Obstetrics

WHITE SULPHUR SPRINGS, W.VA. — Most physicians who prescribe hormone therapy still overestimate both its long-term risks and benefits, R. Stan Williams, M.D., said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Compared with internists and family doctors, ob.gyns. were the most likely to display an accurate understanding of these issues. But a large portion still gave incorrect answers to Dr. Williams' statewide physician survey on hormone therapy (HT).

“These people thought they understood the results of the Women's Health Initiative [WHI] and said they were counseling their patients about it, but only 28% of their answers were correct,” said Dr. Williams, professor of ob.gyn of the University of Florida, Gainesville, and chief of the university's division of reproductive endocrinology and infertility.

“Most respondents (67%) dramatically overestimated the risks and benefits,” and 5% of the answers “were actually in the wrong direction; they thought it was a risk when it was actually a benefit,” he said.

In March 2004, Dr. Williams mailed his survey to all primary care physicians in Florida. The survey asked a specific question about the percentage of annual attributable change of risk of heart disease, stroke, venous thrombosis, breast cancer, colon cancer, hip fracture and death, as reported in the WHI.

He sent out more than 6,000 surveys; 600 were returned (203 from ob.gyns., 145 from internists, 219 from family physicians, and 33 from other physicians).

About 35% of ob.gyns., 30% of family physicians, and 17% of internists correctly answered that HT increased the risk of heart disease by less than 1% per year of use. Many thought there was no change in risk (35% of internists, 33% of ob.gyns, and 27% of family physicians). About 20% of internists and 15% of family physicians said the risk was increased 10%-30% per year of use.

About 50% of ob.gyns., 35% of internists, and 30% of family physicians correctly answered that HT increased the risk of stroke by less than 1% per year of use. About 20% of family physicians, 17% of internists, and 15% of ob.gyns. said the increased risk was 10%-30% per year of use.

About 50% of ob.gyns., 30% of internists, and 27% of family physicians correctly answered that HT increases the risk of venous thrombosis by less than 1% per year of use. About 30% of ob.gyns., 25% of internists, and 30% of family physicians said the risk was increased by 10%-30% per year of use.

About half of ob.gyns, half of family physicians, and 40% of internists correctly answered that HT increases the risk of breast cancer by less than 1% per year of use. About 17% of internists, 15% of family physicians, and 8% of ob.gyns said the increased risk was 10%-30% per year of use.

The benefits of HT also were misunderstood. Only about 35% of ob.gyns, 20% of internists, and 17% of family physicians correctly answered that the decrease in risk of breast cancer was about 1% per year of use.

Most internists (70%) and family physicians (55%) and 30% of ob.gyns. said HT did not change the risk of colon cancer. Only 20% of ob.gyns., 18% of family physicians, and 20% of internists correctly answered that the decreased risk was 1% per year of use.

About 17% of ob.gyns., 15% of internists, and 10% of family physicians correctly answered that HT decreases the risk of osteoporotic hip fracture by 1% per year of use.

About 60% of family physicians, 55% of ob.gyns., and 50% of family physicians thought the risk reduction was 10%-30% per year of use.

Most respondents understood that there is no change in overall mortality rates associated with HT use. About 85% of ob.gyns. and 65% of internists and family physicians answered correctly. But a few respondents said the overall mortality risk increased 3%-10% per year of use.

Dr. Williams also asked respondents' views of HT on a scale of 1-5, with 5 being positive. The average rating was 3.89 among ob.gyns., 3.0 among family physicians, and 2.7 among internists.

In 2004, Dr. Williams presented the results of a similar survey he conducted among 1,000 women aged 45-65. This study showed that up to 36% believed that their attributable risk for heart disease and stroke was 10%-30% per year of HT use.

More than half believed the risk for breast cancer was 10%-30% per year of HT, and 60% believed HT could reduce their risk of osteoporotic hip fracture by up to 30% per year.

WHITE SULPHUR SPRINGS, W.VA. — Most physicians who prescribe hormone therapy still overestimate both its long-term risks and benefits, R. Stan Williams, M.D., said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Compared with internists and family doctors, ob.gyns. were the most likely to display an accurate understanding of these issues. But a large portion still gave incorrect answers to Dr. Williams' statewide physician survey on hormone therapy (HT).

“These people thought they understood the results of the Women's Health Initiative [WHI] and said they were counseling their patients about it, but only 28% of their answers were correct,” said Dr. Williams, professor of ob.gyn of the University of Florida, Gainesville, and chief of the university's division of reproductive endocrinology and infertility.

“Most respondents (67%) dramatically overestimated the risks and benefits,” and 5% of the answers “were actually in the wrong direction; they thought it was a risk when it was actually a benefit,” he said.

In March 2004, Dr. Williams mailed his survey to all primary care physicians in Florida. The survey asked a specific question about the percentage of annual attributable change of risk of heart disease, stroke, venous thrombosis, breast cancer, colon cancer, hip fracture and death, as reported in the WHI.

He sent out more than 6,000 surveys; 600 were returned (203 from ob.gyns., 145 from internists, 219 from family physicians, and 33 from other physicians).

About 35% of ob.gyns., 30% of family physicians, and 17% of internists correctly answered that HT increased the risk of heart disease by less than 1% per year of use. Many thought there was no change in risk (35% of internists, 33% of ob.gyns, and 27% of family physicians). About 20% of internists and 15% of family physicians said the risk was increased 10%-30% per year of use.

About 50% of ob.gyns., 35% of internists, and 30% of family physicians correctly answered that HT increased the risk of stroke by less than 1% per year of use. About 20% of family physicians, 17% of internists, and 15% of ob.gyns. said the increased risk was 10%-30% per year of use.

About 50% of ob.gyns., 30% of internists, and 27% of family physicians correctly answered that HT increases the risk of venous thrombosis by less than 1% per year of use. About 30% of ob.gyns., 25% of internists, and 30% of family physicians said the risk was increased by 10%-30% per year of use.

About half of ob.gyns, half of family physicians, and 40% of internists correctly answered that HT increases the risk of breast cancer by less than 1% per year of use. About 17% of internists, 15% of family physicians, and 8% of ob.gyns said the increased risk was 10%-30% per year of use.

The benefits of HT also were misunderstood. Only about 35% of ob.gyns, 20% of internists, and 17% of family physicians correctly answered that the decrease in risk of breast cancer was about 1% per year of use.

Most internists (70%) and family physicians (55%) and 30% of ob.gyns. said HT did not change the risk of colon cancer. Only 20% of ob.gyns., 18% of family physicians, and 20% of internists correctly answered that the decreased risk was 1% per year of use.

About 17% of ob.gyns., 15% of internists, and 10% of family physicians correctly answered that HT decreases the risk of osteoporotic hip fracture by 1% per year of use.

About 60% of family physicians, 55% of ob.gyns., and 50% of family physicians thought the risk reduction was 10%-30% per year of use.

Most respondents understood that there is no change in overall mortality rates associated with HT use. About 85% of ob.gyns. and 65% of internists and family physicians answered correctly. But a few respondents said the overall mortality risk increased 3%-10% per year of use.

Dr. Williams also asked respondents' views of HT on a scale of 1-5, with 5 being positive. The average rating was 3.89 among ob.gyns., 3.0 among family physicians, and 2.7 among internists.

In 2004, Dr. Williams presented the results of a similar survey he conducted among 1,000 women aged 45-65. This study showed that up to 36% believed that their attributable risk for heart disease and stroke was 10%-30% per year of HT use.

More than half believed the risk for breast cancer was 10%-30% per year of HT, and 60% believed HT could reduce their risk of osteoporotic hip fracture by up to 30% per year.

WHITE SULPHUR SPRINGS, W.VA. — Most physicians who prescribe hormone therapy still overestimate both its long-term risks and benefits, R. Stan Williams, M.D., said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Compared with internists and family doctors, ob.gyns. were the most likely to display an accurate understanding of these issues. But a large portion still gave incorrect answers to Dr. Williams' statewide physician survey on hormone therapy (HT).

