Ob.Gyn. News

“Papa! Where donut?” asks my 2½ year-old sitting with her legs dangling and hands folded in a bustling Starbucks. We’ve been waiting for 8 minutes and we’ve reached her limit of tolerance. She’s unimpressed by the queued customers who compliment her curly blonde hair, many of whom have come and gone since we’ve been waiting. I agree – how long does it take to pour a kiddie milk and grab a donut? We can both see it in the case right there!

No one likes to wait. Truly, one of the great benefits of the modern world is that wait times are now incredibly short. Many Starbucks customers, unlike my daughter, ordered their drink ahead and waited exactly 0 minutes to get their drink. What about Amazon? I ordered a bird feeder this morning and it’s already hanging in the yard. It’s still daylight. Feel like Himalayan Momo Dumplings tonight? Your food could arrive in 37 minutes. The modern wait standard has been set impossibly high for us.

Yes, medicine is no doubt at the top of the list of “Worst Wait Times.” We make patients wait for appointments (sometimes months), wait to be seen, wait for biopsy results, wait for follow-up surgery, wait for those second results, even wait for PET scans and treatment plans for some. We created a whole room just for waiting. Airlines call theirs “The Platinum Executive Lounge.” Ours is “The waiting room.”

Excess waiting is a significant reason why health care gets beat up in reviews. We’re unable to keep up with the new expectations. Waiting is also a significant cause of distress. Many patients report the most difficult part of their cancer diagnosis was the waiting for results, not the treatment. It’s because when under stress, we are hardwired to take action. Binding patients into inaction while they wait is very uncomfortable.

Fortunately, the psychology of waiting is well understood and there are best practices that can help. First, anxiety makes waiting much worse. Conveying confidence and reassuring patients they are in the right place and that everything will be OK makes the wait time feel shorter for them. Uncertainty also compounds their apprehension. If you believe the diagnosis will be melanoma, tell them that at the time of the biopsy and tell them what you expect next. This is better than saying, “Well, that could be cancer. We’ll see.”

Knowing a wait time is also much better than not. Have your staff advise patients on how much longer they can expect before seeing you (telling them they’re next isn’t as effective). Advise that test results should be back by the end of next week. Of course, under promise and over deliver. When the results are back on Tuesday, you’ve got a pleased patient.

Explaining that you had to add in an urgent patient helps. Even if it’s not your fault, it’s still better to apologize. For example, the 78 highway, the left anterior descending artery to our office, has been closed because of a sinkhole this month (not kidding). I’ve been apologizing to a lot of patients saying that all our patients are arriving late, which is putting us behind. As they can envision the linear parking lot that used to be a highway, it helps.

Lastly, as any child can tell you, waiting has to not only be, but to also appear, fair. The only thing worse than waiting for an appointment, or donut, is seeing someone who came in after you get their donut before you do. If you’re pulling both Mohs and cosmetics patients from the same waiting area, then your surgery patients will see a lot of patients come and go while they are sitting. Demarcating one sitting area for Mohs and one for clinics might help. So does ordering ahead. I’d show my daughter how to use the app so we don’t have to wait so long next week, but she’s 2 and I’m quite sure she already knows.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

“Papa! Where donut?” asks my 2½ year-old sitting with her legs dangling and hands folded in a bustling Starbucks. We’ve been waiting for 8 minutes and we’ve reached her limit of tolerance. She’s unimpressed by the queued customers who compliment her curly blonde hair, many of whom have come and gone since we’ve been waiting. I agree – how long does it take to pour a kiddie milk and grab a donut? We can both see it in the case right there!

No one likes to wait. Truly, one of the great benefits of the modern world is that wait times are now incredibly short. Many Starbucks customers, unlike my daughter, ordered their drink ahead and waited exactly 0 minutes to get their drink. What about Amazon? I ordered a bird feeder this morning and it’s already hanging in the yard. It’s still daylight. Feel like Himalayan Momo Dumplings tonight? Your food could arrive in 37 minutes. The modern wait standard has been set impossibly high for us.

Yes, medicine is no doubt at the top of the list of “Worst Wait Times.” We make patients wait for appointments (sometimes months), wait to be seen, wait for biopsy results, wait for follow-up surgery, wait for those second results, even wait for PET scans and treatment plans for some. We created a whole room just for waiting. Airlines call theirs “The Platinum Executive Lounge.” Ours is “The waiting room.”

Excess waiting is a significant reason why health care gets beat up in reviews. We’re unable to keep up with the new expectations. Waiting is also a significant cause of distress. Many patients report the most difficult part of their cancer diagnosis was the waiting for results, not the treatment. It’s because when under stress, we are hardwired to take action. Binding patients into inaction while they wait is very uncomfortable.

Fortunately, the psychology of waiting is well understood and there are best practices that can help. First, anxiety makes waiting much worse. Conveying confidence and reassuring patients they are in the right place and that everything will be OK makes the wait time feel shorter for them. Uncertainty also compounds their apprehension. If you believe the diagnosis will be melanoma, tell them that at the time of the biopsy and tell them what you expect next. This is better than saying, “Well, that could be cancer. We’ll see.”

Knowing a wait time is also much better than not. Have your staff advise patients on how much longer they can expect before seeing you (telling them they’re next isn’t as effective). Advise that test results should be back by the end of next week. Of course, under promise and over deliver. When the results are back on Tuesday, you’ve got a pleased patient.

Explaining that you had to add in an urgent patient helps. Even if it’s not your fault, it’s still better to apologize. For example, the 78 highway, the left anterior descending artery to our office, has been closed because of a sinkhole this month (not kidding). I’ve been apologizing to a lot of patients saying that all our patients are arriving late, which is putting us behind. As they can envision the linear parking lot that used to be a highway, it helps.

Lastly, as any child can tell you, waiting has to not only be, but to also appear, fair. The only thing worse than waiting for an appointment, or donut, is seeing someone who came in after you get their donut before you do. If you’re pulling both Mohs and cosmetics patients from the same waiting area, then your surgery patients will see a lot of patients come and go while they are sitting. Demarcating one sitting area for Mohs and one for clinics might help. So does ordering ahead. I’d show my daughter how to use the app so we don’t have to wait so long next week, but she’s 2 and I’m quite sure she already knows.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

“Papa! Where donut?” asks my 2½ year-old sitting with her legs dangling and hands folded in a bustling Starbucks. We’ve been waiting for 8 minutes and we’ve reached her limit of tolerance. She’s unimpressed by the queued customers who compliment her curly blonde hair, many of whom have come and gone since we’ve been waiting. I agree – how long does it take to pour a kiddie milk and grab a donut? We can both see it in the case right there!

No one likes to wait. Truly, one of the great benefits of the modern world is that wait times are now incredibly short. Many Starbucks customers, unlike my daughter, ordered their drink ahead and waited exactly 0 minutes to get their drink. What about Amazon? I ordered a bird feeder this morning and it’s already hanging in the yard. It’s still daylight. Feel like Himalayan Momo Dumplings tonight? Your food could arrive in 37 minutes. The modern wait standard has been set impossibly high for us.

Yes, medicine is no doubt at the top of the list of “Worst Wait Times.” We make patients wait for appointments (sometimes months), wait to be seen, wait for biopsy results, wait for follow-up surgery, wait for those second results, even wait for PET scans and treatment plans for some. We created a whole room just for waiting. Airlines call theirs “The Platinum Executive Lounge.” Ours is “The waiting room.”

Excess waiting is a significant reason why health care gets beat up in reviews. We’re unable to keep up with the new expectations. Waiting is also a significant cause of distress. Many patients report the most difficult part of their cancer diagnosis was the waiting for results, not the treatment. It’s because when under stress, we are hardwired to take action. Binding patients into inaction while they wait is very uncomfortable.

Fortunately, the psychology of waiting is well understood and there are best practices that can help. First, anxiety makes waiting much worse. Conveying confidence and reassuring patients they are in the right place and that everything will be OK makes the wait time feel shorter for them. Uncertainty also compounds their apprehension. If you believe the diagnosis will be melanoma, tell them that at the time of the biopsy and tell them what you expect next. This is better than saying, “Well, that could be cancer. We’ll see.”

Knowing a wait time is also much better than not. Have your staff advise patients on how much longer they can expect before seeing you (telling them they’re next isn’t as effective). Advise that test results should be back by the end of next week. Of course, under promise and over deliver. When the results are back on Tuesday, you’ve got a pleased patient.

Explaining that you had to add in an urgent patient helps. Even if it’s not your fault, it’s still better to apologize. For example, the 78 highway, the left anterior descending artery to our office, has been closed because of a sinkhole this month (not kidding). I’ve been apologizing to a lot of patients saying that all our patients are arriving late, which is putting us behind. As they can envision the linear parking lot that used to be a highway, it helps.

Lastly, as any child can tell you, waiting has to not only be, but to also appear, fair. The only thing worse than waiting for an appointment, or donut, is seeing someone who came in after you get their donut before you do. If you’re pulling both Mohs and cosmetics patients from the same waiting area, then your surgery patients will see a lot of patients come and go while they are sitting. Demarcating one sitting area for Mohs and one for clinics might help. So does ordering ahead. I’d show my daughter how to use the app so we don’t have to wait so long next week, but she’s 2 and I’m quite sure she already knows.

Dr. Benabio is director of Healthcare Transformation and chief of dermatology at Kaiser Permanente San Diego. The opinions expressed in this column are his own and do not represent those of Kaiser Permanente. Dr. Benabio is @Dermdoc on Twitter. Write to him at [email protected].

Since its introduction in 1950, the combined oral contraceptive pill has been used by countless women as a method for birth control (Liao P. Can Fam Physician. 2012 Dec; 58[12]:e757-e760).

Hormonal contraception (HC) provides women with both contraceptive and noncontraceptive benefits, most notably a method for avoiding unintended pregnancy. In addition to being an effective method of contraception, oral contraceptive pills (OCPs) are well established for treating conditions such as hirsutism, pain symptoms associated with endometriosis and adenomyosis, and pelvic inflammatory disease, among others (Schindler A. Int J Endocrinol Metab. 2013 Winter;11[1]:41-7).

IntimMedicine Specialists

Combined hormonal contraceptives are also first-line treatment for women with menstrual disorders, and in women with polycystic ovary syndrome, can offer an effective long-term method to regulate their menstrual cycle, decrease androgens, clear up oily skin and acne, and reduce facial hair while also providing them with effective contraception (de Melo et al. Open Access J Contracept. 2017;8:13-23).
 

Associations between ‘the pill’ and mood effects remain controversial

More than 100 million women worldwide use hormonal contraceptives today, yet despite this, the data are mixed regarding the prevalence and extent of neuropsychiatric symptoms and mood changes associated with use of “the pill.” Some studies show combined oral contraceptives are associated with a decrease in general well-being, but had no effect on depression, in women compared with placebo (Zethraeus N et al. Fertil Steril. 2017 May;107[5]:1238-45).

However, a large Danish study published in JAMA Psychiatry of more than 1 million women found a significant association between use of hormonal contraception and antidepressant use or first diagnosis of depression, with adolescents having a higher rate of first depression diagnosis and antidepressant use compared with women 20–30 years old (Skovlund C et al. JAMA Psychiatry. 2016 Nov 1;73[11]:1154-62).

Studies have also shown long-term exposure to levonorgestrel is significantly associated with anxiety and sleep problems in women without a history of these issues (Slattery J et al. Drug Saf. 2018 Oct;41[10]:951-8). A recent small nationwide cohort study in France suggests this may also be true of levonorgestrel delivered by intrauterine devices (IUD) and the association may be dose-dependent (Roland N et al. JAMA. 2023;329[3]:257-9).

Of note, a study published in the American Journal of Psychiatry found a nearly twofold risk of suicide attempt and over threefold risk of suicide among women taking hormonal contraception compared with women who had never used hormonal contraceptives (Skovlund et al. Am J Psychiatry. 2017 Nov 17:appiajp201717060616).
 

Knowledge gaps make drawing conclusions difficult

The latest information on use of antidepressant and antianxiety medications in women of reproductive age (18-44 years) is sparse and, in some cases, outdated. According to data from the National Health and Nutrition Examination Survey, 18.6% of adult women 18 years or older reported using antidepressant medications within the last 30 days in 2017-2018, an increase from 13.8% in 2009-2010. Among women aged 15-44 year with private employer–sponsored insurance surveyed during 2008-2013, the results showed 15.4% of women filled a prescription for an antidepressant. We must look back further to find data on antianxiety medication use among women aged 18-44 years where use of antianxiety drugs (anxiolytics, sedatives, and hypnotics) was 4.3% between 2005 and 2008.

A lack of literature in this area is likely due to significant underreporting, and an inability to select patients who are sensitive to or at risk of developing neuropsychiatric symptoms resulting from hormonal contraception use because the true pathophysiology is unknown. Existing studies tend to use varying methods to assess mood changes, and do not usually specify hormonal contraceptive use type in their analyses (Schaffir J et al. Eur J Contracept Reprod Health Care. 2016 Oct;21[5]:347-55).

Studies of this nature also require large sample sizes, but the percentage of women who develop neuropsychiatric symptoms from hormonal contraceptive use has historically been relatively small. In the late 1990s, Rosenberg and colleagues found 46% of 1,657 women discontinued oral contraceptives due to side effects within 6 months of starting a new prescription; of these women, 5% reported mood changes as their reason for discontinuing oral contraceptives (Rosenberg M et al. Am J Obstet Gynecol. 1998 Sep;179[3 Pt 1]:577-82).

One might expect that, as lower dosage combined hormonal contraceptives were developed in the 1980s, that the rate of reporting psychological side effects would continue to decrease as well. Yet greater awareness of the potential for mood changes while on “the pill” as outlined by the lay press and social media may be leading to increased reporting of neuropsychiatric effects in women. In a recent cross-sectional survey of 188 women in New York, 43.6% said they experienced mood changes while on hormonal contraceptives, and 61.2% of women with histories of psychiatric illness reported mood changes they attributed to hormonal contraceptives (Martell S et al. Contracept Reprod Med. 2023;8:9).

Martell and colleagues found 48.3% of women cited side effects as a reason for discontinuing hormonal contraception, and 43 participants mentioned psychological side effects unprompted, including 2 patients with suicidal thoughts. The authors said this suggests “psychological side effects, at least in part, may have impacted” HC users’ decisions to switch from OCPs to an alternative method of contraception.

It is also not clear what risk factors exist for women who develop neuropsychiatric symptoms from hormonal contraceptive use. First, it is important to note that both progestin-only contraceptives and combined hormonal contraceptives are classified by the Centers for Disease Control and Prevention’s US Medical Eligibility Criteria for Contraceptive Use, 2016 as having no restrictions for use, including among patients with depression. While women in a smaller subgroup have significant neuropsychiatric symptoms related to their hormonal contraceptives, the underlying mechanism is unknown, and is thought to be largely related to the progestogen component of combined hormonal contraceptives or progestogen-only contraceptives (Mu E. Aust Prescr. 2022 Jun; 45[3]:75-9). We know that some women are hormone sensitive, while others are less so, and some not at all. Progestogens could affect mood as a direct action of the progestogen, because progestogens can be neurosteroids, or the progestogen effect could be mediated secondarily through a change in that woman’s own production of or bioavailability of androgens or naturally occurring estrogens (Giatti S. J Mol Endocrinol. 2016 Aug;57[2]:R109-26).

Here, we also find that currently available evidence limits our ability to draw firm conclusions. A study by Berry-Bibee and colleagues found a “low concern for clinically significant interactions” between hormonal contraception and psychotropic drugs, but was limited by quality/quantity of evidence (Berry-Bibee E et al. Contraception. 2016 Dec;94[6]:650-67). Interestingly, a study by Robinson and colleagues from the mid-2000s posited based on low evidence that “psychological response to the practice of contraception” was a potential explanation for the side effect profile of hormonal contraception (Robinson S et al. Med Hypotheses. 2004;63[2]:268-73).

Further, it may be that women with premenstrual dysphoric disorder (PMDD) might be selected for oral contraceptives, and they are predisposed to other neuropsychiatric problems. Estimates have placed the prevalence of comorbid psychiatric disorders such as anxiety, major depression, bipolar disorder, and posttraumatic stress disorder as high as 70% for women with PMDD (Sepede G et al. Neuropsychiatr Dis Treat. 2020;16:415-26). This phenomenon is not new, having been characterized in the lay literature nearly 20 years ago, by endocrinologist Geoffrey P. Redmond, MD (Redmond GP. The Hormonally Vulnerable Woman. New York: HarperCollins; 2005).

While the cause is not exactly idiosyncratic, there do appear to be some women who are more sensitive, either mood-related or otherwise, directly or indirectly to their contraceptive progestogens in terms of mood. They tend to have an entire spectrum of responses to the progestogens in combined or progestin-only contraceptives, ranging from just a flattened affect – which could easily be explained by their flattened level of endogenous hormones – to frank depression. Their frank depression, in turn, can be demonstrated to include suicidal ideation and actual suicide.

