

He recommends a 2-month course of fluticasone propionate and possibly, maintenance with montelukast, noting that some specialists also suggest a 1− to 2− month course of proton pump inhibitors prior to performing a second endoscopy.

“We will treat these patients very aggressively for 2 months before thinking about dilation,” he said.

In children, eosinophilic esophagitis seems to stabilize and improve over time, while in adults, limited studies suggest it persists or worsens.

“One of our fears is that in adults, this is a progressive or static disease that has to be recognized and treated early.”

LOS ANGELES — Eosinophilic esophagitis appears to be a different disease in adults than it is in children, sharing similar pathophysiologic features and perhaps an allergic etiology, but displaying a different pattern of symptoms, Dr. David A. Katzka said at the annual Digestive Disease Week.

“Certainly this is a new kid on the block, with many of us feeling this is a totally new disease,” said Dr. Katzka, director of the swallowing program at the University of Pennsylvania in Philadelphia.

It is generally agreed that eosinophilia is on the rise. Children with eosinophilic esophagitis complain of a “plethora” of symptoms, including nausea and vomiting, epigastric pain, heartburn, and dysphagia. “In adults, by far and away, the most dominant symptom is dysphagia,” Dr. Katzka stressed. “It may be intermittent. It may be catastrophic,” he said, noting that it has become a highly prevalent cause of food impaction, despite the fact the disease was only described in 1993.

At first believed to be a variant of gastroesophageal reflux disease (GERD), the disease is clearly a distinct entity with a genetic component in some families. On the other hand, many adults with the disease have GERD symptoms and some respond to aggressive acid suppression with proton pump inhibitors, making the connection between the two entities vexing.

In both children and adults, the diagnosis is pathologic and based on an ill-defined elevated rate of eosinophils found in a patchy pattern in the esophageal mucosa.

He emphasized the importance of taking multiple biopsies, since there may be 5 eosinophils per high-powered field in one spot, and “50 in another.”

Longitudinal furrows are very common findings on endoscopy in all age groups.

In addition, rings throughout the esophagus and strictures are commonly seen in adults (and less often, in children) even on radiographic films.

Eosinophilic abscesses, visualized as white specks, are seen in 17%–20% of children with the disease and are “almost pathopneumonic” in adults. The esophagus may have a “firm, woody feel,” he said.

Debate rages as to whether a person with a normal-appearing esophagus can have the disease. Dr. Katzka said he believes it is possible.

The peripheral eosinophil count is normal in about 90% of patients.

Although studies have not been done in adults to direct management, Dr. Katzka recommends RAST testing, patch testing, and skin testing to try to identify an allergen or combination of allergens that may be responsible. However, he warned of an “imprecise correlation between skin, blood, and esophageal findings” and said some adult patients do not respond to avoidance of known allergens.

The biggest problem is convincing patients to avoid foods that may be contributing to the condition.

In children, treatment with steroids, leukotriene inhibitors, and mast cell stabilizers have been shown effective.

In adults, “we're flying by the seat of our pants” in regard to treatment, he said.

He recommends a 2-month course of fluticasone propionate and possibly, maintenance with montelukast, noting that some specialists also suggest a 1− to 2− month course of proton pump inhibitors prior to performing a second endoscopy.

“We will treat these patients very aggressively for 2 months before thinking about dilation,” he said.

In children, eosinophilic esophagitis seems to stabilize and improve over time, while in adults, limited studies suggest it persists or worsens.

“One of our fears is that in adults, this is a progressive or static disease that has to be recognized and treated early.”

LAS VEGAS — Capsule colonoscopy achieved a higher sensitivity for detecting polyps than did virtual colonoscopy in a comparative study presented at the annual meeting of the American College of Gastroenterology.

Two studies presented at the meeting focused on early clinical trials using the PillCam, a 31-mm capsule fitted with two video cameras, each capable of taking two frames per second during a journey of about 10 hours through the gastrointestinal tract. The investigational device, manufactured by Given Imaging Ltd., of Yoqneam, Israel, has not yet received Food and Drug Administration approval for colonoscopy. The company sponsored both studies.