“These people thought they understood the results of the Women's Health Initiative [WHI] and said they were counseling their patients about it, but only 28% of their answers were correct,” said Dr. Williams, professor of ob.gyn of the University of Florida, Gainesville, and chief of the university's division of reproductive endocrinology and infertility.

“Most respondents (67%) dramatically overestimated the risks and benefits,” and 5% of the answers “were actually in the wrong direction; they thought it was a risk when it was actually a benefit,” he said.

In March 2004, Dr. Williams mailed his survey to all primary care physicians in Florida. The survey asked a specific question about the percentage of annual attributable change of risk of heart disease, stroke, venous thrombosis, breast cancer, colon cancer, hip fracture and death, as reported in the WHI.

He sent out more than 6,000 surveys; 600 were returned (203 from ob.gyns., 145 from internists, 219 from family physicians, and 33 from other physicians).

About 35% of ob.gyns., 30% of family physicians, and 17% of internists correctly answered that HT increased the risk of heart disease by less than 1% per year of use. Many thought there was no change in risk (35% of internists, 33% of ob.gyns, and 27% of family physicians). About 20% of internists and 15% of family physicians said the risk was increased 10%-30% per year of use.

About 50% of ob.gyns., 35% of internists, and 30% of family physicians correctly answered that HT increased the risk of stroke by less than 1% per year of use. About 20% of family physicians, 17% of internists, and 15% of ob.gyns. said the increased risk was 10%-30% per year of use.

About 50% of ob.gyns., 30% of internists, and 27% of family physicians correctly answered that HT increases the risk of venous thrombosis by less than 1% per year of use. About 30% of ob.gyns., 25% of internists, and 30% of family physicians said the risk was increased by 10%-30% per year of use.

About half of ob.gyns, half of family physicians, and 40% of internists correctly answered that HT increases the risk of breast cancer by less than 1% per year of use. About 17% of internists, 15% of family physicians, and 8% of ob.gyns said the increased risk was 10%-30% per year of use.

The benefits of HT also were misunderstood. Only about 35% of ob.gyns, 20% of internists, and 17% of family physicians correctly answered that the decrease in risk of breast cancer was about 1% per year of use.

Most internists (70%) and family physicians (55%) and 30% of ob.gyns. said HT did not change the risk of colon cancer. Only 20% of ob.gyns., 18% of family physicians, and 20% of internists correctly answered that the decreased risk was 1% per year of use.

About 17% of ob.gyns., 15% of internists, and 10% of family physicians correctly answered that HT decreases the risk of osteoporotic hip fracture by 1% per year of use.

About 60% of family physicians, 55% of ob.gyns., and 50% of family physicians thought the risk reduction was 10%-30% per year of use.

Most respondents understood that there is no change in overall mortality rates associated with HT use. About 85% of ob.gyns. and 65% of internists and family physicians answered correctly. But a few respondents said the overall mortality risk increased 3%-10% per year of use.

Dr. Williams also asked respondents' views of HT on a scale of 1-5, with 5 being positive. The average rating was 3.89 among ob.gyns., 3.0 among family physicians, and 2.7 among internists.

In 2004, Dr. Williams presented the results of a similar survey he conducted among 1,000 women aged 45-65. This study showed that up to 36% believed that their attributable risk for heart disease and stroke was 10%-30% per year of HT use.

More than half believed the risk for breast cancer was 10%-30% per year of HT, and 60% believed HT could reduce their risk of osteoporotic hip fracture by up to 30% per year.

SAN FRANCISCO — In an overwhelming majority of women presenting with chronic pelvic pain, the bladder is the pain-generating organ, Edward J. Stanford, M.D., said at the annual meeting of the American Association of Gynecologic Laparoscopists.

In three studies of almost 300 women with chronic pelvic pain, the prevalence of interstitial cystitis ranged from 70% to 82%, said Dr. Stanford of St. Mary's Good Samaritan Medical Center, Centralia, Ill.

In the most recent and thorough of these studies, Dr. Stanford followed 64 women with chronic pelvic pain for a year. Each patient completed the Pelvic Pain and Urgency/Frequency questionnaire and underwent a vulvar touch test, a potassium sensitivity test, cystoscopy with hydrodissection, and laparoscopy. During the laparoscopic period, suspicious lesions were biopsied and adhesions removed.

Although 64% did have adhesions, the pain could not be attributed to this cause, Dr. Stanford said. In 70% the bladder was the pain-generating organ, 28% had biopsy-proven endometriosis, and 20% had vulvar pain. Therefore, in the differential diagnosis of chronic pelvic pain, interstitial cystitis must be ranked first, with irritable bowel syndrome, endometriosis, and vulvodynia ranked second, third, and fourth, respectively.

SAN FRANCISCO — In an overwhelming majority of women presenting with chronic pelvic pain, the bladder is the pain-generating organ, Edward J. Stanford, M.D., said at the annual meeting of the American Association of Gynecologic Laparoscopists.

In three studies of almost 300 women with chronic pelvic pain, the prevalence of interstitial cystitis ranged from 70% to 82%, said Dr. Stanford of St. Mary's Good Samaritan Medical Center, Centralia, Ill.

In the most recent and thorough of these studies, Dr. Stanford followed 64 women with chronic pelvic pain for a year. Each patient completed the Pelvic Pain and Urgency/Frequency questionnaire and underwent a vulvar touch test, a potassium sensitivity test, cystoscopy with hydrodissection, and laparoscopy. During the laparoscopic period, suspicious lesions were biopsied and adhesions removed.

Although 64% did have adhesions, the pain could not be attributed to this cause, Dr. Stanford said. In 70% the bladder was the pain-generating organ, 28% had biopsy-proven endometriosis, and 20% had vulvar pain. Therefore, in the differential diagnosis of chronic pelvic pain, interstitial cystitis must be ranked first, with irritable bowel syndrome, endometriosis, and vulvodynia ranked second, third, and fourth, respectively.

SAN FRANCISCO — In an overwhelming majority of women presenting with chronic pelvic pain, the bladder is the pain-generating organ, Edward J. Stanford, M.D., said at the annual meeting of the American Association of Gynecologic Laparoscopists.

In three studies of almost 300 women with chronic pelvic pain, the prevalence of interstitial cystitis ranged from 70% to 82%, said Dr. Stanford of St. Mary's Good Samaritan Medical Center, Centralia, Ill.

In the most recent and thorough of these studies, Dr. Stanford followed 64 women with chronic pelvic pain for a year. Each patient completed the Pelvic Pain and Urgency/Frequency questionnaire and underwent a vulvar touch test, a potassium sensitivity test, cystoscopy with hydrodissection, and laparoscopy. During the laparoscopic period, suspicious lesions were biopsied and adhesions removed.

Although 64% did have adhesions, the pain could not be attributed to this cause, Dr. Stanford said. In 70% the bladder was the pain-generating organ, 28% had biopsy-proven endometriosis, and 20% had vulvar pain. Therefore, in the differential diagnosis of chronic pelvic pain, interstitial cystitis must be ranked first, with irritable bowel syndrome, endometriosis, and vulvodynia ranked second, third, and fourth, respectively.

EXETER, ENGLAND — A standardized ear acupuncture protocol effectively reduced hot flashes in women receiving tamoxifen as adjuvant treatment for breast cancer, according to an interim analysis presented at a symposium on alternative and complementary therapies sponsored by the universities of Exeter and Plymouth.

The National Acupuncture and Detoxification Association (NADA) protocol has been used for 30 years to treat withdrawal symptoms in substance abusers, most famously at the Lincoln Medical and Mental Health Center in New York City's South Bronx, Beverley de Valois said.

Ms. de Valois, a Ph.D. candidate at Thames Valley University, London, and a research acupuncturist at the Lynda Jackson Macmillan Centre at Mount Vernon Hospital, Northwood, had previously done a study of traditional acupuncture for women experiencing adverse effects during tamoxifen treatment. “The results were encouraging, but the methodology is complex and time consuming, and our goal at the center is to make treatment for tamoxifen-related side effects widely and easily available,” she said.