Compounding this issue is a woman’s perception of her sexuality. Some women with low sexual desire or sexual problems who are younger may have more distress about their problems compared with women of older reproductive age. While the reason for that is not clear, it may be that in the sexual arena, it is more important for some younger women to be a sexual person than in perimenopausal women, or that women who are younger are more likely to be partnered than women of older reproductive age. While the European Society of Sexual Medicine concluded in a 2019 position statement that there is inconclusive evidence whether hormonal contraception may be contributing to changes in sexual desire and sexual dysfunction, it appears that “a minority of women” experience “better or worse sexual functioning” from taking combined oral contraceptives (Both S et al. J Sex Med. 2019 Nov;16[11]:1681-95), suggesting that the majority of women report no significant changes.
 

Practitioners should discuss mood effects during consultation

An ob.gyn., primary care physicians, or others with prescriptive authority (i.e. nurse practitioners and physician assistants) in clinical practice may encounter a patient who seems to have mood side effects owing to progestogen-containing contraceptives that they prescribe. However, many ob.gyns. are likely unaware of the prevalence, or that some of those same patients can have such significant mood effects that they would become or are suicidal.

I believe questioning patients about mood effects during consultation and particularly during follow-up following the initiation of any hormonal contraceptive is worth a passing comment for every patient, which should include mood effects in broader discussion for anyone currently using an antidepressant, patients with a history of antidepressant use, and patients who have considered suicide. As we do with other drugs, these questions can be posed in the form of a questionnaire followed up by the practitioner in counseling.

Practitioners who encounter a patient with mood changes as a result of hormonal contraceptive use can consider changing to a nonhormonal method of birth control, or recommending the patient use a barrier method during sexual activity, as none of these options have neuropsychiatric side effects.

Ultimately, practitioners of all types need to engage in shared decision-making to identify the key benefits and risks of hormonal contraceptive use for each patient, which may involve trial and error to determine the ideal treatment. It is critical that practitioners of all types strike a balance between alleviating patient concerns about potential mood changes, monitoring patients with an appreciable risk of mood changes, and continuing patients on hormonal contraception for whom the benefits outweigh the risks.
 

Dr. Simon is a clinical professor at George Washington University and the medical director and founder of IntimMedicine Specialists in Washington, which provides patient-focused care for women across the reproductive life cycle. He is a past president of the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. Dr. Simon has been a consultant to, received grant and research support from, and served on the speakers bureau for various pharmaceutical companies that develop combination hormonal contraceptives. Email Dr. Simon at [email protected].

Since its introduction in 1950, the combined oral contraceptive pill has been used by countless women as a method for birth control (Liao P. Can Fam Physician. 2012 Dec; 58[12]:e757-e760).

Hormonal contraception (HC) provides women with both contraceptive and noncontraceptive benefits, most notably a method for avoiding unintended pregnancy. In addition to being an effective method of contraception, oral contraceptive pills (OCPs) are well established for treating conditions such as hirsutism, pain symptoms associated with endometriosis and adenomyosis, and pelvic inflammatory disease, among others (Schindler A. Int J Endocrinol Metab. 2013 Winter;11[1]:41-7).

IntimMedicine Specialists

Combined hormonal contraceptives are also first-line treatment for women with menstrual disorders, and in women with polycystic ovary syndrome, can offer an effective long-term method to regulate their menstrual cycle, decrease androgens, clear up oily skin and acne, and reduce facial hair while also providing them with effective contraception (de Melo et al. Open Access J Contracept. 2017;8:13-23).
 

Associations between ‘the pill’ and mood effects remain controversial

More than 100 million women worldwide use hormonal contraceptives today, yet despite this, the data are mixed regarding the prevalence and extent of neuropsychiatric symptoms and mood changes associated with use of “the pill.” Some studies show combined oral contraceptives are associated with a decrease in general well-being, but had no effect on depression, in women compared with placebo (Zethraeus N et al. Fertil Steril. 2017 May;107[5]:1238-45).

However, a large Danish study published in JAMA Psychiatry of more than 1 million women found a significant association between use of hormonal contraception and antidepressant use or first diagnosis of depression, with adolescents having a higher rate of first depression diagnosis and antidepressant use compared with women 20–30 years old (Skovlund C et al. JAMA Psychiatry. 2016 Nov 1;73[11]:1154-62).

Studies have also shown long-term exposure to levonorgestrel is significantly associated with anxiety and sleep problems in women without a history of these issues (Slattery J et al. Drug Saf. 2018 Oct;41[10]:951-8). A recent small nationwide cohort study in France suggests this may also be true of levonorgestrel delivered by intrauterine devices (IUD) and the association may be dose-dependent (Roland N et al. JAMA. 2023;329[3]:257-9).

Of note, a study published in the American Journal of Psychiatry found a nearly twofold risk of suicide attempt and over threefold risk of suicide among women taking hormonal contraception compared with women who had never used hormonal contraceptives (Skovlund et al. Am J Psychiatry. 2017 Nov 17:appiajp201717060616).
 

Knowledge gaps make drawing conclusions difficult

The latest information on use of antidepressant and antianxiety medications in women of reproductive age (18-44 years) is sparse and, in some cases, outdated. According to data from the National Health and Nutrition Examination Survey, 18.6% of adult women 18 years or older reported using antidepressant medications within the last 30 days in 2017-2018, an increase from 13.8% in 2009-2010. Among women aged 15-44 year with private employer–sponsored insurance surveyed during 2008-2013, the results showed 15.4% of women filled a prescription for an antidepressant. We must look back further to find data on antianxiety medication use among women aged 18-44 years where use of antianxiety drugs (anxiolytics, sedatives, and hypnotics) was 4.3% between 2005 and 2008.

A lack of literature in this area is likely due to significant underreporting, and an inability to select patients who are sensitive to or at risk of developing neuropsychiatric symptoms resulting from hormonal contraception use because the true pathophysiology is unknown. Existing studies tend to use varying methods to assess mood changes, and do not usually specify hormonal contraceptive use type in their analyses (Schaffir J et al. Eur J Contracept Reprod Health Care. 2016 Oct;21[5]:347-55).

Studies of this nature also require large sample sizes, but the percentage of women who develop neuropsychiatric symptoms from hormonal contraceptive use has historically been relatively small. In the late 1990s, Rosenberg and colleagues found 46% of 1,657 women discontinued oral contraceptives due to side effects within 6 months of starting a new prescription; of these women, 5% reported mood changes as their reason for discontinuing oral contraceptives (Rosenberg M et al. Am J Obstet Gynecol. 1998 Sep;179[3 Pt 1]:577-82).

One might expect that, as lower dosage combined hormonal contraceptives were developed in the 1980s, that the rate of reporting psychological side effects would continue to decrease as well. Yet greater awareness of the potential for mood changes while on “the pill” as outlined by the lay press and social media may be leading to increased reporting of neuropsychiatric effects in women. In a recent cross-sectional survey of 188 women in New York, 43.6% said they experienced mood changes while on hormonal contraceptives, and 61.2% of women with histories of psychiatric illness reported mood changes they attributed to hormonal contraceptives (Martell S et al. Contracept Reprod Med. 2023;8:9).

Martell and colleagues found 48.3% of women cited side effects as a reason for discontinuing hormonal contraception, and 43 participants mentioned psychological side effects unprompted, including 2 patients with suicidal thoughts. The authors said this suggests “psychological side effects, at least in part, may have impacted” HC users’ decisions to switch from OCPs to an alternative method of contraception.

It is also not clear what risk factors exist for women who develop neuropsychiatric symptoms from hormonal contraceptive use. First, it is important to note that both progestin-only contraceptives and combined hormonal contraceptives are classified by the Centers for Disease Control and Prevention’s US Medical Eligibility Criteria for Contraceptive Use, 2016 as having no restrictions for use, including among patients with depression. While women in a smaller subgroup have significant neuropsychiatric symptoms related to their hormonal contraceptives, the underlying mechanism is unknown, and is thought to be largely related to the progestogen component of combined hormonal contraceptives or progestogen-only contraceptives (Mu E. Aust Prescr. 2022 Jun; 45[3]:75-9). We know that some women are hormone sensitive, while others are less so, and some not at all. Progestogens could affect mood as a direct action of the progestogen, because progestogens can be neurosteroids, or the progestogen effect could be mediated secondarily through a change in that woman’s own production of or bioavailability of androgens or naturally occurring estrogens (Giatti S. J Mol Endocrinol. 2016 Aug;57[2]:R109-26).

Here, we also find that currently available evidence limits our ability to draw firm conclusions. A study by Berry-Bibee and colleagues found a “low concern for clinically significant interactions” between hormonal contraception and psychotropic drugs, but was limited by quality/quantity of evidence (Berry-Bibee E et al. Contraception. 2016 Dec;94[6]:650-67). Interestingly, a study by Robinson and colleagues from the mid-2000s posited based on low evidence that “psychological response to the practice of contraception” was a potential explanation for the side effect profile of hormonal contraception (Robinson S et al. Med Hypotheses. 2004;63[2]:268-73).

Further, it may be that women with premenstrual dysphoric disorder (PMDD) might be selected for oral contraceptives, and they are predisposed to other neuropsychiatric problems. Estimates have placed the prevalence of comorbid psychiatric disorders such as anxiety, major depression, bipolar disorder, and posttraumatic stress disorder as high as 70% for women with PMDD (Sepede G et al. Neuropsychiatr Dis Treat. 2020;16:415-26). This phenomenon is not new, having been characterized in the lay literature nearly 20 years ago, by endocrinologist Geoffrey P. Redmond, MD (Redmond GP. The Hormonally Vulnerable Woman. New York: HarperCollins; 2005).

While the cause is not exactly idiosyncratic, there do appear to be some women who are more sensitive, either mood-related or otherwise, directly or indirectly to their contraceptive progestogens in terms of mood. They tend to have an entire spectrum of responses to the progestogens in combined or progestin-only contraceptives, ranging from just a flattened affect – which could easily be explained by their flattened level of endogenous hormones – to frank depression. Their frank depression, in turn, can be demonstrated to include suicidal ideation and actual suicide.

Compounding this issue is a woman’s perception of her sexuality. Some women with low sexual desire or sexual problems who are younger may have more distress about their problems compared with women of older reproductive age. While the reason for that is not clear, it may be that in the sexual arena, it is more important for some younger women to be a sexual person than in perimenopausal women, or that women who are younger are more likely to be partnered than women of older reproductive age. While the European Society of Sexual Medicine concluded in a 2019 position statement that there is inconclusive evidence whether hormonal contraception may be contributing to changes in sexual desire and sexual dysfunction, it appears that “a minority of women” experience “better or worse sexual functioning” from taking combined oral contraceptives (Both S et al. J Sex Med. 2019 Nov;16[11]:1681-95), suggesting that the majority of women report no significant changes.
 

Practitioners should discuss mood effects during consultation

An ob.gyn., primary care physicians, or others with prescriptive authority (i.e. nurse practitioners and physician assistants) in clinical practice may encounter a patient who seems to have mood side effects owing to progestogen-containing contraceptives that they prescribe. However, many ob.gyns. are likely unaware of the prevalence, or that some of those same patients can have such significant mood effects that they would become or are suicidal.

I believe questioning patients about mood effects during consultation and particularly during follow-up following the initiation of any hormonal contraceptive is worth a passing comment for every patient, which should include mood effects in broader discussion for anyone currently using an antidepressant, patients with a history of antidepressant use, and patients who have considered suicide. As we do with other drugs, these questions can be posed in the form of a questionnaire followed up by the practitioner in counseling.

Practitioners who encounter a patient with mood changes as a result of hormonal contraceptive use can consider changing to a nonhormonal method of birth control, or recommending the patient use a barrier method during sexual activity, as none of these options have neuropsychiatric side effects.

Ultimately, practitioners of all types need to engage in shared decision-making to identify the key benefits and risks of hormonal contraceptive use for each patient, which may involve trial and error to determine the ideal treatment. It is critical that practitioners of all types strike a balance between alleviating patient concerns about potential mood changes, monitoring patients with an appreciable risk of mood changes, and continuing patients on hormonal contraception for whom the benefits outweigh the risks.
 

Dr. Simon is a clinical professor at George Washington University and the medical director and founder of IntimMedicine Specialists in Washington, which provides patient-focused care for women across the reproductive life cycle. He is a past president of the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. Dr. Simon has been a consultant to, received grant and research support from, and served on the speakers bureau for various pharmaceutical companies that develop combination hormonal contraceptives. Email Dr. Simon at [email protected].

Since its introduction in 1950, the combined oral contraceptive pill has been used by countless women as a method for birth control (Liao P. Can Fam Physician. 2012 Dec; 58[12]:e757-e760).

Hormonal contraception (HC) provides women with both contraceptive and noncontraceptive benefits, most notably a method for avoiding unintended pregnancy. In addition to being an effective method of contraception, oral contraceptive pills (OCPs) are well established for treating conditions such as hirsutism, pain symptoms associated with endometriosis and adenomyosis, and pelvic inflammatory disease, among others (Schindler A. Int J Endocrinol Metab. 2013 Winter;11[1]:41-7).

IntimMedicine Specialists

Combined hormonal contraceptives are also first-line treatment for women with menstrual disorders, and in women with polycystic ovary syndrome, can offer an effective long-term method to regulate their menstrual cycle, decrease androgens, clear up oily skin and acne, and reduce facial hair while also providing them with effective contraception (de Melo et al. Open Access J Contracept. 2017;8:13-23).
 

Associations between ‘the pill’ and mood effects remain controversial

More than 100 million women worldwide use hormonal contraceptives today, yet despite this, the data are mixed regarding the prevalence and extent of neuropsychiatric symptoms and mood changes associated with use of “the pill.” Some studies show combined oral contraceptives are associated with a decrease in general well-being, but had no effect on depression, in women compared with placebo (Zethraeus N et al. Fertil Steril. 2017 May;107[5]:1238-45).

However, a large Danish study published in JAMA Psychiatry of more than 1 million women found a significant association between use of hormonal contraception and antidepressant use or first diagnosis of depression, with adolescents having a higher rate of first depression diagnosis and antidepressant use compared with women 20–30 years old (Skovlund C et al. JAMA Psychiatry. 2016 Nov 1;73[11]:1154-62).

Studies have also shown long-term exposure to levonorgestrel is significantly associated with anxiety and sleep problems in women without a history of these issues (Slattery J et al. Drug Saf. 2018 Oct;41[10]:951-8). A recent small nationwide cohort study in France suggests this may also be true of levonorgestrel delivered by intrauterine devices (IUD) and the association may be dose-dependent (Roland N et al. JAMA. 2023;329[3]:257-9).

Of note, a study published in the American Journal of Psychiatry found a nearly twofold risk of suicide attempt and over threefold risk of suicide among women taking hormonal contraception compared with women who had never used hormonal contraceptives (Skovlund et al. Am J Psychiatry. 2017 Nov 17:appiajp201717060616).
 

Knowledge gaps make drawing conclusions difficult

The latest information on use of antidepressant and antianxiety medications in women of reproductive age (18-44 years) is sparse and, in some cases, outdated. According to data from the National Health and Nutrition Examination Survey, 18.6% of adult women 18 years or older reported using antidepressant medications within the last 30 days in 2017-2018, an increase from 13.8% in 2009-2010. Among women aged 15-44 year with private employer–sponsored insurance surveyed during 2008-2013, the results showed 15.4% of women filled a prescription for an antidepressant. We must look back further to find data on antianxiety medication use among women aged 18-44 years where use of antianxiety drugs (anxiolytics, sedatives, and hypnotics) was 4.3% between 2005 and 2008.

A lack of literature in this area is likely due to significant underreporting, and an inability to select patients who are sensitive to or at risk of developing neuropsychiatric symptoms resulting from hormonal contraception use because the true pathophysiology is unknown. Existing studies tend to use varying methods to assess mood changes, and do not usually specify hormonal contraceptive use type in their analyses (Schaffir J et al. Eur J Contracept Reprod Health Care. 2016 Oct;21[5]:347-55).

Studies of this nature also require large sample sizes, but the percentage of women who develop neuropsychiatric symptoms from hormonal contraceptive use has historically been relatively small. In the late 1990s, Rosenberg and colleagues found 46% of 1,657 women discontinued oral contraceptives due to side effects within 6 months of starting a new prescription; of these women, 5% reported mood changes as their reason for discontinuing oral contraceptives (Rosenberg M et al. Am J Obstet Gynecol. 1998 Sep;179[3 Pt 1]:577-82).

One might expect that, as lower dosage combined hormonal contraceptives were developed in the 1980s, that the rate of reporting psychological side effects would continue to decrease as well. Yet greater awareness of the potential for mood changes while on “the pill” as outlined by the lay press and social media may be leading to increased reporting of neuropsychiatric effects in women. In a recent cross-sectional survey of 188 women in New York, 43.6% said they experienced mood changes while on hormonal contraceptives, and 61.2% of women with histories of psychiatric illness reported mood changes they attributed to hormonal contraceptives (Martell S et al. Contracept Reprod Med. 2023;8:9).

