Obstetrics

SAN ANTONIO — The improved local control of breast cancer achieved via radiotherapy translates into a significant reduction in mortality due to the malignancy that becomes apparent only late, at 10 and 15 years' follow-up, Sir Richard Peto, Ph.D., reported at a breast cancer symposium sponsored by the Cancer Therapy and Research Center.

That's the good news regarding radiotherapy from a new metaanalysis of the world's total randomized clinical trial experience in early breast cancer. The bad news: This reduction in breast cancer mortality is essentially canceled out—and in some subgroups outweighed—by a radiotherapy-induced excess in late deaths due to cardiovascular disease.

“The big thing about radiotherapy is it causes deaths from heart disease, not in the first decade after treatment, but in the second,” said Dr. Peto, professor of medical statistics and epidemiology at the University of Oxford (England).

Still, the central point remains: Local control of breast cancer matters. And if preliminary evidence turns out to be correct in suggesting modern radiotherapy techniques achieve it with much less cardiotoxicity than the radiotherapy of the 1980s, then physicians can expect to see a continued further decline in overall mortality in breast cancer patients in the decade beginning in 2010, he said.

“Local recurrence is not a cosmetic problem, it's a life-or-death problem,” he said. “Breast cancer is a disease where you've really got to think of what you're achieving on a time scale of decades, not years. The question is not 5-year survival, the question for a middle-aged woman is what is the 20-year survival?”

Dr. Peto presented a metaanalysis of data from the Early Breast Cancer Trialists' Collaborative Group (EBCTCG) involving 24,000 women randomized to radiotherapy or no radiotherapy in 46 clinical trials that enrolled patients in the mid-1980s.

“With a quarter of a million woman-years of observation after year 5, we've got really clear results,” he noted.

The 15-year rate of isolated local recurrence was 10% in women who received radiotherapy and 31% in those who did not. And 15-year mortality due to breast cancer was 44% in radiotherapy recipients, compared with 48% in controls. “It's a small but real benefit,” Dr. Peto said.

Through stratification of trials based upon the magnitude of difference in local control, it became apparent that the greater the difference in local control in a given study, the bigger the long-term difference in breast cancer mortality, he said.

Looking more narrowly at the impact of radiotherapy after breast-conserving therapy in a series of randomized trials involving 6,097 women with node-negative disease, he found that the 10-year rate of isolated local recurrence was 10% in those who got radiotherapy, compared with 29% in controls. Ten-year breast cancer mortality was 17% in radiotherapy-treated women and 20% in controls.

The EBCTCG data show that in addition to the marked increase in late cardiovascular deaths associated with radiation therapy as practiced in the 1980s, treated women also face smaller but nonetheless significant increases in risk of death due to lung, esophageal, and contralateral breast cancer.

Nevertheless, he characterized the overall improvement in breast cancer outcomes since the 1980s as “a brilliant success.” It's estimated that in 2010, mortality in middle age due to breast cancer in the United Kingdom will be just half of what it was in 1980, and a similar trend applies in the United States.

That's a success story unrivaled in oncology. Only the reduction in lung cancer deaths in recent decades even comes close—and that's not due to screening and treatment advances, but, rather, to smoking cessation efforts.

SAN ANTONIO — The improved local control of breast cancer achieved via radiotherapy translates into a significant reduction in mortality due to the malignancy that becomes apparent only late, at 10 and 15 years' follow-up, Sir Richard Peto, Ph.D., reported at a breast cancer symposium sponsored by the Cancer Therapy and Research Center.

That's the good news regarding radiotherapy from a new metaanalysis of the world's total randomized clinical trial experience in early breast cancer. The bad news: This reduction in breast cancer mortality is essentially canceled out—and in some subgroups outweighed—by a radiotherapy-induced excess in late deaths due to cardiovascular disease.

“The big thing about radiotherapy is it causes deaths from heart disease, not in the first decade after treatment, but in the second,” said Dr. Peto, professor of medical statistics and epidemiology at the University of Oxford (England).

Still, the central point remains: Local control of breast cancer matters. And if preliminary evidence turns out to be correct in suggesting modern radiotherapy techniques achieve it with much less cardiotoxicity than the radiotherapy of the 1980s, then physicians can expect to see a continued further decline in overall mortality in breast cancer patients in the decade beginning in 2010, he said.

“Local recurrence is not a cosmetic problem, it's a life-or-death problem,” he said. “Breast cancer is a disease where you've really got to think of what you're achieving on a time scale of decades, not years. The question is not 5-year survival, the question for a middle-aged woman is what is the 20-year survival?”

Dr. Peto presented a metaanalysis of data from the Early Breast Cancer Trialists' Collaborative Group (EBCTCG) involving 24,000 women randomized to radiotherapy or no radiotherapy in 46 clinical trials that enrolled patients in the mid-1980s.

“With a quarter of a million woman-years of observation after year 5, we've got really clear results,” he noted.

The 15-year rate of isolated local recurrence was 10% in women who received radiotherapy and 31% in those who did not. And 15-year mortality due to breast cancer was 44% in radiotherapy recipients, compared with 48% in controls. “It's a small but real benefit,” Dr. Peto said.

Through stratification of trials based upon the magnitude of difference in local control, it became apparent that the greater the difference in local control in a given study, the bigger the long-term difference in breast cancer mortality, he said.

Looking more narrowly at the impact of radiotherapy after breast-conserving therapy in a series of randomized trials involving 6,097 women with node-negative disease, he found that the 10-year rate of isolated local recurrence was 10% in those who got radiotherapy, compared with 29% in controls. Ten-year breast cancer mortality was 17% in radiotherapy-treated women and 20% in controls.

The EBCTCG data show that in addition to the marked increase in late cardiovascular deaths associated with radiation therapy as practiced in the 1980s, treated women also face smaller but nonetheless significant increases in risk of death due to lung, esophageal, and contralateral breast cancer.

Nevertheless, he characterized the overall improvement in breast cancer outcomes since the 1980s as “a brilliant success.” It's estimated that in 2010, mortality in middle age due to breast cancer in the United Kingdom will be just half of what it was in 1980, and a similar trend applies in the United States.

That's a success story unrivaled in oncology. Only the reduction in lung cancer deaths in recent decades even comes close—and that's not due to screening and treatment advances, but, rather, to smoking cessation efforts.

SAN ANTONIO — The improved local control of breast cancer achieved via radiotherapy translates into a significant reduction in mortality due to the malignancy that becomes apparent only late, at 10 and 15 years' follow-up, Sir Richard Peto, Ph.D., reported at a breast cancer symposium sponsored by the Cancer Therapy and Research Center.

That's the good news regarding radiotherapy from a new metaanalysis of the world's total randomized clinical trial experience in early breast cancer. The bad news: This reduction in breast cancer mortality is essentially canceled out—and in some subgroups outweighed—by a radiotherapy-induced excess in late deaths due to cardiovascular disease.

“The big thing about radiotherapy is it causes deaths from heart disease, not in the first decade after treatment, but in the second,” said Dr. Peto, professor of medical statistics and epidemiology at the University of Oxford (England).

Still, the central point remains: Local control of breast cancer matters. And if preliminary evidence turns out to be correct in suggesting modern radiotherapy techniques achieve it with much less cardiotoxicity than the radiotherapy of the 1980s, then physicians can expect to see a continued further decline in overall mortality in breast cancer patients in the decade beginning in 2010, he said.

“Local recurrence is not a cosmetic problem, it's a life-or-death problem,” he said. “Breast cancer is a disease where you've really got to think of what you're achieving on a time scale of decades, not years. The question is not 5-year survival, the question for a middle-aged woman is what is the 20-year survival?”

Dr. Peto presented a metaanalysis of data from the Early Breast Cancer Trialists' Collaborative Group (EBCTCG) involving 24,000 women randomized to radiotherapy or no radiotherapy in 46 clinical trials that enrolled patients in the mid-1980s.

“With a quarter of a million woman-years of observation after year 5, we've got really clear results,” he noted.

The 15-year rate of isolated local recurrence was 10% in women who received radiotherapy and 31% in those who did not. And 15-year mortality due to breast cancer was 44% in radiotherapy recipients, compared with 48% in controls. “It's a small but real benefit,” Dr. Peto said.

Through stratification of trials based upon the magnitude of difference in local control, it became apparent that the greater the difference in local control in a given study, the bigger the long-term difference in breast cancer mortality, he said.

Looking more narrowly at the impact of radiotherapy after breast-conserving therapy in a series of randomized trials involving 6,097 women with node-negative disease, he found that the 10-year rate of isolated local recurrence was 10% in those who got radiotherapy, compared with 29% in controls. Ten-year breast cancer mortality was 17% in radiotherapy-treated women and 20% in controls.

The EBCTCG data show that in addition to the marked increase in late cardiovascular deaths associated with radiation therapy as practiced in the 1980s, treated women also face smaller but nonetheless significant increases in risk of death due to lung, esophageal, and contralateral breast cancer.

Nevertheless, he characterized the overall improvement in breast cancer outcomes since the 1980s as “a brilliant success.” It's estimated that in 2010, mortality in middle age due to breast cancer in the United Kingdom will be just half of what it was in 1980, and a similar trend applies in the United States.

That's a success story unrivaled in oncology. Only the reduction in lung cancer deaths in recent decades even comes close—and that's not due to screening and treatment advances, but, rather, to smoking cessation efforts.

SAN ANTONIO — The timing of breast cancer surgery with respect to menstrual cycle phase failed to affect prognosis in two large multicenter prospective observational studies presented at the annual breast cancer symposium sponsored by the Cancer Therapy and Research Center.