There also were some difficulties in administering traditional acupuncture. Needling the limb on the affected side is discouraged because of fears that this might lead to lymphedema, she said. This restriction was particularly problematic for women who had had bilateral mastectomies.

She had previously worked with the NADA protocol, and because some of the side effects of tamoxifen—night sweats, anxiety, and sleep difficulties—resemble those of withdrawal, she thought this might be useful for these patients as well.

A total of 50 women were recruited for the study. They had to be taking tamoxifen for at least 6 months and having four or more vasomotor incidents per day. The treatment involved eight acupuncture sessions, five patients at a time, during a 29-week period. Participants recorded the frequency and severity of hot flashes in diaries and were asked how they subjectively rated the treatment.

There was no control group, and any placebo effect was not addressed.

An interim analysis of the first 35 patients showed a reduction in frequency from a mean of 10.32 flashes per day at baseline to 7.24 at the end of treatment, a statistically significant mean reduction of 24.4%, Ms. de Valois said. Sleep also improved as nocturnal hot flashes decreased.

Participants gave high marks to the experience of receiving the treatment in groups, where they met others with similar problems and were able to share experiences and information, she said.

EXETER, ENGLAND — A standardized ear acupuncture protocol effectively reduced hot flashes in women receiving tamoxifen as adjuvant treatment for breast cancer, according to an interim analysis presented at a symposium on alternative and complementary therapies sponsored by the universities of Exeter and Plymouth.

The National Acupuncture and Detoxification Association (NADA) protocol has been used for 30 years to treat withdrawal symptoms in substance abusers, most famously at the Lincoln Medical and Mental Health Center in New York City's South Bronx, Beverley de Valois said.

Ms. de Valois, a Ph.D. candidate at Thames Valley University, London, and a research acupuncturist at the Lynda Jackson Macmillan Centre at Mount Vernon Hospital, Northwood, had previously done a study of traditional acupuncture for women experiencing adverse effects during tamoxifen treatment. “The results were encouraging, but the methodology is complex and time consuming, and our goal at the center is to make treatment for tamoxifen-related side effects widely and easily available,” she said.

There also were some difficulties in administering traditional acupuncture. Needling the limb on the affected side is discouraged because of fears that this might lead to lymphedema, she said. This restriction was particularly problematic for women who had had bilateral mastectomies.

She had previously worked with the NADA protocol, and because some of the side effects of tamoxifen—night sweats, anxiety, and sleep difficulties—resemble those of withdrawal, she thought this might be useful for these patients as well.

A total of 50 women were recruited for the study. They had to be taking tamoxifen for at least 6 months and having four or more vasomotor incidents per day. The treatment involved eight acupuncture sessions, five patients at a time, during a 29-week period. Participants recorded the frequency and severity of hot flashes in diaries and were asked how they subjectively rated the treatment.

There was no control group, and any placebo effect was not addressed.

An interim analysis of the first 35 patients showed a reduction in frequency from a mean of 10.32 flashes per day at baseline to 7.24 at the end of treatment, a statistically significant mean reduction of 24.4%, Ms. de Valois said. Sleep also improved as nocturnal hot flashes decreased.

Participants gave high marks to the experience of receiving the treatment in groups, where they met others with similar problems and were able to share experiences and information, she said.

EXETER, ENGLAND — A standardized ear acupuncture protocol effectively reduced hot flashes in women receiving tamoxifen as adjuvant treatment for breast cancer, according to an interim analysis presented at a symposium on alternative and complementary therapies sponsored by the universities of Exeter and Plymouth.

The National Acupuncture and Detoxification Association (NADA) protocol has been used for 30 years to treat withdrawal symptoms in substance abusers, most famously at the Lincoln Medical and Mental Health Center in New York City's South Bronx, Beverley de Valois said.

Ms. de Valois, a Ph.D. candidate at Thames Valley University, London, and a research acupuncturist at the Lynda Jackson Macmillan Centre at Mount Vernon Hospital, Northwood, had previously done a study of traditional acupuncture for women experiencing adverse effects during tamoxifen treatment. “The results were encouraging, but the methodology is complex and time consuming, and our goal at the center is to make treatment for tamoxifen-related side effects widely and easily available,” she said.

There also were some difficulties in administering traditional acupuncture. Needling the limb on the affected side is discouraged because of fears that this might lead to lymphedema, she said. This restriction was particularly problematic for women who had had bilateral mastectomies.

She had previously worked with the NADA protocol, and because some of the side effects of tamoxifen—night sweats, anxiety, and sleep difficulties—resemble those of withdrawal, she thought this might be useful for these patients as well.

A total of 50 women were recruited for the study. They had to be taking tamoxifen for at least 6 months and having four or more vasomotor incidents per day. The treatment involved eight acupuncture sessions, five patients at a time, during a 29-week period. Participants recorded the frequency and severity of hot flashes in diaries and were asked how they subjectively rated the treatment.

There was no control group, and any placebo effect was not addressed.

An interim analysis of the first 35 patients showed a reduction in frequency from a mean of 10.32 flashes per day at baseline to 7.24 at the end of treatment, a statistically significant mean reduction of 24.4%, Ms. de Valois said. Sleep also improved as nocturnal hot flashes decreased.

Participants gave high marks to the experience of receiving the treatment in groups, where they met others with similar problems and were able to share experiences and information, she said.

The Food and Drug Administration is warning consumers about possible false results from several unapproved home-use diagnostic test kits marketed in the United States via the Internet by Globus Media of Montreal.

The test kits are not approved for sale in the United States. There is concern that the use of these products could lead to false results that could contribute to significant adverse health consequences, but there are no confirmed instances of false results, according to the FDA.

The kits are labeled as Rapid HIV Test Kit, Rapid Syphilis Test Kit, One Step Cassette Style Cocaine Test, One Step Cassette Style Marijuana (THC) Test, One Step Cassette Style Amphetamine Test, Rapid Dengue Fever Test, and One Step Midstream Style HCG Urine (Home) Pregnancy Test.

The tests, sold through Web sites such as www.htkit.com

No home-use test kits intended for diagnosing HIV, syphilis, and dengue fever have been approved for sale in the United States.

The Food and Drug Administration is warning consumers about possible false results from several unapproved home-use diagnostic test kits marketed in the United States via the Internet by Globus Media of Montreal.

The test kits are not approved for sale in the United States. There is concern that the use of these products could lead to false results that could contribute to significant adverse health consequences, but there are no confirmed instances of false results, according to the FDA.

The kits are labeled as Rapid HIV Test Kit, Rapid Syphilis Test Kit, One Step Cassette Style Cocaine Test, One Step Cassette Style Marijuana (THC) Test, One Step Cassette Style Amphetamine Test, Rapid Dengue Fever Test, and One Step Midstream Style HCG Urine (Home) Pregnancy Test.

The tests, sold through Web sites such as www.htkit.com

No home-use test kits intended for diagnosing HIV, syphilis, and dengue fever have been approved for sale in the United States.

The Food and Drug Administration is warning consumers about possible false results from several unapproved home-use diagnostic test kits marketed in the United States via the Internet by Globus Media of Montreal.

The test kits are not approved for sale in the United States. There is concern that the use of these products could lead to false results that could contribute to significant adverse health consequences, but there are no confirmed instances of false results, according to the FDA.

The kits are labeled as Rapid HIV Test Kit, Rapid Syphilis Test Kit, One Step Cassette Style Cocaine Test, One Step Cassette Style Marijuana (THC) Test, One Step Cassette Style Amphetamine Test, Rapid Dengue Fever Test, and One Step Midstream Style HCG Urine (Home) Pregnancy Test.

The tests, sold through Web sites such as www.htkit.com

No home-use test kits intended for diagnosing HIV, syphilis, and dengue fever have been approved for sale in the United States.

BOSTON — A few adjustments might be needed to make your practice approachable and comfortable for adolescent patients, but the long-term payoffs can be worth it.

“Why is it some people aren't so comfortable taking care of adolescents? They think they take more time in the office. They have varied issues. It's sometimes challenging, and a lot of ob.gyn. residency programs didn't address pediatric or adolescent gynecology specifically, Marc Laufer, M.D., said at an ob.gyn. meeting sponsored by Harvard Medical School.