Martell and colleagues found 48.3% of women cited side effects as a reason for discontinuing hormonal contraception, and 43 participants mentioned psychological side effects unprompted, including 2 patients with suicidal thoughts. The authors said this suggests “psychological side effects, at least in part, may have impacted” HC users’ decisions to switch from OCPs to an alternative method of contraception.

It is also not clear what risk factors exist for women who develop neuropsychiatric symptoms from hormonal contraceptive use. First, it is important to note that both progestin-only contraceptives and combined hormonal contraceptives are classified by the Centers for Disease Control and Prevention’s US Medical Eligibility Criteria for Contraceptive Use, 2016 as having no restrictions for use, including among patients with depression. While women in a smaller subgroup have significant neuropsychiatric symptoms related to their hormonal contraceptives, the underlying mechanism is unknown, and is thought to be largely related to the progestogen component of combined hormonal contraceptives or progestogen-only contraceptives (Mu E. Aust Prescr. 2022 Jun; 45[3]:75-9). We know that some women are hormone sensitive, while others are less so, and some not at all. Progestogens could affect mood as a direct action of the progestogen, because progestogens can be neurosteroids, or the progestogen effect could be mediated secondarily through a change in that woman’s own production of or bioavailability of androgens or naturally occurring estrogens (Giatti S. J Mol Endocrinol. 2016 Aug;57[2]:R109-26).

Here, we also find that currently available evidence limits our ability to draw firm conclusions. A study by Berry-Bibee and colleagues found a “low concern for clinically significant interactions” between hormonal contraception and psychotropic drugs, but was limited by quality/quantity of evidence (Berry-Bibee E et al. Contraception. 2016 Dec;94[6]:650-67). Interestingly, a study by Robinson and colleagues from the mid-2000s posited based on low evidence that “psychological response to the practice of contraception” was a potential explanation for the side effect profile of hormonal contraception (Robinson S et al. Med Hypotheses. 2004;63[2]:268-73).

Further, it may be that women with premenstrual dysphoric disorder (PMDD) might be selected for oral contraceptives, and they are predisposed to other neuropsychiatric problems. Estimates have placed the prevalence of comorbid psychiatric disorders such as anxiety, major depression, bipolar disorder, and posttraumatic stress disorder as high as 70% for women with PMDD (Sepede G et al. Neuropsychiatr Dis Treat. 2020;16:415-26). This phenomenon is not new, having been characterized in the lay literature nearly 20 years ago, by endocrinologist Geoffrey P. Redmond, MD (Redmond GP. The Hormonally Vulnerable Woman. New York: HarperCollins; 2005).

While the cause is not exactly idiosyncratic, there do appear to be some women who are more sensitive, either mood-related or otherwise, directly or indirectly to their contraceptive progestogens in terms of mood. They tend to have an entire spectrum of responses to the progestogens in combined or progestin-only contraceptives, ranging from just a flattened affect – which could easily be explained by their flattened level of endogenous hormones – to frank depression. Their frank depression, in turn, can be demonstrated to include suicidal ideation and actual suicide.

Compounding this issue is a woman’s perception of her sexuality. Some women with low sexual desire or sexual problems who are younger may have more distress about their problems compared with women of older reproductive age. While the reason for that is not clear, it may be that in the sexual arena, it is more important for some younger women to be a sexual person than in perimenopausal women, or that women who are younger are more likely to be partnered than women of older reproductive age. While the European Society of Sexual Medicine concluded in a 2019 position statement that there is inconclusive evidence whether hormonal contraception may be contributing to changes in sexual desire and sexual dysfunction, it appears that “a minority of women” experience “better or worse sexual functioning” from taking combined oral contraceptives (Both S et al. J Sex Med. 2019 Nov;16[11]:1681-95), suggesting that the majority of women report no significant changes.
 

Practitioners should discuss mood effects during consultation

An ob.gyn., primary care physicians, or others with prescriptive authority (i.e. nurse practitioners and physician assistants) in clinical practice may encounter a patient who seems to have mood side effects owing to progestogen-containing contraceptives that they prescribe. However, many ob.gyns. are likely unaware of the prevalence, or that some of those same patients can have such significant mood effects that they would become or are suicidal.

I believe questioning patients about mood effects during consultation and particularly during follow-up following the initiation of any hormonal contraceptive is worth a passing comment for every patient, which should include mood effects in broader discussion for anyone currently using an antidepressant, patients with a history of antidepressant use, and patients who have considered suicide. As we do with other drugs, these questions can be posed in the form of a questionnaire followed up by the practitioner in counseling.

Practitioners who encounter a patient with mood changes as a result of hormonal contraceptive use can consider changing to a nonhormonal method of birth control, or recommending the patient use a barrier method during sexual activity, as none of these options have neuropsychiatric side effects.

Ultimately, practitioners of all types need to engage in shared decision-making to identify the key benefits and risks of hormonal contraceptive use for each patient, which may involve trial and error to determine the ideal treatment. It is critical that practitioners of all types strike a balance between alleviating patient concerns about potential mood changes, monitoring patients with an appreciable risk of mood changes, and continuing patients on hormonal contraception for whom the benefits outweigh the risks.
 

Dr. Simon is a clinical professor at George Washington University and the medical director and founder of IntimMedicine Specialists in Washington, which provides patient-focused care for women across the reproductive life cycle. He is a past president of the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. Dr. Simon has been a consultant to, received grant and research support from, and served on the speakers bureau for various pharmaceutical companies that develop combination hormonal contraceptives. Email Dr. Simon at [email protected].

Artificial intelligence (AI) has recently gained significant public attention, primarily driven by the launch of a noteworthy program by OpenAI called Chat Generative Pre-trained Transformer (ChatGPT). This large language model is an AI system that enables users to interact with it using plain language. In just the first 2 months since its release, over 100 million subscribers have registered to use ChatGPT.

AI is now deeply integrated into our daily lives, pervading a wide array of smart devices such as phones, tablets, and numerous other gadgets that we rely on every day. These sophisticated technologies operate seamlessly in the background, often without us being consciously aware of their presence. Nevertheless, we greatly appreciate the way they enhance our lives by simplifying tasks and streamlining our routines.

A key factor contributing to ChatGPT’s popularity is its ability to accept input in the form of prompts in plain English. Our team published a comprehensive journal article showcasing examples of how this technology can be utilized by general ob.gyn. practitioners. ChatGPT has the potential to streamline work flow, generate letters to insurance companies, draft clinical plans, and assist with various other routine tasks in any ob.gyn. practice environment.

As with any new technology, it is essential for users to familiarize themselves with its capabilities and understand its limitations. A critical aspect to consider with the current version of ChatGPT is that it was developed using information primarily sourced from the Internet up until September 2021. This limitation is especially significant in the field of medicine, where practitioners consistently seek the most up-to-date and current information to inform their decisions.

However, it is expected that, in the near future, these programs will gain access to real-time information from a diverse range of sources, including but not limited to the Internet. This development will enhance the program’s utility and relevance in medical contexts.

Another limitation of ChatGPT is its propensity to “hallucinate.” Large language models are trained to respond to the best of their abilities, occasionally attempting to fill knowledge gaps with fabricated information. Being aware of these limitations enables users to recognize the program’s potential while also understanding the need for careful monitoring.

Our expertise and clinical knowledge are crucial in guiding and refining this technology, ensuring that it serves as a valuable tool in the ever-evolving landscape of medicine.

Another crucial factor to consider is that users must adhere to all guidelines and policies established within their work environment. This entails complying with HIPAA regulations and ensuring that any information generated by these programs is thoroughly examined before being integrated into practice work flows. As an increasing number of organizations develop specific guidelines for such technologies, the aim is to safeguard patients, users, and the organization itself. The individuals utilizing these technologies must exercise utmost caution and refrain from storing or sharing any sensitive or proprietary information.

The aim of this article is not to provide an exhaustive overview, but rather to offer a selection of examples and inspire readers to consider adopting these programs. By doing so, we hope to facilitate the exploration of innovative approaches that can improve the practice of ob.gyn.

The first example illustrates a common scenario that we frequently encounter – the situation in which an insurance company denies coverage for specific care or treatment for a patient. In fact, this was one of the first examples that was demonstrated by others on social media as a possible benefit for this technology. It effectively demonstrated the ability to save time and surmount the challenges of writer’s block that we occasionally encounter.
 

Prompt input:

“Write a letter to the insurance company who is denying cervical length surveillance for a patient with a short cervix and add references.”

ChatGPT response:

[Your Name]

[Your Address]

[City, State, Zip Code]

[Date]

[Insurance Company Name]

[Claims Department]

[Insurance Company Address]

[City, State, Zip Code]

Re: Request for Reconsideration – Cervical Length Surveillance

Policy Number: [Policy Number]

Insured: [Patient’s Name]

Date of Birth: [Patient’s Date of Birth]

Claim Number: [Claim Number]

Date of Service: [Date of Service]

Dear Claims Reviewer,

I am writing to request a reconsideration of the denial for cervical length surveillance for my patient, [Patient’s Name], who has been diagnosed with a short cervix. As a healthcare provider, I strongly believe that this is a medically necessary service for the patient in order to prevent preterm birth and its associated complications.

A short cervix is a well-established risk factor for preterm birth, and numerous studies have shown the efficacy of cervical length surveillance in the prevention and management of preterm birth. I kindly request that you reconsider the coverage for this essential service and refer to the following authoritative sources:

Berghella, V., & Saccone, G. (2019). Fetal fibronectin testing for reducing the risk of preterm birth. Cochrane Database of Systematic Reviews, 2019(7). doi:10.1002/14651858.CD004843.pub3

American College of Obstetricians and Gynecologists (2016). Practice Bulletin No. 171: Management of Preterm Labor. Obstetrics & Gynecology, 128(4), e155-e164. doi:10.1097/AOG.0000000000001711

Society for Maternal-Fetal Medicine (SMFM), McIntosh, J., Feltovich, H., Berghella, V., & Manuck, T. (2016). The role of routine cervical length screening in selected high- and low-risk women for preterm birth prevention. American Journal of Obstetrics & Gynecology, 215(3), B2-B7. doi:10.1016/j.ajog.2016.03.015

By denying coverage for cervical length surveillance, the insurance company is putting [Patient’s Name] at an increased risk for preterm birth and the numerous health complications that can accompany it, both for the mother and the infant. It is crucial to provide this service in order to improve health outcomes and reduce the risk of costly neonatal intensive care unit (NICU) admissions and long-term medical issues.

I kindly request that you review this case with the provided references and reconsider the coverage for cervical length surveillance for [Patient’s Name]. Thank you for your attention to this matter. Please feel free to contact me if you require any further information or clarification.

Sincerely,

[Your Name]

[Your Title]

[Your Phone Number]

[Your Email Address]

The document took less than 15 seconds to generate, it is well written and concise, and can also be utilized as a template for future use. But as mentioned above, it is important to confirm all the information within the document. For example, references 1 and 3 in the ChatGPT-generated letter above include document objective identifiers that do not correctly correspond to the reference.

Other uses that the reader might consider: patient education, helping to answer a patient question utilizing appropriate grade-level language, dietary plans for a patient - the potential list is endless. Another key aspect of utilizing these types of programs is understanding how to effectively ask a question. This involves providing ample detail about the inquiry you wish to have answered by the program. With some practice and review of guidance on how to do this from the Internet, one can become highly proficient at crafting questions and generating relevant responses. But as mentioned above, it is important to keep in mind that all information generated by this program needs to be vetted prior to utilization.

This groundbreaking technology is not only here to stay but will continue to become increasingly pervasive. It is already being integrated into conventional search engines such as Google and Bing. Microsoft has ambitious plans to incorporate this innovation into its entire suite of Office products. Just imagine working on a document and seeking assistance for editing or rephrasing, effortlessly searching your inbox for all emails containing a specific phrase or topic, or even crafting a PowerPoint presentation for a lecture while receiving help with both content and formatting. These scenarios offer just a glimpse of how AI programs can significantly assist and enhance our workflow.

I also anticipate that our patients will increasingly adopt this type of technology to generate customized lists of questions tailored to their specific medical conditions, which they can then ask their health care providers. Often, our patients express uncertainty about the appropriate questions to ask during a particular visit. Now envision a scenario in which they can effortlessly obtain a comprehensive list of relevant questions, specifically designed for their office consultation. This would empower them to engage more actively in their health care and enhance communication with their clinical team.

I highly recommend that readers explore and experiment with these programs. By doing so, we can provide valuable assistance and guidance not only within our specific medical specialties but also for our patients. In this way, we can effectively harness the power of technology to improve patient care and optimize our office work flow, ultimately benefiting both our patients and our practices.

Dr. Chavez is professor, department of obstetrics and gynecology, at NYU Long Island School of Medicine and director of maternal and fetal medicine at NYU Langone Hospital–Long Island, both in Mineola, N.Y. He has no disclosures.

Artificial intelligence (AI) has recently gained significant public attention, primarily driven by the launch of a noteworthy program by OpenAI called Chat Generative Pre-trained Transformer (ChatGPT). This large language model is an AI system that enables users to interact with it using plain language. In just the first 2 months since its release, over 100 million subscribers have registered to use ChatGPT.

AI is now deeply integrated into our daily lives, pervading a wide array of smart devices such as phones, tablets, and numerous other gadgets that we rely on every day. These sophisticated technologies operate seamlessly in the background, often without us being consciously aware of their presence. Nevertheless, we greatly appreciate the way they enhance our lives by simplifying tasks and streamlining our routines.

A key factor contributing to ChatGPT’s popularity is its ability to accept input in the form of prompts in plain English. Our team published a comprehensive journal article showcasing examples of how this technology can be utilized by general ob.gyn. practitioners. ChatGPT has the potential to streamline work flow, generate letters to insurance companies, draft clinical plans, and assist with various other routine tasks in any ob.gyn. practice environment.

As with any new technology, it is essential for users to familiarize themselves with its capabilities and understand its limitations. A critical aspect to consider with the current version of ChatGPT is that it was developed using information primarily sourced from the Internet up until September 2021. This limitation is especially significant in the field of medicine, where practitioners consistently seek the most up-to-date and current information to inform their decisions.

However, it is expected that, in the near future, these programs will gain access to real-time information from a diverse range of sources, including but not limited to the Internet. This development will enhance the program’s utility and relevance in medical contexts.

Another limitation of ChatGPT is its propensity to “hallucinate.” Large language models are trained to respond to the best of their abilities, occasionally attempting to fill knowledge gaps with fabricated information. Being aware of these limitations enables users to recognize the program’s potential while also understanding the need for careful monitoring.

Our expertise and clinical knowledge are crucial in guiding and refining this technology, ensuring that it serves as a valuable tool in the ever-evolving landscape of medicine.

Another crucial factor to consider is that users must adhere to all guidelines and policies established within their work environment. This entails complying with HIPAA regulations and ensuring that any information generated by these programs is thoroughly examined before being integrated into practice work flows. As an increasing number of organizations develop specific guidelines for such technologies, the aim is to safeguard patients, users, and the organization itself. The individuals utilizing these technologies must exercise utmost caution and refrain from storing or sharing any sensitive or proprietary information.

The aim of this article is not to provide an exhaustive overview, but rather to offer a selection of examples and inspire readers to consider adopting these programs. By doing so, we hope to facilitate the exploration of innovative approaches that can improve the practice of ob.gyn.

The first example illustrates a common scenario that we frequently encounter – the situation in which an insurance company denies coverage for specific care or treatment for a patient. In fact, this was one of the first examples that was demonstrated by others on social media as a possible benefit for this technology. It effectively demonstrated the ability to save time and surmount the challenges of writer’s block that we occasionally encounter.
 

Prompt input:

“Write a letter to the insurance company who is denying cervical length surveillance for a patient with a short cervix and add references.”

ChatGPT response:

[Your Name]

[Your Address]

[City, State, Zip Code]

[Date]

[Insurance Company Name]

[Claims Department]

[Insurance Company Address]

[City, State, Zip Code]

Re: Request for Reconsideration – Cervical Length Surveillance

Policy Number: [Policy Number]

Insured: [Patient’s Name]

Date of Birth: [Patient’s Date of Birth]

Claim Number: [Claim Number]

Date of Service: [Date of Service]

Dear Claims Reviewer,

I am writing to request a reconsideration of the denial for cervical length surveillance for my patient, [Patient’s Name], who has been diagnosed with a short cervix. As a healthcare provider, I strongly believe that this is a medically necessary service for the patient in order to prevent preterm birth and its associated complications.