This has been a longstanding controversy. Since 1989, roughly two dozen surgical studies have examined the issue. Close to half have reported a survival advantage for breast cancer patients who undergo their surgery during the luteal phase of the menstrual cycle. The remaining studies concluded timing of surgery had no impact upon disease-free or overall survival.

But most prior studies involved a few hundred patients or less, many were single-center retrospective series, and nearly all relied upon patient recall of the last menstrual period, which has the potential for inaccuracy.

To shed light on the issue, investigators from the North Central Cancer Treatment Group conducted a study in which 842 patients undergoing breast cancer surgery at 103 sites were categorized as to menstrual cycle phase both by biochemical determination at time of surgery and by recall of last menstrual period, explained Clive S. Grant, M.D., professor of surgery at the Mayo Clinic, Rochester, Minn.

Five-year disease-free survival in 231 women operated on during the luteal phase was 81.9%, not significantly different than the 82.2% rate among 364 women in the follicular phase or the 79.1% rate in women in an indeterminate menstrual phase. Nor did overall survival differ between the groups.

Biochemical determination of menstrual phase based upon hormone levels at the time of surgery demonstrated that reliance upon last reported menstrual period would have resulted in misclassification of 29% of women, a finding that casts doubt upon the validity of much of the prior work in this area.

In a separate presentation, Richard Sainsbury, M.D., reported on 412 women followed for a median 59 months after undergoing breast cancer surgery in a multicenter study. The 3-year overall survival of 90.7% wasn't affected by timing of surgery in relation to menstrual cycle.

The initial data analysis relied upon patient report of last menstrual period. Hormone levels at the time of surgery were also measured, however, and in the near future the data will be reanalyzed using those measurements to categorize patient menstrual status, according to Dr. Sainsbury, professor of surgery at University of Leeds (England).

SAN ANTONIO — The timing of breast cancer surgery with respect to menstrual cycle phase failed to affect prognosis in two large multicenter prospective observational studies presented at the annual breast cancer symposium sponsored by the Cancer Therapy and Research Center.

This has been a longstanding controversy. Since 1989, roughly two dozen surgical studies have examined the issue. Close to half have reported a survival advantage for breast cancer patients who undergo their surgery during the luteal phase of the menstrual cycle. The remaining studies concluded timing of surgery had no impact upon disease-free or overall survival.

But most prior studies involved a few hundred patients or less, many were single-center retrospective series, and nearly all relied upon patient recall of the last menstrual period, which has the potential for inaccuracy.

To shed light on the issue, investigators from the North Central Cancer Treatment Group conducted a study in which 842 patients undergoing breast cancer surgery at 103 sites were categorized as to menstrual cycle phase both by biochemical determination at time of surgery and by recall of last menstrual period, explained Clive S. Grant, M.D., professor of surgery at the Mayo Clinic, Rochester, Minn.

Five-year disease-free survival in 231 women operated on during the luteal phase was 81.9%, not significantly different than the 82.2% rate among 364 women in the follicular phase or the 79.1% rate in women in an indeterminate menstrual phase. Nor did overall survival differ between the groups.

Biochemical determination of menstrual phase based upon hormone levels at the time of surgery demonstrated that reliance upon last reported menstrual period would have resulted in misclassification of 29% of women, a finding that casts doubt upon the validity of much of the prior work in this area.

In a separate presentation, Richard Sainsbury, M.D., reported on 412 women followed for a median 59 months after undergoing breast cancer surgery in a multicenter study. The 3-year overall survival of 90.7% wasn't affected by timing of surgery in relation to menstrual cycle.

The initial data analysis relied upon patient report of last menstrual period. Hormone levels at the time of surgery were also measured, however, and in the near future the data will be reanalyzed using those measurements to categorize patient menstrual status, according to Dr. Sainsbury, professor of surgery at University of Leeds (England).

SAN ANTONIO — The timing of breast cancer surgery with respect to menstrual cycle phase failed to affect prognosis in two large multicenter prospective observational studies presented at the annual breast cancer symposium sponsored by the Cancer Therapy and Research Center.

This has been a longstanding controversy. Since 1989, roughly two dozen surgical studies have examined the issue. Close to half have reported a survival advantage for breast cancer patients who undergo their surgery during the luteal phase of the menstrual cycle. The remaining studies concluded timing of surgery had no impact upon disease-free or overall survival.

But most prior studies involved a few hundred patients or less, many were single-center retrospective series, and nearly all relied upon patient recall of the last menstrual period, which has the potential for inaccuracy.

To shed light on the issue, investigators from the North Central Cancer Treatment Group conducted a study in which 842 patients undergoing breast cancer surgery at 103 sites were categorized as to menstrual cycle phase both by biochemical determination at time of surgery and by recall of last menstrual period, explained Clive S. Grant, M.D., professor of surgery at the Mayo Clinic, Rochester, Minn.

Five-year disease-free survival in 231 women operated on during the luteal phase was 81.9%, not significantly different than the 82.2% rate among 364 women in the follicular phase or the 79.1% rate in women in an indeterminate menstrual phase. Nor did overall survival differ between the groups.

Biochemical determination of menstrual phase based upon hormone levels at the time of surgery demonstrated that reliance upon last reported menstrual period would have resulted in misclassification of 29% of women, a finding that casts doubt upon the validity of much of the prior work in this area.

In a separate presentation, Richard Sainsbury, M.D., reported on 412 women followed for a median 59 months after undergoing breast cancer surgery in a multicenter study. The 3-year overall survival of 90.7% wasn't affected by timing of surgery in relation to menstrual cycle.

The initial data analysis relied upon patient report of last menstrual period. Hormone levels at the time of surgery were also measured, however, and in the near future the data will be reanalyzed using those measurements to categorize patient menstrual status, according to Dr. Sainsbury, professor of surgery at University of Leeds (England).

SAN ANTONIO — The considerable excess in cardiovascular mortality caused by older radiotherapy regimens for breast cancer appears to be greatly diminished with more modern ones, Sarah C. Darby, Ph.D., reported at a breast cancer symposium sponsored by the Cancer Therapy and Research Center.

This was the principal conclusion of her analysis of nearly 309,000 cases of early breast cancer enrolled in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry in 1973-2001.

A total of 37% of the SEER population received radiotherapy.

Heart disease was the leading cause of death in radiotherapy-treated patients; however, a straightforward comparison of cardiovascular mortality rates in women who did or did not get radiotherapy wouldn't be appropriate, since SEER participants were not randomized to this treatment.

A better comparison would take advantage of the fact that the heart is located slightly left of center in the body; thus, radiotherapy recipients with cancer of the left breast will get a higher radiation dose than those with right-sided cancer, explained Dr. Darby of the University of Oxford (England).

Sure enough, among SEER participants who received radiotherapy and subsequently died of heart disease, there was a highly significant 16% excess of cancers of the left breast. In the subset of radiotherapy-treated patients followed for 15 years or more, this excess risk climbed to 53%.

In contrast, among those patients who did not get radiotherapy, death due to heart disease was equally common in women with left- and right-sided breast cancer, the study found.

The key question is whether the excess cardiovascular risk associated with radiotherapy is a relic of outdated techniques or is still present with more recent regimens. A statistically significant downward trend in excess cardiovascular mortality in left-sided breast cancer patients was evident when SEER radiotherapy recipients were stratified by decade of cancer diagnosis. (See chart.)

However, it's too soon to say the hazard has gone away completely, since there are no 10-year follow-up data on the most recent radiotherapy group. And it's by no means clear that regimens just now being introduced—such as intensity-modulated radiation therapy—are going to be free from cardiovascular risk, she said at the meeting.

SAN ANTONIO — The considerable excess in cardiovascular mortality caused by older radiotherapy regimens for breast cancer appears to be greatly diminished with more modern ones, Sarah C. Darby, Ph.D., reported at a breast cancer symposium sponsored by the Cancer Therapy and Research Center.

This was the principal conclusion of her analysis of nearly 309,000 cases of early breast cancer enrolled in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry in 1973-2001.

A total of 37% of the SEER population received radiotherapy.

Heart disease was the leading cause of death in radiotherapy-treated patients; however, a straightforward comparison of cardiovascular mortality rates in women who did or did not get radiotherapy wouldn't be appropriate, since SEER participants were not randomized to this treatment.

A better comparison would take advantage of the fact that the heart is located slightly left of center in the body; thus, radiotherapy recipients with cancer of the left breast will get a higher radiation dose than those with right-sided cancer, explained Dr. Darby of the University of Oxford (England).

Sure enough, among SEER participants who received radiotherapy and subsequently died of heart disease, there was a highly significant 16% excess of cancers of the left breast. In the subset of radiotherapy-treated patients followed for 15 years or more, this excess risk climbed to 53%.

In contrast, among those patients who did not get radiotherapy, death due to heart disease was equally common in women with left- and right-sided breast cancer, the study found.

The key question is whether the excess cardiovascular risk associated with radiotherapy is a relic of outdated techniques or is still present with more recent regimens. A statistically significant downward trend in excess cardiovascular mortality in left-sided breast cancer patients was evident when SEER radiotherapy recipients were stratified by decade of cancer diagnosis. (See chart.)

However, it's too soon to say the hazard has gone away completely, since there are no 10-year follow-up data on the most recent radiotherapy group. And it's by no means clear that regimens just now being introduced—such as intensity-modulated radiation therapy—are going to be free from cardiovascular risk, she said at the meeting.

SAN ANTONIO — The considerable excess in cardiovascular mortality caused by older radiotherapy regimens for breast cancer appears to be greatly diminished with more modern ones, Sarah C. Darby, Ph.D., reported at a breast cancer symposium sponsored by the Cancer Therapy and Research Center.

This was the principal conclusion of her analysis of nearly 309,000 cases of early breast cancer enrolled in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry in 1973-2001.

A total of 37% of the SEER population received radiotherapy.