Capsule colonoscopy requires bowel cleansing, as does traditional colonoscopy, but permits “direct visualization of the colon mucosa with no sedation, no insufflation, and no radiation,” said Dr. Rami Eliakim of Rambam Medical Center in Haifa, Israel, director of a three-center, prospective feasibility trial of capsule colonoscopy. Among 84 Israeli patients who underwent both tests for colorectal cancer screening or symptoms, polyps were detected in 34 by capsule colonoscopy and in 36 by traditional colonoscopy. Polyps considered “significant” were detected in 14 patients by capsule colonoscopy and in 16 by traditional colonoscopy.

Each test detected some polyps that the other test missed. Repeated traditional colonoscopies in four patients confirmed the presence of polyps seen only by capsule colonoscopy the first time around.

Dr. Blair Lewis, a gastroenterologist at Mount Sinai School of Medicine in New York, reported on a three-way, blinded, multicenter study comparing capsule colonoscopy, virtual colonoscopy, and traditional colonoscopy in 51 patients at average or high risk for colorectal cancer.

Seventeen precancerous polyps were found in 15 patients: 12 detected by capsule colonoscopy, 5 by virtual colonoscopy, and 16 by traditional colonoscopy. Results suggest capsule colonoscopy was “more sensitive than was virtual colonoscopy and almost [as] sensitive as standard colonos-copy,” Dr. Lewis said during a press briefing. Although capsule colonoscopy is still investigational, Dr. Lewis said he could envision its eventual usefulness in examining the right colon in patients with a prior incomplete colonoscopy, and patients who cannot undergo traditional colonoscopy.

Dr. Steven H. Itzkowitz announced during the meeting that a refined version of a stool-derived DNA test achieved a sensitivity for detecting colon cancer of 88%, a considerable improvement over the commercially available DNA test, which has a sensitivity of about 52%–53%.

The specificity for the new test is just 82%, potentially explained by the fact that one of the two markers targeted by the test is a methylated gene. Presumed “false positives” may be an age-related phenomenon, or the test may be picking up the earliest sign of transformation of a gene in a person destined to get colorectal cancer.

“We don't know how [these new technologies] interdigitate with colonoscopy,” said Dr. Itzkowitz, professor of medicine at Mount Sinai School of Medicine. “If there is a miss rate for colonoscopies, what do we do between colonoscopies? Maybe one of the roles for these noninvasive technologies is to use them 1 year later.”

LAS VEGAS — Capsule colonoscopy achieved a higher sensitivity for detecting polyps than did virtual colonoscopy in a comparative study presented at the annual meeting of the American College of Gastroenterology.

Two studies presented at the meeting focused on early clinical trials using the PillCam, a 31-mm capsule fitted with two video cameras, each capable of taking two frames per second during a journey of about 10 hours through the gastrointestinal tract. The investigational device, manufactured by Given Imaging Ltd., of Yoqneam, Israel, has not yet received Food and Drug Administration approval for colonoscopy. The company sponsored both studies.

Capsule colonoscopy requires bowel cleansing, as does traditional colonoscopy, but permits “direct visualization of the colon mucosa with no sedation, no insufflation, and no radiation,” said Dr. Rami Eliakim of Rambam Medical Center in Haifa, Israel, director of a three-center, prospective feasibility trial of capsule colonoscopy. Among 84 Israeli patients who underwent both tests for colorectal cancer screening or symptoms, polyps were detected in 34 by capsule colonoscopy and in 36 by traditional colonoscopy. Polyps considered “significant” were detected in 14 patients by capsule colonoscopy and in 16 by traditional colonoscopy.

Each test detected some polyps that the other test missed. Repeated traditional colonoscopies in four patients confirmed the presence of polyps seen only by capsule colonoscopy the first time around.