A short cervix is a well-established risk factor for preterm birth, and numerous studies have shown the efficacy of cervical length surveillance in the prevention and management of preterm birth. I kindly request that you reconsider the coverage for this essential service and refer to the following authoritative sources:

Berghella, V., & Saccone, G. (2019). Fetal fibronectin testing for reducing the risk of preterm birth. Cochrane Database of Systematic Reviews, 2019(7). doi:10.1002/14651858.CD004843.pub3

American College of Obstetricians and Gynecologists (2016). Practice Bulletin No. 171: Management of Preterm Labor. Obstetrics & Gynecology, 128(4), e155-e164. doi:10.1097/AOG.0000000000001711

Society for Maternal-Fetal Medicine (SMFM), McIntosh, J., Feltovich, H., Berghella, V., & Manuck, T. (2016). The role of routine cervical length screening in selected high- and low-risk women for preterm birth prevention. American Journal of Obstetrics & Gynecology, 215(3), B2-B7. doi:10.1016/j.ajog.2016.03.015

By denying coverage for cervical length surveillance, the insurance company is putting [Patient’s Name] at an increased risk for preterm birth and the numerous health complications that can accompany it, both for the mother and the infant. It is crucial to provide this service in order to improve health outcomes and reduce the risk of costly neonatal intensive care unit (NICU) admissions and long-term medical issues.

I kindly request that you review this case with the provided references and reconsider the coverage for cervical length surveillance for [Patient’s Name]. Thank you for your attention to this matter. Please feel free to contact me if you require any further information or clarification.

Sincerely,

[Your Name]

[Your Title]

[Your Phone Number]

[Your Email Address]

The document took less than 15 seconds to generate, it is well written and concise, and can also be utilized as a template for future use. But as mentioned above, it is important to confirm all the information within the document. For example, references 1 and 3 in the ChatGPT-generated letter above include document objective identifiers that do not correctly correspond to the reference.

Other uses that the reader might consider: patient education, helping to answer a patient question utilizing appropriate grade-level language, dietary plans for a patient - the potential list is endless. Another key aspect of utilizing these types of programs is understanding how to effectively ask a question. This involves providing ample detail about the inquiry you wish to have answered by the program. With some practice and review of guidance on how to do this from the Internet, one can become highly proficient at crafting questions and generating relevant responses. But as mentioned above, it is important to keep in mind that all information generated by this program needs to be vetted prior to utilization.

This groundbreaking technology is not only here to stay but will continue to become increasingly pervasive. It is already being integrated into conventional search engines such as Google and Bing. Microsoft has ambitious plans to incorporate this innovation into its entire suite of Office products. Just imagine working on a document and seeking assistance for editing or rephrasing, effortlessly searching your inbox for all emails containing a specific phrase or topic, or even crafting a PowerPoint presentation for a lecture while receiving help with both content and formatting. These scenarios offer just a glimpse of how AI programs can significantly assist and enhance our workflow.

I also anticipate that our patients will increasingly adopt this type of technology to generate customized lists of questions tailored to their specific medical conditions, which they can then ask their health care providers. Often, our patients express uncertainty about the appropriate questions to ask during a particular visit. Now envision a scenario in which they can effortlessly obtain a comprehensive list of relevant questions, specifically designed for their office consultation. This would empower them to engage more actively in their health care and enhance communication with their clinical team.

I highly recommend that readers explore and experiment with these programs. By doing so, we can provide valuable assistance and guidance not only within our specific medical specialties but also for our patients. In this way, we can effectively harness the power of technology to improve patient care and optimize our office work flow, ultimately benefiting both our patients and our practices.

Dr. Chavez is professor, department of obstetrics and gynecology, at NYU Long Island School of Medicine and director of maternal and fetal medicine at NYU Langone Hospital–Long Island, both in Mineola, N.Y. He has no disclosures.

Artificial intelligence (AI) has recently gained significant public attention, primarily driven by the launch of a noteworthy program by OpenAI called Chat Generative Pre-trained Transformer (ChatGPT). This large language model is an AI system that enables users to interact with it using plain language. In just the first 2 months since its release, over 100 million subscribers have registered to use ChatGPT.

AI is now deeply integrated into our daily lives, pervading a wide array of smart devices such as phones, tablets, and numerous other gadgets that we rely on every day. These sophisticated technologies operate seamlessly in the background, often without us being consciously aware of their presence. Nevertheless, we greatly appreciate the way they enhance our lives by simplifying tasks and streamlining our routines.

A key factor contributing to ChatGPT’s popularity is its ability to accept input in the form of prompts in plain English. Our team published a comprehensive journal article showcasing examples of how this technology can be utilized by general ob.gyn. practitioners. ChatGPT has the potential to streamline work flow, generate letters to insurance companies, draft clinical plans, and assist with various other routine tasks in any ob.gyn. practice environment.

As with any new technology, it is essential for users to familiarize themselves with its capabilities and understand its limitations. A critical aspect to consider with the current version of ChatGPT is that it was developed using information primarily sourced from the Internet up until September 2021. This limitation is especially significant in the field of medicine, where practitioners consistently seek the most up-to-date and current information to inform their decisions.

However, it is expected that, in the near future, these programs will gain access to real-time information from a diverse range of sources, including but not limited to the Internet. This development will enhance the program’s utility and relevance in medical contexts.

Another limitation of ChatGPT is its propensity to “hallucinate.” Large language models are trained to respond to the best of their abilities, occasionally attempting to fill knowledge gaps with fabricated information. Being aware of these limitations enables users to recognize the program’s potential while also understanding the need for careful monitoring.

Our expertise and clinical knowledge are crucial in guiding and refining this technology, ensuring that it serves as a valuable tool in the ever-evolving landscape of medicine.

Another crucial factor to consider is that users must adhere to all guidelines and policies established within their work environment. This entails complying with HIPAA regulations and ensuring that any information generated by these programs is thoroughly examined before being integrated into practice work flows. As an increasing number of organizations develop specific guidelines for such technologies, the aim is to safeguard patients, users, and the organization itself. The individuals utilizing these technologies must exercise utmost caution and refrain from storing or sharing any sensitive or proprietary information.

The aim of this article is not to provide an exhaustive overview, but rather to offer a selection of examples and inspire readers to consider adopting these programs. By doing so, we hope to facilitate the exploration of innovative approaches that can improve the practice of ob.gyn.

The first example illustrates a common scenario that we frequently encounter – the situation in which an insurance company denies coverage for specific care or treatment for a patient. In fact, this was one of the first examples that was demonstrated by others on social media as a possible benefit for this technology. It effectively demonstrated the ability to save time and surmount the challenges of writer’s block that we occasionally encounter.
 

Prompt input:

“Write a letter to the insurance company who is denying cervical length surveillance for a patient with a short cervix and add references.”

ChatGPT response:

[Your Name]

[Your Address]

[City, State, Zip Code]

[Date]

[Insurance Company Name]

[Claims Department]

[Insurance Company Address]

[City, State, Zip Code]

Re: Request for Reconsideration – Cervical Length Surveillance

Policy Number: [Policy Number]

Insured: [Patient’s Name]

Date of Birth: [Patient’s Date of Birth]

Claim Number: [Claim Number]

Date of Service: [Date of Service]

Dear Claims Reviewer,

I am writing to request a reconsideration of the denial for cervical length surveillance for my patient, [Patient’s Name], who has been diagnosed with a short cervix. As a healthcare provider, I strongly believe that this is a medically necessary service for the patient in order to prevent preterm birth and its associated complications.

A short cervix is a well-established risk factor for preterm birth, and numerous studies have shown the efficacy of cervical length surveillance in the prevention and management of preterm birth. I kindly request that you reconsider the coverage for this essential service and refer to the following authoritative sources:

Berghella, V., & Saccone, G. (2019). Fetal fibronectin testing for reducing the risk of preterm birth. Cochrane Database of Systematic Reviews, 2019(7). doi:10.1002/14651858.CD004843.pub3

American College of Obstetricians and Gynecologists (2016). Practice Bulletin No. 171: Management of Preterm Labor. Obstetrics & Gynecology, 128(4), e155-e164. doi:10.1097/AOG.0000000000001711

Society for Maternal-Fetal Medicine (SMFM), McIntosh, J., Feltovich, H., Berghella, V., & Manuck, T. (2016). The role of routine cervical length screening in selected high- and low-risk women for preterm birth prevention. American Journal of Obstetrics & Gynecology, 215(3), B2-B7. doi:10.1016/j.ajog.2016.03.015

By denying coverage for cervical length surveillance, the insurance company is putting [Patient’s Name] at an increased risk for preterm birth and the numerous health complications that can accompany it, both for the mother and the infant. It is crucial to provide this service in order to improve health outcomes and reduce the risk of costly neonatal intensive care unit (NICU) admissions and long-term medical issues.

I kindly request that you review this case with the provided references and reconsider the coverage for cervical length surveillance for [Patient’s Name]. Thank you for your attention to this matter. Please feel free to contact me if you require any further information or clarification.

Sincerely,

[Your Name]

[Your Title]

[Your Phone Number]

[Your Email Address]

The document took less than 15 seconds to generate, it is well written and concise, and can also be utilized as a template for future use. But as mentioned above, it is important to confirm all the information within the document. For example, references 1 and 3 in the ChatGPT-generated letter above include document objective identifiers that do not correctly correspond to the reference.

Other uses that the reader might consider: patient education, helping to answer a patient question utilizing appropriate grade-level language, dietary plans for a patient - the potential list is endless. Another key aspect of utilizing these types of programs is understanding how to effectively ask a question. This involves providing ample detail about the inquiry you wish to have answered by the program. With some practice and review of guidance on how to do this from the Internet, one can become highly proficient at crafting questions and generating relevant responses. But as mentioned above, it is important to keep in mind that all information generated by this program needs to be vetted prior to utilization.

This groundbreaking technology is not only here to stay but will continue to become increasingly pervasive. It is already being integrated into conventional search engines such as Google and Bing. Microsoft has ambitious plans to incorporate this innovation into its entire suite of Office products. Just imagine working on a document and seeking assistance for editing or rephrasing, effortlessly searching your inbox for all emails containing a specific phrase or topic, or even crafting a PowerPoint presentation for a lecture while receiving help with both content and formatting. These scenarios offer just a glimpse of how AI programs can significantly assist and enhance our workflow.

I also anticipate that our patients will increasingly adopt this type of technology to generate customized lists of questions tailored to their specific medical conditions, which they can then ask their health care providers. Often, our patients express uncertainty about the appropriate questions to ask during a particular visit. Now envision a scenario in which they can effortlessly obtain a comprehensive list of relevant questions, specifically designed for their office consultation. This would empower them to engage more actively in their health care and enhance communication with their clinical team.

I highly recommend that readers explore and experiment with these programs. By doing so, we can provide valuable assistance and guidance not only within our specific medical specialties but also for our patients. In this way, we can effectively harness the power of technology to improve patient care and optimize our office work flow, ultimately benefiting both our patients and our practices.

Dr. Chavez is professor, department of obstetrics and gynecology, at NYU Long Island School of Medicine and director of maternal and fetal medicine at NYU Langone Hospital–Long Island, both in Mineola, N.Y. He has no disclosures.

Rates of perinatal HIV have dropped so much that the disease is effectively eliminated in the United States, with less than 1 baby for every 100,000 live births having the virus, a new study released by researchers at the Centers for Disease Control and Prevention finds.

The report marks significant progress on the U.S. government’s goal to eradicate perinatal HIV, an immune-weakening and potentially deadly virus that is passed from mother to baby during pregnancy. Just 32 children in the country were diagnosed in 2019, compared with twice as many in 2010, according to the CDC.

Mothers who are HIV positive can prevent transmission of the infection by receiving antiretroviral therapy, according to Monica Gandhi, MD, MPH, a professor of medicine at University of California, San Francisco’s division of HIV, infectious disease and global medicine.

Dr. Gandhi said she could recall only one case of perinatal HIV in the San Francisco area over the last decade.

“This country has been really aggressive about counseling women who are pregnant and getting mothers in care,” Dr. Gandhi said.

The treatment method was discovered more than 30 years ago. Prior to the therapy and ensuing awareness campaigns to prevent transmission, mothers with HIV would typically pass the virus to their child in utero, during delivery, or while breastfeeding.

“There should be zero children born with HIV, given that we’ve had these drugs for so long,” Dr. Ghandi said. 
 

Disparities persist

But challenges remain in some communities, where babies born to Black mothers are disproportionately affected by the disease, the new study found. “Racial and ethnic differences in perinatal HIV diagnoses persisted through the 10-year period,” the report’s authors concluded. “The highest rates of perinatal HIV diagnoses were seen among infants born to Black women.”

Although rates of perinatal HIV declined for babies born to Black mothers over the decade-long study, the diagnosis rate was above the goal of elimination at 3.1 for every 100,000 live births, according to the data.

Meanwhile, transmission rates hovered around 1%-2% for Latinx and Hispanic women and mothers who identified as “other races,” including Native American.

Despite the availability of medication, expectant mothers may face several hurdles to getting the daily treatment they need to prevent transmission to their fetus, according to Jennifer Jao, MD, MPH, a physician of infectious diseases at Lurie Children’s Hospital of Chicago.

They might have trouble securing health insurance or finding transportation to doctor’s appointments, or face other problems like lacking secure housing or food – all factors that prevent them from prioritizing the care.

“All of those things play into the mix,” Dr. Jao said. “We see over and over again that closing the gap means you’ve got to reach the women who are pregnant and who don’t have resources.”
 

Progress in ‘danger’

Experts said they’re not sure what the impact of the COVID-19 pandemic, accompanied by a recent uptick in sexually transmitted diseases, will be on rates of perinatal HIV. Some women were unable to access prenatal health care during the pandemic because they couldn’t access public transportation or childcare, the U.S. Government Accountability Office said in 2022.

Globally, a decline in rates of HIV and AIDS rates has slowed, prompting the World Health Organization to warn last year that progress on the disease is in danger. Researchers only included HIV rates in the United States through 2019, so the data are outdated, Dr. Gandhi noted.

“All of this put together means we don’t know where we are with perinatal transmission over the last 3 years,” she said.

In an accompanying editorial, coauthors Nahida Chakhtoura, MD, MsGH, and Bill Kapogiannis, MD, both with the National Institutes of Health, urge health care professionals to take an active role in eliminating these racial and ethnic disparities in an effort to – as the title of their editorial proclaims – achieve a “road to zero perinatal HIV transmission” in the United States.

“The more proactive we are in identifying and promptly addressing systematic deficiencies that exacerbate health inequities in cutting-edge research innovations and optimal clinical service provision,” they write, “the less reactive we will need to be when new transmissible infections appear at our doorstep.”

A version of this article first appeared on Medscape.com.

Rates of perinatal HIV have dropped so much that the disease is effectively eliminated in the United States, with less than 1 baby for every 100,000 live births having the virus, a new study released by researchers at the Centers for Disease Control and Prevention finds.

The report marks significant progress on the U.S. government’s goal to eradicate perinatal HIV, an immune-weakening and potentially deadly virus that is passed from mother to baby during pregnancy. Just 32 children in the country were diagnosed in 2019, compared with twice as many in 2010, according to the CDC.

Mothers who are HIV positive can prevent transmission of the infection by receiving antiretroviral therapy, according to Monica Gandhi, MD, MPH, a professor of medicine at University of California, San Francisco’s division of HIV, infectious disease and global medicine.

Dr. Gandhi said she could recall only one case of perinatal HIV in the San Francisco area over the last decade.

“This country has been really aggressive about counseling women who are pregnant and getting mothers in care,” Dr. Gandhi said.

The treatment method was discovered more than 30 years ago. Prior to the therapy and ensuing awareness campaigns to prevent transmission, mothers with HIV would typically pass the virus to their child in utero, during delivery, or while breastfeeding.

“There should be zero children born with HIV, given that we’ve had these drugs for so long,” Dr. Ghandi said. 
 

Disparities persist

But challenges remain in some communities, where babies born to Black mothers are disproportionately affected by the disease, the new study found. “Racial and ethnic differences in perinatal HIV diagnoses persisted through the 10-year period,” the report’s authors concluded. “The highest rates of perinatal HIV diagnoses were seen among infants born to Black women.”

Although rates of perinatal HIV declined for babies born to Black mothers over the decade-long study, the diagnosis rate was above the goal of elimination at 3.1 for every 100,000 live births, according to the data.

Meanwhile, transmission rates hovered around 1%-2% for Latinx and Hispanic women and mothers who identified as “other races,” including Native American.

Despite the availability of medication, expectant mothers may face several hurdles to getting the daily treatment they need to prevent transmission to their fetus, according to Jennifer Jao, MD, MPH, a physician of infectious diseases at Lurie Children’s Hospital of Chicago.

They might have trouble securing health insurance or finding transportation to doctor’s appointments, or face other problems like lacking secure housing or food – all factors that prevent them from prioritizing the care.

“All of those things play into the mix,” Dr. Jao said. “We see over and over again that closing the gap means you’ve got to reach the women who are pregnant and who don’t have resources.”
 

Progress in ‘danger’

Experts said they’re not sure what the impact of the COVID-19 pandemic, accompanied by a recent uptick in sexually transmitted diseases, will be on rates of perinatal HIV. Some women were unable to access prenatal health care during the pandemic because they couldn’t access public transportation or childcare, the U.S. Government Accountability Office said in 2022.

Globally, a decline in rates of HIV and AIDS rates has slowed, prompting the World Health Organization to warn last year that progress on the disease is in danger. Researchers only included HIV rates in the United States through 2019, so the data are outdated, Dr. Gandhi noted.

