Nancy A. Melville

SCOTTSDALE, ARIZ. — The tissue adhesive Dermabond has gained popularity, especially in pediatric and emergency settings, because of its short application time and improved cosmesis over older adhesives, and despite its limitations, the product has many uses, said Bari Cunningham, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

Although studies have shown that Dermabond offers no significant improvement in cosmesis over traditional suturing, its benefits are reflected in substantially higher pain scores and shorter procedure time, which have made the product ideal in emergency department and pediatric settings (JAMA 1997;277:1527-30; J. Pediatr. 1998;132:1067-70).

"It's a few seconds versus the time it takes for stitches—which with children can take upward of half an hour. So the benefit is obvious," said Dr. Cunningham of Children's Hospital, San Diego, and the University of California, San Diego.

Another advantage of Dermabond over suturing is that a follow-up visit is not needed, which is convenient for patients needing to travel a long distance. In addition, wounds treated with Dermabond can withstand wetness, which is indispensable for patients who want to swim.

Dermabond's maker, Ethicon Inc., says the product seals out most infection-causing bacteria, such as certain staph, pseudomonas, and Escherichia coli. Although it's not yet certain whether that will translate into fewer postop infections, the possible antibacterial properties are intriguing, Dr. Cunningham said.

Dermabond is a relatively new tissue adhesive about three times as strong as the old cyanoacrylates, which were too weak for widespread use and tended to be brittle and prone to cracking, Dr. Cunningham said.

The product has evolved in response to dermatologists' preferences, with newer formulations being more viscous and featuring better applicator tips.

Most studies that have shown benefits to Dermabond looked at uses in incisional surgery, whereas a majority of dermatologists work more with excisional surgery. To determine the adhesive's benefits in that context, Dr. Cunningham and her colleagues conducted a study comparing suturing with tissue adhesive. In a 2-month follow-up, they found significantly better cosmesis with suturing than with the skin glue (Arch. Derm. 2001;137:1177-80).

The adhesive is ideal for incisions such as low-tension closures for cysts but is not appropriate for high-tension areas. She urged care in the eye area; there have been cases of doctors accidentally gluing a patient's eye shut. In such instances, avoid trying to pry the eye open or using water, which can make the situation worse. Instead, apply a petrolatum-based product to gently ease the eye open.

In addition to Dermabond's inappropriateness for high-tension areas, another disadvantage is that the adhesive doesn't obviate sutures altogether, because subcutaneous sutures are still required.

And then there's the price; at about $30 a vial, some question whether Dermabond is worth the cost. But, Dr. Cunningham argued, "if you factor in the cost of time taken for a postoperative visit, suture removal, and nursing, it is often more cost effective to use the Dermabond."

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

SCOTTSDALE, ARIZ. — The tissue adhesive Dermabond has gained popularity, especially in pediatric and emergency settings, because of its short application time and improved cosmesis over older adhesives, and despite its limitations, the product has many uses, said Bari Cunningham, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

Although studies have shown that Dermabond offers no significant improvement in cosmesis over traditional suturing, its benefits are reflected in substantially higher pain scores and shorter procedure time, which have made the product ideal in emergency department and pediatric settings (JAMA 1997;277:1527-30; J. Pediatr. 1998;132:1067-70).

"It's a few seconds versus the time it takes for stitches—which with children can take upward of half an hour. So the benefit is obvious," said Dr. Cunningham of Children's Hospital, San Diego, and the University of California, San Diego.

Another advantage of Dermabond over suturing is that a follow-up visit is not needed, which is convenient for patients needing to travel a long distance. In addition, wounds treated with Dermabond can withstand wetness, which is indispensable for patients who want to swim.

Dermabond's maker, Ethicon Inc., says the product seals out most infection-causing bacteria, such as certain staph, pseudomonas, and Escherichia coli. Although it's not yet certain whether that will translate into fewer postop infections, the possible antibacterial properties are intriguing, Dr. Cunningham said.

Dermabond is a relatively new tissue adhesive about three times as strong as the old cyanoacrylates, which were too weak for widespread use and tended to be brittle and prone to cracking, Dr. Cunningham said.

The product has evolved in response to dermatologists' preferences, with newer formulations being more viscous and featuring better applicator tips.

Most studies that have shown benefits to Dermabond looked at uses in incisional surgery, whereas a majority of dermatologists work more with excisional surgery. To determine the adhesive's benefits in that context, Dr. Cunningham and her colleagues conducted a study comparing suturing with tissue adhesive. In a 2-month follow-up, they found significantly better cosmesis with suturing than with the skin glue (Arch. Derm. 2001;137:1177-80).

The adhesive is ideal for incisions such as low-tension closures for cysts but is not appropriate for high-tension areas. She urged care in the eye area; there have been cases of doctors accidentally gluing a patient's eye shut. In such instances, avoid trying to pry the eye open or using water, which can make the situation worse. Instead, apply a petrolatum-based product to gently ease the eye open.

In addition to Dermabond's inappropriateness for high-tension areas, another disadvantage is that the adhesive doesn't obviate sutures altogether, because subcutaneous sutures are still required.

And then there's the price; at about $30 a vial, some question whether Dermabond is worth the cost. But, Dr. Cunningham argued, "if you factor in the cost of time taken for a postoperative visit, suture removal, and nursing, it is often more cost effective to use the Dermabond."

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

SCOTTSDALE, ARIZ. — The tissue adhesive Dermabond has gained popularity, especially in pediatric and emergency settings, because of its short application time and improved cosmesis over older adhesives, and despite its limitations, the product has many uses, said Bari Cunningham, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

Although studies have shown that Dermabond offers no significant improvement in cosmesis over traditional suturing, its benefits are reflected in substantially higher pain scores and shorter procedure time, which have made the product ideal in emergency department and pediatric settings (JAMA 1997;277:1527-30; J. Pediatr. 1998;132:1067-70).

"It's a few seconds versus the time it takes for stitches—which with children can take upward of half an hour. So the benefit is obvious," said Dr. Cunningham of Children's Hospital, San Diego, and the University of California, San Diego.

Another advantage of Dermabond over suturing is that a follow-up visit is not needed, which is convenient for patients needing to travel a long distance. In addition, wounds treated with Dermabond can withstand wetness, which is indispensable for patients who want to swim.

Dermabond's maker, Ethicon Inc., says the product seals out most infection-causing bacteria, such as certain staph, pseudomonas, and Escherichia coli. Although it's not yet certain whether that will translate into fewer postop infections, the possible antibacterial properties are intriguing, Dr. Cunningham said.

Dermabond is a relatively new tissue adhesive about three times as strong as the old cyanoacrylates, which were too weak for widespread use and tended to be brittle and prone to cracking, Dr. Cunningham said.

The product has evolved in response to dermatologists' preferences, with newer formulations being more viscous and featuring better applicator tips.

Most studies that have shown benefits to Dermabond looked at uses in incisional surgery, whereas a majority of dermatologists work more with excisional surgery. To determine the adhesive's benefits in that context, Dr. Cunningham and her colleagues conducted a study comparing suturing with tissue adhesive. In a 2-month follow-up, they found significantly better cosmesis with suturing than with the skin glue (Arch. Derm. 2001;137:1177-80).

The adhesive is ideal for incisions such as low-tension closures for cysts but is not appropriate for high-tension areas. She urged care in the eye area; there have been cases of doctors accidentally gluing a patient's eye shut. In such instances, avoid trying to pry the eye open or using water, which can make the situation worse. Instead, apply a petrolatum-based product to gently ease the eye open.

In addition to Dermabond's inappropriateness for high-tension areas, another disadvantage is that the adhesive doesn't obviate sutures altogether, because subcutaneous sutures are still required.

And then there's the price; at about $30 a vial, some question whether Dermabond is worth the cost. But, Dr. Cunningham argued, "if you factor in the cost of time taken for a postoperative visit, suture removal, and nursing, it is often more cost effective to use the Dermabond."

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

SCOTTSDALE, ARIZ. — The incidence of pseudotumor cerebri is rising among the obese, so physicians should keep this relatively uncommon condition in mind when obese patients present with symptoms resembling brain tumor or intracranial pressure, said Deborah Friedman, M.D., at the American Headache Society's 2004 Headache Symposium.

Pseudotumor cerebri is primarily seen in obese women of childbearing age, and although the condition affects only 1 in 100,000 people in the United States, the rate for obese women between the ages of 20 and 44 is about 19 per 100,000.

In areas with higher levels of obesity, however, pseudotumor cerebri is being seen more frequently.

In Mississippi, called the most overweight state in the nation because a quarter of its population is considered obese by BMI criteria, the incidence of pseudotumor cerebri in the overall population is double, at 2 per 100,000, and among obese women aged 20–44, the rate is about 25 per 100,000.

Large increases in pseudotumor cerebri incidence rates have also been noted in men in the region, said Dr. Friedman of the University of Rochester (New York).

The most common symptom, headache, occurs in about 90% of patients. Descriptions of the pain range from headache behind the eyes that feels like pressure to headache in the morning, said Dr. Friedman.

Visual symptoms, seen in about three-quarters of patients, are the second most common symptom, and papilledema is also very common.

“Patients will often describe blurriness or say that if they bend over, their vision goes out for a few seconds when they straighten up again,” Dr. Friedman said. “It's usually a sign that the optic nerve is swollen.”

About 60% of patients also experience the third most common symptom of intracranial noises, usually described as a whooshing in the ear or the sound of their heartbeat in the ear.

In diagnosing the disease, imaging and mental status are typically normal, and a lumbar puncture should show increased cranial pressure with otherwise normal spinal fluid content.

Dr. Friedman underscored the need for a lumbar puncture.