Dr. Blair Lewis, a gastroenterologist at Mount Sinai School of Medicine in New York, reported on a three-way, blinded, multicenter study comparing capsule colonoscopy, virtual colonoscopy, and traditional colonoscopy in 51 patients at average or high risk for colorectal cancer.

Seventeen precancerous polyps were found in 15 patients: 12 detected by capsule colonoscopy, 5 by virtual colonoscopy, and 16 by traditional colonoscopy. Results suggest capsule colonoscopy was “more sensitive than was virtual colonoscopy and almost [as] sensitive as standard colonos-copy,” Dr. Lewis said during a press briefing. Although capsule colonoscopy is still investigational, Dr. Lewis said he could envision its eventual usefulness in examining the right colon in patients with a prior incomplete colonoscopy, and patients who cannot undergo traditional colonoscopy.

Dr. Steven H. Itzkowitz announced during the meeting that a refined version of a stool-derived DNA test achieved a sensitivity for detecting colon cancer of 88%, a considerable improvement over the commercially available DNA test, which has a sensitivity of about 52%–53%.

The specificity for the new test is just 82%, potentially explained by the fact that one of the two markers targeted by the test is a methylated gene. Presumed “false positives” may be an age-related phenomenon, or the test may be picking up the earliest sign of transformation of a gene in a person destined to get colorectal cancer.

“We don't know how [these new technologies] interdigitate with colonoscopy,” said Dr. Itzkowitz, professor of medicine at Mount Sinai School of Medicine. “If there is a miss rate for colonoscopies, what do we do between colonoscopies? Maybe one of the roles for these noninvasive technologies is to use them 1 year later.”

LAS VEGAS — Capsule colonoscopy achieved a higher sensitivity for detecting polyps than did virtual colonoscopy in a comparative study presented at the annual meeting of the American College of Gastroenterology.

Two studies presented at the meeting focused on early clinical trials using the PillCam, a 31-mm capsule fitted with two video cameras, each capable of taking two frames per second during a journey of about 10 hours through the gastrointestinal tract. The investigational device, manufactured by Given Imaging Ltd., of Yoqneam, Israel, has not yet received Food and Drug Administration approval for colonoscopy. The company sponsored both studies.

Capsule colonoscopy requires bowel cleansing, as does traditional colonoscopy, but permits “direct visualization of the colon mucosa with no sedation, no insufflation, and no radiation,” said Dr. Rami Eliakim of Rambam Medical Center in Haifa, Israel, director of a three-center, prospective feasibility trial of capsule colonoscopy. Among 84 Israeli patients who underwent both tests for colorectal cancer screening or symptoms, polyps were detected in 34 by capsule colonoscopy and in 36 by traditional colonoscopy. Polyps considered “significant” were detected in 14 patients by capsule colonoscopy and in 16 by traditional colonoscopy.

Each test detected some polyps that the other test missed. Repeated traditional colonoscopies in four patients confirmed the presence of polyps seen only by capsule colonoscopy the first time around.

Dr. Blair Lewis, a gastroenterologist at Mount Sinai School of Medicine in New York, reported on a three-way, blinded, multicenter study comparing capsule colonoscopy, virtual colonoscopy, and traditional colonoscopy in 51 patients at average or high risk for colorectal cancer.

Seventeen precancerous polyps were found in 15 patients: 12 detected by capsule colonoscopy, 5 by virtual colonoscopy, and 16 by traditional colonoscopy. Results suggest capsule colonoscopy was “more sensitive than was virtual colonoscopy and almost [as] sensitive as standard colonos-copy,” Dr. Lewis said during a press briefing. Although capsule colonoscopy is still investigational, Dr. Lewis said he could envision its eventual usefulness in examining the right colon in patients with a prior incomplete colonoscopy, and patients who cannot undergo traditional colonoscopy.

Dr. Steven H. Itzkowitz announced during the meeting that a refined version of a stool-derived DNA test achieved a sensitivity for detecting colon cancer of 88%, a considerable improvement over the commercially available DNA test, which has a sensitivity of about 52%–53%.