“All of this put together means we don’t know where we are with perinatal transmission over the last 3 years,” she said.

In an accompanying editorial, coauthors Nahida Chakhtoura, MD, MsGH, and Bill Kapogiannis, MD, both with the National Institutes of Health, urge health care professionals to take an active role in eliminating these racial and ethnic disparities in an effort to – as the title of their editorial proclaims – achieve a “road to zero perinatal HIV transmission” in the United States.

“The more proactive we are in identifying and promptly addressing systematic deficiencies that exacerbate health inequities in cutting-edge research innovations and optimal clinical service provision,” they write, “the less reactive we will need to be when new transmissible infections appear at our doorstep.”

A version of this article first appeared on Medscape.com.

Rates of perinatal HIV have dropped so much that the disease is effectively eliminated in the United States, with less than 1 baby for every 100,000 live births having the virus, a new study released by researchers at the Centers for Disease Control and Prevention finds.

The report marks significant progress on the U.S. government’s goal to eradicate perinatal HIV, an immune-weakening and potentially deadly virus that is passed from mother to baby during pregnancy. Just 32 children in the country were diagnosed in 2019, compared with twice as many in 2010, according to the CDC.

Mothers who are HIV positive can prevent transmission of the infection by receiving antiretroviral therapy, according to Monica Gandhi, MD, MPH, a professor of medicine at University of California, San Francisco’s division of HIV, infectious disease and global medicine.

Dr. Gandhi said she could recall only one case of perinatal HIV in the San Francisco area over the last decade.

“This country has been really aggressive about counseling women who are pregnant and getting mothers in care,” Dr. Gandhi said.

The treatment method was discovered more than 30 years ago. Prior to the therapy and ensuing awareness campaigns to prevent transmission, mothers with HIV would typically pass the virus to their child in utero, during delivery, or while breastfeeding.

“There should be zero children born with HIV, given that we’ve had these drugs for so long,” Dr. Ghandi said. 
 

Disparities persist

But challenges remain in some communities, where babies born to Black mothers are disproportionately affected by the disease, the new study found. “Racial and ethnic differences in perinatal HIV diagnoses persisted through the 10-year period,” the report’s authors concluded. “The highest rates of perinatal HIV diagnoses were seen among infants born to Black women.”

Although rates of perinatal HIV declined for babies born to Black mothers over the decade-long study, the diagnosis rate was above the goal of elimination at 3.1 for every 100,000 live births, according to the data.

Meanwhile, transmission rates hovered around 1%-2% for Latinx and Hispanic women and mothers who identified as “other races,” including Native American.

Despite the availability of medication, expectant mothers may face several hurdles to getting the daily treatment they need to prevent transmission to their fetus, according to Jennifer Jao, MD, MPH, a physician of infectious diseases at Lurie Children’s Hospital of Chicago.

They might have trouble securing health insurance or finding transportation to doctor’s appointments, or face other problems like lacking secure housing or food – all factors that prevent them from prioritizing the care.

“All of those things play into the mix,” Dr. Jao said. “We see over and over again that closing the gap means you’ve got to reach the women who are pregnant and who don’t have resources.”
 

Progress in ‘danger’

Experts said they’re not sure what the impact of the COVID-19 pandemic, accompanied by a recent uptick in sexually transmitted diseases, will be on rates of perinatal HIV. Some women were unable to access prenatal health care during the pandemic because they couldn’t access public transportation or childcare, the U.S. Government Accountability Office said in 2022.

Globally, a decline in rates of HIV and AIDS rates has slowed, prompting the World Health Organization to warn last year that progress on the disease is in danger. Researchers only included HIV rates in the United States through 2019, so the data are outdated, Dr. Gandhi noted.

“All of this put together means we don’t know where we are with perinatal transmission over the last 3 years,” she said.

In an accompanying editorial, coauthors Nahida Chakhtoura, MD, MsGH, and Bill Kapogiannis, MD, both with the National Institutes of Health, urge health care professionals to take an active role in eliminating these racial and ethnic disparities in an effort to – as the title of their editorial proclaims – achieve a “road to zero perinatal HIV transmission” in the United States.

“The more proactive we are in identifying and promptly addressing systematic deficiencies that exacerbate health inequities in cutting-edge research innovations and optimal clinical service provision,” they write, “the less reactive we will need to be when new transmissible infections appear at our doorstep.”

A version of this article first appeared on Medscape.com.

Women who underwent bilateral salpingo-oophorectomy with a benign hysterectomy had a higher 10-year mortality rate across all ages than those who had hysterectomies alone, based on data from more than 140,000 individuals.

Although bilateral salpingo-oophorectomy (BSO) with hysterectomy has been shown to reduce the risk for ovarian cancer in women at increased risk, current guidelines are touting ovarian conservation, especially in premenopausal women, wrote Mathilde Gottschau, MD, of the Danish Cancer Society Research Center, Copenhagen, and colleagues. However, post-hysterectomy outcomes in women with and without BSO have not been well examined.

In a study published in the Annals of Internal Medicine, the researchers reviewed data from a nationwide registry of women in Denmark aged 20 years and older who underwent benign hysterectomies with BSO (22,974 women) and without BSO (120,011 women) between 1977 and 2017. The women were divided into subgroups based on age; those younger than 45 years were defined as premenopausal, those aged 45-54 years were defined as perimenopausal, those aged 55-64 were defined as early postmenopausal, and those aged 65 and older were defined as late menopausal.

The primary outcomes were hospitalization for cardiovascular disease, cancer incidence, and all-cause mortality over a median follow-up period of 22 years.

For women younger than 45 years, the 10-year cumulative risk for all cancer was lower with BSO than without, but the risk of overall cardiovascular disease was higher with BSO, with higher levels of ischemic heart disease and stroke, compared with women without BSO. The 10-year cumulative mortality was higher with BSO than without (2.16% vs. 1.94%).

For women aged 45-54 years, the 10-year cumulative cancer risk was higher in those with BSO than those without BSO (risk difference, 0.73 percentage points) associated mainly with nonbreast cancer, and both 10-year and 20-year mortality were higher in those with BSO than those without.

For women aged 55-65 years, the 10-year cumulative cancer risk was higher in those with BSO than those without BSO. Cumulative overall mortality was higher at 10 years for those with BSO, but lower at 20 years.

For women aged 65 years and older, both 10-year and 20-year cumulative overall cancer risk was higher with BSO than without (RD, 2.54 and 4.57 percentage points, respectively). Cumulative mortality was higher in the BSO group at 10 years, but lower at 20 years.

The study findings were limited by several factors including the use of age to determine menopausal status and the lack of genetic predisposition data, and the focus only on a relatively homogeneous population that may not be generalizable to other populations, the researchers noted.

However, the results were strengthened by the use of a nationwide registry and the long-term follow-up period, they said. The current study indicates that the health risks outweigh the potential benefits of BSO with benign hysterectomy for premenopausal women and supports the current guidelines for ovarian conservation in these women with low lifetime ovarian cancer risk, they said. For postmenopausal women, the data support a cautious approach to BSO given the lack of a clear survival benefit and cancer excess, they concluded.
 

Delayed diagnosis of ovarian cancers favors BSO

“The question of removing ovaries at the time of benign hysterectomy to prevent ovarian cancer in low-risk women has been widely debated,” which has contributed to the variation in incidence rates of unilateral and bilateral oophorectomy over time, wrote Elizabeth Casiano Evans, MD, of the University of Texas, San Antonio, and Deslyn T.G. Hobson, MD, of Wayne State University, Detroit, in an accompanying editorial.

Ovarian cancer often goes undiagnosed until an advanced stage, and BSO can significantly reduce risk in women with BRCA1 and BRCA2 mutations, they noted.

For women without increased risk, those who are premenopausal may wish to preserve ovarian function, but women also may benefit from improvements in a range of menopause-related symptoms including vasomotor and urogenital symptoms, sexual dysfunction, and psychiatric and cognitive symptoms, they said.

“In addition, salpingectomy alone has a role in significantly reducing ovarian cancer incidence without compromising ovarian function because the fallopian tube has been found to be at the origin of many ovarian cancer cases,” they noted. In the current study, “the crude ovarian cancer risk was lower with BSO” across all age groups, the editorialists said.

The choice of whether to include BSO at the time of benign hysterectomy is complicated, with many factors to consider, the editorialists wrote, and the current study supports the need for informed, shared decision-making between clinicians and patients.

The study was supported by the Danish Cancer Society’s Scientific Committee and the Mermaid Project. The researchers had no financial conflicts to disclose. The editorial authors had no financial conflicts to disclose.
 

Women who underwent bilateral salpingo-oophorectomy with a benign hysterectomy had a higher 10-year mortality rate across all ages than those who had hysterectomies alone, based on data from more than 140,000 individuals.

Although bilateral salpingo-oophorectomy (BSO) with hysterectomy has been shown to reduce the risk for ovarian cancer in women at increased risk, current guidelines are touting ovarian conservation, especially in premenopausal women, wrote Mathilde Gottschau, MD, of the Danish Cancer Society Research Center, Copenhagen, and colleagues. However, post-hysterectomy outcomes in women with and without BSO have not been well examined.

In a study published in the Annals of Internal Medicine, the researchers reviewed data from a nationwide registry of women in Denmark aged 20 years and older who underwent benign hysterectomies with BSO (22,974 women) and without BSO (120,011 women) between 1977 and 2017. The women were divided into subgroups based on age; those younger than 45 years were defined as premenopausal, those aged 45-54 years were defined as perimenopausal, those aged 55-64 were defined as early postmenopausal, and those aged 65 and older were defined as late menopausal.

The primary outcomes were hospitalization for cardiovascular disease, cancer incidence, and all-cause mortality over a median follow-up period of 22 years.

For women younger than 45 years, the 10-year cumulative risk for all cancer was lower with BSO than without, but the risk of overall cardiovascular disease was higher with BSO, with higher levels of ischemic heart disease and stroke, compared with women without BSO. The 10-year cumulative mortality was higher with BSO than without (2.16% vs. 1.94%).

For women aged 45-54 years, the 10-year cumulative cancer risk was higher in those with BSO than those without BSO (risk difference, 0.73 percentage points) associated mainly with nonbreast cancer, and both 10-year and 20-year mortality were higher in those with BSO than those without.

For women aged 55-65 years, the 10-year cumulative cancer risk was higher in those with BSO than those without BSO. Cumulative overall mortality was higher at 10 years for those with BSO, but lower at 20 years.

For women aged 65 years and older, both 10-year and 20-year cumulative overall cancer risk was higher with BSO than without (RD, 2.54 and 4.57 percentage points, respectively). Cumulative mortality was higher in the BSO group at 10 years, but lower at 20 years.

The study findings were limited by several factors including the use of age to determine menopausal status and the lack of genetic predisposition data, and the focus only on a relatively homogeneous population that may not be generalizable to other populations, the researchers noted.

However, the results were strengthened by the use of a nationwide registry and the long-term follow-up period, they said. The current study indicates that the health risks outweigh the potential benefits of BSO with benign hysterectomy for premenopausal women and supports the current guidelines for ovarian conservation in these women with low lifetime ovarian cancer risk, they said. For postmenopausal women, the data support a cautious approach to BSO given the lack of a clear survival benefit and cancer excess, they concluded.
 

Delayed diagnosis of ovarian cancers favors BSO

“The question of removing ovaries at the time of benign hysterectomy to prevent ovarian cancer in low-risk women has been widely debated,” which has contributed to the variation in incidence rates of unilateral and bilateral oophorectomy over time, wrote Elizabeth Casiano Evans, MD, of the University of Texas, San Antonio, and Deslyn T.G. Hobson, MD, of Wayne State University, Detroit, in an accompanying editorial.

Ovarian cancer often goes undiagnosed until an advanced stage, and BSO can significantly reduce risk in women with BRCA1 and BRCA2 mutations, they noted.

For women without increased risk, those who are premenopausal may wish to preserve ovarian function, but women also may benefit from improvements in a range of menopause-related symptoms including vasomotor and urogenital symptoms, sexual dysfunction, and psychiatric and cognitive symptoms, they said.

“In addition, salpingectomy alone has a role in significantly reducing ovarian cancer incidence without compromising ovarian function because the fallopian tube has been found to be at the origin of many ovarian cancer cases,” they noted. In the current study, “the crude ovarian cancer risk was lower with BSO” across all age groups, the editorialists said.

The choice of whether to include BSO at the time of benign hysterectomy is complicated, with many factors to consider, the editorialists wrote, and the current study supports the need for informed, shared decision-making between clinicians and patients.

The study was supported by the Danish Cancer Society’s Scientific Committee and the Mermaid Project. The researchers had no financial conflicts to disclose. The editorial authors had no financial conflicts to disclose.
 

Women who underwent bilateral salpingo-oophorectomy with a benign hysterectomy had a higher 10-year mortality rate across all ages than those who had hysterectomies alone, based on data from more than 140,000 individuals.

Although bilateral salpingo-oophorectomy (BSO) with hysterectomy has been shown to reduce the risk for ovarian cancer in women at increased risk, current guidelines are touting ovarian conservation, especially in premenopausal women, wrote Mathilde Gottschau, MD, of the Danish Cancer Society Research Center, Copenhagen, and colleagues. However, post-hysterectomy outcomes in women with and without BSO have not been well examined.

In a study published in the Annals of Internal Medicine, the researchers reviewed data from a nationwide registry of women in Denmark aged 20 years and older who underwent benign hysterectomies with BSO (22,974 women) and without BSO (120,011 women) between 1977 and 2017. The women were divided into subgroups based on age; those younger than 45 years were defined as premenopausal, those aged 45-54 years were defined as perimenopausal, those aged 55-64 were defined as early postmenopausal, and those aged 65 and older were defined as late menopausal.

The primary outcomes were hospitalization for cardiovascular disease, cancer incidence, and all-cause mortality over a median follow-up period of 22 years.

For women younger than 45 years, the 10-year cumulative risk for all cancer was lower with BSO than without, but the risk of overall cardiovascular disease was higher with BSO, with higher levels of ischemic heart disease and stroke, compared with women without BSO. The 10-year cumulative mortality was higher with BSO than without (2.16% vs. 1.94%).

For women aged 45-54 years, the 10-year cumulative cancer risk was higher in those with BSO than those without BSO (risk difference, 0.73 percentage points) associated mainly with nonbreast cancer, and both 10-year and 20-year mortality were higher in those with BSO than those without.

For women aged 55-65 years, the 10-year cumulative cancer risk was higher in those with BSO than those without BSO. Cumulative overall mortality was higher at 10 years for those with BSO, but lower at 20 years.

For women aged 65 years and older, both 10-year and 20-year cumulative overall cancer risk was higher with BSO than without (RD, 2.54 and 4.57 percentage points, respectively). Cumulative mortality was higher in the BSO group at 10 years, but lower at 20 years.

The study findings were limited by several factors including the use of age to determine menopausal status and the lack of genetic predisposition data, and the focus only on a relatively homogeneous population that may not be generalizable to other populations, the researchers noted.

However, the results were strengthened by the use of a nationwide registry and the long-term follow-up period, they said. The current study indicates that the health risks outweigh the potential benefits of BSO with benign hysterectomy for premenopausal women and supports the current guidelines for ovarian conservation in these women with low lifetime ovarian cancer risk, they said. For postmenopausal women, the data support a cautious approach to BSO given the lack of a clear survival benefit and cancer excess, they concluded.
 

Delayed diagnosis of ovarian cancers favors BSO

“The question of removing ovaries at the time of benign hysterectomy to prevent ovarian cancer in low-risk women has been widely debated,” which has contributed to the variation in incidence rates of unilateral and bilateral oophorectomy over time, wrote Elizabeth Casiano Evans, MD, of the University of Texas, San Antonio, and Deslyn T.G. Hobson, MD, of Wayne State University, Detroit, in an accompanying editorial.

Ovarian cancer often goes undiagnosed until an advanced stage, and BSO can significantly reduce risk in women with BRCA1 and BRCA2 mutations, they noted.

For women without increased risk, those who are premenopausal may wish to preserve ovarian function, but women also may benefit from improvements in a range of menopause-related symptoms including vasomotor and urogenital symptoms, sexual dysfunction, and psychiatric and cognitive symptoms, they said.

“In addition, salpingectomy alone has a role in significantly reducing ovarian cancer incidence without compromising ovarian function because the fallopian tube has been found to be at the origin of many ovarian cancer cases,” they noted. In the current study, “the crude ovarian cancer risk was lower with BSO” across all age groups, the editorialists said.

The choice of whether to include BSO at the time of benign hysterectomy is complicated, with many factors to consider, the editorialists wrote, and the current study supports the need for informed, shared decision-making between clinicians and patients.

The study was supported by the Danish Cancer Society’s Scientific Committee and the Mermaid Project. The researchers had no financial conflicts to disclose. The editorial authors had no financial conflicts to disclose.
 