Heart disease was the leading cause of death in radiotherapy-treated patients; however, a straightforward comparison of cardiovascular mortality rates in women who did or did not get radiotherapy wouldn't be appropriate, since SEER participants were not randomized to this treatment.

A better comparison would take advantage of the fact that the heart is located slightly left of center in the body; thus, radiotherapy recipients with cancer of the left breast will get a higher radiation dose than those with right-sided cancer, explained Dr. Darby of the University of Oxford (England).

Sure enough, among SEER participants who received radiotherapy and subsequently died of heart disease, there was a highly significant 16% excess of cancers of the left breast. In the subset of radiotherapy-treated patients followed for 15 years or more, this excess risk climbed to 53%.

In contrast, among those patients who did not get radiotherapy, death due to heart disease was equally common in women with left- and right-sided breast cancer, the study found.

The key question is whether the excess cardiovascular risk associated with radiotherapy is a relic of outdated techniques or is still present with more recent regimens. A statistically significant downward trend in excess cardiovascular mortality in left-sided breast cancer patients was evident when SEER radiotherapy recipients were stratified by decade of cancer diagnosis. (See chart.)

However, it's too soon to say the hazard has gone away completely, since there are no 10-year follow-up data on the most recent radiotherapy group. And it's by no means clear that regimens just now being introduced—such as intensity-modulated radiation therapy—are going to be free from cardiovascular risk, she said at the meeting.

SANTA FE, N.M. — While the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders defines only one type of female sexual arousal disorder, there is now physiologic evidence that there are at least two subtypes of the disorder, Lori A. Brotto, Ph.D., reported during the annual meeting of the Society for Psychophysiological Research.

For a diagnosis of female sexual arousal disorder (FSAD), DSM-IV-TR requires “persistent or recurrent inability to attain … an adequate lubrication-swelling response of sexual excitement.”

Although some women with the disorder do complain mostly of genital impairment, others report that while their body becomes aroused, they don't become aroused psychologically.

In a study involving 70 women, Dr. Brotto of the University of Washington in Seattle examined 8 women reporting the genital subtype of FSAD, 26 reporting the subjective subtype, and 36 control subjects reporting no difficulties in becoming aroused.

All of the women watched neutral and erotic films while their vaginal pulse amplitude—a reliable measure of genital arousal—was measured by a vaginal photoplethysmograph. The women in the study also provided a continuous measure of their subjective responses by changing the position of a lever.

The women underwent testing on two occasions, once after laboratory-induced hyperventilation. In previous studies, Dr. Brotto determined that in normal women, hyperventilation, which activates the sympathetic nervous system, increased the change in vaginal pulse amplitude between neutral and erotic films.

In both the control women and the women with FSAD, the erotic film resulted in significant increases in vaginal pulse amplitude.

All of the participants responded to the erotic film with perceived autonomic arousal and perceived physical arousal, but the women with FSAD reported less arousal, the researchers said.

Overall, women in the control group reported greater arousal and more positive affect than did women with FSAD.

The vaginal photoplethysmography supported the reports of women who had complained of problems with genital arousal. Those women showed no significant increase in vaginal pulse amplitude in response to the erotic films.

Women who had complained of a subjective arousal disorder, on the other hand, did show evidence of significant genital arousal, according to the study.

While the women in the control group and the women with the genital arousal subtype of FSAD showed a potentiated physiologic response to the erotic film after hyperventilation, the women with the subjective subtype of FSAD showed a significantly smaller physiologic response after hyperventilation than before.

Hyperventilation resulted in no significant changes in the subjective measures in either the control or the FSAD women. The study finding suggests that the effect of this manipulation occurred exclusively at a physiologic level and was not due to some distraction or other psychological causes.

One implication of the study is that women with the subjective subtype of FSAD may have differences in basal sympathetic tone, compared with women with the genital subtype or women without FSAD, according to Dr. Brotto and the other researchers.

Another implication of the study findings is that vaginal photoplethysmography, now exclusively a laboratory technique, may find a place as a diagnostic tool used to differentiate between FSAD subtypes.

Dr. Brotto pointed out that other data from her lab suggest that photoplethysmographic patterns can serve as an indicator of which women will respond to vasoactive medications with increased arousal.

SANTA FE, N.M. — While the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders defines only one type of female sexual arousal disorder, there is now physiologic evidence that there are at least two subtypes of the disorder, Lori A. Brotto, Ph.D., reported during the annual meeting of the Society for Psychophysiological Research.

For a diagnosis of female sexual arousal disorder (FSAD), DSM-IV-TR requires “persistent or recurrent inability to attain … an adequate lubrication-swelling response of sexual excitement.”

Although some women with the disorder do complain mostly of genital impairment, others report that while their body becomes aroused, they don't become aroused psychologically.

In a study involving 70 women, Dr. Brotto of the University of Washington in Seattle examined 8 women reporting the genital subtype of FSAD, 26 reporting the subjective subtype, and 36 control subjects reporting no difficulties in becoming aroused.

All of the women watched neutral and erotic films while their vaginal pulse amplitude—a reliable measure of genital arousal—was measured by a vaginal photoplethysmograph. The women in the study also provided a continuous measure of their subjective responses by changing the position of a lever.

The women underwent testing on two occasions, once after laboratory-induced hyperventilation. In previous studies, Dr. Brotto determined that in normal women, hyperventilation, which activates the sympathetic nervous system, increased the change in vaginal pulse amplitude between neutral and erotic films.

In both the control women and the women with FSAD, the erotic film resulted in significant increases in vaginal pulse amplitude.

All of the participants responded to the erotic film with perceived autonomic arousal and perceived physical arousal, but the women with FSAD reported less arousal, the researchers said.

Overall, women in the control group reported greater arousal and more positive affect than did women with FSAD.

The vaginal photoplethysmography supported the reports of women who had complained of problems with genital arousal. Those women showed no significant increase in vaginal pulse amplitude in response to the erotic films.

Women who had complained of a subjective arousal disorder, on the other hand, did show evidence of significant genital arousal, according to the study.

While the women in the control group and the women with the genital arousal subtype of FSAD showed a potentiated physiologic response to the erotic film after hyperventilation, the women with the subjective subtype of FSAD showed a significantly smaller physiologic response after hyperventilation than before.

Hyperventilation resulted in no significant changes in the subjective measures in either the control or the FSAD women. The study finding suggests that the effect of this manipulation occurred exclusively at a physiologic level and was not due to some distraction or other psychological causes.

One implication of the study is that women with the subjective subtype of FSAD may have differences in basal sympathetic tone, compared with women with the genital subtype or women without FSAD, according to Dr. Brotto and the other researchers.

Another implication of the study findings is that vaginal photoplethysmography, now exclusively a laboratory technique, may find a place as a diagnostic tool used to differentiate between FSAD subtypes.

Dr. Brotto pointed out that other data from her lab suggest that photoplethysmographic patterns can serve as an indicator of which women will respond to vasoactive medications with increased arousal.

SANTA FE, N.M. — While the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders defines only one type of female sexual arousal disorder, there is now physiologic evidence that there are at least two subtypes of the disorder, Lori A. Brotto, Ph.D., reported during the annual meeting of the Society for Psychophysiological Research.

For a diagnosis of female sexual arousal disorder (FSAD), DSM-IV-TR requires “persistent or recurrent inability to attain … an adequate lubrication-swelling response of sexual excitement.”

Although some women with the disorder do complain mostly of genital impairment, others report that while their body becomes aroused, they don't become aroused psychologically.

In a study involving 70 women, Dr. Brotto of the University of Washington in Seattle examined 8 women reporting the genital subtype of FSAD, 26 reporting the subjective subtype, and 36 control subjects reporting no difficulties in becoming aroused.

All of the women watched neutral and erotic films while their vaginal pulse amplitude—a reliable measure of genital arousal—was measured by a vaginal photoplethysmograph. The women in the study also provided a continuous measure of their subjective responses by changing the position of a lever.

The women underwent testing on two occasions, once after laboratory-induced hyperventilation. In previous studies, Dr. Brotto determined that in normal women, hyperventilation, which activates the sympathetic nervous system, increased the change in vaginal pulse amplitude between neutral and erotic films.

In both the control women and the women with FSAD, the erotic film resulted in significant increases in vaginal pulse amplitude.

All of the participants responded to the erotic film with perceived autonomic arousal and perceived physical arousal, but the women with FSAD reported less arousal, the researchers said.

Overall, women in the control group reported greater arousal and more positive affect than did women with FSAD.

The vaginal photoplethysmography supported the reports of women who had complained of problems with genital arousal. Those women showed no significant increase in vaginal pulse amplitude in response to the erotic films.

Women who had complained of a subjective arousal disorder, on the other hand, did show evidence of significant genital arousal, according to the study.

While the women in the control group and the women with the genital arousal subtype of FSAD showed a potentiated physiologic response to the erotic film after hyperventilation, the women with the subjective subtype of FSAD showed a significantly smaller physiologic response after hyperventilation than before.

Hyperventilation resulted in no significant changes in the subjective measures in either the control or the FSAD women. The study finding suggests that the effect of this manipulation occurred exclusively at a physiologic level and was not due to some distraction or other psychological causes.

One implication of the study is that women with the subjective subtype of FSAD may have differences in basal sympathetic tone, compared with women with the genital subtype or women without FSAD, according to Dr. Brotto and the other researchers.

Another implication of the study findings is that vaginal photoplethysmography, now exclusively a laboratory technique, may find a place as a diagnostic tool used to differentiate between FSAD subtypes.

Dr. Brotto pointed out that other data from her lab suggest that photoplethysmographic patterns can serve as an indicator of which women will respond to vasoactive medications with increased arousal.