The specificity for the new test is just 82%, potentially explained by the fact that one of the two markers targeted by the test is a methylated gene. Presumed “false positives” may be an age-related phenomenon, or the test may be picking up the earliest sign of transformation of a gene in a person destined to get colorectal cancer.

“We don't know how [these new technologies] interdigitate with colonoscopy,” said Dr. Itzkowitz, professor of medicine at Mount Sinai School of Medicine. “If there is a miss rate for colonoscopies, what do we do between colonoscopies? Maybe one of the roles for these noninvasive technologies is to use them 1 year later.”

LAS VEGAS — The safety, efficacy, and perhaps most important, the tolerability of bowel preparation for colonoscopy came under intense scrutiny at the annual meeting of the American College of Gastroenterology.

“We desperately need to have one regimen that gives us the ideal preparation,” said Dr. Douglas K. Rex, professor of medicine and director of endoscopy at Indiana University Hospital in Indianapolis.

“Bowel preparation is a very, very big deal,” he continued during the Emily Couric Annual Lecture at the meeting. “We already know it's the thing patients complain about most.”

The problems with bowel preparation are twofold: People who are referred for colonoscopy often don't get it done because they expect the preparation to be inconvenient and uncomfortable, and the difficulties of currently available methods of bowel preparation often lead to incomplete cleansing. The latter problem leads to inadequate visualization in up to 25% of colonoscopies, Dr. Rex added.

“The costs of that over time are enormous,” he said.

One method is the use of aqueous sodium phosphate solutions, which have proven efficacious and reasonably tolerable. However, there is some concern among gastroenterologists about their safety because of problems with electrolyte imbalances, dehydration, and renal failure, Dr. Rex explained.

Polyethylene glycol-electrolyte (PEG-ES) lavage preparations are considered safer but are not as well tolerated, he said.

A third alternative, hydrotherapy, may offer a reasonable alternative, if early studies can be replicated, he said. In a 45-minute procedure immediately preceding colonoscopy, a trained technician uses a pressure-controlled device to lavage the colon with a constant flow of warm water.

In a study presented at the meeting, the hydrotherapy method was compared, on the basis of efficacy and tolerability, with two other methods: 4 L of PEG-ES and aqueous sodium phosphate given in two doses. Patients aged 38–80 years (average age, 61) were randomized to one of the three procedures.

Hydrotherapy received significantly higher colon cleansing quality scores for every area of the colon (right, transverse, and left), compared with either the sodium phosphate or PEG-ES methods, reported Dr. Joseph J. Fiorito of Danbury (Conn.) Hospital. The ratings were completed by endoscopists blinded to the preparation method used.

For example, in the right colon, the quality of cleansing was rated as “good” in 32 of 52 patients (62%) who received aqueous sodium phosphate, 27 of 55 patients (49%) who took PEG-ES, and 49 of 53 (92%) who underwent hydrotherapy.

Patients who received hydrotherapy reported significantly higher scores on measures of ease, convenience, and comfort than patients who underwent other bowel preparation methods.

When patients were asked if they would prefer a different bowel cleansing method if they were to undergo another colonoscopy, 1 of 53 (2%) who had hydrotherapy cleansing said yes, compared with 25 of 52 (48%) of those who took aqueous sodium phosphate and 33 of 55 (60%) who had PEG-ES.

One patient (not included in the final analyses) did not complete the hydrotherapy procedure because of discomfort.

Dr. Fiorito said that the patients in the study were not charged for colonoscopy preparation, but that the estimated cost of hydrotherapy ranges from $35 to $75.

“It would be nice to have insurance companies or Medicare to look at this as an alternative method of preparation,” he said.

Hydrotherapy Inc. of Las Vegas funded the study.

Another study, which was presented as a poster at the meeting, compared a new, 32-tablet form of sodium phosphate preparation with a bowel preparation kit containing 2 L of PEG and bisacodyl tablets.