Weight loss in otherwise healthy older adults is linked to an increased risk of mortality, even from conditions not typically associated with weight change, with a substantially stronger link in men versus women, suggesting the need for clinicians to be alert to such changes.

“Our study emphasizes the importance of weight loss even in relatively healthy individuals who are free from evident cardiovascular disease [CVD], dementia, physical disability, or life-limiting chronic illness,” first author Monira Hussain, MBBS, MPH, PhD, said in an interview.

“Clinicians should be aware that even minor weight loss of 5% or more in older adults without life-limiting illnesses can increase mortality risk,” Dr. Hussain said. “Regular monitoring of weight changes can help early identification of associated risks.”

The study was published online in JAMA Network Open.

The researchers noted that data on the significance of weight changes among older individuals who are otherwise relatively healthy and not diagnosed with life-limited diseases are limited, with the exception that “it is widely acknowledged that weight loss may precede a diagnosis of cancer.” But the association with the other types of non–cancer-related premature death is notable.

“In our study, weight loss also preceded an increased mortality from CVD and other causes, [such as] deaths from trauma, dementia, Parkinson disease, and other less common causes.”

Therefore, “a likely explanation for these findings is that weight loss can be an early prodromal indicator of the presence of various life-shortening diseases,” Dr. Hussain, of Monash University, Melbourne, and colleagues wrote.

In terms of why weight loss shows such a stronger link to mortality in older men, compared with women, Dr. Hussain speculated that this may be caused by “differences in body composition,” between the two sexes. “Men have a higher proportion of muscle and bone mass, and weight loss [in men] primarily involves loss of these tissues.”
 

10% weight loss quadrupled risk of premature death among men

To investigate this phenomenon, the researchers conducted a post hoc analysis of the Aspirin in Reducing Events in the Elderly (ASPREE) randomized trial, which included information on a variety of body size parameters, such as weight and waist circumference, measured annually, from a large population of healthy individuals with no evident CVD, dementia, physical disability, or life-limiting chronic illness.

The 16,523 participants included in the study had a mean age of 75 years and 55.6% were women. During a mean follow-up of 4.4 years, 1,256 deaths occurred in the cohort.

Looking at rates of all-cause mortality, stratified by gender, the results showed that among men who had a 5%-10% decrease in weight over the course of the study, the risk of all-cause mortality was 33% higher than that of men who had a stable weight (less than 5% change; hazard ratio, 1.33).

Among men who had a more than 10% decrease in weight, the mortality risk was as much as 289%, or nearly four times higher compared with those with a stable weight (HR, 3.89).

For women, the mortality risk was also increased, however, to a lesser degree. A 5%-10% loss of body weight was associated with a 26% increased mortality risk (HR, 1.26), and a loss of more than 10% was linked to a 114% increased risk of all-cause mortality (HR, 2.14).

In terms of cancer-specific deaths, the risk was significantly increased only among men who had a greater than 10% weight decrease (HR, 3.49), while the increased risk in women was observed with a 5%-10% decrease in weight (HR, 1.44) as well as a more than 10% decrease (HR, 2.78).

The risk of CVD-specific death was significantly increased with a more than 10% decrease in weight in both sexes, but the risk was again higher among men (HR, 3.14) than women (HR, 1.92), compared with stable weight groups.

And the noncancer, non–CVD-specific mortality risk was nearly five times higher among men who had a more than 10% decrease in weight versus stable weight (HR, 4.98); however, the association was not significant among women (HR, 1.49).

Looking at the effects of change in waist circumference, a decrease of more than 10% was associated with a higher risk in all-cause mortality that was again higher for men (HR, 2.14) versus women (HR, 1.34); however, no link with all-cause mortality was observed with a less than 10% decrease in either sex.

A greater than 10% decrease in waist circumference was also associated with higher risk of cancer death for men and women, and higher noncancer, non-CVD death among men, but not women, while there was no association between waist circumference and CVD mortality in men or women.
 

Association with mortality remained after adjustment for hospitalization

The results persisted after adjustment for age, frailty status, baseline body mass index, country of birth, smoking, hypertension, diabetes, and hospitalization in the previous 24 months.

The adjustment for recent hospitalization was especially important for ruling out weight loss that may have occurred because of hospitalization for acute conditions that could have contributed to mortality, the authors noted.

The authors reported no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Weight loss in otherwise healthy older adults is linked to an increased risk of mortality, even from conditions not typically associated with weight change, with a substantially stronger link in men versus women, suggesting the need for clinicians to be alert to such changes.

“Our study emphasizes the importance of weight loss even in relatively healthy individuals who are free from evident cardiovascular disease [CVD], dementia, physical disability, or life-limiting chronic illness,” first author Monira Hussain, MBBS, MPH, PhD, said in an interview.

“Clinicians should be aware that even minor weight loss of 5% or more in older adults without life-limiting illnesses can increase mortality risk,” Dr. Hussain said. “Regular monitoring of weight changes can help early identification of associated risks.”

The study was published online in JAMA Network Open.

The researchers noted that data on the significance of weight changes among older individuals who are otherwise relatively healthy and not diagnosed with life-limited diseases are limited, with the exception that “it is widely acknowledged that weight loss may precede a diagnosis of cancer.” But the association with the other types of non–cancer-related premature death is notable.

“In our study, weight loss also preceded an increased mortality from CVD and other causes, [such as] deaths from trauma, dementia, Parkinson disease, and other less common causes.”

Therefore, “a likely explanation for these findings is that weight loss can be an early prodromal indicator of the presence of various life-shortening diseases,” Dr. Hussain, of Monash University, Melbourne, and colleagues wrote.

In terms of why weight loss shows such a stronger link to mortality in older men, compared with women, Dr. Hussain speculated that this may be caused by “differences in body composition,” between the two sexes. “Men have a higher proportion of muscle and bone mass, and weight loss [in men] primarily involves loss of these tissues.”
 

10% weight loss quadrupled risk of premature death among men

To investigate this phenomenon, the researchers conducted a post hoc analysis of the Aspirin in Reducing Events in the Elderly (ASPREE) randomized trial, which included information on a variety of body size parameters, such as weight and waist circumference, measured annually, from a large population of healthy individuals with no evident CVD, dementia, physical disability, or life-limiting chronic illness.

The 16,523 participants included in the study had a mean age of 75 years and 55.6% were women. During a mean follow-up of 4.4 years, 1,256 deaths occurred in the cohort.

Looking at rates of all-cause mortality, stratified by gender, the results showed that among men who had a 5%-10% decrease in weight over the course of the study, the risk of all-cause mortality was 33% higher than that of men who had a stable weight (less than 5% change; hazard ratio, 1.33).

Among men who had a more than 10% decrease in weight, the mortality risk was as much as 289%, or nearly four times higher compared with those with a stable weight (HR, 3.89).

For women, the mortality risk was also increased, however, to a lesser degree. A 5%-10% loss of body weight was associated with a 26% increased mortality risk (HR, 1.26), and a loss of more than 10% was linked to a 114% increased risk of all-cause mortality (HR, 2.14).

In terms of cancer-specific deaths, the risk was significantly increased only among men who had a greater than 10% weight decrease (HR, 3.49), while the increased risk in women was observed with a 5%-10% decrease in weight (HR, 1.44) as well as a more than 10% decrease (HR, 2.78).

The risk of CVD-specific death was significantly increased with a more than 10% decrease in weight in both sexes, but the risk was again higher among men (HR, 3.14) than women (HR, 1.92), compared with stable weight groups.

And the noncancer, non–CVD-specific mortality risk was nearly five times higher among men who had a more than 10% decrease in weight versus stable weight (HR, 4.98); however, the association was not significant among women (HR, 1.49).

Looking at the effects of change in waist circumference, a decrease of more than 10% was associated with a higher risk in all-cause mortality that was again higher for men (HR, 2.14) versus women (HR, 1.34); however, no link with all-cause mortality was observed with a less than 10% decrease in either sex.

A greater than 10% decrease in waist circumference was also associated with higher risk of cancer death for men and women, and higher noncancer, non-CVD death among men, but not women, while there was no association between waist circumference and CVD mortality in men or women.
 

Association with mortality remained after adjustment for hospitalization

The results persisted after adjustment for age, frailty status, baseline body mass index, country of birth, smoking, hypertension, diabetes, and hospitalization in the previous 24 months.

The adjustment for recent hospitalization was especially important for ruling out weight loss that may have occurred because of hospitalization for acute conditions that could have contributed to mortality, the authors noted.

The authors reported no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Weight loss in otherwise healthy older adults is linked to an increased risk of mortality, even from conditions not typically associated with weight change, with a substantially stronger link in men versus women, suggesting the need for clinicians to be alert to such changes.

“Our study emphasizes the importance of weight loss even in relatively healthy individuals who are free from evident cardiovascular disease [CVD], dementia, physical disability, or life-limiting chronic illness,” first author Monira Hussain, MBBS, MPH, PhD, said in an interview.

“Clinicians should be aware that even minor weight loss of 5% or more in older adults without life-limiting illnesses can increase mortality risk,” Dr. Hussain said. “Regular monitoring of weight changes can help early identification of associated risks.”

The study was published online in JAMA Network Open.

The researchers noted that data on the significance of weight changes among older individuals who are otherwise relatively healthy and not diagnosed with life-limited diseases are limited, with the exception that “it is widely acknowledged that weight loss may precede a diagnosis of cancer.” But the association with the other types of non–cancer-related premature death is notable.

“In our study, weight loss also preceded an increased mortality from CVD and other causes, [such as] deaths from trauma, dementia, Parkinson disease, and other less common causes.”

Therefore, “a likely explanation for these findings is that weight loss can be an early prodromal indicator of the presence of various life-shortening diseases,” Dr. Hussain, of Monash University, Melbourne, and colleagues wrote.

In terms of why weight loss shows such a stronger link to mortality in older men, compared with women, Dr. Hussain speculated that this may be caused by “differences in body composition,” between the two sexes. “Men have a higher proportion of muscle and bone mass, and weight loss [in men] primarily involves loss of these tissues.”
 

10% weight loss quadrupled risk of premature death among men

To investigate this phenomenon, the researchers conducted a post hoc analysis of the Aspirin in Reducing Events in the Elderly (ASPREE) randomized trial, which included information on a variety of body size parameters, such as weight and waist circumference, measured annually, from a large population of healthy individuals with no evident CVD, dementia, physical disability, or life-limiting chronic illness.

The 16,523 participants included in the study had a mean age of 75 years and 55.6% were women. During a mean follow-up of 4.4 years, 1,256 deaths occurred in the cohort.

Looking at rates of all-cause mortality, stratified by gender, the results showed that among men who had a 5%-10% decrease in weight over the course of the study, the risk of all-cause mortality was 33% higher than that of men who had a stable weight (less than 5% change; hazard ratio, 1.33).

Among men who had a more than 10% decrease in weight, the mortality risk was as much as 289%, or nearly four times higher compared with those with a stable weight (HR, 3.89).

For women, the mortality risk was also increased, however, to a lesser degree. A 5%-10% loss of body weight was associated with a 26% increased mortality risk (HR, 1.26), and a loss of more than 10% was linked to a 114% increased risk of all-cause mortality (HR, 2.14).

In terms of cancer-specific deaths, the risk was significantly increased only among men who had a greater than 10% weight decrease (HR, 3.49), while the increased risk in women was observed with a 5%-10% decrease in weight (HR, 1.44) as well as a more than 10% decrease (HR, 2.78).

The risk of CVD-specific death was significantly increased with a more than 10% decrease in weight in both sexes, but the risk was again higher among men (HR, 3.14) than women (HR, 1.92), compared with stable weight groups.

And the noncancer, non–CVD-specific mortality risk was nearly five times higher among men who had a more than 10% decrease in weight versus stable weight (HR, 4.98); however, the association was not significant among women (HR, 1.49).

Looking at the effects of change in waist circumference, a decrease of more than 10% was associated with a higher risk in all-cause mortality that was again higher for men (HR, 2.14) versus women (HR, 1.34); however, no link with all-cause mortality was observed with a less than 10% decrease in either sex.

A greater than 10% decrease in waist circumference was also associated with higher risk of cancer death for men and women, and higher noncancer, non-CVD death among men, but not women, while there was no association between waist circumference and CVD mortality in men or women.
 

Association with mortality remained after adjustment for hospitalization

The results persisted after adjustment for age, frailty status, baseline body mass index, country of birth, smoking, hypertension, diabetes, and hospitalization in the previous 24 months.

The adjustment for recent hospitalization was especially important for ruling out weight loss that may have occurred because of hospitalization for acute conditions that could have contributed to mortality, the authors noted.

The authors reported no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

The new COVID-19 strain known as “Arcturus” has increased in the United States so much that it has been added to the Centers for Disease and Control’s watch list.

Officially labeled XBB.1.16, Arcturus is a subvariant of Omicron that was first seen in India and has been on the World Health Organization’s watchlist since the end of March. The CDC’s most recent update now lists Arcturus as causing 7% of U.S. coronavirus cases, landing it in second place behind its long-predominant Omicron cousin XBB.1.5, which causes 78% of cases.

Arcturus is more transmissible but not more dangerous than recent chart-topping strains, experts say.

“It is causing increasing case counts in certain parts of the world, including India. We’re not seeing high rates of XBB.1.16 yet in the United States, but it may become more prominent in coming weeks,” Mayo Clinic viral disease expert Matthew Binnicker, PhD, told The Seattle Times.

Arcturus has been causing a new symptom in children, Indian medical providers have reported.

“One new feature of cases caused by this variant is that it seems to be causing conjunctivitis, or red and itchy eyes, in young patients,” Dr. Binnicker said. “This is not something that we’ve seen with prior strains of the virus.”

More than 11,000 people in the United States remained hospitalized with COVID at the end of last week, and 1,327 people died of the virus last week, CDC data show. To date, 6.9 million people worldwide have died from COVID, the WHO says. Of those deaths, more than 1.1 million occurred in the U.S.

A version of this article originally appeared on WebMD.com.

The new COVID-19 strain known as “Arcturus” has increased in the United States so much that it has been added to the Centers for Disease and Control’s watch list.

Officially labeled XBB.1.16, Arcturus is a subvariant of Omicron that was first seen in India and has been on the World Health Organization’s watchlist since the end of March. The CDC’s most recent update now lists Arcturus as causing 7% of U.S. coronavirus cases, landing it in second place behind its long-predominant Omicron cousin XBB.1.5, which causes 78% of cases.

Arcturus is more transmissible but not more dangerous than recent chart-topping strains, experts say.

“It is causing increasing case counts in certain parts of the world, including India. We’re not seeing high rates of XBB.1.16 yet in the United States, but it may become more prominent in coming weeks,” Mayo Clinic viral disease expert Matthew Binnicker, PhD, told The Seattle Times.

Arcturus has been causing a new symptom in children, Indian medical providers have reported.

“One new feature of cases caused by this variant is that it seems to be causing conjunctivitis, or red and itchy eyes, in young patients,” Dr. Binnicker said. “This is not something that we’ve seen with prior strains of the virus.”

More than 11,000 people in the United States remained hospitalized with COVID at the end of last week, and 1,327 people died of the virus last week, CDC data show. To date, 6.9 million people worldwide have died from COVID, the WHO says. Of those deaths, more than 1.1 million occurred in the U.S.

A version of this article originally appeared on WebMD.com.

The new COVID-19 strain known as “Arcturus” has increased in the United States so much that it has been added to the Centers for Disease and Control’s watch list.

Officially labeled XBB.1.16, Arcturus is a subvariant of Omicron that was first seen in India and has been on the World Health Organization’s watchlist since the end of March. The CDC’s most recent update now lists Arcturus as causing 7% of U.S. coronavirus cases, landing it in second place behind its long-predominant Omicron cousin XBB.1.5, which causes 78% of cases.

Arcturus is more transmissible but not more dangerous than recent chart-topping strains, experts say.

“It is causing increasing case counts in certain parts of the world, including India. We’re not seeing high rates of XBB.1.16 yet in the United States, but it may become more prominent in coming weeks,” Mayo Clinic viral disease expert Matthew Binnicker, PhD, told The Seattle Times.

Arcturus has been causing a new symptom in children, Indian medical providers have reported.

“One new feature of cases caused by this variant is that it seems to be causing conjunctivitis, or red and itchy eyes, in young patients,” Dr. Binnicker said. “This is not something that we’ve seen with prior strains of the virus.”

More than 11,000 people in the United States remained hospitalized with COVID at the end of last week, and 1,327 people died of the virus last week, CDC data show. To date, 6.9 million people worldwide have died from COVID, the WHO says. Of those deaths, more than 1.1 million occurred in the U.S.

A version of this article originally appeared on WebMD.com.

Performing intimate exams under anesthesia (EUA) is a standard part of medical training. Yet, some researchers and opponents argue that pelvic and prostate exams too often occur without explicit patient consent, resulting in a professional breach of conduct that undermines institutional trust, leaves learners morally conflicted, raises racial equity concerns, and has more states stepping in to prohibit the practice.