The weight loss drug orlistat may prove to be a useful adjunct in the treatment of polycystic ovarian syndrome, according to findings from a small randomized study that compared the drug with metformin.

“[We've] demonstrated the therapeutic potential of orlistat in PCOS,” said Vijay Jayagopal, M.D., of the University of Hull (England) and his associates.

After a 12-week treatment period, 10 women treated with orlistat lost significantly more weight than 11 patients treated with metformin (a 4.7% vs. a 1% reduction) and had similar, statistically significant reductions in total serum testosterone (J. Clin. Endocrinol. Metab. 2005;90:729-33).

Neither drug produced significant reductions in fasting insulin, insulin resistance, sex hormone-binding globulin, or any of several lipid parameters studied.

In a written statement, Andrea E. Dunaif, M.D., president-elect of the Endocrine Society, said further research is needed to determine “where [weight-loss medications] will fit into the treatment of PCOS.”

The current study, however, “suggests that [the] medications may be an effective treatment option for not only the obesity but also the testosterone excess associated with PCOS,” said Dr. Dunaif of Northwestern University, Chicago.

Before drug treatment, all 21 patients—white women with PCOS—underwent an 8-week period of dietary modification (there were no significant changes in weight); they were then randomized to receive orlistat, which inhibits triglyceride and lipid absorption, or the insulin-sensitizing agent metformin.

Compared with baseline, a significant reduction in serum testosterone was observed after treatment in both the orlistat-treated group (approximately 94 ng/dL vs. 115 ng/dL) and the metformin-treated group (approximately 97 ng/dlL vs. 120 ng/dL).

Investigators noted that despite the lack of statistically significant improvements in many of the endocrine and metabolic parameters studied, the percentage changes from baseline were “more marked” in the orlistat group.

This may suggest that “the weight reduction had an overall stronger impact on these parameters than the insulin-sensitizing effect of metformin, the mechanism of which remains largely unknown,” they said.

Insulin resistance was calculated using the homeostasis model of assessment (HOMA-IR) method. The lack of statistically significant improvement in insulin resistance may be due in part to the large variability in HOMA-IR values in such a small group of patients, Dr. Jayagopal and his associates said.

The investigators did not collect information on menstrual change and ovulation, and the study was not powered to assess lipid changes. Such information is “clearly important” to acquire in larger studies, the investigators said.

In the meantime, Dr. Dunaif said, “we know that metformin is a proven and effective treatment for women with polycystic ovary syndrome.”

The weight loss drug orlistat may prove to be a useful adjunct in the treatment of polycystic ovarian syndrome, according to findings from a small randomized study that compared the drug with metformin.

“[We've] demonstrated the therapeutic potential of orlistat in PCOS,” said Vijay Jayagopal, M.D., of the University of Hull (England) and his associates.

After a 12-week treatment period, 10 women treated with orlistat lost significantly more weight than 11 patients treated with metformin (a 4.7% vs. a 1% reduction) and had similar, statistically significant reductions in total serum testosterone (J. Clin. Endocrinol. Metab. 2005;90:729-33).

Neither drug produced significant reductions in fasting insulin, insulin resistance, sex hormone-binding globulin, or any of several lipid parameters studied.

In a written statement, Andrea E. Dunaif, M.D., president-elect of the Endocrine Society, said further research is needed to determine “where [weight-loss medications] will fit into the treatment of PCOS.”

The current study, however, “suggests that [the] medications may be an effective treatment option for not only the obesity but also the testosterone excess associated with PCOS,” said Dr. Dunaif of Northwestern University, Chicago.

Before drug treatment, all 21 patients—white women with PCOS—underwent an 8-week period of dietary modification (there were no significant changes in weight); they were then randomized to receive orlistat, which inhibits triglyceride and lipid absorption, or the insulin-sensitizing agent metformin.

Compared with baseline, a significant reduction in serum testosterone was observed after treatment in both the orlistat-treated group (approximately 94 ng/dL vs. 115 ng/dL) and the metformin-treated group (approximately 97 ng/dlL vs. 120 ng/dL).

Investigators noted that despite the lack of statistically significant improvements in many of the endocrine and metabolic parameters studied, the percentage changes from baseline were “more marked” in the orlistat group.

This may suggest that “the weight reduction had an overall stronger impact on these parameters than the insulin-sensitizing effect of metformin, the mechanism of which remains largely unknown,” they said.

Insulin resistance was calculated using the homeostasis model of assessment (HOMA-IR) method. The lack of statistically significant improvement in insulin resistance may be due in part to the large variability in HOMA-IR values in such a small group of patients, Dr. Jayagopal and his associates said.

The investigators did not collect information on menstrual change and ovulation, and the study was not powered to assess lipid changes. Such information is “clearly important” to acquire in larger studies, the investigators said.

In the meantime, Dr. Dunaif said, “we know that metformin is a proven and effective treatment for women with polycystic ovary syndrome.”

The weight loss drug orlistat may prove to be a useful adjunct in the treatment of polycystic ovarian syndrome, according to findings from a small randomized study that compared the drug with metformin.

“[We've] demonstrated the therapeutic potential of orlistat in PCOS,” said Vijay Jayagopal, M.D., of the University of Hull (England) and his associates.

After a 12-week treatment period, 10 women treated with orlistat lost significantly more weight than 11 patients treated with metformin (a 4.7% vs. a 1% reduction) and had similar, statistically significant reductions in total serum testosterone (J. Clin. Endocrinol. Metab. 2005;90:729-33).

Neither drug produced significant reductions in fasting insulin, insulin resistance, sex hormone-binding globulin, or any of several lipid parameters studied.

In a written statement, Andrea E. Dunaif, M.D., president-elect of the Endocrine Society, said further research is needed to determine “where [weight-loss medications] will fit into the treatment of PCOS.”

The current study, however, “suggests that [the] medications may be an effective treatment option for not only the obesity but also the testosterone excess associated with PCOS,” said Dr. Dunaif of Northwestern University, Chicago.

Before drug treatment, all 21 patients—white women with PCOS—underwent an 8-week period of dietary modification (there were no significant changes in weight); they were then randomized to receive orlistat, which inhibits triglyceride and lipid absorption, or the insulin-sensitizing agent metformin.

Compared with baseline, a significant reduction in serum testosterone was observed after treatment in both the orlistat-treated group (approximately 94 ng/dL vs. 115 ng/dL) and the metformin-treated group (approximately 97 ng/dlL vs. 120 ng/dL).

Investigators noted that despite the lack of statistically significant improvements in many of the endocrine and metabolic parameters studied, the percentage changes from baseline were “more marked” in the orlistat group.

This may suggest that “the weight reduction had an overall stronger impact on these parameters than the insulin-sensitizing effect of metformin, the mechanism of which remains largely unknown,” they said.

Insulin resistance was calculated using the homeostasis model of assessment (HOMA-IR) method. The lack of statistically significant improvement in insulin resistance may be due in part to the large variability in HOMA-IR values in such a small group of patients, Dr. Jayagopal and his associates said.

The investigators did not collect information on menstrual change and ovulation, and the study was not powered to assess lipid changes. Such information is “clearly important” to acquire in larger studies, the investigators said.

In the meantime, Dr. Dunaif said, “we know that metformin is a proven and effective treatment for women with polycystic ovary syndrome.”

Adolescent women who use the injectable contraceptive depot medroxyprogesterone acetate lose bone mineral density each year they are on the drug but appear to rapidly recover that loss when the drug is withdrawn, results of a prospective study suggest.

When counseling young women on birth control methods, physicians should consider DMPA's effect on bone mineral density (BMD).

“The potential loss of bone density is one consideration of the many that go into a women's choice of contraceptive method,” said Delia Scholes, Ph.D., of the Center for Health Studies, Seattle, and her associates.

The researchers prospectively examined BMD in a cohort of 170 females aged 14-18. A total of 80 participants were using DMPA, and 90 were not. The DMPA-exposed teens were significantly more likely to be current smokers, to have been pregnant, have reached earlier menarche, and have a higher body mass index and body fat percentage (Arch. Pediatr. Adolesc. Med. 2005;159:139-44).

During the study, 61 of the DMP users discontinued the contraceptive, affording the opportunity to observe any subsequent changes in BMD.

The DMPA-exposed subjects were receiving the standard dose of 150 mg every 3 months. About 30% of them had received only 1 injection, 31% had received 2 or 3 injections, 21% had received 4-7 injections, and 18% had received at least 18 injections.

In the comparison group, 19% were using oral contraceptives at baseline.

BMD was measured at the hip, spine, and whole body every 6 months for 24-36 months.

After adjusting for baseline and time-dependent variables, the researchers determined that the DMPA users lost significantly more BMD at the hip (-1.81% vs. -0.19%) and spine (-0.97% vs. 1.32%), compared with nonusers. Both groups gained BMD when the whole body was measured, but the DMPA users gained significantly less than the nonusers (0.73% vs. 0.88%).

New users lost bone faster than continuous users. After 24 months, new users showed a -6.09% change at the hip, compared with -2.05% in continuous users and -0.92% in nonusers.

Among the 61 subjects who discontinued DMPA during the study, BMD increased. Their annualized adjusted mean change in BMD was 1.34% for hip, 2.86% for spine, and 3.56% for the whole body.

There was no significance in BMD between nonusers and those who had discontinued DMPA 18 months earlier.

The injection is highly effective in preventing pregnancy, and its quarterly administration helps reduce compliance problems sometime seen in young women using other contraceptives, the researchers said.

In 2004, the Food and Drug Administration issued a black box warning for DMPA stating that prolonged use of the drug could result in significant loss of bone density, that the loss is greater the longer the drug is administered, and that bone density loss may not be completely reversible after discontinuing the drug.