The study results showed that significantly less irrigation was necessary during colonoscopy and more polyps were identified when subjects took the tablets rather than using the preparation kit.

The new tablet formulation, marketed as OsmoPrep, is made by Salix Pharmaceuticals Inc. of Morrisville, N.C., which sponsored the study.

LAS VEGAS — The safety, efficacy, and perhaps most important, the tolerability of bowel preparation for colonoscopy came under intense scrutiny at the annual meeting of the American College of Gastroenterology.

“We desperately need to have one regimen that gives us the ideal preparation,” said Dr. Douglas K. Rex, professor of medicine and director of endoscopy at Indiana University Hospital in Indianapolis.

“Bowel preparation is a very, very big deal,” he continued during the Emily Couric Annual Lecture at the meeting. “We already know it's the thing patients complain about most.”

The problems with bowel preparation are twofold: People who are referred for colonoscopy often don't get it done because they expect the preparation to be inconvenient and uncomfortable, and the difficulties of currently available methods of bowel preparation often lead to incomplete cleansing. The latter problem leads to inadequate visualization in up to 25% of colonoscopies, Dr. Rex added.

“The costs of that over time are enormous,” he said.

One method is the use of aqueous sodium phosphate solutions, which have proven efficacious and reasonably tolerable. However, there is some concern among gastroenterologists about their safety because of problems with electrolyte imbalances, dehydration, and renal failure, Dr. Rex explained.

Polyethylene glycol-electrolyte (PEG-ES) lavage preparations are considered safer but are not as well tolerated, he said.

A third alternative, hydrotherapy, may offer a reasonable alternative, if early studies can be replicated, he said. In a 45-minute procedure immediately preceding colonoscopy, a trained technician uses a pressure-controlled device to lavage the colon with a constant flow of warm water.

In a study presented at the meeting, the hydrotherapy method was compared, on the basis of efficacy and tolerability, with two other methods: 4 L of PEG-ES and aqueous sodium phosphate given in two doses. Patients aged 38–80 years (average age, 61) were randomized to one of the three procedures.

Hydrotherapy received significantly higher colon cleansing quality scores for every area of the colon (right, transverse, and left), compared with either the sodium phosphate or PEG-ES methods, reported Dr. Joseph J. Fiorito of Danbury (Conn.) Hospital. The ratings were completed by endoscopists blinded to the preparation method used.

For example, in the right colon, the quality of cleansing was rated as “good” in 32 of 52 patients (62%) who received aqueous sodium phosphate, 27 of 55 patients (49%) who took PEG-ES, and 49 of 53 (92%) who underwent hydrotherapy.

Patients who received hydrotherapy reported significantly higher scores on measures of ease, convenience, and comfort than patients who underwent other bowel preparation methods.

When patients were asked if they would prefer a different bowel cleansing method if they were to undergo another colonoscopy, 1 of 53 (2%) who had hydrotherapy cleansing said yes, compared with 25 of 52 (48%) of those who took aqueous sodium phosphate and 33 of 55 (60%) who had PEG-ES.

One patient (not included in the final analyses) did not complete the hydrotherapy procedure because of discomfort.

Dr. Fiorito said that the patients in the study were not charged for colonoscopy preparation, but that the estimated cost of hydrotherapy ranges from $35 to $75.

“It would be nice to have insurance companies or Medicare to look at this as an alternative method of preparation,” he said.

Hydrotherapy Inc. of Las Vegas funded the study.

Another study, which was presented as a poster at the meeting, compared a new, 32-tablet form of sodium phosphate preparation with a bowel preparation kit containing 2 L of PEG and bisacodyl tablets.

The study results showed that significantly less irrigation was necessary during colonoscopy and more polyps were identified when subjects took the tablets rather than using the preparation kit.

The new tablet formulation, marketed as OsmoPrep, is made by Salix Pharmaceuticals Inc. of Morrisville, N.C., which sponsored the study.