“We're aware of that, and we're trying to address it through the American College of Obstetricians and Gynecologists and the North American Society for Pediatric and Adolescent Gynecology [NASPAG],” said Dr. Laufer of Harvard and chief of gynecology at Children's Hospital Boston.

Confidentiality is “one of the key issues” in making a practice more friendly for adolescents. One critical move is to make sure sound doesn't carry. If office walls aren't soundproof, Dr. Laufer suggested using sound machines, such as white noise machines or sound conditioners, which can help mask sounds between offices.

A lot of care for these patients can be conducted by their primary care providers. But when it comes to certain diseases, “if we treat and diagnose them when people are younger, we may improve their long-term health care,” Dr. Laufer said at the meeting cosponsored by Brigham and Women's Hospital. Dr. Laufer said if polycystic ovary syndrome were diagnosed and treated during adolescence, there would be a greater chance of decreasing rates of obesity and diabetes. The same holds for endometriosis. An early diagnosis likely would result in less pelvic pain over the patient's lifetime and lead to improved long-term fertility.

Since most adolescents are “Internet savvy,” Dr. Laufer encouraged physicians to direct young patients to online resources such as the Web site by the Center for Young Women's Health at Children's Hospital Boston (www.youngwomenshealth.org

The NASPAG's Web site (www.naspag.org

BOSTON — A few adjustments might be needed to make your practice approachable and comfortable for adolescent patients, but the long-term payoffs can be worth it.

“Why is it some people aren't so comfortable taking care of adolescents? They think they take more time in the office. They have varied issues. It's sometimes challenging, and a lot of ob.gyn. residency programs didn't address pediatric or adolescent gynecology specifically, Marc Laufer, M.D., said at an ob.gyn. meeting sponsored by Harvard Medical School.

“We're aware of that, and we're trying to address it through the American College of Obstetricians and Gynecologists and the North American Society for Pediatric and Adolescent Gynecology [NASPAG],” said Dr. Laufer of Harvard and chief of gynecology at Children's Hospital Boston.

Confidentiality is “one of the key issues” in making a practice more friendly for adolescents. One critical move is to make sure sound doesn't carry. If office walls aren't soundproof, Dr. Laufer suggested using sound machines, such as white noise machines or sound conditioners, which can help mask sounds between offices.

A lot of care for these patients can be conducted by their primary care providers. But when it comes to certain diseases, “if we treat and diagnose them when people are younger, we may improve their long-term health care,” Dr. Laufer said at the meeting cosponsored by Brigham and Women's Hospital. Dr. Laufer said if polycystic ovary syndrome were diagnosed and treated during adolescence, there would be a greater chance of decreasing rates of obesity and diabetes. The same holds for endometriosis. An early diagnosis likely would result in less pelvic pain over the patient's lifetime and lead to improved long-term fertility.

Since most adolescents are “Internet savvy,” Dr. Laufer encouraged physicians to direct young patients to online resources such as the Web site by the Center for Young Women's Health at Children's Hospital Boston (www.youngwomenshealth.org

The NASPAG's Web site (www.naspag.org

BOSTON — A few adjustments might be needed to make your practice approachable and comfortable for adolescent patients, but the long-term payoffs can be worth it.

“Why is it some people aren't so comfortable taking care of adolescents? They think they take more time in the office. They have varied issues. It's sometimes challenging, and a lot of ob.gyn. residency programs didn't address pediatric or adolescent gynecology specifically, Marc Laufer, M.D., said at an ob.gyn. meeting sponsored by Harvard Medical School.

“We're aware of that, and we're trying to address it through the American College of Obstetricians and Gynecologists and the North American Society for Pediatric and Adolescent Gynecology [NASPAG],” said Dr. Laufer of Harvard and chief of gynecology at Children's Hospital Boston.

Confidentiality is “one of the key issues” in making a practice more friendly for adolescents. One critical move is to make sure sound doesn't carry. If office walls aren't soundproof, Dr. Laufer suggested using sound machines, such as white noise machines or sound conditioners, which can help mask sounds between offices.

A lot of care for these patients can be conducted by their primary care providers. But when it comes to certain diseases, “if we treat and diagnose them when people are younger, we may improve their long-term health care,” Dr. Laufer said at the meeting cosponsored by Brigham and Women's Hospital. Dr. Laufer said if polycystic ovary syndrome were diagnosed and treated during adolescence, there would be a greater chance of decreasing rates of obesity and diabetes. The same holds for endometriosis. An early diagnosis likely would result in less pelvic pain over the patient's lifetime and lead to improved long-term fertility.

Since most adolescents are “Internet savvy,” Dr. Laufer encouraged physicians to direct young patients to online resources such as the Web site by the Center for Young Women's Health at Children's Hospital Boston (www.youngwomenshealth.org

The NASPAG's Web site (www.naspag.org

WHITE SULPHUR SPRINGS, W.VA. — Within just 6-12 months of discontinuing hormone therapy, more than 96% of postmenopausal women will show altered vaginal pH, a marker for tissue change and its associated genital atrophy, Murray Freedman, M.D., reported.

Only 10 of 300 women maintained a normal vaginal pH of 4.5 or less after discontinuing HT use, and seven of those women had elevated serum estradiol levels related to obesity-driven estrogen production, said Dr. Freedman, of the Medical College of Georgia, Augusta.

The rest of the women had both elevated vaginal pH and decreased serum estradiol. The most common clinical finding in the study was involution of the vulvar structures and a rapidly occurring introital stenosis, which correlated with frequent complaints of dyspareunia, he noted at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Because the onset of genital atrophy is insidious and its measurement subjective, the number who experienced it was “hard to quantify,” Dr. Freedman said in an interview. “There is no real measurement for it. But for many of these women, the stenosis became noticeable within 6-12 months.”

Dr. Freedman's observations have led him to conclude that the dyspareunia many postmenopausal women experience has more to do with introital stenosis than with vaginal dryness. “The dryness was secondary to the stenosis and the involution of the distal vagina. Once you got past the introitus, the upper vagina was uncompromised.”

His prospective observational study evaluated a total of 300 women who had discontinued hormone therapy after publication of the initial Women's Health Initiative results in July 2002. All women underwent a pelvic exam and had their vaginal pH tested within 12 months of therapy discontinuation (most within 6 months). Those women with a normal vaginal pH level (4.5 or below) had their serum estradiol level evaluated.

The vast majority of the women (290) had a pH level of more than 4.5. Only 10 maintained a normal vaginal pH. Three of those women had serum estradiol of less than 20 pcg/mL, consistent with postmenopausal status.

The other seven had normal circulating estradiol levels. One of these was a 50-year-old woman with her uterus, fallopian tubes, and ovaries intact, who had been placed on HT for menopausal symptoms. The other six women were older (57-76 years) and either overweight or obese. “Their normal estrogen levels and the resulting normal vaginal pH were due to a high production of endogenous estrogen secondary to obesity,” Dr. Freedman said.

In addition to observing introital stenosis, he noted that the urethral meatus became more prominent in many women, assuming almost a tubular form and expanding to constitute up to two-thirds of the introitus. This is not surprising, he said, because the urethra and trigone are just as heavily endowed with estrogen receptors as are the lower vagina and vulva and just as susceptible to involutional change with estrogen deficiency.

“Embryologically, the vulva, distal vagina, trigone, and urethra are all derived from the urogenital sinus and contain the highest concentration of estrogen receptors. The upper vagina is actually a downgrowth of the müllerian system” and so less susceptible to change associated with estrogen depletion.

Because genital atrophy is so widespread and rapid after menopause in the absence of HT, women should be proactively counseled about how to maintain good genital health. If the decision is made to discontinue HT, topical estrogen can prevent genital atrophy and, if administered within the first year of estrogen cessation, can even reverse some changes.

Coitus at least once a week helps maintain tissue integrity by dilation and increased genital blood flow. “In the absence of both estrogen and sexual activity, the rapidity of involution is compounded,” he said.