Adolescent women who use the injectable contraceptive depot medroxyprogesterone acetate lose bone mineral density each year they are on the drug but appear to rapidly recover that loss when the drug is withdrawn, results of a prospective study suggest.

When counseling young women on birth control methods, physicians should consider DMPA's effect on bone mineral density (BMD).

“The potential loss of bone density is one consideration of the many that go into a women's choice of contraceptive method,” said Delia Scholes, Ph.D., of the Center for Health Studies, Seattle, and her associates.

The researchers prospectively examined BMD in a cohort of 170 females aged 14-18. A total of 80 participants were using DMPA, and 90 were not. The DMPA-exposed teens were significantly more likely to be current smokers, to have been pregnant, have reached earlier menarche, and have a higher body mass index and body fat percentage (Arch. Pediatr. Adolesc. Med. 2005;159:139-44).

During the study, 61 of the DMP users discontinued the contraceptive, affording the opportunity to observe any subsequent changes in BMD.

The DMPA-exposed subjects were receiving the standard dose of 150 mg every 3 months. About 30% of them had received only 1 injection, 31% had received 2 or 3 injections, 21% had received 4-7 injections, and 18% had received at least 18 injections.

In the comparison group, 19% were using oral contraceptives at baseline.

BMD was measured at the hip, spine, and whole body every 6 months for 24-36 months.

After adjusting for baseline and time-dependent variables, the researchers determined that the DMPA users lost significantly more BMD at the hip (-1.81% vs. -0.19%) and spine (-0.97% vs. 1.32%), compared with nonusers. Both groups gained BMD when the whole body was measured, but the DMPA users gained significantly less than the nonusers (0.73% vs. 0.88%).

New users lost bone faster than continuous users. After 24 months, new users showed a -6.09% change at the hip, compared with -2.05% in continuous users and -0.92% in nonusers.

Among the 61 subjects who discontinued DMPA during the study, BMD increased. Their annualized adjusted mean change in BMD was 1.34% for hip, 2.86% for spine, and 3.56% for the whole body.

There was no significance in BMD between nonusers and those who had discontinued DMPA 18 months earlier.

The injection is highly effective in preventing pregnancy, and its quarterly administration helps reduce compliance problems sometime seen in young women using other contraceptives, the researchers said.

In 2004, the Food and Drug Administration issued a black box warning for DMPA stating that prolonged use of the drug could result in significant loss of bone density, that the loss is greater the longer the drug is administered, and that bone density loss may not be completely reversible after discontinuing the drug.

Adolescent women who use the injectable contraceptive depot medroxyprogesterone acetate lose bone mineral density each year they are on the drug but appear to rapidly recover that loss when the drug is withdrawn, results of a prospective study suggest.

When counseling young women on birth control methods, physicians should consider DMPA's effect on bone mineral density (BMD).

“The potential loss of bone density is one consideration of the many that go into a women's choice of contraceptive method,” said Delia Scholes, Ph.D., of the Center for Health Studies, Seattle, and her associates.

The researchers prospectively examined BMD in a cohort of 170 females aged 14-18. A total of 80 participants were using DMPA, and 90 were not. The DMPA-exposed teens were significantly more likely to be current smokers, to have been pregnant, have reached earlier menarche, and have a higher body mass index and body fat percentage (Arch. Pediatr. Adolesc. Med. 2005;159:139-44).

During the study, 61 of the DMP users discontinued the contraceptive, affording the opportunity to observe any subsequent changes in BMD.

The DMPA-exposed subjects were receiving the standard dose of 150 mg every 3 months. About 30% of them had received only 1 injection, 31% had received 2 or 3 injections, 21% had received 4-7 injections, and 18% had received at least 18 injections.

In the comparison group, 19% were using oral contraceptives at baseline.

BMD was measured at the hip, spine, and whole body every 6 months for 24-36 months.

After adjusting for baseline and time-dependent variables, the researchers determined that the DMPA users lost significantly more BMD at the hip (-1.81% vs. -0.19%) and spine (-0.97% vs. 1.32%), compared with nonusers. Both groups gained BMD when the whole body was measured, but the DMPA users gained significantly less than the nonusers (0.73% vs. 0.88%).

New users lost bone faster than continuous users. After 24 months, new users showed a -6.09% change at the hip, compared with -2.05% in continuous users and -0.92% in nonusers.

Among the 61 subjects who discontinued DMPA during the study, BMD increased. Their annualized adjusted mean change in BMD was 1.34% for hip, 2.86% for spine, and 3.56% for the whole body.

There was no significance in BMD between nonusers and those who had discontinued DMPA 18 months earlier.

The injection is highly effective in preventing pregnancy, and its quarterly administration helps reduce compliance problems sometime seen in young women using other contraceptives, the researchers said.

In 2004, the Food and Drug Administration issued a black box warning for DMPA stating that prolonged use of the drug could result in significant loss of bone density, that the loss is greater the longer the drug is administered, and that bone density loss may not be completely reversible after discontinuing the drug.

WASHINGTON — Primary care physicians are less likely than specialists to initiate a work-up for secondary causes of bone loss in patients with scans indicating low bone density, despite a recommendation to do so.

That finding emerged from a study presented in poster form during the annual meeting of the North American Menopause Society.

Some patients with scans indicating osteoporosis were premenopausal women who started treatment with a bisphosphonate after their physicians received the scan results. Eventually, however, these patients were diagnosed with vitamin D deficiency, according to Andrea Sikon, M.D., of the Cleveland Clinic Women's Health Center, and her associates.

The study involved a review of 1,114 consecutive dual energy x-ray absorptiometry (DXA) scans performed at the center from July 2002 to August 2003. Of these scans, 712 (64%) were considered indicative of osteopenia (a T score ranging from -1.1 to -2.4), or of osteoporosis (a T score of -2.5 or below), according to World Health Organization criteria.

An evaluation for secondary causes of low bone density was recommended by the interpreter reading the scans in 77 of the 712 women with z scores equal to or less than -1.5.

These 77 women were aged 27-84 years, with a mean of 53 years.

But only 49 (64%) of the 77 women actually had a secondary evaluation as recommended, and laboratory tests were drawn only in 42 (55%) of these women.

Most of the specialists—which included rheumatologists, osteoporosis specialists, and North American Menopause Society-certified women's health specialists—followed up with patients as recommended, compared with less than one-third of primary care physicians, which included general ob.gyns., internists, and family physicians who practiced at the Cleveland Clinic.

Of the 41 women whose DXA scan had been ordered by a specialist, 39 (95%) had a secondary work-up initiated by the physician. But among the 36 whose primary care physician had ordered the DXA scan, only 10 (28%) had a work-up, according to the investigators.

Of the 42 women who had the full work-up, including lab tests, 23 (55%) were diagnosed with vitamin D deficiency, 4 (9%) were diagnosed with primary hyperparathyroidism, and 5 (12%) were diagnosed with premature ovarian insufficiency.

Concluding that specialists were more likely to perform the secondary evaluation, the study authors recommended that vitamin D, 25-hydroxyvitamin D, and parathyroid hormone levels should be drawn on all women with z scores that are at or below -1.5.

In an interview with this newspaper, study investigator Holly L. Thacker, M.D., who is the head of the Cleveland Clinic Women's Health Center, said it is unclear whether the physicians read the entire report or perhaps did not know which secondary work-up to conduct.

WASHINGTON — Primary care physicians are less likely than specialists to initiate a work-up for secondary causes of bone loss in patients with scans indicating low bone density, despite a recommendation to do so.

That finding emerged from a study presented in poster form during the annual meeting of the North American Menopause Society.

Some patients with scans indicating osteoporosis were premenopausal women who started treatment with a bisphosphonate after their physicians received the scan results. Eventually, however, these patients were diagnosed with vitamin D deficiency, according to Andrea Sikon, M.D., of the Cleveland Clinic Women's Health Center, and her associates.

The study involved a review of 1,114 consecutive dual energy x-ray absorptiometry (DXA) scans performed at the center from July 2002 to August 2003. Of these scans, 712 (64%) were considered indicative of osteopenia (a T score ranging from -1.1 to -2.4), or of osteoporosis (a T score of -2.5 or below), according to World Health Organization criteria.

An evaluation for secondary causes of low bone density was recommended by the interpreter reading the scans in 77 of the 712 women with z scores equal to or less than -1.5.

These 77 women were aged 27-84 years, with a mean of 53 years.

But only 49 (64%) of the 77 women actually had a secondary evaluation as recommended, and laboratory tests were drawn only in 42 (55%) of these women.

Most of the specialists—which included rheumatologists, osteoporosis specialists, and North American Menopause Society-certified women's health specialists—followed up with patients as recommended, compared with less than one-third of primary care physicians, which included general ob.gyns., internists, and family physicians who practiced at the Cleveland Clinic.

Of the 41 women whose DXA scan had been ordered by a specialist, 39 (95%) had a secondary work-up initiated by the physician. But among the 36 whose primary care physician had ordered the DXA scan, only 10 (28%) had a work-up, according to the investigators.

Of the 42 women who had the full work-up, including lab tests, 23 (55%) were diagnosed with vitamin D deficiency, 4 (9%) were diagnosed with primary hyperparathyroidism, and 5 (12%) were diagnosed with premature ovarian insufficiency.

Concluding that specialists were more likely to perform the secondary evaluation, the study authors recommended that vitamin D, 25-hydroxyvitamin D, and parathyroid hormone levels should be drawn on all women with z scores that are at or below -1.5.

In an interview with this newspaper, study investigator Holly L. Thacker, M.D., who is the head of the Cleveland Clinic Women's Health Center, said it is unclear whether the physicians read the entire report or perhaps did not know which secondary work-up to conduct.