LAS VEGAS — The safety, efficacy, and perhaps most important, the tolerability of bowel preparation for colonoscopy came under intense scrutiny at the annual meeting of the American College of Gastroenterology.

“We desperately need to have one regimen that gives us the ideal preparation,” said Dr. Douglas K. Rex, professor of medicine and director of endoscopy at Indiana University Hospital in Indianapolis.

“Bowel preparation is a very, very big deal,” he continued during the Emily Couric Annual Lecture at the meeting. “We already know it's the thing patients complain about most.”

The problems with bowel preparation are twofold: People who are referred for colonoscopy often don't get it done because they expect the preparation to be inconvenient and uncomfortable, and the difficulties of currently available methods of bowel preparation often lead to incomplete cleansing. The latter problem leads to inadequate visualization in up to 25% of colonoscopies, Dr. Rex added.

“The costs of that over time are enormous,” he said.

One method is the use of aqueous sodium phosphate solutions, which have proven efficacious and reasonably tolerable. However, there is some concern among gastroenterologists about their safety because of problems with electrolyte imbalances, dehydration, and renal failure, Dr. Rex explained.

Polyethylene glycol-electrolyte (PEG-ES) lavage preparations are considered safer but are not as well tolerated, he said.

A third alternative, hydrotherapy, may offer a reasonable alternative, if early studies can be replicated, he said. In a 45-minute procedure immediately preceding colonoscopy, a trained technician uses a pressure-controlled device to lavage the colon with a constant flow of warm water.

In a study presented at the meeting, the hydrotherapy method was compared, on the basis of efficacy and tolerability, with two other methods: 4 L of PEG-ES and aqueous sodium phosphate given in two doses. Patients aged 38–80 years (average age, 61) were randomized to one of the three procedures.

Hydrotherapy received significantly higher colon cleansing quality scores for every area of the colon (right, transverse, and left), compared with either the sodium phosphate or PEG-ES methods, reported Dr. Joseph J. Fiorito of Danbury (Conn.) Hospital. The ratings were completed by endoscopists blinded to the preparation method used.

For example, in the right colon, the quality of cleansing was rated as “good” in 32 of 52 patients (62%) who received aqueous sodium phosphate, 27 of 55 patients (49%) who took PEG-ES, and 49 of 53 (92%) who underwent hydrotherapy.

Patients who received hydrotherapy reported significantly higher scores on measures of ease, convenience, and comfort than patients who underwent other bowel preparation methods.

When patients were asked if they would prefer a different bowel cleansing method if they were to undergo another colonoscopy, 1 of 53 (2%) who had hydrotherapy cleansing said yes, compared with 25 of 52 (48%) of those who took aqueous sodium phosphate and 33 of 55 (60%) who had PEG-ES.

One patient (not included in the final analyses) did not complete the hydrotherapy procedure because of discomfort.

Dr. Fiorito said that the patients in the study were not charged for colonoscopy preparation, but that the estimated cost of hydrotherapy ranges from $35 to $75.

“It would be nice to have insurance companies or Medicare to look at this as an alternative method of preparation,” he said.

Hydrotherapy Inc. of Las Vegas funded the study.

Another study, which was presented as a poster at the meeting, compared a new, 32-tablet form of sodium phosphate preparation with a bowel preparation kit containing 2 L of PEG and bisacodyl tablets.

The study results showed that significantly less irrigation was necessary during colonoscopy and more polyps were identified when subjects took the tablets rather than using the preparation kit.

The new tablet formulation, marketed as OsmoPrep, is made by Salix Pharmaceuticals Inc. of Morrisville, N.C., which sponsored the study.

LOS ANGELES – A relatively low dose of oral almotriptan significantly relieved migraine pain, photophobia, and phonophobia in a large, randomized, placebo-controlled, parallel group study of adolescent patients, Dr. Steven L. Linder reported at the annual meeting of the American Headache Society.

However, because of a stringent definition of success set by the Food and Drug Administration, the study was still considered a negative trial, failing once again to pave the way to approval of a triptan in the treatment of acute migraine in adolescents or children.