“Whenever I talk about this at conferences around the country, people always come up to me and say it’s still happening at their institutions,” Lori Bruce, MA, MBE, HEC-C, associate director of the Interdisciplinary Center for Bioethics at Yale University, New Haven, Conn., told this news organization.

Most think this is a women’s issue, which occurs only in unconscious patients, she said. But Ms. Bruce found otherwise in a survey last year in which she polled the general public about their intimate exam experiences.

“Unconsented exams happen much more than we imagined, and they happen as often to men [having] prostate exams without consent as to women. Black [respondents] were nearly four times more likely to have reported receiving an unconsented intimate pelvic or prostate exam,” she said, based on her research. And Ms. Bruce believes it can happen across the economic spectrum.

Concern about unconsented EUAs arose in the early 2000s. In a study at that time, 75% of medical students reported that their patients had not given consent to be examined during surgical procedures. An ethics committee of the American College of Obstetricians and Gynecologists published guidelines for EUAs and states began passing legislation with patient protections and medical training consent policies.

California is believed to be the first to adopt legislation outlawing unconsented pelvic exams for training purposes in 2003, followed by Virginia in 2007, along with a handful of other states.

In 2019, on the heels of the #MeToo movement and renewed calls to end unconsented exams, more patients and providers began to speak publicly about their experiences with the practice. Some posted on social media using the #MeTooPelvic hashtag. In 2022, an award-winning documentary was also released about consent, “At Your Cervix.”More states subsequently passed legislation, and some medical schools strengthened their EUA consent policies.

Today, nearly half the states in the country have enacted laws against unconsented intimate EUAs, with some carrying misdemeanor charges for both the individual conducting the exam and the supervising physician. Other states leave open the option to fine the physician and revoke or suspend medical licenses.

Much of the new legislation requires explicit consent for intimate exams involving the pelvis, prostate, and rectum, with exceptions for emergency procedures and, in some cases, the collection of court-ordered forensic evidence. In addition, several states, including Colorado, Indiana, and Ohio, have pending or recently introduced bills. Last month, sister bills in Missouri passed the House and Senate, gaining more traction than previous legislative attempts. A similar bill was introduced in the Kansas House several times, including this year, and is expected to be on the agenda again in the next session. 

Intimate exams on patients without consent are “unethical and unacceptable,” said Alison Whelan, MD, chief academic officer of the Association of American Medical Colleges. Although medical students learn sensitive procedures through simulation labs and gynecological teaching associates – individuals specifically trained to help students develop physical exam skills –  EUAs require strict adherence to widely accepted guidelines.

“Learners in the clinical setting should only perform such examinations for teaching purposes when the exam is explicitly consented to, related to the planned procedure, performed by a student who is recognized by the patient as a part of their care team, and done under direct supervision by an educator,” Dr. Whelan said.
 

Medical students bear moral burden

Arthur Caplan, PhD, director of medical ethics at New York University, has called unconsented intimate exams a “cousin issue” to abusive predatory behavior.

If the public is outraged that physicians “have misused their authority with athletes, then we should be equally outraged if that authority, even for a higher purpose [like] teaching and training, is still misused in terms of getting permission and consent,” he said in a video discussing Connecticut’s legislation to strengthen intimate exam requirements, which went into effect Jan. 1.   

Advocates of stricter EUA consent policies say the variability in consent practices destroys patient trust by ignoring the basic principles of respect and autonomy. Because patients are usually unaware a violation has occurred, reporting typically depends on medical students raising questions with educators and attendings, which they may hesitate to do for fear of repercussions.

Current practices, such as patients signing consent documents in the outpatient setting where students aren’t always privy to the discussion, contribute to the lack of transparency, Karampreet Kaur, MD, a 2nd-year ob.gyn. resident at the Hospital of the University of Pennsylvania, Philadelphia, said.

A 2019 survey of medical students by Elle magazine found that nearly half did not meet patients before conducting an intimate EUA. Of the 92% who performed a pelvic EUA, 61% reported doing so without obtaining explicit patient consent.

Dr. Kaur recently coauthored a survey of students from six medical schools and found that 84% completed at least one pelvic EUA during their ob.gyn. clerkships. About half of the students surveyed observed patients giving informed consent most or every time. Of those, 67% reported they never or rarely witnessed an explicit explanation that a medical student may perform a pelvic EUA.

This burden weighs on the consciences of medical students. Respondents reported that they wanted to honor patient autonomy but felt they lacked the authority to object to pelvic EUAs when consent was unclear, which led to significant emotional distress.

“It’s not that physicians don’t care,” Dr. Kaur said. “I think most want to make sure patients feel safe and fully informed of the care they are receiving.”
 

To consent or not 

Incorporating a separate EUA consent form, typically signed during a preoperative visit but occasionally on the day of surgery, offers one potential solution as it ensures “clear and consistent language is used and forces documentation of this conversation,” said Dr. Kaur. At her current institution, providers and medical students must review charted EUA documentation, then that information is “made clear to attendings, fellows, residents, students, and even the OR staff,” she said.  

In Dr. Kaur’s survey, 11% of respondents supported a separate consent. Another study of 3rd- and 4th-year medical students published last year found that 45% agreed with having a separate signature line on the surgical consent form.

Legislation introduced recently in Colorado states that medical students must meet the patient, and patients must receive a written or electronic document titled, in at least 18-point bolded font, “consent for examination of breasts, pelvic region, rectum, and/or prostate.” The form must also include the names of medical students performing or observing an intimate exam for educational purposes.

Elizabeth Newman, MPP, public policy director at the Colorado Coalition Against Sexual Assault and supporter of the state’s intimate exam bill, said the legislation will allow medical students to learn the intricacies of these sensitive body systems and provide better patient care, particularly following the rollback of Roe v. Wade.

“Abortion is available and accessible in Colorado, and we are surrounded by states where it’s not,” said Ms. Newman. “Medical students in states where it’s outright banned are coming to Colorado to learn how to provide abortion care in their residencies and fellowships, so we want to maintain that access and not take those learning opportunities away with this law.”

Opponents of a separate form say it complicates the consent process. Dr. Kaur said she originally thought it would involve a lot of extra work, but it only takes 3-5 minutes. Few patients decline the exam after the conversation, and students benefit from the clear guidelines and transparency, she said.

“I had hoped that the many medical association guidelines [supporting] explicit consent would have influenced hospital policy, but it did not have that effect,” said Ms. Bruce, adding that recent legislative efforts have largely been driven by concerned bioethicists, lawmakers, and some medical students and physicians. “It all circles back to the patient having the right to refuse; it’s their body.”

A version of this article first appeared on Medscape.com.

Performing intimate exams under anesthesia (EUA) is a standard part of medical training. Yet, some researchers and opponents argue that pelvic and prostate exams too often occur without explicit patient consent, resulting in a professional breach of conduct that undermines institutional trust, leaves learners morally conflicted, raises racial equity concerns, and has more states stepping in to prohibit the practice.

“Whenever I talk about this at conferences around the country, people always come up to me and say it’s still happening at their institutions,” Lori Bruce, MA, MBE, HEC-C, associate director of the Interdisciplinary Center for Bioethics at Yale University, New Haven, Conn., told this news organization.

Most think this is a women’s issue, which occurs only in unconscious patients, she said. But Ms. Bruce found otherwise in a survey last year in which she polled the general public about their intimate exam experiences.

“Unconsented exams happen much more than we imagined, and they happen as often to men [having] prostate exams without consent as to women. Black [respondents] were nearly four times more likely to have reported receiving an unconsented intimate pelvic or prostate exam,” she said, based on her research. And Ms. Bruce believes it can happen across the economic spectrum.

Concern about unconsented EUAs arose in the early 2000s. In a study at that time, 75% of medical students reported that their patients had not given consent to be examined during surgical procedures. An ethics committee of the American College of Obstetricians and Gynecologists published guidelines for EUAs and states began passing legislation with patient protections and medical training consent policies.

California is believed to be the first to adopt legislation outlawing unconsented pelvic exams for training purposes in 2003, followed by Virginia in 2007, along with a handful of other states.

In 2019, on the heels of the #MeToo movement and renewed calls to end unconsented exams, more patients and providers began to speak publicly about their experiences with the practice. Some posted on social media using the #MeTooPelvic hashtag. In 2022, an award-winning documentary was also released about consent, “At Your Cervix.”More states subsequently passed legislation, and some medical schools strengthened their EUA consent policies.

Today, nearly half the states in the country have enacted laws against unconsented intimate EUAs, with some carrying misdemeanor charges for both the individual conducting the exam and the supervising physician. Other states leave open the option to fine the physician and revoke or suspend medical licenses.

Much of the new legislation requires explicit consent for intimate exams involving the pelvis, prostate, and rectum, with exceptions for emergency procedures and, in some cases, the collection of court-ordered forensic evidence. In addition, several states, including Colorado, Indiana, and Ohio, have pending or recently introduced bills. Last month, sister bills in Missouri passed the House and Senate, gaining more traction than previous legislative attempts. A similar bill was introduced in the Kansas House several times, including this year, and is expected to be on the agenda again in the next session. 

Intimate exams on patients without consent are “unethical and unacceptable,” said Alison Whelan, MD, chief academic officer of the Association of American Medical Colleges. Although medical students learn sensitive procedures through simulation labs and gynecological teaching associates – individuals specifically trained to help students develop physical exam skills –  EUAs require strict adherence to widely accepted guidelines.

“Learners in the clinical setting should only perform such examinations for teaching purposes when the exam is explicitly consented to, related to the planned procedure, performed by a student who is recognized by the patient as a part of their care team, and done under direct supervision by an educator,” Dr. Whelan said.
 

Medical students bear moral burden

Arthur Caplan, PhD, director of medical ethics at New York University, has called unconsented intimate exams a “cousin issue” to abusive predatory behavior.

If the public is outraged that physicians “have misused their authority with athletes, then we should be equally outraged if that authority, even for a higher purpose [like] teaching and training, is still misused in terms of getting permission and consent,” he said in a video discussing Connecticut’s legislation to strengthen intimate exam requirements, which went into effect Jan. 1.   

Advocates of stricter EUA consent policies say the variability in consent practices destroys patient trust by ignoring the basic principles of respect and autonomy. Because patients are usually unaware a violation has occurred, reporting typically depends on medical students raising questions with educators and attendings, which they may hesitate to do for fear of repercussions.

Current practices, such as patients signing consent documents in the outpatient setting where students aren’t always privy to the discussion, contribute to the lack of transparency, Karampreet Kaur, MD, a 2nd-year ob.gyn. resident at the Hospital of the University of Pennsylvania, Philadelphia, said.

A 2019 survey of medical students by Elle magazine found that nearly half did not meet patients before conducting an intimate EUA. Of the 92% who performed a pelvic EUA, 61% reported doing so without obtaining explicit patient consent.

Dr. Kaur recently coauthored a survey of students from six medical schools and found that 84% completed at least one pelvic EUA during their ob.gyn. clerkships. About half of the students surveyed observed patients giving informed consent most or every time. Of those, 67% reported they never or rarely witnessed an explicit explanation that a medical student may perform a pelvic EUA.

This burden weighs on the consciences of medical students. Respondents reported that they wanted to honor patient autonomy but felt they lacked the authority to object to pelvic EUAs when consent was unclear, which led to significant emotional distress.

“It’s not that physicians don’t care,” Dr. Kaur said. “I think most want to make sure patients feel safe and fully informed of the care they are receiving.”
 

To consent or not 

Incorporating a separate EUA consent form, typically signed during a preoperative visit but occasionally on the day of surgery, offers one potential solution as it ensures “clear and consistent language is used and forces documentation of this conversation,” said Dr. Kaur. At her current institution, providers and medical students must review charted EUA documentation, then that information is “made clear to attendings, fellows, residents, students, and even the OR staff,” she said.  

In Dr. Kaur’s survey, 11% of respondents supported a separate consent. Another study of 3rd- and 4th-year medical students published last year found that 45% agreed with having a separate signature line on the surgical consent form.

Legislation introduced recently in Colorado states that medical students must meet the patient, and patients must receive a written or electronic document titled, in at least 18-point bolded font, “consent for examination of breasts, pelvic region, rectum, and/or prostate.” The form must also include the names of medical students performing or observing an intimate exam for educational purposes.

Elizabeth Newman, MPP, public policy director at the Colorado Coalition Against Sexual Assault and supporter of the state’s intimate exam bill, said the legislation will allow medical students to learn the intricacies of these sensitive body systems and provide better patient care, particularly following the rollback of Roe v. Wade.

“Abortion is available and accessible in Colorado, and we are surrounded by states where it’s not,” said Ms. Newman. “Medical students in states where it’s outright banned are coming to Colorado to learn how to provide abortion care in their residencies and fellowships, so we want to maintain that access and not take those learning opportunities away with this law.”

Opponents of a separate form say it complicates the consent process. Dr. Kaur said she originally thought it would involve a lot of extra work, but it only takes 3-5 minutes. Few patients decline the exam after the conversation, and students benefit from the clear guidelines and transparency, she said.

“I had hoped that the many medical association guidelines [supporting] explicit consent would have influenced hospital policy, but it did not have that effect,” said Ms. Bruce, adding that recent legislative efforts have largely been driven by concerned bioethicists, lawmakers, and some medical students and physicians. “It all circles back to the patient having the right to refuse; it’s their body.”

A version of this article first appeared on Medscape.com.

Performing intimate exams under anesthesia (EUA) is a standard part of medical training. Yet, some researchers and opponents argue that pelvic and prostate exams too often occur without explicit patient consent, resulting in a professional breach of conduct that undermines institutional trust, leaves learners morally conflicted, raises racial equity concerns, and has more states stepping in to prohibit the practice.

“Whenever I talk about this at conferences around the country, people always come up to me and say it’s still happening at their institutions,” Lori Bruce, MA, MBE, HEC-C, associate director of the Interdisciplinary Center for Bioethics at Yale University, New Haven, Conn., told this news organization.

Most think this is a women’s issue, which occurs only in unconscious patients, she said. But Ms. Bruce found otherwise in a survey last year in which she polled the general public about their intimate exam experiences.

“Unconsented exams happen much more than we imagined, and they happen as often to men [having] prostate exams without consent as to women. Black [respondents] were nearly four times more likely to have reported receiving an unconsented intimate pelvic or prostate exam,” she said, based on her research. And Ms. Bruce believes it can happen across the economic spectrum.

Concern about unconsented EUAs arose in the early 2000s. In a study at that time, 75% of medical students reported that their patients had not given consent to be examined during surgical procedures. An ethics committee of the American College of Obstetricians and Gynecologists published guidelines for EUAs and states began passing legislation with patient protections and medical training consent policies.

California is believed to be the first to adopt legislation outlawing unconsented pelvic exams for training purposes in 2003, followed by Virginia in 2007, along with a handful of other states.

In 2019, on the heels of the #MeToo movement and renewed calls to end unconsented exams, more patients and providers began to speak publicly about their experiences with the practice. Some posted on social media using the #MeTooPelvic hashtag. In 2022, an award-winning documentary was also released about consent, “At Your Cervix.”More states subsequently passed legislation, and some medical schools strengthened their EUA consent policies.

Today, nearly half the states in the country have enacted laws against unconsented intimate EUAs, with some carrying misdemeanor charges for both the individual conducting the exam and the supervising physician. Other states leave open the option to fine the physician and revoke or suspend medical licenses.

Much of the new legislation requires explicit consent for intimate exams involving the pelvis, prostate, and rectum, with exceptions for emergency procedures and, in some cases, the collection of court-ordered forensic evidence. In addition, several states, including Colorado, Indiana, and Ohio, have pending or recently introduced bills. Last month, sister bills in Missouri passed the House and Senate, gaining more traction than previous legislative attempts. A similar bill was introduced in the Kansas House several times, including this year, and is expected to be on the agenda again in the next session. 

Intimate exams on patients without consent are “unethical and unacceptable,” said Alison Whelan, MD, chief academic officer of the Association of American Medical Colleges. Although medical students learn sensitive procedures through simulation labs and gynecological teaching associates – individuals specifically trained to help students develop physical exam skills –  EUAs require strict adherence to widely accepted guidelines.

“Learners in the clinical setting should only perform such examinations for teaching purposes when the exam is explicitly consented to, related to the planned procedure, performed by a student who is recognized by the patient as a part of their care team, and done under direct supervision by an educator,” Dr. Whelan said.
 

Medical students bear moral burden

Arthur Caplan, PhD, director of medical ethics at New York University, has called unconsented intimate exams a “cousin issue” to abusive predatory behavior.

If the public is outraged that physicians “have misused their authority with athletes, then we should be equally outraged if that authority, even for a higher purpose [like] teaching and training, is still misused in terms of getting permission and consent,” he said in a video discussing Connecticut’s legislation to strengthen intimate exam requirements, which went into effect Jan. 1.   

Advocates of stricter EUA consent policies say the variability in consent practices destroys patient trust by ignoring the basic principles of respect and autonomy. Because patients are usually unaware a violation has occurred, reporting typically depends on medical students raising questions with educators and attendings, which they may hesitate to do for fear of repercussions.