“You have to do a spinal tap to make a diagnosis,” she stressed. “It's disheartening how many people I see who come in without having a lumbar puncture.”

There are no evidence-based guidelines for treating pseudotumor cerebri, and not all patients even require treatment.

However, with the possibility of vision loss, the most important goal of treatment should be to preserve a patient's vision, Dr. Friedman said.

An ophthalmologist needs to be brought in for such cases, but it's essential that the physicians collaborate on care.

“Most of the time, there's no captain of the ship in management, and the doctors aren't working as a team,” said Dr. Friedman, adding that an ophthalmologist and a neurologist should both follow the patient and communicate about management.

SCOTTSDALE, ARIZ. — The incidence of pseudotumor cerebri is rising among the obese, so physicians should keep this relatively uncommon condition in mind when obese patients present with symptoms resembling brain tumor or intracranial pressure, said Deborah Friedman, M.D., at the American Headache Society's 2004 Headache Symposium.

Pseudotumor cerebri is primarily seen in obese women of childbearing age, and although the condition affects only 1 in 100,000 people in the United States, the rate for obese women between the ages of 20 and 44 is about 19 per 100,000.

In areas with higher levels of obesity, however, pseudotumor cerebri is being seen more frequently.

In Mississippi, called the most overweight state in the nation because a quarter of its population is considered obese by BMI criteria, the incidence of pseudotumor cerebri in the overall population is double, at 2 per 100,000, and among obese women aged 20–44, the rate is about 25 per 100,000.

Large increases in pseudotumor cerebri incidence rates have also been noted in men in the region, said Dr. Friedman of the University of Rochester (New York).

The most common symptom, headache, occurs in about 90% of patients. Descriptions of the pain range from headache behind the eyes that feels like pressure to headache in the morning, said Dr. Friedman.

Visual symptoms, seen in about three-quarters of patients, are the second most common symptom, and papilledema is also very common.

“Patients will often describe blurriness or say that if they bend over, their vision goes out for a few seconds when they straighten up again,” Dr. Friedman said. “It's usually a sign that the optic nerve is swollen.”

About 60% of patients also experience the third most common symptom of intracranial noises, usually described as a whooshing in the ear or the sound of their heartbeat in the ear.

In diagnosing the disease, imaging and mental status are typically normal, and a lumbar puncture should show increased cranial pressure with otherwise normal spinal fluid content.

Dr. Friedman underscored the need for a lumbar puncture.

“You have to do a spinal tap to make a diagnosis,” she stressed. “It's disheartening how many people I see who come in without having a lumbar puncture.”

There are no evidence-based guidelines for treating pseudotumor cerebri, and not all patients even require treatment.

However, with the possibility of vision loss, the most important goal of treatment should be to preserve a patient's vision, Dr. Friedman said.

An ophthalmologist needs to be brought in for such cases, but it's essential that the physicians collaborate on care.

“Most of the time, there's no captain of the ship in management, and the doctors aren't working as a team,” said Dr. Friedman, adding that an ophthalmologist and a neurologist should both follow the patient and communicate about management.

SCOTTSDALE, ARIZ. — The incidence of pseudotumor cerebri is rising among the obese, so physicians should keep this relatively uncommon condition in mind when obese patients present with symptoms resembling brain tumor or intracranial pressure, said Deborah Friedman, M.D., at the American Headache Society's 2004 Headache Symposium.

Pseudotumor cerebri is primarily seen in obese women of childbearing age, and although the condition affects only 1 in 100,000 people in the United States, the rate for obese women between the ages of 20 and 44 is about 19 per 100,000.

In areas with higher levels of obesity, however, pseudotumor cerebri is being seen more frequently.

In Mississippi, called the most overweight state in the nation because a quarter of its population is considered obese by BMI criteria, the incidence of pseudotumor cerebri in the overall population is double, at 2 per 100,000, and among obese women aged 20–44, the rate is about 25 per 100,000.

Large increases in pseudotumor cerebri incidence rates have also been noted in men in the region, said Dr. Friedman of the University of Rochester (New York).

The most common symptom, headache, occurs in about 90% of patients. Descriptions of the pain range from headache behind the eyes that feels like pressure to headache in the morning, said Dr. Friedman.

Visual symptoms, seen in about three-quarters of patients, are the second most common symptom, and papilledema is also very common.

“Patients will often describe blurriness or say that if they bend over, their vision goes out for a few seconds when they straighten up again,” Dr. Friedman said. “It's usually a sign that the optic nerve is swollen.”

About 60% of patients also experience the third most common symptom of intracranial noises, usually described as a whooshing in the ear or the sound of their heartbeat in the ear.

In diagnosing the disease, imaging and mental status are typically normal, and a lumbar puncture should show increased cranial pressure with otherwise normal spinal fluid content.

Dr. Friedman underscored the need for a lumbar puncture.

“You have to do a spinal tap to make a diagnosis,” she stressed. “It's disheartening how many people I see who come in without having a lumbar puncture.”

There are no evidence-based guidelines for treating pseudotumor cerebri, and not all patients even require treatment.

However, with the possibility of vision loss, the most important goal of treatment should be to preserve a patient's vision, Dr. Friedman said.

An ophthalmologist needs to be brought in for such cases, but it's essential that the physicians collaborate on care.

“Most of the time, there's no captain of the ship in management, and the doctors aren't working as a team,” said Dr. Friedman, adding that an ophthalmologist and a neurologist should both follow the patient and communicate about management.

PHOENIX, ARIZ. — Pregnancies achieved using donor-egg in vitro fertilization can present a higher risk of pregnancy-induced hypertension than those achieved through standard IVF, according to the results of a retrospective study.

Investigators compared 50 oocyte-donation pregnancies with 50 standard IVF pregnancies at three private practice medical groups at the California Pacific Medical Center in San Francisco. The rate of pregnancy-induced hypertension (PIH) was more than three times higher in the donor-egg IVF group than in the standard IVF group (27% vs. 8%), said Donna Wiggins, M.D., the study's lead investigator and a San Francisco ob.gyn.

PIH was defined as a systolic blood pressure (BP) of at least 140 mm Hg or a diastolic BP of at least 90 mm Hg occurring after 20 weeks' gestation in a woman with previously normal BP.

In looking separately at nulliparous patients, the researchers found greater PIH rates in the donor-egg IVF group (37% vs. 8%), she said at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

Among women who had twins, 58% of those in the donor-egg IVF group and 17% of the standard IVF group developed PIH.

The women were between the ages of 30 and 50 years, and the average maternal age in the donor-egg IVF group was 42, compared with 38 in the standard IVF group. But Dr. Wiggins explained that when age stratifications were applied, there was not an increasing incidence with advancing age. And when the multiple logistic regression was applied, age fell out as an indicator of significance with regard to PIH.

Aside from the PIH rates, the two groups showed similar results in most other categories. The cesarean-section rate was 43% in the donor-egg group and 45% in the standard IVF group.

First-trimester bleeding occurred in 12% of the donor-egg group and 14% in standard IVF. And the most common postpartum complications of “lactation difficulties” and postpartum depression occurred in both groups at about the same rate of 10%.

Birthweight was an average of 3,044 g in the donor-egg group and 3,017 g in standard IVF group, and premature labor occurred in the donor-egg group at a rate of 16%, compared with 10% in the standard IVF group.

“In looking at donor-egg and [standard] IVF pregnancies, there aren't that many differences, aside from the significant difference in hypertensive disorders,” said Dr. Wiggins. “All things considered, however, the women for the most part had good outcomes.”

The reasons for the higher PIH rates in donor-egg IVF may have to do with the fact that the donor egg is foreign, Dr. Wiggins speculated. “Unlike any other pregnancy, a donor-egg pregnancy is 100% allogeneic, and this may affect the adequacy of trophoblast invasion and hence hypertensive disorders,” she said at the meeting, cosponsored by the American College of Obstetricians and Gynecologists.

When initially introduced in 1984, donor-egg IVF was primarily indicated for premature ovarian failure, defined as menopause occurring before the age of 40. But the primary indication for egg donation at most IVF centers is now diminished ovarian reserve in women with functioning ovaries, Dr. Wiggins said.

PHOENIX, ARIZ. — Pregnancies achieved using donor-egg in vitro fertilization can present a higher risk of pregnancy-induced hypertension than those achieved through standard IVF, according to the results of a retrospective study.

Investigators compared 50 oocyte-donation pregnancies with 50 standard IVF pregnancies at three private practice medical groups at the California Pacific Medical Center in San Francisco. The rate of pregnancy-induced hypertension (PIH) was more than three times higher in the donor-egg IVF group than in the standard IVF group (27% vs. 8%), said Donna Wiggins, M.D., the study's lead investigator and a San Francisco ob.gyn.

PIH was defined as a systolic blood pressure (BP) of at least 140 mm Hg or a diastolic BP of at least 90 mm Hg occurring after 20 weeks' gestation in a woman with previously normal BP.

In looking separately at nulliparous patients, the researchers found greater PIH rates in the donor-egg IVF group (37% vs. 8%), she said at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

Among women who had twins, 58% of those in the donor-egg IVF group and 17% of the standard IVF group developed PIH.

The women were between the ages of 30 and 50 years, and the average maternal age in the donor-egg IVF group was 42, compared with 38 in the standard IVF group. But Dr. Wiggins explained that when age stratifications were applied, there was not an increasing incidence with advancing age. And when the multiple logistic regression was applied, age fell out as an indicator of significance with regard to PIH.

Aside from the PIH rates, the two groups showed similar results in most other categories. The cesarean-section rate was 43% in the donor-egg group and 45% in the standard IVF group.