WASHINGTON — Primary care physicians are less likely than specialists to initiate a work-up for secondary causes of bone loss in patients with scans indicating low bone density, despite a recommendation to do so.

That finding emerged from a study presented in poster form during the annual meeting of the North American Menopause Society.

Some patients with scans indicating osteoporosis were premenopausal women who started treatment with a bisphosphonate after their physicians received the scan results. Eventually, however, these patients were diagnosed with vitamin D deficiency, according to Andrea Sikon, M.D., of the Cleveland Clinic Women's Health Center, and her associates.

The study involved a review of 1,114 consecutive dual energy x-ray absorptiometry (DXA) scans performed at the center from July 2002 to August 2003. Of these scans, 712 (64%) were considered indicative of osteopenia (a T score ranging from -1.1 to -2.4), or of osteoporosis (a T score of -2.5 or below), according to World Health Organization criteria.

An evaluation for secondary causes of low bone density was recommended by the interpreter reading the scans in 77 of the 712 women with z scores equal to or less than -1.5.

These 77 women were aged 27-84 years, with a mean of 53 years.

But only 49 (64%) of the 77 women actually had a secondary evaluation as recommended, and laboratory tests were drawn only in 42 (55%) of these women.

Most of the specialists—which included rheumatologists, osteoporosis specialists, and North American Menopause Society-certified women's health specialists—followed up with patients as recommended, compared with less than one-third of primary care physicians, which included general ob.gyns., internists, and family physicians who practiced at the Cleveland Clinic.

Of the 41 women whose DXA scan had been ordered by a specialist, 39 (95%) had a secondary work-up initiated by the physician. But among the 36 whose primary care physician had ordered the DXA scan, only 10 (28%) had a work-up, according to the investigators.

Of the 42 women who had the full work-up, including lab tests, 23 (55%) were diagnosed with vitamin D deficiency, 4 (9%) were diagnosed with primary hyperparathyroidism, and 5 (12%) were diagnosed with premature ovarian insufficiency.

Concluding that specialists were more likely to perform the secondary evaluation, the study authors recommended that vitamin D, 25-hydroxyvitamin D, and parathyroid hormone levels should be drawn on all women with z scores that are at or below -1.5.

In an interview with this newspaper, study investigator Holly L. Thacker, M.D., who is the head of the Cleveland Clinic Women's Health Center, said it is unclear whether the physicians read the entire report or perhaps did not know which secondary work-up to conduct.

WASHINGTON — Women's perceptions that they gain weight when taking hormonal contraceptives are not realities, according to a randomized study.

Data from a poster presented at the annual meeting of the Association of Reproductive Health Professionals refuted the long-held association between use of hormonal contraception and weight gain, showing that women's perceived weight changes didn't match their actual weight changes while using contraceptives.

Concerns about weight gain may lead women to discontinue hormonal contraception, according to Lauren Osborne, a graduate student, and colleagues at Columbia University, New York. No significant weight changes occurred from baseline among women who used hormonal contraception in the form of either a pill or the vaginal ring in their randomized study of 201 subjects.

Overall, 167 of the 201 women completed three menstrual cycles using either oral contraception in the form of Ortho TriCyclen Lo (ethinyl estradiol and norgestimate) or a vaginal contraceptive ring (ethinyl estradiol and etonogestrel). The study was supported by a grant from Organon Pharmaceuticals Inc., maker of the NuvaRing vaginal contraceptive ring.

On average, the women who participated in the study gained 2.8 pounds, regardless of baseline weight or BMI and type of contraceptive used. The 34 women who reported a “bad change” in weight at the study's end had gained an average of 4.4 pounds, while the 112 women who reported “no change” had gained 2.2 pounds, and the 14 women who reported a “good change” had gained 3.3 pounds.

The mean weight of all the women studied was 146 pounds, and included women with BMIs in the healthy (less than 25), overweight (from 25 to 30), and obese (greater than 30) range.

WASHINGTON — Women's perceptions that they gain weight when taking hormonal contraceptives are not realities, according to a randomized study.

Data from a poster presented at the annual meeting of the Association of Reproductive Health Professionals refuted the long-held association between use of hormonal contraception and weight gain, showing that women's perceived weight changes didn't match their actual weight changes while using contraceptives.

Concerns about weight gain may lead women to discontinue hormonal contraception, according to Lauren Osborne, a graduate student, and colleagues at Columbia University, New York. No significant weight changes occurred from baseline among women who used hormonal contraception in the form of either a pill or the vaginal ring in their randomized study of 201 subjects.

Overall, 167 of the 201 women completed three menstrual cycles using either oral contraception in the form of Ortho TriCyclen Lo (ethinyl estradiol and norgestimate) or a vaginal contraceptive ring (ethinyl estradiol and etonogestrel). The study was supported by a grant from Organon Pharmaceuticals Inc., maker of the NuvaRing vaginal contraceptive ring.

On average, the women who participated in the study gained 2.8 pounds, regardless of baseline weight or BMI and type of contraceptive used. The 34 women who reported a “bad change” in weight at the study's end had gained an average of 4.4 pounds, while the 112 women who reported “no change” had gained 2.2 pounds, and the 14 women who reported a “good change” had gained 3.3 pounds.

The mean weight of all the women studied was 146 pounds, and included women with BMIs in the healthy (less than 25), overweight (from 25 to 30), and obese (greater than 30) range.

WASHINGTON — Women's perceptions that they gain weight when taking hormonal contraceptives are not realities, according to a randomized study.

Data from a poster presented at the annual meeting of the Association of Reproductive Health Professionals refuted the long-held association between use of hormonal contraception and weight gain, showing that women's perceived weight changes didn't match their actual weight changes while using contraceptives.

Concerns about weight gain may lead women to discontinue hormonal contraception, according to Lauren Osborne, a graduate student, and colleagues at Columbia University, New York. No significant weight changes occurred from baseline among women who used hormonal contraception in the form of either a pill or the vaginal ring in their randomized study of 201 subjects.

Overall, 167 of the 201 women completed three menstrual cycles using either oral contraception in the form of Ortho TriCyclen Lo (ethinyl estradiol and norgestimate) or a vaginal contraceptive ring (ethinyl estradiol and etonogestrel). The study was supported by a grant from Organon Pharmaceuticals Inc., maker of the NuvaRing vaginal contraceptive ring.

On average, the women who participated in the study gained 2.8 pounds, regardless of baseline weight or BMI and type of contraceptive used. The 34 women who reported a “bad change” in weight at the study's end had gained an average of 4.4 pounds, while the 112 women who reported “no change” had gained 2.2 pounds, and the 14 women who reported a “good change” had gained 3.3 pounds.

The mean weight of all the women studied was 146 pounds, and included women with BMIs in the healthy (less than 25), overweight (from 25 to 30), and obese (greater than 30) range.

WHITE SULPHUR SPRINGS, W.VA. — A treatment algorithm based on DNA identification of high-risk human papilloma virus subtypes could eliminate much unnecessary surgical intervention for women eventually found to have no cervical abnormality, William Irvin, M.D., reported.

“If the initial HPV DNA screening is negative, the likelihood that the patient harbors a high-grade squamous cervical lesion is very low, and rather than continue with diagnostic loop electrosurgical excision or conization, we would recommend conservative follow-up,” Dr. Irvin of the University of Virginia, Charlottesville, said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

“It's hoped that by following this algorithm, we can reduce or avoid unnecessary conization and electrosurgical excision procedures in women who are truly at low risk for cervical or endocervical lesions.” (See box.)

Dr. Irvin based his suggestions on the results of two studies. A 1999 Kaiser Permanente study of 137 women with cytologic atypical glandular cells (AGC) found that HPV DNA testing identified 94% of those with high-grade squamous intraepithelial lesions (HSIL) and 100% of those with endocervical adenocarcinoma in situ (Hum. Pathol. 1999;30:816-25).

And his own small study of 28 women with cytologic AGC found that the DNA testing had both a 100% sensitivity for detecting cervical intraepithelial neoplasia and a 100% negative predictive value for ruling out dysplasia.

“The take-home message of our study is that when a patient presents with cytologic AGC, and the HPV testing is negative [for high-risk strains], the likelihood of a high-grade endocervical lesion is exceedingly small, and you could consider that smear to be either reactive in nature or, if pathologic, most likely to be arising from lesions of the endometrium or adnexa,” he said.

Dr. Irvin prospectively analyzed 28 women who presented to a colposcopy clinic from 2002 to 2004. All of the women had a repeat ThinPrep System Pap smear for cytology and HPV testing, a colposcopy, and Fischer electrosurgical conization, followed by Pipelle endometrial biopsy.

A total of 58% of the group had significant pathologic abnormalities. Squamous intraepithelial lesions occurred in 50% of the group; 11 of those were HSIL, and 3 were low-grade squamous intraepithelial lesions. One woman had endocervical adenocarcinoma in situ, and one had endometrial hyperplasia.

Normal cells were found in 42% of the group. No cancers were found in study participants. Four of the HPV DNA samples were contaminated with blood, so results were available for 24 patients. Of those, 17 were positive for high-risk HPV, including all 13 dysplastic patients. Seven of the tests were negative for high-risk HPV, and none of the patients with negative test outcomes had dysplasia.

Management Tips for Women With Cytologic Atypical Glandular Cells

▸For women older than 35 years, women younger than 35 years who have abnormal bleeding, and women with AGC that “favors endometrial cells”: Perform endometrial sampling.

▸If AGC “favors endocervical adenocarcinoma in situ”: Perform cold-knife conization and subsequent cervical curettage.

▸ For AGC not otherwise specified: Perform HPV DNA testing.

If the patient is negative for high-risk HPV, repeat cytology at 6-month intervals until two consecutive normal results are obtained. If abnormal cytology persists, refer the patient to colposcopy.