Women who do not have a male partner can be counseled to use topical estrogen and a vibrator or vaginal dilator, and to become orgasmic, periodically. “This will maintain a normal, healthy vagina,” Dr. Freedman said.

However, he continued, most physicians — especially males — never really broach the subject of sexuality with their postmenopausal patients.

“To those men, I would put this question: 'At what age would you like your genitalia to begin shrinking?'” Dr. Freedman said. “I bet it wouldn't be 51, which is the average age of menopause in this country.”

This 55-year-old who quit HT a year ago exhibits almost total involution of the genitalia. Courtesy Dr. Murray Freedman

WHITE SULPHUR SPRINGS, W.VA. — Within just 6-12 months of discontinuing hormone therapy, more than 96% of postmenopausal women will show altered vaginal pH, a marker for tissue change and its associated genital atrophy, Murray Freedman, M.D., reported.

Only 10 of 300 women maintained a normal vaginal pH of 4.5 or less after discontinuing HT use, and seven of those women had elevated serum estradiol levels related to obesity-driven estrogen production, said Dr. Freedman, of the Medical College of Georgia, Augusta.

The rest of the women had both elevated vaginal pH and decreased serum estradiol. The most common clinical finding in the study was involution of the vulvar structures and a rapidly occurring introital stenosis, which correlated with frequent complaints of dyspareunia, he noted at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Because the onset of genital atrophy is insidious and its measurement subjective, the number who experienced it was “hard to quantify,” Dr. Freedman said in an interview. “There is no real measurement for it. But for many of these women, the stenosis became noticeable within 6-12 months.”

Dr. Freedman's observations have led him to conclude that the dyspareunia many postmenopausal women experience has more to do with introital stenosis than with vaginal dryness. “The dryness was secondary to the stenosis and the involution of the distal vagina. Once you got past the introitus, the upper vagina was uncompromised.”

His prospective observational study evaluated a total of 300 women who had discontinued hormone therapy after publication of the initial Women's Health Initiative results in July 2002. All women underwent a pelvic exam and had their vaginal pH tested within 12 months of therapy discontinuation (most within 6 months). Those women with a normal vaginal pH level (4.5 or below) had their serum estradiol level evaluated.

The vast majority of the women (290) had a pH level of more than 4.5. Only 10 maintained a normal vaginal pH. Three of those women had serum estradiol of less than 20 pcg/mL, consistent with postmenopausal status.

The other seven had normal circulating estradiol levels. One of these was a 50-year-old woman with her uterus, fallopian tubes, and ovaries intact, who had been placed on HT for menopausal symptoms. The other six women were older (57-76 years) and either overweight or obese. “Their normal estrogen levels and the resulting normal vaginal pH were due to a high production of endogenous estrogen secondary to obesity,” Dr. Freedman said.

In addition to observing introital stenosis, he noted that the urethral meatus became more prominent in many women, assuming almost a tubular form and expanding to constitute up to two-thirds of the introitus. This is not surprising, he said, because the urethra and trigone are just as heavily endowed with estrogen receptors as are the lower vagina and vulva and just as susceptible to involutional change with estrogen deficiency.

“Embryologically, the vulva, distal vagina, trigone, and urethra are all derived from the urogenital sinus and contain the highest concentration of estrogen receptors. The upper vagina is actually a downgrowth of the müllerian system” and so less susceptible to change associated with estrogen depletion.

Because genital atrophy is so widespread and rapid after menopause in the absence of HT, women should be proactively counseled about how to maintain good genital health. If the decision is made to discontinue HT, topical estrogen can prevent genital atrophy and, if administered within the first year of estrogen cessation, can even reverse some changes.

Coitus at least once a week helps maintain tissue integrity by dilation and increased genital blood flow. “In the absence of both estrogen and sexual activity, the rapidity of involution is compounded,” he said.

Women who do not have a male partner can be counseled to use topical estrogen and a vibrator or vaginal dilator, and to become orgasmic, periodically. “This will maintain a normal, healthy vagina,” Dr. Freedman said.

However, he continued, most physicians — especially males — never really broach the subject of sexuality with their postmenopausal patients.

“To those men, I would put this question: 'At what age would you like your genitalia to begin shrinking?'” Dr. Freedman said. “I bet it wouldn't be 51, which is the average age of menopause in this country.”

This 55-year-old who quit HT a year ago exhibits almost total involution of the genitalia. Courtesy Dr. Murray Freedman

WHITE SULPHUR SPRINGS, W.VA. — Within just 6-12 months of discontinuing hormone therapy, more than 96% of postmenopausal women will show altered vaginal pH, a marker for tissue change and its associated genital atrophy, Murray Freedman, M.D., reported.

Only 10 of 300 women maintained a normal vaginal pH of 4.5 or less after discontinuing HT use, and seven of those women had elevated serum estradiol levels related to obesity-driven estrogen production, said Dr. Freedman, of the Medical College of Georgia, Augusta.

The rest of the women had both elevated vaginal pH and decreased serum estradiol. The most common clinical finding in the study was involution of the vulvar structures and a rapidly occurring introital stenosis, which correlated with frequent complaints of dyspareunia, he noted at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Because the onset of genital atrophy is insidious and its measurement subjective, the number who experienced it was “hard to quantify,” Dr. Freedman said in an interview. “There is no real measurement for it. But for many of these women, the stenosis became noticeable within 6-12 months.”

Dr. Freedman's observations have led him to conclude that the dyspareunia many postmenopausal women experience has more to do with introital stenosis than with vaginal dryness. “The dryness was secondary to the stenosis and the involution of the distal vagina. Once you got past the introitus, the upper vagina was uncompromised.”

His prospective observational study evaluated a total of 300 women who had discontinued hormone therapy after publication of the initial Women's Health Initiative results in July 2002. All women underwent a pelvic exam and had their vaginal pH tested within 12 months of therapy discontinuation (most within 6 months). Those women with a normal vaginal pH level (4.5 or below) had their serum estradiol level evaluated.

The vast majority of the women (290) had a pH level of more than 4.5. Only 10 maintained a normal vaginal pH. Three of those women had serum estradiol of less than 20 pcg/mL, consistent with postmenopausal status.

The other seven had normal circulating estradiol levels. One of these was a 50-year-old woman with her uterus, fallopian tubes, and ovaries intact, who had been placed on HT for menopausal symptoms. The other six women were older (57-76 years) and either overweight or obese. “Their normal estrogen levels and the resulting normal vaginal pH were due to a high production of endogenous estrogen secondary to obesity,” Dr. Freedman said.

In addition to observing introital stenosis, he noted that the urethral meatus became more prominent in many women, assuming almost a tubular form and expanding to constitute up to two-thirds of the introitus. This is not surprising, he said, because the urethra and trigone are just as heavily endowed with estrogen receptors as are the lower vagina and vulva and just as susceptible to involutional change with estrogen deficiency.

“Embryologically, the vulva, distal vagina, trigone, and urethra are all derived from the urogenital sinus and contain the highest concentration of estrogen receptors. The upper vagina is actually a downgrowth of the müllerian system” and so less susceptible to change associated with estrogen depletion.

Because genital atrophy is so widespread and rapid after menopause in the absence of HT, women should be proactively counseled about how to maintain good genital health. If the decision is made to discontinue HT, topical estrogen can prevent genital atrophy and, if administered within the first year of estrogen cessation, can even reverse some changes.

Coitus at least once a week helps maintain tissue integrity by dilation and increased genital blood flow. “In the absence of both estrogen and sexual activity, the rapidity of involution is compounded,” he said.

Women who do not have a male partner can be counseled to use topical estrogen and a vibrator or vaginal dilator, and to become orgasmic, periodically. “This will maintain a normal, healthy vagina,” Dr. Freedman said.

However, he continued, most physicians — especially males — never really broach the subject of sexuality with their postmenopausal patients.

“To those men, I would put this question: 'At what age would you like your genitalia to begin shrinking?'” Dr. Freedman said. “I bet it wouldn't be 51, which is the average age of menopause in this country.”