First-trimester bleeding occurred in 12% of the donor-egg group and 14% in standard IVF. And the most common postpartum complications of “lactation difficulties” and postpartum depression occurred in both groups at about the same rate of 10%.

Birthweight was an average of 3,044 g in the donor-egg group and 3,017 g in standard IVF group, and premature labor occurred in the donor-egg group at a rate of 16%, compared with 10% in the standard IVF group.

“In looking at donor-egg and [standard] IVF pregnancies, there aren't that many differences, aside from the significant difference in hypertensive disorders,” said Dr. Wiggins. “All things considered, however, the women for the most part had good outcomes.”

The reasons for the higher PIH rates in donor-egg IVF may have to do with the fact that the donor egg is foreign, Dr. Wiggins speculated. “Unlike any other pregnancy, a donor-egg pregnancy is 100% allogeneic, and this may affect the adequacy of trophoblast invasion and hence hypertensive disorders,” she said at the meeting, cosponsored by the American College of Obstetricians and Gynecologists.

When initially introduced in 1984, donor-egg IVF was primarily indicated for premature ovarian failure, defined as menopause occurring before the age of 40. But the primary indication for egg donation at most IVF centers is now diminished ovarian reserve in women with functioning ovaries, Dr. Wiggins said.

PHOENIX, ARIZ. — Pregnancies achieved using donor-egg in vitro fertilization can present a higher risk of pregnancy-induced hypertension than those achieved through standard IVF, according to the results of a retrospective study.

Investigators compared 50 oocyte-donation pregnancies with 50 standard IVF pregnancies at three private practice medical groups at the California Pacific Medical Center in San Francisco. The rate of pregnancy-induced hypertension (PIH) was more than three times higher in the donor-egg IVF group than in the standard IVF group (27% vs. 8%), said Donna Wiggins, M.D., the study's lead investigator and a San Francisco ob.gyn.

PIH was defined as a systolic blood pressure (BP) of at least 140 mm Hg or a diastolic BP of at least 90 mm Hg occurring after 20 weeks' gestation in a woman with previously normal BP.

In looking separately at nulliparous patients, the researchers found greater PIH rates in the donor-egg IVF group (37% vs. 8%), she said at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

Among women who had twins, 58% of those in the donor-egg IVF group and 17% of the standard IVF group developed PIH.

The women were between the ages of 30 and 50 years, and the average maternal age in the donor-egg IVF group was 42, compared with 38 in the standard IVF group. But Dr. Wiggins explained that when age stratifications were applied, there was not an increasing incidence with advancing age. And when the multiple logistic regression was applied, age fell out as an indicator of significance with regard to PIH.

Aside from the PIH rates, the two groups showed similar results in most other categories. The cesarean-section rate was 43% in the donor-egg group and 45% in the standard IVF group.

First-trimester bleeding occurred in 12% of the donor-egg group and 14% in standard IVF. And the most common postpartum complications of “lactation difficulties” and postpartum depression occurred in both groups at about the same rate of 10%.

Birthweight was an average of 3,044 g in the donor-egg group and 3,017 g in standard IVF group, and premature labor occurred in the donor-egg group at a rate of 16%, compared with 10% in the standard IVF group.

“In looking at donor-egg and [standard] IVF pregnancies, there aren't that many differences, aside from the significant difference in hypertensive disorders,” said Dr. Wiggins. “All things considered, however, the women for the most part had good outcomes.”

The reasons for the higher PIH rates in donor-egg IVF may have to do with the fact that the donor egg is foreign, Dr. Wiggins speculated. “Unlike any other pregnancy, a donor-egg pregnancy is 100% allogeneic, and this may affect the adequacy of trophoblast invasion and hence hypertensive disorders,” she said at the meeting, cosponsored by the American College of Obstetricians and Gynecologists.

When initially introduced in 1984, donor-egg IVF was primarily indicated for premature ovarian failure, defined as menopause occurring before the age of 40. But the primary indication for egg donation at most IVF centers is now diminished ovarian reserve in women with functioning ovaries, Dr. Wiggins said.

PHOENIX, ARIZ. — About one-quarter of a diverse group of pregnant women would not consider a pregnancy termination for a fetus with Down syndrome, according to a study presented at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

The prospective study of 1,038 pregnant women who were participating in research at the University of California, San Francisco, department of obstetrics, gynecology, and reproductive sciences showed that 24% said they would not consider a termination if testing showed the fetus had Down syndrome.

Among the 76% of women who said they would consider an abortion under such circumstances, half said they would do so only in the first trimester, 36% said they would do so only in the first or second trimester, and 14% said they would at any point in the pregnancy, said lead author Lee A. Learman, M.D., of the UCSF department.

The women were interviewed before 20 weeks' gestation and were of diverse socioeconomic backgrounds.

When asked about their attitudes regarding abortion in general, 23% said that they thought abortion should be available only in cases of rape or incest, and 8% said abortion should not be available under any circumstances.

Seventy-two percent of the women answered yes to the question of whether they would ever consider having an abortion, and 52% reported that they had had an abortion in the past.

With adjustment for various factors, women were more likely to consider an abortion if they were older, had a previous abortion, or expressed distrust in the health care system. Conversely, they were less likely to consider an abortion if they had at least two prior births, were married, were fatalistic about the outcome of their pregnancy, or were not white.

“The overarching goal of the project is to help understand the tradeoffs involved in screening and testing strategies and to help patients make decisions that are consistent with their personal values and feelings,” Dr. Learman said.

In a commentary on the study, Anita Nelson, M.D., medical director of Women's Health Care Programs at Harbor-UCLA Medical Center in Torrance, Calif., brought up the possibility that patients' actions may not always be consistent with their declared beliefs. Dr. Learman agreed, saying his lab is working on research to track discrepancies between actions and beliefs.

Dr. Nelson added that efforts to better prepare women for the many possible outcomes of a pregnancy should also extend to the preconception period to prevent unrealistic expectations.

“When women expect perfect outcomes, we can find ourselves in a bit of a legal jam, and it's therefore important to lay on the table all the risks of pregnancy while all options are still open—including the option to not become pregnant,” she said during the meeting.

PHOENIX, ARIZ. — About one-quarter of a diverse group of pregnant women would not consider a pregnancy termination for a fetus with Down syndrome, according to a study presented at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

The prospective study of 1,038 pregnant women who were participating in research at the University of California, San Francisco, department of obstetrics, gynecology, and reproductive sciences showed that 24% said they would not consider a termination if testing showed the fetus had Down syndrome.

Among the 76% of women who said they would consider an abortion under such circumstances, half said they would do so only in the first trimester, 36% said they would do so only in the first or second trimester, and 14% said they would at any point in the pregnancy, said lead author Lee A. Learman, M.D., of the UCSF department.

The women were interviewed before 20 weeks' gestation and were of diverse socioeconomic backgrounds.

When asked about their attitudes regarding abortion in general, 23% said that they thought abortion should be available only in cases of rape or incest, and 8% said abortion should not be available under any circumstances.

Seventy-two percent of the women answered yes to the question of whether they would ever consider having an abortion, and 52% reported that they had had an abortion in the past.

With adjustment for various factors, women were more likely to consider an abortion if they were older, had a previous abortion, or expressed distrust in the health care system. Conversely, they were less likely to consider an abortion if they had at least two prior births, were married, were fatalistic about the outcome of their pregnancy, or were not white.

“The overarching goal of the project is to help understand the tradeoffs involved in screening and testing strategies and to help patients make decisions that are consistent with their personal values and feelings,” Dr. Learman said.

In a commentary on the study, Anita Nelson, M.D., medical director of Women's Health Care Programs at Harbor-UCLA Medical Center in Torrance, Calif., brought up the possibility that patients' actions may not always be consistent with their declared beliefs. Dr. Learman agreed, saying his lab is working on research to track discrepancies between actions and beliefs.

Dr. Nelson added that efforts to better prepare women for the many possible outcomes of a pregnancy should also extend to the preconception period to prevent unrealistic expectations.

“When women expect perfect outcomes, we can find ourselves in a bit of a legal jam, and it's therefore important to lay on the table all the risks of pregnancy while all options are still open—including the option to not become pregnant,” she said during the meeting.

PHOENIX, ARIZ. — About one-quarter of a diverse group of pregnant women would not consider a pregnancy termination for a fetus with Down syndrome, according to a study presented at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

The prospective study of 1,038 pregnant women who were participating in research at the University of California, San Francisco, department of obstetrics, gynecology, and reproductive sciences showed that 24% said they would not consider a termination if testing showed the fetus had Down syndrome.

Among the 76% of women who said they would consider an abortion under such circumstances, half said they would do so only in the first trimester, 36% said they would do so only in the first or second trimester, and 14% said they would at any point in the pregnancy, said lead author Lee A. Learman, M.D., of the UCSF department.

The women were interviewed before 20 weeks' gestation and were of diverse socioeconomic backgrounds.

When asked about their attitudes regarding abortion in general, 23% said that they thought abortion should be available only in cases of rape or incest, and 8% said abortion should not be available under any circumstances.

Seventy-two percent of the women answered yes to the question of whether they would ever consider having an abortion, and 52% reported that they had had an abortion in the past.

With adjustment for various factors, women were more likely to consider an abortion if they were older, had a previous abortion, or expressed distrust in the health care system. Conversely, they were less likely to consider an abortion if they had at least two prior births, were married, were fatalistic about the outcome of their pregnancy, or were not white.

“The overarching goal of the project is to help understand the tradeoffs involved in screening and testing strategies and to help patients make decisions that are consistent with their personal values and feelings,” Dr. Learman said.