If the patient is positive for high-risk HPV, the likelihood of a dysplastic cervical lesion—typically high-grade—is high. Perform colposcopy, biopsy as indicated, and obtain endocervical samplings. Base further management on the results of the evaluation.

Source: Dr. Irvin

WHITE SULPHUR SPRINGS, W.VA. — A treatment algorithm based on DNA identification of high-risk human papilloma virus subtypes could eliminate much unnecessary surgical intervention for women eventually found to have no cervical abnormality, William Irvin, M.D., reported.

“If the initial HPV DNA screening is negative, the likelihood that the patient harbors a high-grade squamous cervical lesion is very low, and rather than continue with diagnostic loop electrosurgical excision or conization, we would recommend conservative follow-up,” Dr. Irvin of the University of Virginia, Charlottesville, said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

“It's hoped that by following this algorithm, we can reduce or avoid unnecessary conization and electrosurgical excision procedures in women who are truly at low risk for cervical or endocervical lesions.” (See box.)

Dr. Irvin based his suggestions on the results of two studies. A 1999 Kaiser Permanente study of 137 women with cytologic atypical glandular cells (AGC) found that HPV DNA testing identified 94% of those with high-grade squamous intraepithelial lesions (HSIL) and 100% of those with endocervical adenocarcinoma in situ (Hum. Pathol. 1999;30:816-25).

And his own small study of 28 women with cytologic AGC found that the DNA testing had both a 100% sensitivity for detecting cervical intraepithelial neoplasia and a 100% negative predictive value for ruling out dysplasia.

“The take-home message of our study is that when a patient presents with cytologic AGC, and the HPV testing is negative [for high-risk strains], the likelihood of a high-grade endocervical lesion is exceedingly small, and you could consider that smear to be either reactive in nature or, if pathologic, most likely to be arising from lesions of the endometrium or adnexa,” he said.

Dr. Irvin prospectively analyzed 28 women who presented to a colposcopy clinic from 2002 to 2004. All of the women had a repeat ThinPrep System Pap smear for cytology and HPV testing, a colposcopy, and Fischer electrosurgical conization, followed by Pipelle endometrial biopsy.

A total of 58% of the group had significant pathologic abnormalities. Squamous intraepithelial lesions occurred in 50% of the group; 11 of those were HSIL, and 3 were low-grade squamous intraepithelial lesions. One woman had endocervical adenocarcinoma in situ, and one had endometrial hyperplasia.

Normal cells were found in 42% of the group. No cancers were found in study participants. Four of the HPV DNA samples were contaminated with blood, so results were available for 24 patients. Of those, 17 were positive for high-risk HPV, including all 13 dysplastic patients. Seven of the tests were negative for high-risk HPV, and none of the patients with negative test outcomes had dysplasia.

Management Tips for Women With Cytologic Atypical Glandular Cells

▸For women older than 35 years, women younger than 35 years who have abnormal bleeding, and women with AGC that “favors endometrial cells”: Perform endometrial sampling.

▸If AGC “favors endocervical adenocarcinoma in situ”: Perform cold-knife conization and subsequent cervical curettage.

▸ For AGC not otherwise specified: Perform HPV DNA testing.

If the patient is negative for high-risk HPV, repeat cytology at 6-month intervals until two consecutive normal results are obtained. If abnormal cytology persists, refer the patient to colposcopy.

If the patient is positive for high-risk HPV, the likelihood of a dysplastic cervical lesion—typically high-grade—is high. Perform colposcopy, biopsy as indicated, and obtain endocervical samplings. Base further management on the results of the evaluation.

Source: Dr. Irvin

WHITE SULPHUR SPRINGS, W.VA. — A treatment algorithm based on DNA identification of high-risk human papilloma virus subtypes could eliminate much unnecessary surgical intervention for women eventually found to have no cervical abnormality, William Irvin, M.D., reported.

“If the initial HPV DNA screening is negative, the likelihood that the patient harbors a high-grade squamous cervical lesion is very low, and rather than continue with diagnostic loop electrosurgical excision or conization, we would recommend conservative follow-up,” Dr. Irvin of the University of Virginia, Charlottesville, said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

“It's hoped that by following this algorithm, we can reduce or avoid unnecessary conization and electrosurgical excision procedures in women who are truly at low risk for cervical or endocervical lesions.” (See box.)

Dr. Irvin based his suggestions on the results of two studies. A 1999 Kaiser Permanente study of 137 women with cytologic atypical glandular cells (AGC) found that HPV DNA testing identified 94% of those with high-grade squamous intraepithelial lesions (HSIL) and 100% of those with endocervical adenocarcinoma in situ (Hum. Pathol. 1999;30:816-25).

And his own small study of 28 women with cytologic AGC found that the DNA testing had both a 100% sensitivity for detecting cervical intraepithelial neoplasia and a 100% negative predictive value for ruling out dysplasia.

“The take-home message of our study is that when a patient presents with cytologic AGC, and the HPV testing is negative [for high-risk strains], the likelihood of a high-grade endocervical lesion is exceedingly small, and you could consider that smear to be either reactive in nature or, if pathologic, most likely to be arising from lesions of the endometrium or adnexa,” he said.

Dr. Irvin prospectively analyzed 28 women who presented to a colposcopy clinic from 2002 to 2004. All of the women had a repeat ThinPrep System Pap smear for cytology and HPV testing, a colposcopy, and Fischer electrosurgical conization, followed by Pipelle endometrial biopsy.

A total of 58% of the group had significant pathologic abnormalities. Squamous intraepithelial lesions occurred in 50% of the group; 11 of those were HSIL, and 3 were low-grade squamous intraepithelial lesions. One woman had endocervical adenocarcinoma in situ, and one had endometrial hyperplasia.

Normal cells were found in 42% of the group. No cancers were found in study participants. Four of the HPV DNA samples were contaminated with blood, so results were available for 24 patients. Of those, 17 were positive for high-risk HPV, including all 13 dysplastic patients. Seven of the tests were negative for high-risk HPV, and none of the patients with negative test outcomes had dysplasia.

Management Tips for Women With Cytologic Atypical Glandular Cells

▸For women older than 35 years, women younger than 35 years who have abnormal bleeding, and women with AGC that “favors endometrial cells”: Perform endometrial sampling.

▸If AGC “favors endocervical adenocarcinoma in situ”: Perform cold-knife conization and subsequent cervical curettage.

▸ For AGC not otherwise specified: Perform HPV DNA testing.

If the patient is negative for high-risk HPV, repeat cytology at 6-month intervals until two consecutive normal results are obtained. If abnormal cytology persists, refer the patient to colposcopy.

If the patient is positive for high-risk HPV, the likelihood of a dysplastic cervical lesion—typically high-grade—is high. Perform colposcopy, biopsy as indicated, and obtain endocervical samplings. Base further management on the results of the evaluation.

Source: Dr. Irvin

WASHINGTON — Brooke Gurland, M.D., realized that, despite her training as a colorectal surgeon, she didn't have a complete perspective on pelvic floor dysfunction.

Fellows in colorectal surgery “weren't even trained to know the anatomy of the other organs, much less how to work with other pelvic specialists in the hospital system,” said Dr. Gurland, a colorectal surgeon at Maimonides Hospital in New York.

A multidisciplinary approach to women's pelvic floor disorders is important, because multiple pelvic floor defects often exist in the absence of patient complaints, she said at the annual meeting of the Gerontological Society of America.

Older women tend to underreport pelvic floor problems, especially those associated with fecal incontinence or defecation problems, because they don't feel comfortable raising the subject with their doctors, or because they find ways to compensate, such as using an enema or finger to complete their defecation.

Research in pelvic floor symptomatology is limited, and many physicians don't know that different treatment options exist for pelvic floor dysfunction, said Dr. Gurland, who is spearheading a pelvic floor task force at Maimonides. The main objectives are to establish a center to evaluate the pelvic floor compartments as a functional unit, to educate health professionals and the community about pelvic floor disorders, to create a database, and to coordinate studies of multicompartment pelvic floor disorders to improve knowledge in this area.

To help finance these efforts, Dr. Gurland received a career development grant totaling $200,000 over 2 years from the American Geriatrics Society to establish the Maimonides Center for Pelvic Floor Dysfunction and Reconstructive Surgery.

The first step was to identify a pelvic floor task force that includes physicians, nurse practitioners, continence specialists, physician assistants, and pain specialists from fields such as urology, gynecology, colorectal surgery, and geriatrics.

Education plans have included a nurses' public health symposium and a fellowship program in which an ob.gyn. would work with Dr. Gurland and a colleague in urogynecology. The staff conducted community outreach by placing ads in local newspapers to encourage women with pelvic floor complaints to visit the center.

“We are getting patients who would not have approached their primary doctors, but are seeking us out specifically,” Dr. Gurland noted.

The designated support staff has made all the difference in establishing the center and creating a multidisciplinary treatment protocol, she said. “I have two physician assistants and two medical assistants who coordinate care between subspecialists. They coordinate surgeries and are trained to do pelvic floor rehabilitation and biofeedback, and provide emotional support to the patients.”

In addition, Dr. Gurland combines office hours with a urogynecologist, which minimizes patient visits and eases the travel burden for elderly patients.

“Once we make a decision on how to care for a patient, I can sit down with the urogynecologist and create a plan,” Dr. Gurland commented. “We can also see the postops together and see how people are responding to treatment.”

Dr. Gurland and her colleagues list the symptoms of fecal dysfunction on their database for tracking patients and conducting research. They use the Wexner fecal incontinence score, which ranges from 0 to 20 (no incontinence to complete fecal incontinence) and included incontinence to flatus, liquid, and solid stool. The frequency of accidents and its effect on lifestyle also are included. In addition, the Rome criteria are used to define obstructive defecation, such as a feeling of anal blockage 25% of the time and the need for an enema or other help to fully evacuate.