Current practices, such as patients signing consent documents in the outpatient setting where students aren’t always privy to the discussion, contribute to the lack of transparency, Karampreet Kaur, MD, a 2nd-year ob.gyn. resident at the Hospital of the University of Pennsylvania, Philadelphia, said.

A 2019 survey of medical students by Elle magazine found that nearly half did not meet patients before conducting an intimate EUA. Of the 92% who performed a pelvic EUA, 61% reported doing so without obtaining explicit patient consent.

Dr. Kaur recently coauthored a survey of students from six medical schools and found that 84% completed at least one pelvic EUA during their ob.gyn. clerkships. About half of the students surveyed observed patients giving informed consent most or every time. Of those, 67% reported they never or rarely witnessed an explicit explanation that a medical student may perform a pelvic EUA.

This burden weighs on the consciences of medical students. Respondents reported that they wanted to honor patient autonomy but felt they lacked the authority to object to pelvic EUAs when consent was unclear, which led to significant emotional distress.

“It’s not that physicians don’t care,” Dr. Kaur said. “I think most want to make sure patients feel safe and fully informed of the care they are receiving.”
 

To consent or not 

Incorporating a separate EUA consent form, typically signed during a preoperative visit but occasionally on the day of surgery, offers one potential solution as it ensures “clear and consistent language is used and forces documentation of this conversation,” said Dr. Kaur. At her current institution, providers and medical students must review charted EUA documentation, then that information is “made clear to attendings, fellows, residents, students, and even the OR staff,” she said.  

In Dr. Kaur’s survey, 11% of respondents supported a separate consent. Another study of 3rd- and 4th-year medical students published last year found that 45% agreed with having a separate signature line on the surgical consent form.

Legislation introduced recently in Colorado states that medical students must meet the patient, and patients must receive a written or electronic document titled, in at least 18-point bolded font, “consent for examination of breasts, pelvic region, rectum, and/or prostate.” The form must also include the names of medical students performing or observing an intimate exam for educational purposes.

Elizabeth Newman, MPP, public policy director at the Colorado Coalition Against Sexual Assault and supporter of the state’s intimate exam bill, said the legislation will allow medical students to learn the intricacies of these sensitive body systems and provide better patient care, particularly following the rollback of Roe v. Wade.

“Abortion is available and accessible in Colorado, and we are surrounded by states where it’s not,” said Ms. Newman. “Medical students in states where it’s outright banned are coming to Colorado to learn how to provide abortion care in their residencies and fellowships, so we want to maintain that access and not take those learning opportunities away with this law.”

Opponents of a separate form say it complicates the consent process. Dr. Kaur said she originally thought it would involve a lot of extra work, but it only takes 3-5 minutes. Few patients decline the exam after the conversation, and students benefit from the clear guidelines and transparency, she said.

“I had hoped that the many medical association guidelines [supporting] explicit consent would have influenced hospital policy, but it did not have that effect,” said Ms. Bruce, adding that recent legislative efforts have largely been driven by concerned bioethicists, lawmakers, and some medical students and physicians. “It all circles back to the patient having the right to refuse; it’s their body.”

A version of this article first appeared on Medscape.com.

Risk-stratified timing of birth at term may reduce a mother’s risk of preeclampsia by half, analysis of a large U.K. cohort suggests.

Timed birth strategies include scheduled labor inductions and cesarean deliveries.

In this observational analysis of nearly 90,000 pregnancies, at-term preeclampsia occurred with similar frequency among women routinely screened during the first trimester and among at-risk women screened during the third trimester.

Overall, on average, at-risk women delivered at 40 weeks, with two-thirds experiencing spontaneous onset of labor. About one-fourth had cesarean deliveries.

“We anticipated that timed birth at 37 weeks could reduce the occurrence of more than half of preeclampsia, [but] this is not an intervention that could be recommended, as complications for the baby would be increased,” Laura A. Magee, MD, of King’s College London, told this news organization.

“However, we were delighted to see that a personalized approach to timed birth, based on an individual woman’s risk of preeclampsia, could prevent a similar number of cases of preeclampsia, with fewer women requiring timed birth and at later gestational ages, when newborn problems would be less frequent.”

Although not currently recommended to prevent at-term preeclampsia, “timed birth by labor induction is a very common timing of birth strategy,” she noted. “At least one-third of women currently undergo labor induction at term gestational age, and one in six choose to deliver by elective cesarean.”

The study was published online in the journal Hypertension.
 

Screening at 35-36 weeks superior

The investigators analyzed data from a nonintervention cohort study of singleton pregnancies delivering at ≥ 24 weeks, without major anomalies, at two U.K. hospitals.

At routine visits at 11-13 weeks’ gestation, 57,131 pregnancies were screened, and 1,138 term preeclampsia cases developed.

Most of these women were in their early 30s, self-identified as White, and had a BMI at the upper limits of normal. About 10% were smokers; fewer than 3% had a medical history of high blood pressure, type 2 diabetes, or autoimmune disease; and 3.9% reported a family history of preeclampsia.

At 35-36 weeks, in a different cohort, 29,035 pregnancies were screened and term preeclampsia developed in 619 women. Demographics and pregnancy characteristics were similar to those screened at 11-13 weeks, although the average BMI was higher – in the overweight range – and there were fewer Black women, although they still made up 10% of the screened population.

Patient-specific preeclampsia risks were determined by the United Kingdom National Institute for Health and Care Excellence (NICE) guidance, and the Fetal Medicine Foundation competing-risks model, available through an online calculator.

Timing of birth for term preeclampsia prevention was evaluated at 37, 38, 39, and 40 weeks or depending on preeclampsia risk by the competing-risks model at 35-36 weeks.

The primary outcomes were the proportion of term preeclampsia prevented, and number-needed-to-deliver to prevent one term preeclampsia case.

The investigators found that overall, the proportion of term preeclampsia prevented was highest, and number-needed-to-deliver lowest, for preeclampsia screening at 35-36 weeks rather than at 11-13 weeks.

For delivery at 37 weeks, fewer cases of preeclampsia were prevented with NICE criteria (28.8%) than with the competing-risks model (59.8%), and the number-needed-to-deliver was higher (16.4 vs 6.9, respectively).

At 35-36 weeks, the risk-stratified approach had similar preeclampsia prevention (57.2%) and number-needed-to-deliver (8.4), but fewer women would be induced at 37 weeks (1.2% vs. 8.8%).

Although personalized timed birth at term may be an effective way to address at-term preeclampsia, “clinicians should wait for definitive clinical trial evidence,” Dr. Magee said.
 

‘Stay tuned’

Vesna D. Garovic, MD, PhD, Mayo Clinic, Rochester, Minn., and chair of the 2021 AHA Scientific Statement, “Hypertension in Pregnancy: Diagnosis, Blood Pressure Goals, and Pharmacotherapy,” agrees.

The new data “set the stage for adequately designed and powered studies that will provide ultimate response/evidence regarding the efficacy of this approach,” she told this news organization.

“Future studies need to address the safety of this approach,” she added, “as close to 10 timed/planned deliveries will be needed to prevent one case of preeclampsia.”

For now, she said, “While these preliminary data are promising, they are not sufficient to adopt timed birth in daily practice. Prospective studies that will provide sufficient evidence regarding the efficacy and safety of this approach are likely to follow. Stay tuned.”

Indeed, Dr. Magee noted that the Fetal Medicine Foundation is about to launch a randomized trial of a personalized “timing of birth” strategy at term based on the preeclampsia risk described in her group’s study vs. usual care at term – that is, “watchful waiting, and delivery should preeclampsia or another indication for birth develop.”

The study was supported by grants from the Fetal Medicine Foundation, United Kingdom, and various biotech companies provided reagents and relevant equipment free of charge. Dr. Magee and Dr. Garovic reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Risk-stratified timing of birth at term may reduce a mother’s risk of preeclampsia by half, analysis of a large U.K. cohort suggests.

Timed birth strategies include scheduled labor inductions and cesarean deliveries.

In this observational analysis of nearly 90,000 pregnancies, at-term preeclampsia occurred with similar frequency among women routinely screened during the first trimester and among at-risk women screened during the third trimester.

Overall, on average, at-risk women delivered at 40 weeks, with two-thirds experiencing spontaneous onset of labor. About one-fourth had cesarean deliveries.

“We anticipated that timed birth at 37 weeks could reduce the occurrence of more than half of preeclampsia, [but] this is not an intervention that could be recommended, as complications for the baby would be increased,” Laura A. Magee, MD, of King’s College London, told this news organization.

“However, we were delighted to see that a personalized approach to timed birth, based on an individual woman’s risk of preeclampsia, could prevent a similar number of cases of preeclampsia, with fewer women requiring timed birth and at later gestational ages, when newborn problems would be less frequent.”

Although not currently recommended to prevent at-term preeclampsia, “timed birth by labor induction is a very common timing of birth strategy,” she noted. “At least one-third of women currently undergo labor induction at term gestational age, and one in six choose to deliver by elective cesarean.”

The study was published online in the journal Hypertension.
 

Screening at 35-36 weeks superior

The investigators analyzed data from a nonintervention cohort study of singleton pregnancies delivering at ≥ 24 weeks, without major anomalies, at two U.K. hospitals.

At routine visits at 11-13 weeks’ gestation, 57,131 pregnancies were screened, and 1,138 term preeclampsia cases developed.

Most of these women were in their early 30s, self-identified as White, and had a BMI at the upper limits of normal. About 10% were smokers; fewer than 3% had a medical history of high blood pressure, type 2 diabetes, or autoimmune disease; and 3.9% reported a family history of preeclampsia.

At 35-36 weeks, in a different cohort, 29,035 pregnancies were screened and term preeclampsia developed in 619 women. Demographics and pregnancy characteristics were similar to those screened at 11-13 weeks, although the average BMI was higher – in the overweight range – and there were fewer Black women, although they still made up 10% of the screened population.

Patient-specific preeclampsia risks were determined by the United Kingdom National Institute for Health and Care Excellence (NICE) guidance, and the Fetal Medicine Foundation competing-risks model, available through an online calculator.

Timing of birth for term preeclampsia prevention was evaluated at 37, 38, 39, and 40 weeks or depending on preeclampsia risk by the competing-risks model at 35-36 weeks.

The primary outcomes were the proportion of term preeclampsia prevented, and number-needed-to-deliver to prevent one term preeclampsia case.

The investigators found that overall, the proportion of term preeclampsia prevented was highest, and number-needed-to-deliver lowest, for preeclampsia screening at 35-36 weeks rather than at 11-13 weeks.

For delivery at 37 weeks, fewer cases of preeclampsia were prevented with NICE criteria (28.8%) than with the competing-risks model (59.8%), and the number-needed-to-deliver was higher (16.4 vs 6.9, respectively).

At 35-36 weeks, the risk-stratified approach had similar preeclampsia prevention (57.2%) and number-needed-to-deliver (8.4), but fewer women would be induced at 37 weeks (1.2% vs. 8.8%).

Although personalized timed birth at term may be an effective way to address at-term preeclampsia, “clinicians should wait for definitive clinical trial evidence,” Dr. Magee said.
 

‘Stay tuned’

Vesna D. Garovic, MD, PhD, Mayo Clinic, Rochester, Minn., and chair of the 2021 AHA Scientific Statement, “Hypertension in Pregnancy: Diagnosis, Blood Pressure Goals, and Pharmacotherapy,” agrees.

The new data “set the stage for adequately designed and powered studies that will provide ultimate response/evidence regarding the efficacy of this approach,” she told this news organization.

“Future studies need to address the safety of this approach,” she added, “as close to 10 timed/planned deliveries will be needed to prevent one case of preeclampsia.”

For now, she said, “While these preliminary data are promising, they are not sufficient to adopt timed birth in daily practice. Prospective studies that will provide sufficient evidence regarding the efficacy and safety of this approach are likely to follow. Stay tuned.”

Indeed, Dr. Magee noted that the Fetal Medicine Foundation is about to launch a randomized trial of a personalized “timing of birth” strategy at term based on the preeclampsia risk described in her group’s study vs. usual care at term – that is, “watchful waiting, and delivery should preeclampsia or another indication for birth develop.”

The study was supported by grants from the Fetal Medicine Foundation, United Kingdom, and various biotech companies provided reagents and relevant equipment free of charge. Dr. Magee and Dr. Garovic reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.

Risk-stratified timing of birth at term may reduce a mother’s risk of preeclampsia by half, analysis of a large U.K. cohort suggests.

Timed birth strategies include scheduled labor inductions and cesarean deliveries.

In this observational analysis of nearly 90,000 pregnancies, at-term preeclampsia occurred with similar frequency among women routinely screened during the first trimester and among at-risk women screened during the third trimester.

Overall, on average, at-risk women delivered at 40 weeks, with two-thirds experiencing spontaneous onset of labor. About one-fourth had cesarean deliveries.

“We anticipated that timed birth at 37 weeks could reduce the occurrence of more than half of preeclampsia, [but] this is not an intervention that could be recommended, as complications for the baby would be increased,” Laura A. Magee, MD, of King’s College London, told this news organization.

“However, we were delighted to see that a personalized approach to timed birth, based on an individual woman’s risk of preeclampsia, could prevent a similar number of cases of preeclampsia, with fewer women requiring timed birth and at later gestational ages, when newborn problems would be less frequent.”

Although not currently recommended to prevent at-term preeclampsia, “timed birth by labor induction is a very common timing of birth strategy,” she noted. “At least one-third of women currently undergo labor induction at term gestational age, and one in six choose to deliver by elective cesarean.”

The study was published online in the journal Hypertension.
 

Screening at 35-36 weeks superior

The investigators analyzed data from a nonintervention cohort study of singleton pregnancies delivering at ≥ 24 weeks, without major anomalies, at two U.K. hospitals.

At routine visits at 11-13 weeks’ gestation, 57,131 pregnancies were screened, and 1,138 term preeclampsia cases developed.

Most of these women were in their early 30s, self-identified as White, and had a BMI at the upper limits of normal. About 10% were smokers; fewer than 3% had a medical history of high blood pressure, type 2 diabetes, or autoimmune disease; and 3.9% reported a family history of preeclampsia.

At 35-36 weeks, in a different cohort, 29,035 pregnancies were screened and term preeclampsia developed in 619 women. Demographics and pregnancy characteristics were similar to those screened at 11-13 weeks, although the average BMI was higher – in the overweight range – and there were fewer Black women, although they still made up 10% of the screened population.

Patient-specific preeclampsia risks were determined by the United Kingdom National Institute for Health and Care Excellence (NICE) guidance, and the Fetal Medicine Foundation competing-risks model, available through an online calculator.

Timing of birth for term preeclampsia prevention was evaluated at 37, 38, 39, and 40 weeks or depending on preeclampsia risk by the competing-risks model at 35-36 weeks.

The primary outcomes were the proportion of term preeclampsia prevented, and number-needed-to-deliver to prevent one term preeclampsia case.

The investigators found that overall, the proportion of term preeclampsia prevented was highest, and number-needed-to-deliver lowest, for preeclampsia screening at 35-36 weeks rather than at 11-13 weeks.

For delivery at 37 weeks, fewer cases of preeclampsia were prevented with NICE criteria (28.8%) than with the competing-risks model (59.8%), and the number-needed-to-deliver was higher (16.4 vs 6.9, respectively).

At 35-36 weeks, the risk-stratified approach had similar preeclampsia prevention (57.2%) and number-needed-to-deliver (8.4), but fewer women would be induced at 37 weeks (1.2% vs. 8.8%).

Although personalized timed birth at term may be an effective way to address at-term preeclampsia, “clinicians should wait for definitive clinical trial evidence,” Dr. Magee said.
 

‘Stay tuned’

Vesna D. Garovic, MD, PhD, Mayo Clinic, Rochester, Minn., and chair of the 2021 AHA Scientific Statement, “Hypertension in Pregnancy: Diagnosis, Blood Pressure Goals, and Pharmacotherapy,” agrees.

The new data “set the stage for adequately designed and powered studies that will provide ultimate response/evidence regarding the efficacy of this approach,” she told this news organization.

“Future studies need to address the safety of this approach,” she added, “as close to 10 timed/planned deliveries will be needed to prevent one case of preeclampsia.”

For now, she said, “While these preliminary data are promising, they are not sufficient to adopt timed birth in daily practice. Prospective studies that will provide sufficient evidence regarding the efficacy and safety of this approach are likely to follow. Stay tuned.”

Indeed, Dr. Magee noted that the Fetal Medicine Foundation is about to launch a randomized trial of a personalized “timing of birth” strategy at term based on the preeclampsia risk described in her group’s study vs. usual care at term – that is, “watchful waiting, and delivery should preeclampsia or another indication for birth develop.”

The study was supported by grants from the Fetal Medicine Foundation, United Kingdom, and various biotech companies provided reagents and relevant equipment free of charge. Dr. Magee and Dr. Garovic reported no relevant financial relationships.

A version of this article first appeared on Medscape.com.