In a commentary on the study, Anita Nelson, M.D., medical director of Women's Health Care Programs at Harbor-UCLA Medical Center in Torrance, Calif., brought up the possibility that patients' actions may not always be consistent with their declared beliefs. Dr. Learman agreed, saying his lab is working on research to track discrepancies between actions and beliefs.

Dr. Nelson added that efforts to better prepare women for the many possible outcomes of a pregnancy should also extend to the preconception period to prevent unrealistic expectations.

“When women expect perfect outcomes, we can find ourselves in a bit of a legal jam, and it's therefore important to lay on the table all the risks of pregnancy while all options are still open—including the option to not become pregnant,” she said during the meeting.

SCOTTSDALE, ARIZ. — Fluctuating hormones are believed to be the key culprit behind menstrual migraines, so low-dose monophasic oral contraceptives are generally the best alternative to help such patients, Christine Lay, M.D., said at a symposium sponsored by the American Headache Society.

Physicians often turn to biphasic contraception instead of monophasic pills in the belief that varying the hormone dosage will help alleviate menstrual migraines, but the dosage schedule can in fact make the problem worse, said Dr. Lay, a neurologist with the Headache Institute at Roosevelt Hospital, New York.

Dr. Lay gave the example of Mircette, which contains 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradiol, followed by 2 days of placebo pills and 5 days of 0.01-mg ethinyl estradiol. She noted that numerous physicians prescribe Mircette thinking it might help patient's menstrually related migraines.

Instead, the method introduces another level of fluctuation of estrogen, and it is that fluctuation that is believed to trigger the migraines in the first place, said Dr. Lay. “It's not whether the estrogen is present or absent, but [it's] the change in estrogen and I find many patients don't do well on Mircette because of fluctuations in estrogen.”

Even worse for menstrual migraines are triphasic pills, which cause greater fluctuation in hormone levels and often are high-dose pills, Dr. Lay said.

“The triphasic pills are the worst for migraine patients,” she said. “Invariably, you will have a patient track her calendar and over a month's period of time she will report that within a day or two of switching to a new dose of pill, the woman will experience a migraine attack.”

Migraine patients generally fare much better when using monophasic low-dose (20-mcg) birth control pills, which offer a more uniform hormone level, Dr. Lay said. She added that the estrogen patch is another effective way of providing a more steady level of estrogen.

Newer noncycling methods such as Seasonale (ethinyl estradiol and levonorgestrel) are also good alternatives for migraineurs, she said. “With a 91-day regimen, including 84 days of real pills and then the placebo pills, women skip perhaps three out of every four menstrual migraine attacks, because they're not having a menstrual cycle,” Dr. Lay said in an interview.

Estrogen use in patients who suffered from migraines was frowned upon for many years, but the International Headache Society Task Force on Combined Oral Contraceptives and HRT determined more recently that it was safe for migraineurs, provided that there are no other risk factors for coronary heart disease or vascular disease.

In addition, the migraine should be without aura and patients should be given the lowest effective hormone dose.

In the ebb and flow of hormone levels, it is the withdrawal of estrogen, specifically, that experts believe contributes to menstrual migraines. The withdrawal is believed not only to affect trigeminal pain pathways and have vasculature effects, but it may modulate neurotransmitters and magnesium, Dr. Lay said at the meeting.

The release of prostaglandin also plays a role in migraines, sensitizing peripheral nociceptors to pain and mediating hyperalgesia, and prostaglandin is known to increase during migraine attacks.

A key approach to treatment is having patients maintain a diary in which they track their menses and headache days, Dr. Lay said. The journal can help guide treatment options and determine the role of oral contraceptive use.

Since menstrual migraines can occur in young, otherwise healthy women, Dr. Lay strongly recommended using caution in approaching contraceptive issues.

“This is a critical time to discuss with patients pregnancy planning and medication contraindications in pregnancy because, invariably, some of these patients could wind up getting pregnant” unintentionally.

“Physicians may have the patient go off the pill in order to observe the migraine pattern over time. However, the migraine pattern may not improve for at least 3-6 months. In such cases, it's essential to talk about pregnancy issues if the patient is on the pill for contraceptive purposes,” she said.

SCOTTSDALE, ARIZ. — Fluctuating hormones are believed to be the key culprit behind menstrual migraines, so low-dose monophasic oral contraceptives are generally the best alternative to help such patients, Christine Lay, M.D., said at a symposium sponsored by the American Headache Society.

Physicians often turn to biphasic contraception instead of monophasic pills in the belief that varying the hormone dosage will help alleviate menstrual migraines, but the dosage schedule can in fact make the problem worse, said Dr. Lay, a neurologist with the Headache Institute at Roosevelt Hospital, New York.

Dr. Lay gave the example of Mircette, which contains 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradiol, followed by 2 days of placebo pills and 5 days of 0.01-mg ethinyl estradiol. She noted that numerous physicians prescribe Mircette thinking it might help patient's menstrually related migraines.

Instead, the method introduces another level of fluctuation of estrogen, and it is that fluctuation that is believed to trigger the migraines in the first place, said Dr. Lay. “It's not whether the estrogen is present or absent, but [it's] the change in estrogen and I find many patients don't do well on Mircette because of fluctuations in estrogen.”

Even worse for menstrual migraines are triphasic pills, which cause greater fluctuation in hormone levels and often are high-dose pills, Dr. Lay said.

“The triphasic pills are the worst for migraine patients,” she said. “Invariably, you will have a patient track her calendar and over a month's period of time she will report that within a day or two of switching to a new dose of pill, the woman will experience a migraine attack.”

Migraine patients generally fare much better when using monophasic low-dose (20-mcg) birth control pills, which offer a more uniform hormone level, Dr. Lay said. She added that the estrogen patch is another effective way of providing a more steady level of estrogen.

Newer noncycling methods such as Seasonale (ethinyl estradiol and levonorgestrel) are also good alternatives for migraineurs, she said. “With a 91-day regimen, including 84 days of real pills and then the placebo pills, women skip perhaps three out of every four menstrual migraine attacks, because they're not having a menstrual cycle,” Dr. Lay said in an interview.

Estrogen use in patients who suffered from migraines was frowned upon for many years, but the International Headache Society Task Force on Combined Oral Contraceptives and HRT determined more recently that it was safe for migraineurs, provided that there are no other risk factors for coronary heart disease or vascular disease.

In addition, the migraine should be without aura and patients should be given the lowest effective hormone dose.

In the ebb and flow of hormone levels, it is the withdrawal of estrogen, specifically, that experts believe contributes to menstrual migraines. The withdrawal is believed not only to affect trigeminal pain pathways and have vasculature effects, but it may modulate neurotransmitters and magnesium, Dr. Lay said at the meeting.

The release of prostaglandin also plays a role in migraines, sensitizing peripheral nociceptors to pain and mediating hyperalgesia, and prostaglandin is known to increase during migraine attacks.

A key approach to treatment is having patients maintain a diary in which they track their menses and headache days, Dr. Lay said. The journal can help guide treatment options and determine the role of oral contraceptive use.

Since menstrual migraines can occur in young, otherwise healthy women, Dr. Lay strongly recommended using caution in approaching contraceptive issues.

“This is a critical time to discuss with patients pregnancy planning and medication contraindications in pregnancy because, invariably, some of these patients could wind up getting pregnant” unintentionally.

“Physicians may have the patient go off the pill in order to observe the migraine pattern over time. However, the migraine pattern may not improve for at least 3-6 months. In such cases, it's essential to talk about pregnancy issues if the patient is on the pill for contraceptive purposes,” she said.

SCOTTSDALE, ARIZ. — Fluctuating hormones are believed to be the key culprit behind menstrual migraines, so low-dose monophasic oral contraceptives are generally the best alternative to help such patients, Christine Lay, M.D., said at a symposium sponsored by the American Headache Society.

Physicians often turn to biphasic contraception instead of monophasic pills in the belief that varying the hormone dosage will help alleviate menstrual migraines, but the dosage schedule can in fact make the problem worse, said Dr. Lay, a neurologist with the Headache Institute at Roosevelt Hospital, New York.

Dr. Lay gave the example of Mircette, which contains 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradiol, followed by 2 days of placebo pills and 5 days of 0.01-mg ethinyl estradiol. She noted that numerous physicians prescribe Mircette thinking it might help patient's menstrually related migraines.

Instead, the method introduces another level of fluctuation of estrogen, and it is that fluctuation that is believed to trigger the migraines in the first place, said Dr. Lay. “It's not whether the estrogen is present or absent, but [it's] the change in estrogen and I find many patients don't do well on Mircette because of fluctuations in estrogen.”

Even worse for menstrual migraines are triphasic pills, which cause greater fluctuation in hormone levels and often are high-dose pills, Dr. Lay said.

“The triphasic pills are the worst for migraine patients,” she said. “Invariably, you will have a patient track her calendar and over a month's period of time she will report that within a day or two of switching to a new dose of pill, the woman will experience a migraine attack.”

Migraine patients generally fare much better when using monophasic low-dose (20-mcg) birth control pills, which offer a more uniform hormone level, Dr. Lay said. She added that the estrogen patch is another effective way of providing a more steady level of estrogen.

Newer noncycling methods such as Seasonale (ethinyl estradiol and levonorgestrel) are also good alternatives for migraineurs, she said. “With a 91-day regimen, including 84 days of real pills and then the placebo pills, women skip perhaps three out of every four menstrual migraine attacks, because they're not having a menstrual cycle,” Dr. Lay said in an interview.

Estrogen use in patients who suffered from migraines was frowned upon for many years, but the International Headache Society Task Force on Combined Oral Contraceptives and HRT determined more recently that it was safe for migraineurs, provided that there are no other risk factors for coronary heart disease or vascular disease.