This 55-year-old who quit HT a year ago exhibits almost total involution of the genitalia. Courtesy Dr. Murray Freedman

All pregnant women should undergo screening for Toxoplasma gondii infection once each trimester, and all newborns should be screened for congenital toxoplasmosis, Kenneth M. Boyer, M.D., and colleagues have recommended.

Even a thorough history fails to identify about half of pregnant women who have an acute infection, according to Dr. Boyer of Rush University Medical Center, Chicago. Only a serologic screening process would identify all infected women and newborns in time to administer the medical treatment necessary to prevent neurologic sequelae of the illness in these infants (Am. J. Obstet. Gynecol. 2005;192:564-71).

“It is difficult to imagine that any informed mother or father would choose not to include this screening in their prenatal care, considering that almost all untreated infants who are infected … in utero experience ophthalmologic and/or neurologic disease, and that treatment of the fetus and infant clearly reduces these risks,” they said.

The researchers retrospectively analyzed the medical records of 131 infants and children with congenital toxoplasmosis who were referred to the Chicago Collaborative Treatment Trial. The study focused on demographic data and the mothers' understanding of factors surrounding their exposure to the parasite.

The women were questioned about their exposure during pregnancy to cats, cat litter, gardening, and sandboxes. They also were questioned about their consumption of raw or undercooked meat, eggs, or unpasteurized milk, as well as the nature and timing of their exposure; and any illness during pregnancy that was compatible with infection, especially prolonged fever, night sweats, myalgia, headache, and lymphadenopathy.

Most of the women (75%) could recall a conceivable exposure, but only 39% specifically recalled exposure to cat litter or raw meat dishes. One-quarter of the women could not identify any possible exposure to either cats or raw or undercooked foods.

More than half (52%) could not recall an infectious illness of any kind during pregnancy. Almost half (48%) noted an illness that might have been caused by the parasite; 27% recalled fever or night sweats and 23% recalled lymphadenopathy.

Ten of the women had serologic testing for toxoplasmosis before delivery. Three of those were living in France at the time, where such testing is part of routine obstetric care. Each of the remaining seven women had compatible illness or identified risk factors. One woman was tested because an ultrasound noted ascites in her twin fetuses. Three were tested because their physicians were looking for the cause of the illness, and three were tested as part of routine obstetric care.

Since only three women were tested as part of an investigation of an infectious illness, it is apparent that many physicians do not consider toxoplasmosis as a possible cause of these nonspecific symptoms during pregnancy, the authors noted. “This observation points out the importance of greater recognition by obstetricians of the pediatric implications of maternal infection and infectious symptoms during pregnancy.”

The only way to prevent or detect a higher proportion of infants with congenital infection is by systematic serologic screening, they concluded, adding that cost analyses should be performed before any decision making occurs.

However, the potentially devastating lifelong effects of congenital toxoplasmosis, and the recognized benefits of early identification and treatment, make a compelling case for systematic screening, the researchers said.

Additionally, they noted, congenital toxoplasmosis is more common than many genetic and metabolic diseases, such as phenylketonuria, congenital hypothyroidism, and congenital adrenal hyperplasia, for which mandatory neonatal screening already exists.

The American College of Obstetricians and Gynecologists recommends routine toxoplasmosis screening only in HIV-positive pregnant women. Routine screening also may be justifiable in women who are cat owners, the college says.

ACOG does not recommend routine screening for every pregnant woman, because there is a low incidence of seropositivity in the United States. Countries such as France and Austria, which have mandated screening, have high rates of seropositivity among their populations.

Serologic screening in pregnant women may yield equivocal results because IgM antibodies to the parasite can persist for long periods, according to the American College of Obstetrics and Gynecologists.

All pregnant women should undergo screening for Toxoplasma gondii infection once each trimester, and all newborns should be screened for congenital toxoplasmosis, Kenneth M. Boyer, M.D., and colleagues have recommended.

Even a thorough history fails to identify about half of pregnant women who have an acute infection, according to Dr. Boyer of Rush University Medical Center, Chicago. Only a serologic screening process would identify all infected women and newborns in time to administer the medical treatment necessary to prevent neurologic sequelae of the illness in these infants (Am. J. Obstet. Gynecol. 2005;192:564-71).

“It is difficult to imagine that any informed mother or father would choose not to include this screening in their prenatal care, considering that almost all untreated infants who are infected … in utero experience ophthalmologic and/or neurologic disease, and that treatment of the fetus and infant clearly reduces these risks,” they said.

The researchers retrospectively analyzed the medical records of 131 infants and children with congenital toxoplasmosis who were referred to the Chicago Collaborative Treatment Trial. The study focused on demographic data and the mothers' understanding of factors surrounding their exposure to the parasite.

The women were questioned about their exposure during pregnancy to cats, cat litter, gardening, and sandboxes. They also were questioned about their consumption of raw or undercooked meat, eggs, or unpasteurized milk, as well as the nature and timing of their exposure; and any illness during pregnancy that was compatible with infection, especially prolonged fever, night sweats, myalgia, headache, and lymphadenopathy.

Most of the women (75%) could recall a conceivable exposure, but only 39% specifically recalled exposure to cat litter or raw meat dishes. One-quarter of the women could not identify any possible exposure to either cats or raw or undercooked foods.

More than half (52%) could not recall an infectious illness of any kind during pregnancy. Almost half (48%) noted an illness that might have been caused by the parasite; 27% recalled fever or night sweats and 23% recalled lymphadenopathy.

Ten of the women had serologic testing for toxoplasmosis before delivery. Three of those were living in France at the time, where such testing is part of routine obstetric care. Each of the remaining seven women had compatible illness or identified risk factors. One woman was tested because an ultrasound noted ascites in her twin fetuses. Three were tested because their physicians were looking for the cause of the illness, and three were tested as part of routine obstetric care.

Since only three women were tested as part of an investigation of an infectious illness, it is apparent that many physicians do not consider toxoplasmosis as a possible cause of these nonspecific symptoms during pregnancy, the authors noted. “This observation points out the importance of greater recognition by obstetricians of the pediatric implications of maternal infection and infectious symptoms during pregnancy.”

The only way to prevent or detect a higher proportion of infants with congenital infection is by systematic serologic screening, they concluded, adding that cost analyses should be performed before any decision making occurs.

However, the potentially devastating lifelong effects of congenital toxoplasmosis, and the recognized benefits of early identification and treatment, make a compelling case for systematic screening, the researchers said.

Additionally, they noted, congenital toxoplasmosis is more common than many genetic and metabolic diseases, such as phenylketonuria, congenital hypothyroidism, and congenital adrenal hyperplasia, for which mandatory neonatal screening already exists.

The American College of Obstetricians and Gynecologists recommends routine toxoplasmosis screening only in HIV-positive pregnant women. Routine screening also may be justifiable in women who are cat owners, the college says.

ACOG does not recommend routine screening for every pregnant woman, because there is a low incidence of seropositivity in the United States. Countries such as France and Austria, which have mandated screening, have high rates of seropositivity among their populations.

Serologic screening in pregnant women may yield equivocal results because IgM antibodies to the parasite can persist for long periods, according to the American College of Obstetrics and Gynecologists.

All pregnant women should undergo screening for Toxoplasma gondii infection once each trimester, and all newborns should be screened for congenital toxoplasmosis, Kenneth M. Boyer, M.D., and colleagues have recommended.

Even a thorough history fails to identify about half of pregnant women who have an acute infection, according to Dr. Boyer of Rush University Medical Center, Chicago. Only a serologic screening process would identify all infected women and newborns in time to administer the medical treatment necessary to prevent neurologic sequelae of the illness in these infants (Am. J. Obstet. Gynecol. 2005;192:564-71).

“It is difficult to imagine that any informed mother or father would choose not to include this screening in their prenatal care, considering that almost all untreated infants who are infected … in utero experience ophthalmologic and/or neurologic disease, and that treatment of the fetus and infant clearly reduces these risks,” they said.

The researchers retrospectively analyzed the medical records of 131 infants and children with congenital toxoplasmosis who were referred to the Chicago Collaborative Treatment Trial. The study focused on demographic data and the mothers' understanding of factors surrounding their exposure to the parasite.