Instead, results of the multicenter study will be considered “exploratory data” by the FDA, said Dr. Linder, a pediatric neurologist in private practice in Dallas.

The study randomized 714 preteens and adolescents aged 12–17 years with a history of severe migraines to receive placebo or 6.25 mg, 12.5 mg, or 25 mg of almotriptan, a 5-HT1B/1D agonist, for the treatment of one migraine attack of moderate to severe intensity. The FDA required study results to be gauged on a four-pronged primary end point at 2 hours that included pain relief as well as the absence of photophobia, phonophobia, and nausea.

All four end points had to show superiority over placebo at a significance of 0.05 for the results to be considered positive.

All three dosages outperformed placebo in reducing pain, meeting this criterion in 71.8%, 72.9%, and 66.7% of patients assigned to the groups taking 6.25 mg, 12.5 mg, and 25 mg of the drug, compared with 55.3% of patients who received placebo.

An audience member, Dr. Marcelo E. Bigal, commended the study despite its negative primary end point.

LOS ANGELES – A relatively low dose of oral almotriptan significantly relieved migraine pain, photophobia, and phonophobia in a large, randomized, placebo-controlled, parallel group study of adolescent patients, Dr. Steven L. Linder reported at the annual meeting of the American Headache Society.

However, because of a stringent definition of success set by the Food and Drug Administration, the study was still considered a negative trial, failing once again to pave the way to approval of a triptan in the treatment of acute migraine in adolescents or children.

Instead, results of the multicenter study will be considered “exploratory data” by the FDA, said Dr. Linder, a pediatric neurologist in private practice in Dallas.

The study randomized 714 preteens and adolescents aged 12–17 years with a history of severe migraines to receive placebo or 6.25 mg, 12.5 mg, or 25 mg of almotriptan, a 5-HT1B/1D agonist, for the treatment of one migraine attack of moderate to severe intensity. The FDA required study results to be gauged on a four-pronged primary end point at 2 hours that included pain relief as well as the absence of photophobia, phonophobia, and nausea.

All four end points had to show superiority over placebo at a significance of 0.05 for the results to be considered positive.

All three dosages outperformed placebo in reducing pain, meeting this criterion in 71.8%, 72.9%, and 66.7% of patients assigned to the groups taking 6.25 mg, 12.5 mg, and 25 mg of the drug, compared with 55.3% of patients who received placebo.

An audience member, Dr. Marcelo E. Bigal, commended the study despite its negative primary end point.

LOS ANGELES – A relatively low dose of oral almotriptan significantly relieved migraine pain, photophobia, and phonophobia in a large, randomized, placebo-controlled, parallel group study of adolescent patients, Dr. Steven L. Linder reported at the annual meeting of the American Headache Society.

However, because of a stringent definition of success set by the Food and Drug Administration, the study was still considered a negative trial, failing once again to pave the way to approval of a triptan in the treatment of acute migraine in adolescents or children.

Instead, results of the multicenter study will be considered “exploratory data” by the FDA, said Dr. Linder, a pediatric neurologist in private practice in Dallas.

The study randomized 714 preteens and adolescents aged 12–17 years with a history of severe migraines to receive placebo or 6.25 mg, 12.5 mg, or 25 mg of almotriptan, a 5-HT1B/1D agonist, for the treatment of one migraine attack of moderate to severe intensity. The FDA required study results to be gauged on a four-pronged primary end point at 2 hours that included pain relief as well as the absence of photophobia, phonophobia, and nausea.

All four end points had to show superiority over placebo at a significance of 0.05 for the results to be considered positive.

All three dosages outperformed placebo in reducing pain, meeting this criterion in 71.8%, 72.9%, and 66.7% of patients assigned to the groups taking 6.25 mg, 12.5 mg, and 25 mg of the drug, compared with 55.3% of patients who received placebo.

An audience member, Dr. Marcelo E. Bigal, commended the study despite its negative primary end point.