In addition, the migraine should be without aura and patients should be given the lowest effective hormone dose.

In the ebb and flow of hormone levels, it is the withdrawal of estrogen, specifically, that experts believe contributes to menstrual migraines. The withdrawal is believed not only to affect trigeminal pain pathways and have vasculature effects, but it may modulate neurotransmitters and magnesium, Dr. Lay said at the meeting.

The release of prostaglandin also plays a role in migraines, sensitizing peripheral nociceptors to pain and mediating hyperalgesia, and prostaglandin is known to increase during migraine attacks.

A key approach to treatment is having patients maintain a diary in which they track their menses and headache days, Dr. Lay said. The journal can help guide treatment options and determine the role of oral contraceptive use.

Since menstrual migraines can occur in young, otherwise healthy women, Dr. Lay strongly recommended using caution in approaching contraceptive issues.

“This is a critical time to discuss with patients pregnancy planning and medication contraindications in pregnancy because, invariably, some of these patients could wind up getting pregnant” unintentionally.

“Physicians may have the patient go off the pill in order to observe the migraine pattern over time. However, the migraine pattern may not improve for at least 3-6 months. In such cases, it's essential to talk about pregnancy issues if the patient is on the pill for contraceptive purposes,” she said.

SCOTTSDALE, ARIZ. – Fluctuating hormones are believed to be the key culprit behind menstrual migraines, so low-dose monophasic oral contraceptives are generally the best alternative to help such patients, Christine Lay, M.D., said at a symposium sponsored by the American Headache Society.

Physicians often turn to biphasic contraception instead of monophasic pills in the belief that varying the hormone dosage will help alleviate menstrual migraines, but the dosage schedule can in fact make the problem worse, said Dr. Lay, a neurologist with the Headache Institute at Roosevelt Hospital, New York.

Dr. Lay gave the example of Mircette, which contains 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradiol, followed by 2 days of placebo pills and 5 days of 0.01-mg ethinyl estradiol.

“I have numerous ob.gyns. who put patients on Mircette because they think it might help menstrually-related migraines,” she said.

Instead, the method introduces another level of fluctuation of estrogen, and it is that fluctuation that is believed to trigger the migraines in the first place, said Dr. Lay. “It's not whether the estrogen is present or absent, but [it's] the change in estrogen and I find many patients don't do well on Mircette because of fluctuations in estrogen.”

Even worse for menstrual migraines are triphasic pills, which cause greater fluctuation in hormone levels and often are high-dose pills, Dr. Lay said.

“The triphasic pills are the worst for migraine patients,” she said. “Invariably, you will have a patient track her calendar and over a month's period of time she will report that within a day or two of switching to a new dose of pill, the woman will experience a migraine attack.”

Migraine patients generally fare much better when using monophasic low-dose (20-mcg) birth control pills, which offer a more uniform hormone level, Dr. Lay said. She added that the estrogen patch is another effective way of providing a more steady level of estrogen.

Newer noncycling methods such as Seasonale (ethinyl estradiol and levonorgestrel) are also good alternatives for migraineurs, she said. “With a 91-day regimen, including 84 days of real pills and then the placebo pills, women skip perhaps three out of every four menstrual migraine attacks, because they're not having a menstrual cycle,” Dr. Lay said in an interview.

Estrogen use in patients who suffered from migraines was frowned upon for many years, but the International Headache Society Task Force on Combined Oral Contraceptives and HRT determined more recently that it was safe for migraineurs, provided that there are no other risk factors for coronary heart disease or vascular disease.

In addition, the migraine should be without aura and patients should be given the lowest effective hormone dose.

In the ebb and flow of hormone levels, it is the withdrawal of estrogen, specifically, that experts believe contributes to menstrual migraines. The withdrawal is believed not only to affect trigeminal pain pathways and have vasculature effects, but it may modulate neurotransmitters and magnesium, Dr. Lay said.

The release of prostaglandin also plays a role in migraines, sensitizing peripheral nociceptors to pain and mediating hyperalgesia, and prostaglandin is known to increase during migraine attacks.

A key approach to treatment is having patients maintain a diary in which they track their menses and headache days, Dr. Lay said. The journal can help guide treatment options and determine the role of oral contraceptive use.

“This is a critical time to discuss with patients pregnancy planning and medication contraindications in pregnancy because, invariably, some of these patients could wind up getting pregnant” unintentionally.

“We recommend taking a patient off the pill when efforts to prevent migraines are unsuccessful,” Dr. Lay added. “Physicians may have the patient go off the pill in order to observe the migraine pattern over time. However, the migraine pattern may not improve for at least 3–6 months. In such cases, it's essential to talk about pregnancy issues if the patient is on the pill for contraceptive purposes,” she said.

Short-term prophylaxis approaches recommended range from NSAIDS to triptans, and for a more long-term prevention, Dr. Lay suggested considering standard preventive medications, including tricyclic antidepressants, antiepileptic drugs, β-blockers, and selective serotonin reuptake inhibitors.

SCOTTSDALE, ARIZ. – Fluctuating hormones are believed to be the key culprit behind menstrual migraines, so low-dose monophasic oral contraceptives are generally the best alternative to help such patients, Christine Lay, M.D., said at a symposium sponsored by the American Headache Society.

Physicians often turn to biphasic contraception instead of monophasic pills in the belief that varying the hormone dosage will help alleviate menstrual migraines, but the dosage schedule can in fact make the problem worse, said Dr. Lay, a neurologist with the Headache Institute at Roosevelt Hospital, New York.

Dr. Lay gave the example of Mircette, which contains 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradiol, followed by 2 days of placebo pills and 5 days of 0.01-mg ethinyl estradiol.

“I have numerous ob.gyns. who put patients on Mircette because they think it might help menstrually-related migraines,” she said.

Instead, the method introduces another level of fluctuation of estrogen, and it is that fluctuation that is believed to trigger the migraines in the first place, said Dr. Lay. “It's not whether the estrogen is present or absent, but [it's] the change in estrogen and I find many patients don't do well on Mircette because of fluctuations in estrogen.”

Even worse for menstrual migraines are triphasic pills, which cause greater fluctuation in hormone levels and often are high-dose pills, Dr. Lay said.

“The triphasic pills are the worst for migraine patients,” she said. “Invariably, you will have a patient track her calendar and over a month's period of time she will report that within a day or two of switching to a new dose of pill, the woman will experience a migraine attack.”

Migraine patients generally fare much better when using monophasic low-dose (20-mcg) birth control pills, which offer a more uniform hormone level, Dr. Lay said. She added that the estrogen patch is another effective way of providing a more steady level of estrogen.

Newer noncycling methods such as Seasonale (ethinyl estradiol and levonorgestrel) are also good alternatives for migraineurs, she said. “With a 91-day regimen, including 84 days of real pills and then the placebo pills, women skip perhaps three out of every four menstrual migraine attacks, because they're not having a menstrual cycle,” Dr. Lay said in an interview.

Estrogen use in patients who suffered from migraines was frowned upon for many years, but the International Headache Society Task Force on Combined Oral Contraceptives and HRT determined more recently that it was safe for migraineurs, provided that there are no other risk factors for coronary heart disease or vascular disease.

In addition, the migraine should be without aura and patients should be given the lowest effective hormone dose.

In the ebb and flow of hormone levels, it is the withdrawal of estrogen, specifically, that experts believe contributes to menstrual migraines. The withdrawal is believed not only to affect trigeminal pain pathways and have vasculature effects, but it may modulate neurotransmitters and magnesium, Dr. Lay said.

The release of prostaglandin also plays a role in migraines, sensitizing peripheral nociceptors to pain and mediating hyperalgesia, and prostaglandin is known to increase during migraine attacks.

A key approach to treatment is having patients maintain a diary in which they track their menses and headache days, Dr. Lay said. The journal can help guide treatment options and determine the role of oral contraceptive use.

“This is a critical time to discuss with patients pregnancy planning and medication contraindications in pregnancy because, invariably, some of these patients could wind up getting pregnant” unintentionally.

“We recommend taking a patient off the pill when efforts to prevent migraines are unsuccessful,” Dr. Lay added. “Physicians may have the patient go off the pill in order to observe the migraine pattern over time. However, the migraine pattern may not improve for at least 3–6 months. In such cases, it's essential to talk about pregnancy issues if the patient is on the pill for contraceptive purposes,” she said.

Short-term prophylaxis approaches recommended range from NSAIDS to triptans, and for a more long-term prevention, Dr. Lay suggested considering standard preventive medications, including tricyclic antidepressants, antiepileptic drugs, β-blockers, and selective serotonin reuptake inhibitors.

SCOTTSDALE, ARIZ. – Fluctuating hormones are believed to be the key culprit behind menstrual migraines, so low-dose monophasic oral contraceptives are generally the best alternative to help such patients, Christine Lay, M.D., said at a symposium sponsored by the American Headache Society.

Physicians often turn to biphasic contraception instead of monophasic pills in the belief that varying the hormone dosage will help alleviate menstrual migraines, but the dosage schedule can in fact make the problem worse, said Dr. Lay, a neurologist with the Headache Institute at Roosevelt Hospital, New York.

Dr. Lay gave the example of Mircette, which contains 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradiol, followed by 2 days of placebo pills and 5 days of 0.01-mg ethinyl estradiol.

“I have numerous ob.gyns. who put patients on Mircette because they think it might help menstrually-related migraines,” she said.

Instead, the method introduces another level of fluctuation of estrogen, and it is that fluctuation that is believed to trigger the migraines in the first place, said Dr. Lay. “It's not whether the estrogen is present or absent, but [it's] the change in estrogen and I find many patients don't do well on Mircette because of fluctuations in estrogen.”