The women were questioned about their exposure during pregnancy to cats, cat litter, gardening, and sandboxes. They also were questioned about their consumption of raw or undercooked meat, eggs, or unpasteurized milk, as well as the nature and timing of their exposure; and any illness during pregnancy that was compatible with infection, especially prolonged fever, night sweats, myalgia, headache, and lymphadenopathy.

Most of the women (75%) could recall a conceivable exposure, but only 39% specifically recalled exposure to cat litter or raw meat dishes. One-quarter of the women could not identify any possible exposure to either cats or raw or undercooked foods.

More than half (52%) could not recall an infectious illness of any kind during pregnancy. Almost half (48%) noted an illness that might have been caused by the parasite; 27% recalled fever or night sweats and 23% recalled lymphadenopathy.

Ten of the women had serologic testing for toxoplasmosis before delivery. Three of those were living in France at the time, where such testing is part of routine obstetric care. Each of the remaining seven women had compatible illness or identified risk factors. One woman was tested because an ultrasound noted ascites in her twin fetuses. Three were tested because their physicians were looking for the cause of the illness, and three were tested as part of routine obstetric care.

Since only three women were tested as part of an investigation of an infectious illness, it is apparent that many physicians do not consider toxoplasmosis as a possible cause of these nonspecific symptoms during pregnancy, the authors noted. “This observation points out the importance of greater recognition by obstetricians of the pediatric implications of maternal infection and infectious symptoms during pregnancy.”

The only way to prevent or detect a higher proportion of infants with congenital infection is by systematic serologic screening, they concluded, adding that cost analyses should be performed before any decision making occurs.

However, the potentially devastating lifelong effects of congenital toxoplasmosis, and the recognized benefits of early identification and treatment, make a compelling case for systematic screening, the researchers said.

Additionally, they noted, congenital toxoplasmosis is more common than many genetic and metabolic diseases, such as phenylketonuria, congenital hypothyroidism, and congenital adrenal hyperplasia, for which mandatory neonatal screening already exists.

The American College of Obstetricians and Gynecologists recommends routine toxoplasmosis screening only in HIV-positive pregnant women. Routine screening also may be justifiable in women who are cat owners, the college says.

ACOG does not recommend routine screening for every pregnant woman, because there is a low incidence of seropositivity in the United States. Countries such as France and Austria, which have mandated screening, have high rates of seropositivity among their populations.

Serologic screening in pregnant women may yield equivocal results because IgM antibodies to the parasite can persist for long periods, according to the American College of Obstetrics and Gynecologists.

WASHINGTON — Elective induction did not adversely affect the cesarean-section rate or maternal fetal morbidity in a retrospective cohort study of 361 nulliparous patients.

The women, who were at 37-41 weeks' gestation, were delivered from January 1998 to December 1999 at the Ochsner Clinic Foundation in New Orleans. The women had singleton pregnancies and no medical indications for delivery, David J. Bonilla, M.D., reported in a poster at the annual meeting of District VII of the American College of Obstetricians and Gynecologists.

The women were divided two groups: a spontaneous labor group and a group that had elective induction with a favorable cervix (Bishop score of at least 5), reported Dr. Bonilla of the clinic.

The C-section rate was almost 10% in the group of 114 patients who had elective induction with a favorable cervix, compared with 17% in the 247 patients who had spontaneous labor.

The induction group had a significantly higher rate of instrumental delivery, compared with the spontaneous labor group, 32% vs. 23%. There was a slight increase in admissions to the neonatal ICU in the elective induction group (1.45% vs. 3.23%), but it was not significant. Elective induction did not impact other outcome variables in relation to fetal morbidity

WASHINGTON — Elective induction did not adversely affect the cesarean-section rate or maternal fetal morbidity in a retrospective cohort study of 361 nulliparous patients.

The women, who were at 37-41 weeks' gestation, were delivered from January 1998 to December 1999 at the Ochsner Clinic Foundation in New Orleans. The women had singleton pregnancies and no medical indications for delivery, David J. Bonilla, M.D., reported in a poster at the annual meeting of District VII of the American College of Obstetricians and Gynecologists.

The women were divided two groups: a spontaneous labor group and a group that had elective induction with a favorable cervix (Bishop score of at least 5), reported Dr. Bonilla of the clinic.

The C-section rate was almost 10% in the group of 114 patients who had elective induction with a favorable cervix, compared with 17% in the 247 patients who had spontaneous labor.

The induction group had a significantly higher rate of instrumental delivery, compared with the spontaneous labor group, 32% vs. 23%. There was a slight increase in admissions to the neonatal ICU in the elective induction group (1.45% vs. 3.23%), but it was not significant. Elective induction did not impact other outcome variables in relation to fetal morbidity

WASHINGTON — Elective induction did not adversely affect the cesarean-section rate or maternal fetal morbidity in a retrospective cohort study of 361 nulliparous patients.

The women, who were at 37-41 weeks' gestation, were delivered from January 1998 to December 1999 at the Ochsner Clinic Foundation in New Orleans. The women had singleton pregnancies and no medical indications for delivery, David J. Bonilla, M.D., reported in a poster at the annual meeting of District VII of the American College of Obstetricians and Gynecologists.

The women were divided two groups: a spontaneous labor group and a group that had elective induction with a favorable cervix (Bishop score of at least 5), reported Dr. Bonilla of the clinic.

The C-section rate was almost 10% in the group of 114 patients who had elective induction with a favorable cervix, compared with 17% in the 247 patients who had spontaneous labor.

The induction group had a significantly higher rate of instrumental delivery, compared with the spontaneous labor group, 32% vs. 23%. There was a slight increase in admissions to the neonatal ICU in the elective induction group (1.45% vs. 3.23%), but it was not significant. Elective induction did not impact other outcome variables in relation to fetal morbidity

Nulliparous women who request pain relief early in labor may be better off receiving neuraxial analgesia than systemic opioid analgesia, according to investigators of a recently published, randomized trial.

Of 728 women who had spontaneous labor or spontaneous rupture of membranes, those who received intrathecal fentanyl when cervical dilation was less than 4 cm did not face an increased risk of having a cesarean section and had a shorter duration of labor, compared with those who received systemic hydromorphone early in labor.

Women who received neuraxial analgesia also reported better pain control, according to Cynthia A Wong, M.D., and her colleagues at Northwestern University in Chicago.

The findings show women who request pain relief early in spontaneous labor “can receive neuraxial analgesia at that time without adverse consequences,” the researchers said.

Women who request analgesia early in labor frequently receive systemic opioid analgesia, in keeping with the American College of Obstetricians and Gynecologists recommendation that epidural anesthesia be delayed, when feasible, until cervical dilation is at least 4-5 cm; other forms of analgesia should be used until that time.

Systemic opioid analgesia is often incomplete, however, and has potential maternal and fetal side effects, including neonatal and maternal respiratory depression (N. Engl. J. Med. 2005;352:655-65).

Laura Goetzl, M.D., who helped write ACOG's 2002 Practice Bulletin on Obstetric Analgesia and Anesthesia, said in an interview that the new findings present “another option” for prolonging the time to epidural.

“This is saying, instead of giving a higher dose of [systemic] narcotics to get women further along [until epidural administration], we can give them a smaller dose right into the spinal cord,” said Dr. Goetzl of the Medical University of South Carolina, Charleston.

The investigators studied the analgesia techniques at Northwestern's Prentice Women's Hospital from November 2000 to December 2003. Patients who requested analgesia when cervical dilation was less than 4 cm were randomized (nonblinded) to intrathecal or systemic analgesia.

The median dilation for both groups at the first analgesia request was 2 cm.

Analgesia in the intrathecal group was initiated using a combined spinal-epidural technique. Intrathecal fentanyl (25 mcg) was injected, an epidural catheter sited, and an epidural test dose administered.

When the patients in the intrathecal group made a second request for pain control, epidural analgesia was initiated.