Dr. Gurland reported results from the first 70 patients treated at the center. The women enrolled in the database had symptoms of urinary dysfunction and prolapse and either fecal incontinence or difficult evacuation.

The average age was 66 years, with an average parity of 3. Seventeen had undergone hysterectomies.

Although urinary incontinence was the most common symptom, 38 patients had fecal incontinence, 28 had obstructive defecation, and 22 reported rectal pressure.

Of those with fecal incontinence, 89% had urinary incontinence, 61% had pelvic pressure or a bulge, and 3% had pelvic pain.

An overwhelming majority, 82%, of those with obstructed defecation had rectal pressure, 43% had pelvic pressure or bulge, and 25% had pelvic pain. And of those with rectal pressure, 73% had urinary incontinence, 68% had pelvic pressure, and 18% had pelvic pain.

Rectocele was the most common physical finding in the entire group (60% of patients), followed by cystocele, enterocele, rectal prolapse, and anal sphincter defects diagnosed by endorectal ultrasound.

As for the outcomes, 35% had surgery, 25% are undergoing biofeedback treatment, and approximately 28% are considering surgical or nonsurgical treatment. An additional 10% decided they were satisfied with their quality of life and declined treatment.

WASHINGTON — Brooke Gurland, M.D., realized that, despite her training as a colorectal surgeon, she didn't have a complete perspective on pelvic floor dysfunction.

Fellows in colorectal surgery “weren't even trained to know the anatomy of the other organs, much less how to work with other pelvic specialists in the hospital system,” said Dr. Gurland, a colorectal surgeon at Maimonides Hospital in New York.

A multidisciplinary approach to women's pelvic floor disorders is important, because multiple pelvic floor defects often exist in the absence of patient complaints, she said at the annual meeting of the Gerontological Society of America.

Older women tend to underreport pelvic floor problems, especially those associated with fecal incontinence or defecation problems, because they don't feel comfortable raising the subject with their doctors, or because they find ways to compensate, such as using an enema or finger to complete their defecation.

Research in pelvic floor symptomatology is limited, and many physicians don't know that different treatment options exist for pelvic floor dysfunction, said Dr. Gurland, who is spearheading a pelvic floor task force at Maimonides. The main objectives are to establish a center to evaluate the pelvic floor compartments as a functional unit, to educate health professionals and the community about pelvic floor disorders, to create a database, and to coordinate studies of multicompartment pelvic floor disorders to improve knowledge in this area.

To help finance these efforts, Dr. Gurland received a career development grant totaling $200,000 over 2 years from the American Geriatrics Society to establish the Maimonides Center for Pelvic Floor Dysfunction and Reconstructive Surgery.

The first step was to identify a pelvic floor task force that includes physicians, nurse practitioners, continence specialists, physician assistants, and pain specialists from fields such as urology, gynecology, colorectal surgery, and geriatrics.

Education plans have included a nurses' public health symposium and a fellowship program in which an ob.gyn. would work with Dr. Gurland and a colleague in urogynecology. The staff conducted community outreach by placing ads in local newspapers to encourage women with pelvic floor complaints to visit the center.

“We are getting patients who would not have approached their primary doctors, but are seeking us out specifically,” Dr. Gurland noted.

The designated support staff has made all the difference in establishing the center and creating a multidisciplinary treatment protocol, she said. “I have two physician assistants and two medical assistants who coordinate care between subspecialists. They coordinate surgeries and are trained to do pelvic floor rehabilitation and biofeedback, and provide emotional support to the patients.”

In addition, Dr. Gurland combines office hours with a urogynecologist, which minimizes patient visits and eases the travel burden for elderly patients.

“Once we make a decision on how to care for a patient, I can sit down with the urogynecologist and create a plan,” Dr. Gurland commented. “We can also see the postops together and see how people are responding to treatment.”

Dr. Gurland and her colleagues list the symptoms of fecal dysfunction on their database for tracking patients and conducting research. They use the Wexner fecal incontinence score, which ranges from 0 to 20 (no incontinence to complete fecal incontinence) and included incontinence to flatus, liquid, and solid stool. The frequency of accidents and its effect on lifestyle also are included. In addition, the Rome criteria are used to define obstructive defecation, such as a feeling of anal blockage 25% of the time and the need for an enema or other help to fully evacuate.

Dr. Gurland reported results from the first 70 patients treated at the center. The women enrolled in the database had symptoms of urinary dysfunction and prolapse and either fecal incontinence or difficult evacuation.

The average age was 66 years, with an average parity of 3. Seventeen had undergone hysterectomies.

Although urinary incontinence was the most common symptom, 38 patients had fecal incontinence, 28 had obstructive defecation, and 22 reported rectal pressure.

Of those with fecal incontinence, 89% had urinary incontinence, 61% had pelvic pressure or a bulge, and 3% had pelvic pain.

An overwhelming majority, 82%, of those with obstructed defecation had rectal pressure, 43% had pelvic pressure or bulge, and 25% had pelvic pain. And of those with rectal pressure, 73% had urinary incontinence, 68% had pelvic pressure, and 18% had pelvic pain.

Rectocele was the most common physical finding in the entire group (60% of patients), followed by cystocele, enterocele, rectal prolapse, and anal sphincter defects diagnosed by endorectal ultrasound.

As for the outcomes, 35% had surgery, 25% are undergoing biofeedback treatment, and approximately 28% are considering surgical or nonsurgical treatment. An additional 10% decided they were satisfied with their quality of life and declined treatment.

WASHINGTON — Brooke Gurland, M.D., realized that, despite her training as a colorectal surgeon, she didn't have a complete perspective on pelvic floor dysfunction.

Fellows in colorectal surgery “weren't even trained to know the anatomy of the other organs, much less how to work with other pelvic specialists in the hospital system,” said Dr. Gurland, a colorectal surgeon at Maimonides Hospital in New York.

A multidisciplinary approach to women's pelvic floor disorders is important, because multiple pelvic floor defects often exist in the absence of patient complaints, she said at the annual meeting of the Gerontological Society of America.

Older women tend to underreport pelvic floor problems, especially those associated with fecal incontinence or defecation problems, because they don't feel comfortable raising the subject with their doctors, or because they find ways to compensate, such as using an enema or finger to complete their defecation.

Research in pelvic floor symptomatology is limited, and many physicians don't know that different treatment options exist for pelvic floor dysfunction, said Dr. Gurland, who is spearheading a pelvic floor task force at Maimonides. The main objectives are to establish a center to evaluate the pelvic floor compartments as a functional unit, to educate health professionals and the community about pelvic floor disorders, to create a database, and to coordinate studies of multicompartment pelvic floor disorders to improve knowledge in this area.

To help finance these efforts, Dr. Gurland received a career development grant totaling $200,000 over 2 years from the American Geriatrics Society to establish the Maimonides Center for Pelvic Floor Dysfunction and Reconstructive Surgery.

The first step was to identify a pelvic floor task force that includes physicians, nurse practitioners, continence specialists, physician assistants, and pain specialists from fields such as urology, gynecology, colorectal surgery, and geriatrics.

Education plans have included a nurses' public health symposium and a fellowship program in which an ob.gyn. would work with Dr. Gurland and a colleague in urogynecology. The staff conducted community outreach by placing ads in local newspapers to encourage women with pelvic floor complaints to visit the center.

“We are getting patients who would not have approached their primary doctors, but are seeking us out specifically,” Dr. Gurland noted.

The designated support staff has made all the difference in establishing the center and creating a multidisciplinary treatment protocol, she said. “I have two physician assistants and two medical assistants who coordinate care between subspecialists. They coordinate surgeries and are trained to do pelvic floor rehabilitation and biofeedback, and provide emotional support to the patients.”

In addition, Dr. Gurland combines office hours with a urogynecologist, which minimizes patient visits and eases the travel burden for elderly patients.

“Once we make a decision on how to care for a patient, I can sit down with the urogynecologist and create a plan,” Dr. Gurland commented. “We can also see the postops together and see how people are responding to treatment.”

Dr. Gurland and her colleagues list the symptoms of fecal dysfunction on their database for tracking patients and conducting research. They use the Wexner fecal incontinence score, which ranges from 0 to 20 (no incontinence to complete fecal incontinence) and included incontinence to flatus, liquid, and solid stool. The frequency of accidents and its effect on lifestyle also are included. In addition, the Rome criteria are used to define obstructive defecation, such as a feeling of anal blockage 25% of the time and the need for an enema or other help to fully evacuate.

Dr. Gurland reported results from the first 70 patients treated at the center. The women enrolled in the database had symptoms of urinary dysfunction and prolapse and either fecal incontinence or difficult evacuation.

The average age was 66 years, with an average parity of 3. Seventeen had undergone hysterectomies.

Although urinary incontinence was the most common symptom, 38 patients had fecal incontinence, 28 had obstructive defecation, and 22 reported rectal pressure.

Of those with fecal incontinence, 89% had urinary incontinence, 61% had pelvic pressure or a bulge, and 3% had pelvic pain.

An overwhelming majority, 82%, of those with obstructed defecation had rectal pressure, 43% had pelvic pressure or bulge, and 25% had pelvic pain. And of those with rectal pressure, 73% had urinary incontinence, 68% had pelvic pressure, and 18% had pelvic pain.

Rectocele was the most common physical finding in the entire group (60% of patients), followed by cystocele, enterocele, rectal prolapse, and anal sphincter defects diagnosed by endorectal ultrasound.

As for the outcomes, 35% had surgery, 25% are undergoing biofeedback treatment, and approximately 28% are considering surgical or nonsurgical treatment. An additional 10% decided they were satisfied with their quality of life and declined treatment.