Even worse for menstrual migraines are triphasic pills, which cause greater fluctuation in hormone levels and often are high-dose pills, Dr. Lay said.

“The triphasic pills are the worst for migraine patients,” she said. “Invariably, you will have a patient track her calendar and over a month's period of time she will report that within a day or two of switching to a new dose of pill, the woman will experience a migraine attack.”

Migraine patients generally fare much better when using monophasic low-dose (20-mcg) birth control pills, which offer a more uniform hormone level, Dr. Lay said. She added that the estrogen patch is another effective way of providing a more steady level of estrogen.

Newer noncycling methods such as Seasonale (ethinyl estradiol and levonorgestrel) are also good alternatives for migraineurs, she said. “With a 91-day regimen, including 84 days of real pills and then the placebo pills, women skip perhaps three out of every four menstrual migraine attacks, because they're not having a menstrual cycle,” Dr. Lay said in an interview.

Estrogen use in patients who suffered from migraines was frowned upon for many years, but the International Headache Society Task Force on Combined Oral Contraceptives and HRT determined more recently that it was safe for migraineurs, provided that there are no other risk factors for coronary heart disease or vascular disease.

In addition, the migraine should be without aura and patients should be given the lowest effective hormone dose.

In the ebb and flow of hormone levels, it is the withdrawal of estrogen, specifically, that experts believe contributes to menstrual migraines. The withdrawal is believed not only to affect trigeminal pain pathways and have vasculature effects, but it may modulate neurotransmitters and magnesium, Dr. Lay said.

The release of prostaglandin also plays a role in migraines, sensitizing peripheral nociceptors to pain and mediating hyperalgesia, and prostaglandin is known to increase during migraine attacks.

A key approach to treatment is having patients maintain a diary in which they track their menses and headache days, Dr. Lay said. The journal can help guide treatment options and determine the role of oral contraceptive use.

“This is a critical time to discuss with patients pregnancy planning and medication contraindications in pregnancy because, invariably, some of these patients could wind up getting pregnant” unintentionally.

“We recommend taking a patient off the pill when efforts to prevent migraines are unsuccessful,” Dr. Lay added. “Physicians may have the patient go off the pill in order to observe the migraine pattern over time. However, the migraine pattern may not improve for at least 3–6 months. In such cases, it's essential to talk about pregnancy issues if the patient is on the pill for contraceptive purposes,” she said.

Short-term prophylaxis approaches recommended range from NSAIDS to triptans, and for a more long-term prevention, Dr. Lay suggested considering standard preventive medications, including tricyclic antidepressants, antiepileptic drugs, β-blockers, and selective serotonin reuptake inhibitors.

SCOTTSDALE, ARIZ. — Because fluctuating hormones are believed to be the key culprit behind menstrual migraines, low-dose monophasic oral contraceptives are generally the best alternative to help such patients, Christine Lay, M.D., said at a symposium sponsored by the American Headache Society.

Ob.gyns. often turn to biphasic contraception instead of monophasic pills in the belief that varying the hormone dosage will help alleviate menstrual migraines, but the dosage schedule can make the problem worse, said Dr. Lay, a neurologist with the Headache Institute at Roosevelt Hospital, New York.

Dr. Lay gave the example of Mircette, which contains 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradiol, followed by 2 days of placebo pills and 5 days of 0.01-mg ethinyl estradiol. “I have numerous ob.gyns. who put patients on Mircette because they think it might help menstrually-related migraines,” she said.

Instead, the method introduces another level of fluctuation of estrogen, and it is that fluctuation that is believed to trigger the migraines in the first place, said Dr. Lay

Even worse for menstrual migraines are triphasic pills, which cause greater fluctuation in hormone levels and often are high-dose pills, said Dr. Lay.

“The triphasic pills are the worst for migraine patients,” she said. “Invariably, you will have a patient track her calendar and over a month's period of time she will report that within a day or two of switching to a new dose of pill, the woman will experience a migraine attack.”

Migraine patients generally fare much better when using monophasic low-dose (20-mcg) birth control pills, which offer a more uniform hormone level, Dr. Lay said, adding that the estrogen patch is another effective way of providing a more steady level of estrogen. Newer noncycling methods such as Seasonale (ethinyl estradiol and levonorgestrel) are also good alternatives for migraineurs, she said in an interview

Estrogen use in patients who suffered from migraines was frowned upon for many years, but the International Headache Society Task Force on Combined Oral Contraceptives and HRT determined more recently that it was safe for migraineurs, provided that there are no other risk factors for coronary heart disease or vascular disease.

In addition, the migraine should be without aura and patients should be given the lowest effective hormone dose.

In the ebb and flow of hormone levels, it is the withdrawal of estrogen, specifically, that experts believe contributes to menstrual migraines. The withdrawal is believed not only to affect trigeminal pain pathways and have vasculature effects, but it may modulate neurotransmitters and magnesium, Dr. Lay said at the meeting.

The release of prostaglandin also plays a role in migraines, sensitizing peripheral nociceptors to pain and mediating hyperalgesia, and prostaglandin is known to increase during migraine attacks.

A key approach to treatment is having patients maintain a diary in which they track their menses and headache days, Dr. Lay said. The journal can help guide treatment options and determine the role of oral contraceptive use.

Since menstrual migraines can occur in young, otherwise healthy women, Dr. Lay strongly recommended using caution in approaching contraceptive issues.

“This is a critical time to discuss with patients pregnancy planning and medication contraindications in pregnancy because, invariably, some of these patients could wind up getting pregnant” unintentionally. “We recommend taking a patient off the pill when efforts to prevent migraines are unsuccessful,” Dr. Lay added.

“Physicians may have the patient go off the pill in order to observe the migraine pattern over time. However, the migraine pattern may not improve for at least 3–6 months. In such cases, it's essential to talk about pregnancy issues if the patient is on the pill for contraceptive purposes.”

Short-term prophylaxis approaches recommended to prevent the onset of menstrual migraines range from NSAIDs to triptans, and for a more long-term prevention, Dr. Lay suggested considering standard preventive medications, including tricyclic antidepressant, antiepileptic drugs, β-blockers, and selective serotonin reuptake inhibitors.

SCOTTSDALE, ARIZ. — Because fluctuating hormones are believed to be the key culprit behind menstrual migraines, low-dose monophasic oral contraceptives are generally the best alternative to help such patients, Christine Lay, M.D., said at a symposium sponsored by the American Headache Society.

Ob.gyns. often turn to biphasic contraception instead of monophasic pills in the belief that varying the hormone dosage will help alleviate menstrual migraines, but the dosage schedule can make the problem worse, said Dr. Lay, a neurologist with the Headache Institute at Roosevelt Hospital, New York.

Dr. Lay gave the example of Mircette, which contains 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradiol, followed by 2 days of placebo pills and 5 days of 0.01-mg ethinyl estradiol. “I have numerous ob.gyns. who put patients on Mircette because they think it might help menstrually-related migraines,” she said.

Instead, the method introduces another level of fluctuation of estrogen, and it is that fluctuation that is believed to trigger the migraines in the first place, said Dr. Lay

Even worse for menstrual migraines are triphasic pills, which cause greater fluctuation in hormone levels and often are high-dose pills, said Dr. Lay.

“The triphasic pills are the worst for migraine patients,” she said. “Invariably, you will have a patient track her calendar and over a month's period of time she will report that within a day or two of switching to a new dose of pill, the woman will experience a migraine attack.”

Migraine patients generally fare much better when using monophasic low-dose (20-mcg) birth control pills, which offer a more uniform hormone level, Dr. Lay said, adding that the estrogen patch is another effective way of providing a more steady level of estrogen. Newer noncycling methods such as Seasonale (ethinyl estradiol and levonorgestrel) are also good alternatives for migraineurs, she said in an interview

Estrogen use in patients who suffered from migraines was frowned upon for many years, but the International Headache Society Task Force on Combined Oral Contraceptives and HRT determined more recently that it was safe for migraineurs, provided that there are no other risk factors for coronary heart disease or vascular disease.

In addition, the migraine should be without aura and patients should be given the lowest effective hormone dose.

In the ebb and flow of hormone levels, it is the withdrawal of estrogen, specifically, that experts believe contributes to menstrual migraines. The withdrawal is believed not only to affect trigeminal pain pathways and have vasculature effects, but it may modulate neurotransmitters and magnesium, Dr. Lay said at the meeting.

The release of prostaglandin also plays a role in migraines, sensitizing peripheral nociceptors to pain and mediating hyperalgesia, and prostaglandin is known to increase during migraine attacks.

A key approach to treatment is having patients maintain a diary in which they track their menses and headache days, Dr. Lay said. The journal can help guide treatment options and determine the role of oral contraceptive use.

Since menstrual migraines can occur in young, otherwise healthy women, Dr. Lay strongly recommended using caution in approaching contraceptive issues.

“This is a critical time to discuss with patients pregnancy planning and medication contraindications in pregnancy because, invariably, some of these patients could wind up getting pregnant” unintentionally. “We recommend taking a patient off the pill when efforts to prevent migraines are unsuccessful,” Dr. Lay added.

“Physicians may have the patient go off the pill in order to observe the migraine pattern over time. However, the migraine pattern may not improve for at least 3–6 months. In such cases, it's essential to talk about pregnancy issues if the patient is on the pill for contraceptive purposes.”

Short-term prophylaxis approaches recommended to prevent the onset of menstrual migraines range from NSAIDs to triptans, and for a more long-term prevention, Dr. Lay suggested considering standard preventive medications, including tricyclic antidepressant, antiepileptic drugs, β-blockers, and selective serotonin reuptake inhibitors.

SCOTTSDALE, ARIZ. — Because fluctuating hormones are believed to be the key culprit behind menstrual migraines, low-dose monophasic oral contraceptives are generally the best alternative to help such patients, Christine Lay, M.D., said at a symposium sponsored by the American Headache Society.

Ob.gyns. often turn to biphasic contraception instead of monophasic pills in the belief that varying the hormone dosage will help alleviate menstrual migraines, but the dosage schedule can make the problem worse, said Dr. Lay, a neurologist with the Headache Institute at Roosevelt Hospital, New York.

Dr. Lay gave the example of Mircette, which contains 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradiol, followed by 2 days of placebo pills and 5 days of 0.01-mg ethinyl estradiol. “I have numerous ob.gyns. who put patients on Mircette because they think it might help menstrually-related migraines,” she said.

Instead, the method introduces another level of fluctuation of estrogen, and it is that fluctuation that is believed to trigger the migraines in the first place, said Dr. Lay

Even worse for menstrual migraines are triphasic pills, which cause greater fluctuation in hormone levels and often are high-dose pills, said Dr. Lay.

“The triphasic pills are the worst for migraine patients,” she said. “Invariably, you will have a patient track her calendar and over a month's period of time she will report that within a day or two of switching to a new dose of pill, the woman will experience a migraine attack.”

Migraine patients generally fare much better when using monophasic low-dose (20-mcg) birth control pills, which offer a more uniform hormone level, Dr. Lay said, adding that the estrogen patch is another effective way of providing a more steady level of estrogen. Newer noncycling methods such as Seasonale (ethinyl estradiol and levonorgestrel) are also good alternatives for migraineurs, she said in an interview

Estrogen use in patients who suffered from migraines was frowned upon for many years, but the International Headache Society Task Force on Combined Oral Contraceptives and HRT determined more recently that it was safe for migraineurs, provided that there are no other risk factors for coronary heart disease or vascular disease.

In addition, the migraine should be without aura and patients should be given the lowest effective hormone dose.

In the ebb and flow of hormone levels, it is the withdrawal of estrogen, specifically, that experts believe contributes to menstrual migraines. The withdrawal is believed not only to affect trigeminal pain pathways and have vasculature effects, but it may modulate neurotransmitters and magnesium, Dr. Lay said at the meeting.

The release of prostaglandin also plays a role in migraines, sensitizing peripheral nociceptors to pain and mediating hyperalgesia, and prostaglandin is known to increase during migraine attacks.

A key approach to treatment is having patients maintain a diary in which they track their menses and headache days, Dr. Lay said. The journal can help guide treatment options and determine the role of oral contraceptive use.

Since menstrual migraines can occur in young, otherwise healthy women, Dr. Lay strongly recommended using caution in approaching contraceptive issues.

“This is a critical time to discuss with patients pregnancy planning and medication contraindications in pregnancy because, invariably, some of these patients could wind up getting pregnant” unintentionally. “We recommend taking a patient off the pill when efforts to prevent migraines are unsuccessful,” Dr. Lay added.

“Physicians may have the patient go off the pill in order to observe the migraine pattern over time. However, the migraine pattern may not improve for at least 3–6 months. In such cases, it's essential to talk about pregnancy issues if the patient is on the pill for contraceptive purposes.”

Short-term prophylaxis approaches recommended to prevent the onset of menstrual migraines range from NSAIDs to triptans, and for a more long-term prevention, Dr. Lay suggested considering standard preventive medications, including tricyclic antidepressant, antiepileptic drugs, β-blockers, and selective serotonin reuptake inhibitors.

PHOENIX, ARIZ. — The presence of an isolated intracardiac echogenic focus on fetal ultrasound does not increase the risk for aneuploidy in the absence of other risk factors in women younger than 35 years of age, Kathleen Bradley, M.D., reported at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

Consequently, amniocentesis may not be indicated in these patients, she said.

Dr. Bradley and her associates conducted a study that involved 10,875 patients who had an ultrasound evaluation in the second trimester at Cedars-Sinai Medical Center, Los Angeles, from 1997 to 1999.

A total of 176 cases, or 1.6%, of fetal intracardiac echogenic foci (IEF) were identified. Among them, 80% had an isolated IEF finding, and 20% had other ultrasound findings.

Abnormal karyotypes were identified in the fetuses of three IEF patients. Each of the three patients was at least 35 years old. The three fetuses all had trisomy 21, according to Dr. Bradley, a perinatologist in Tarzana, Calif.

“Our findings suggest that there is not an increased risk of aneuploidy with isolated IEF where there are no other risk factors in women” aged 35 or younger, Dr. Bradley said at the meeting, which was cosponsored by the American College of Obstetricians and Gynecologists.

Dr. Bradley noted a larger study of 12,672 patients evaluated in the second trimester. There were 479 cases of IEF and 11 cases of trisomy 21. Only one fetus with trisomy 21 had an isolated echogenic focus (J. Ultrasound Med. 2004;23:489–96).

“These trends may be helpful for current clinical management,” Dr. Bradley said. She urged a move toward individualized risk assessment to include factors such as advanced maternal age, biochemical screening, and all ultrasound markers, given a relative risk for each soft marker.

“It is important to determine a critical cutoff level to offer invasive clinical diagnosis. Should we use the current age-based risk or the procedure-related risk?” she asked. In addition, Dr. Bradley noted that of the 97 patients involved in the study and who underwent amniocentesis, there were no procedure-related losses.

In a comment on the study, Roger Rowles, M.D., a Yakima, Wash., ob.gyn., emphasized that the findings, along with the larger study, offer important insights into the use of amniocentesis for isolated intracardiac echogenic foci.

“The reasonable conclusion is that finding an IEF should prompt a detailed anatomic survey and, in the absence of other ultrasound markers and risk factors, patients should not be offered amniocentesis,” he said.

PHOENIX, ARIZ. — The presence of an isolated intracardiac echogenic focus on fetal ultrasound does not increase the risk for aneuploidy in the absence of other risk factors in women younger than 35 years of age, Kathleen Bradley, M.D., reported at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

Consequently, amniocentesis may not be indicated in these patients, she said.

Dr. Bradley and her associates conducted a study that involved 10,875 patients who had an ultrasound evaluation in the second trimester at Cedars-Sinai Medical Center, Los Angeles, from 1997 to 1999.

A total of 176 cases, or 1.6%, of fetal intracardiac echogenic foci (IEF) were identified. Among them, 80% had an isolated IEF finding, and 20% had other ultrasound findings.

Abnormal karyotypes were identified in the fetuses of three IEF patients. Each of the three patients was at least 35 years old. The three fetuses all had trisomy 21, according to Dr. Bradley, a perinatologist in Tarzana, Calif.

“Our findings suggest that there is not an increased risk of aneuploidy with isolated IEF where there are no other risk factors in women” aged 35 or younger, Dr. Bradley said at the meeting, which was cosponsored by the American College of Obstetricians and Gynecologists.

Dr. Bradley noted a larger study of 12,672 patients evaluated in the second trimester. There were 479 cases of IEF and 11 cases of trisomy 21. Only one fetus with trisomy 21 had an isolated echogenic focus (J. Ultrasound Med. 2004;23:489–96).

“These trends may be helpful for current clinical management,” Dr. Bradley said. She urged a move toward individualized risk assessment to include factors such as advanced maternal age, biochemical screening, and all ultrasound markers, given a relative risk for each soft marker.

“It is important to determine a critical cutoff level to offer invasive clinical diagnosis. Should we use the current age-based risk or the procedure-related risk?” she asked. In addition, Dr. Bradley noted that of the 97 patients involved in the study and who underwent amniocentesis, there were no procedure-related losses.

In a comment on the study, Roger Rowles, M.D., a Yakima, Wash., ob.gyn., emphasized that the findings, along with the larger study, offer important insights into the use of amniocentesis for isolated intracardiac echogenic foci.

“The reasonable conclusion is that finding an IEF should prompt a detailed anatomic survey and, in the absence of other ultrasound markers and risk factors, patients should not be offered amniocentesis,” he said.

PHOENIX, ARIZ. — The presence of an isolated intracardiac echogenic focus on fetal ultrasound does not increase the risk for aneuploidy in the absence of other risk factors in women younger than 35 years of age, Kathleen Bradley, M.D., reported at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

Consequently, amniocentesis may not be indicated in these patients, she said.

Dr. Bradley and her associates conducted a study that involved 10,875 patients who had an ultrasound evaluation in the second trimester at Cedars-Sinai Medical Center, Los Angeles, from 1997 to 1999.

A total of 176 cases, or 1.6%, of fetal intracardiac echogenic foci (IEF) were identified. Among them, 80% had an isolated IEF finding, and 20% had other ultrasound findings.

Abnormal karyotypes were identified in the fetuses of three IEF patients. Each of the three patients was at least 35 years old. The three fetuses all had trisomy 21, according to Dr. Bradley, a perinatologist in Tarzana, Calif.

“Our findings suggest that there is not an increased risk of aneuploidy with isolated IEF where there are no other risk factors in women” aged 35 or younger, Dr. Bradley said at the meeting, which was cosponsored by the American College of Obstetricians and Gynecologists.

Dr. Bradley noted a larger study of 12,672 patients evaluated in the second trimester. There were 479 cases of IEF and 11 cases of trisomy 21. Only one fetus with trisomy 21 had an isolated echogenic focus (J. Ultrasound Med. 2004;23:489–96).

“These trends may be helpful for current clinical management,” Dr. Bradley said. She urged a move toward individualized risk assessment to include factors such as advanced maternal age, biochemical screening, and all ultrasound markers, given a relative risk for each soft marker.

“It is important to determine a critical cutoff level to offer invasive clinical diagnosis. Should we use the current age-based risk or the procedure-related risk?” she asked. In addition, Dr. Bradley noted that of the 97 patients involved in the study and who underwent amniocentesis, there were no procedure-related losses.

In a comment on the study, Roger Rowles, M.D., a Yakima, Wash., ob.gyn., emphasized that the findings, along with the larger study, offer important insights into the use of amniocentesis for isolated intracardiac echogenic foci.

“The reasonable conclusion is that finding an IEF should prompt a detailed anatomic survey and, in the absence of other ultrasound markers and risk factors, patients should not be offered amniocentesis,” he said.

LAS VEGAS — Behavioral therapies can break the habits and misconceptions that cause chronic insomnia, provided that psychiatric or medical problems are not at play, Dr. Bashir Chaudhary said at a meeting on primary care sponsored by the Southern Medical Association.

Among patients with chronic insomnia (lasting longer than 6 months), the cause is psychiatric in about 35% of cases, psychophysiologic in 15%, related to use of drugs or alcohol in 12%, restless legs syndrome in 12%, and sleep apnea in 6%, said Dr. Chaudhary, emeritus professor of medicine at the Medical College of Georgia, Augusta, and director of the Georgia Sleep Center at the college.

In the absence of medical and psychiatric problems, chronic insomnia may be caused by psychophysiologic factors, in which the patients' anxiety about lack of sleep becomes a big part of the problem.

“These are people who are stressed about sleep all day long,” Dr. Chaudhary said. “They become obsessively worried about it.” Such patients often have conditioned themselves to experience insomnia in their own sleeping environment; if they sleep elsewhere—in another room or at another place—they often have no problem falling or staying asleep.

Other forms of insomnia can typically be swiftly corrected by addressing direct causes, but psychophysiologic cases can often take more effort on the part of the patient and the physician. “Most of the time I spend in cognitive therapy is with these patients,” he said, adding that behavioral techniques and lifestyle guidelines can be effective.

One behavioral therapy approach is stimulus control, which aims to decrease cues for nighttime arousals and focus on cues that help induce sleep. Some key recommendations include:

▸ Go to bed only when sleepy.

▸ Get out of bed if not asleep within 20 minutes.

▸ Wake up at the same time every day. “This is the most important,” he said.

▸ Do not take naps.

Sleep restriction therapy is another effective technique. Dr. Chaudhary advised asking patients how much sleep they get during a typical night, adding about 2 hours to that, and having them restrict themselves to that length of time in bed. Patients should be instructed to wake up at their regular time, but to go to bed at the time that would provide the allocated amount of sleep. If, after several weeks, patients report getting good quality sleep at least 85% of the night, then add increments of about 15 minutes. But if they are not getting the 85%, then further restrict the sleep time.

A metaanalysis of studies shows that nonpharmacologic therapies are highly successful in insomnia, with techniques improving sleep onset in 81% of cases, reducing sleep latency by 35 minutes, and resulting in 74% extension of sleep maintenance (Am. J. Psychiatry 1994;151:1172-80).

Ten Commandments of Good Sleep

As part of his cognitive therapy, Dr. Chaudhary offers patients his “Ten Commandments of Good Sleep”:

1. Thou shalt not stay in bed too long.

2. Thou shalt avoid daytime naps.

3. Thou shalt maintain the circadian cycle.

4. Thou shalt avoid stimulants after lunch.

5. Thou shalt not take a “toddy” before bedtime.

6. Thou shalt not go to bedhungry.

7. Thou shalt not smoke.

8. Thou shalt exercise regularly.

9. Thou shalt keep the bedroom at a comfortable temperature.

10. Thou shalt keep the noise down.

LAS VEGAS — Behavioral therapies can break the habits and misconceptions that cause chronic insomnia, provided that psychiatric or medical problems are not at play, Dr. Bashir Chaudhary said at a meeting on primary care sponsored by the Southern Medical Association.

Among patients with chronic insomnia (lasting longer than 6 months), the cause is psychiatric in about 35% of cases, psychophysiologic in 15%, related to use of drugs or alcohol in 12%, restless legs syndrome in 12%, and sleep apnea in 6%, said Dr. Chaudhary, emeritus professor of medicine at the Medical College of Georgia, Augusta, and director of the Georgia Sleep Center at the college.

In the absence of medical and psychiatric problems, chronic insomnia may be caused by psychophysiologic factors, in which the patients' anxiety about lack of sleep becomes a big part of the problem.

“These are people who are stressed about sleep all day long,” Dr. Chaudhary said. “They become obsessively worried about it.” Such patients often have conditioned themselves to experience insomnia in their own sleeping environment; if they sleep elsewhere—in another room or at another place—they often have no problem falling or staying asleep.

Other forms of insomnia can typically be swiftly corrected by addressing direct causes, but psychophysiologic cases can often take more effort on the part of the patient and the physician. “Most of the time I spend in cognitive therapy is with these patients,” he said, adding that behavioral techniques and lifestyle guidelines can be effective.

One behavioral therapy approach is stimulus control, which aims to decrease cues for nighttime arousals and focus on cues that help induce sleep. Some key recommendations include:

▸ Go to bed only when sleepy.

▸ Get out of bed if not asleep within 20 minutes.

▸ Wake up at the same time every day. “This is the most important,” he said.

▸ Do not take naps.

Sleep restriction therapy is another effective technique. Dr. Chaudhary advised asking patients how much sleep they get during a typical night, adding about 2 hours to that, and having them restrict themselves to that length of time in bed. Patients should be instructed to wake up at their regular time, but to go to bed at the time that would provide the allocated amount of sleep. If, after several weeks, patients report getting good quality sleep at least 85% of the night, then add increments of about 15 minutes. But if they are not getting the 85%, then further restrict the sleep time.

A metaanalysis of studies shows that nonpharmacologic therapies are highly successful in insomnia, with techniques improving sleep onset in 81% of cases, reducing sleep latency by 35 minutes, and resulting in 74% extension of sleep maintenance (Am. J. Psychiatry 1994;151:1172-80).

Ten Commandments of Good Sleep

As part of his cognitive therapy, Dr. Chaudhary offers patients his “Ten Commandments of Good Sleep”:

1. Thou shalt not stay in bed too long.

2. Thou shalt avoid daytime naps.

3. Thou shalt maintain the circadian cycle.

4. Thou shalt avoid stimulants after lunch.

5. Thou shalt not take a “toddy” before bedtime.

6. Thou shalt not go to bedhungry.

7. Thou shalt not smoke.

8. Thou shalt exercise regularly.

9. Thou shalt keep the bedroom at a comfortable temperature.

10. Thou shalt keep the noise down.

LAS VEGAS — Behavioral therapies can break the habits and misconceptions that cause chronic insomnia, provided that psychiatric or medical problems are not at play, Dr. Bashir Chaudhary said at a meeting on primary care sponsored by the Southern Medical Association.

Among patients with chronic insomnia (lasting longer than 6 months), the cause is psychiatric in about 35% of cases, psychophysiologic in 15%, related to use of drugs or alcohol in 12%, restless legs syndrome in 12%, and sleep apnea in 6%, said Dr. Chaudhary, emeritus professor of medicine at the Medical College of Georgia, Augusta, and director of the Georgia Sleep Center at the college.

In the absence of medical and psychiatric problems, chronic insomnia may be caused by psychophysiologic factors, in which the patients' anxiety about lack of sleep becomes a big part of the problem.

“These are people who are stressed about sleep all day long,” Dr. Chaudhary said. “They become obsessively worried about it.” Such patients often have conditioned themselves to experience insomnia in their own sleeping environment; if they sleep elsewhere—in another room or at another place—they often have no problem falling or staying asleep.

Other forms of insomnia can typically be swiftly corrected by addressing direct causes, but psychophysiologic cases can often take more effort on the part of the patient and the physician. “Most of the time I spend in cognitive therapy is with these patients,” he said, adding that behavioral techniques and lifestyle guidelines can be effective.

One behavioral therapy approach is stimulus control, which aims to decrease cues for nighttime arousals and focus on cues that help induce sleep. Some key recommendations include:

▸ Go to bed only when sleepy.

▸ Get out of bed if not asleep within 20 minutes.

▸ Wake up at the same time every day. “This is the most important,” he said.

▸ Do not take naps.

Sleep restriction therapy is another effective technique. Dr. Chaudhary advised asking patients how much sleep they get during a typical night, adding about 2 hours to that, and having them restrict themselves to that length of time in bed. Patients should be instructed to wake up at their regular time, but to go to bed at the time that would provide the allocated amount of sleep. If, after several weeks, patients report getting good quality sleep at least 85% of the night, then add increments of about 15 minutes. But if they are not getting the 85%, then further restrict the sleep time.

A metaanalysis of studies shows that nonpharmacologic therapies are highly successful in insomnia, with techniques improving sleep onset in 81% of cases, reducing sleep latency by 35 minutes, and resulting in 74% extension of sleep maintenance (Am. J. Psychiatry 1994;151:1172-80).

Ten Commandments of Good Sleep

As part of his cognitive therapy, Dr. Chaudhary offers patients his “Ten Commandments of Good Sleep”:

1. Thou shalt not stay in bed too long.

2. Thou shalt avoid daytime naps.

3. Thou shalt maintain the circadian cycle.

4. Thou shalt avoid stimulants after lunch.

5. Thou shalt not take a “toddy” before bedtime.

6. Thou shalt not go to bedhungry.

7. Thou shalt not smoke.

8. Thou shalt exercise regularly.

9. Thou shalt keep the bedroom at a comfortable temperature.

10. Thou shalt keep the noise down.