Patients in the systemic group received 1 mg hydromorphone IM and 1 mg IV. Epidural analgesia was initiated in patients who were at least 4 cm dilated at their second request for pain control (otherwise hydromorphone was repeated), or at their third analgesia request—regardless of dilation.

Epidural analgesia was maintained in both groups until delivery, the investigators said.

The cesarean rate was not significantly different between the two groups (18% in the intrathecal group and 21% in the systemic group); nor was there a significant difference in the rate of instrumental vaginal delivery.

The median time from initial analgesia to complete dilation was significantly shorter after intrathecal analgesia than after systemic analgesia (295 vs. 385 minutes), even after investigators adjusted for cervical dilation at the time of initial anesthesia.

Women who received intrathecal analgesia also had a shorter time to vaginal delivery (398 vs. 479 minutes) and significantly lower average pain scores between the first and second analgesia requests. The incidence of 1-minute Apgar scores below 7 also was significantly lower in this group (17% vs. 24%).

Fetal deceleration occurred more commonly within 30 minutes of intrathecal opioid analgesia than after systemic analgesia. However, the incidence of nonreassuring fetal heart rate “was low, did not differ between groups, and did not result in any adverse neonatal outcome,” the investigators said.

Nulliparous women who request pain relief early in labor may be better off receiving neuraxial analgesia than systemic opioid analgesia, according to investigators of a recently published, randomized trial.

Of 728 women who had spontaneous labor or spontaneous rupture of membranes, those who received intrathecal fentanyl when cervical dilation was less than 4 cm did not face an increased risk of having a cesarean section and had a shorter duration of labor, compared with those who received systemic hydromorphone early in labor.

Women who received neuraxial analgesia also reported better pain control, according to Cynthia A Wong, M.D., and her colleagues at Northwestern University in Chicago.

The findings show women who request pain relief early in spontaneous labor “can receive neuraxial analgesia at that time without adverse consequences,” the researchers said.

Women who request analgesia early in labor frequently receive systemic opioid analgesia, in keeping with the American College of Obstetricians and Gynecologists recommendation that epidural anesthesia be delayed, when feasible, until cervical dilation is at least 4-5 cm; other forms of analgesia should be used until that time.

Systemic opioid analgesia is often incomplete, however, and has potential maternal and fetal side effects, including neonatal and maternal respiratory depression (N. Engl. J. Med. 2005;352:655-65).

Laura Goetzl, M.D., who helped write ACOG's 2002 Practice Bulletin on Obstetric Analgesia and Anesthesia, said in an interview that the new findings present “another option” for prolonging the time to epidural.

“This is saying, instead of giving a higher dose of [systemic] narcotics to get women further along [until epidural administration], we can give them a smaller dose right into the spinal cord,” said Dr. Goetzl of the Medical University of South Carolina, Charleston.

The investigators studied the analgesia techniques at Northwestern's Prentice Women's Hospital from November 2000 to December 2003. Patients who requested analgesia when cervical dilation was less than 4 cm were randomized (nonblinded) to intrathecal or systemic analgesia.

The median dilation for both groups at the first analgesia request was 2 cm.

Analgesia in the intrathecal group was initiated using a combined spinal-epidural technique. Intrathecal fentanyl (25 mcg) was injected, an epidural catheter sited, and an epidural test dose administered.

When the patients in the intrathecal group made a second request for pain control, epidural analgesia was initiated.

Patients in the systemic group received 1 mg hydromorphone IM and 1 mg IV. Epidural analgesia was initiated in patients who were at least 4 cm dilated at their second request for pain control (otherwise hydromorphone was repeated), or at their third analgesia request—regardless of dilation.

Epidural analgesia was maintained in both groups until delivery, the investigators said.

The cesarean rate was not significantly different between the two groups (18% in the intrathecal group and 21% in the systemic group); nor was there a significant difference in the rate of instrumental vaginal delivery.

The median time from initial analgesia to complete dilation was significantly shorter after intrathecal analgesia than after systemic analgesia (295 vs. 385 minutes), even after investigators adjusted for cervical dilation at the time of initial anesthesia.

Women who received intrathecal analgesia also had a shorter time to vaginal delivery (398 vs. 479 minutes) and significantly lower average pain scores between the first and second analgesia requests. The incidence of 1-minute Apgar scores below 7 also was significantly lower in this group (17% vs. 24%).

Fetal deceleration occurred more commonly within 30 minutes of intrathecal opioid analgesia than after systemic analgesia. However, the incidence of nonreassuring fetal heart rate “was low, did not differ between groups, and did not result in any adverse neonatal outcome,” the investigators said.

Nulliparous women who request pain relief early in labor may be better off receiving neuraxial analgesia than systemic opioid analgesia, according to investigators of a recently published, randomized trial.

Of 728 women who had spontaneous labor or spontaneous rupture of membranes, those who received intrathecal fentanyl when cervical dilation was less than 4 cm did not face an increased risk of having a cesarean section and had a shorter duration of labor, compared with those who received systemic hydromorphone early in labor.

Women who received neuraxial analgesia also reported better pain control, according to Cynthia A Wong, M.D., and her colleagues at Northwestern University in Chicago.

The findings show women who request pain relief early in spontaneous labor “can receive neuraxial analgesia at that time without adverse consequences,” the researchers said.

Women who request analgesia early in labor frequently receive systemic opioid analgesia, in keeping with the American College of Obstetricians and Gynecologists recommendation that epidural anesthesia be delayed, when feasible, until cervical dilation is at least 4-5 cm; other forms of analgesia should be used until that time.

Systemic opioid analgesia is often incomplete, however, and has potential maternal and fetal side effects, including neonatal and maternal respiratory depression (N. Engl. J. Med. 2005;352:655-65).

Laura Goetzl, M.D., who helped write ACOG's 2002 Practice Bulletin on Obstetric Analgesia and Anesthesia, said in an interview that the new findings present “another option” for prolonging the time to epidural.

“This is saying, instead of giving a higher dose of [systemic] narcotics to get women further along [until epidural administration], we can give them a smaller dose right into the spinal cord,” said Dr. Goetzl of the Medical University of South Carolina, Charleston.

The investigators studied the analgesia techniques at Northwestern's Prentice Women's Hospital from November 2000 to December 2003. Patients who requested analgesia when cervical dilation was less than 4 cm were randomized (nonblinded) to intrathecal or systemic analgesia.

The median dilation for both groups at the first analgesia request was 2 cm.

Analgesia in the intrathecal group was initiated using a combined spinal-epidural technique. Intrathecal fentanyl (25 mcg) was injected, an epidural catheter sited, and an epidural test dose administered.

When the patients in the intrathecal group made a second request for pain control, epidural analgesia was initiated.

Patients in the systemic group received 1 mg hydromorphone IM and 1 mg IV. Epidural analgesia was initiated in patients who were at least 4 cm dilated at their second request for pain control (otherwise hydromorphone was repeated), or at their third analgesia request—regardless of dilation.

Epidural analgesia was maintained in both groups until delivery, the investigators said.

The cesarean rate was not significantly different between the two groups (18% in the intrathecal group and 21% in the systemic group); nor was there a significant difference in the rate of instrumental vaginal delivery.

The median time from initial analgesia to complete dilation was significantly shorter after intrathecal analgesia than after systemic analgesia (295 vs. 385 minutes), even after investigators adjusted for cervical dilation at the time of initial anesthesia.

Women who received intrathecal analgesia also had a shorter time to vaginal delivery (398 vs. 479 minutes) and significantly lower average pain scores between the first and second analgesia requests. The incidence of 1-minute Apgar scores below 7 also was significantly lower in this group (17% vs. 24%).

Fetal deceleration occurred more commonly within 30 minutes of intrathecal opioid analgesia than after systemic analgesia. However, the incidence of nonreassuring fetal heart rate “was low, did not differ between groups, and did not result in any adverse neonatal outcome,” the investigators said.

Biomarkers of intra-amniotic infection and inflammation can be rapidly detected in amniotic fluid using proteomic analysis. And the identification of a distinctive biomarker profile can predict imminent preterm delivery with 100% accuracy, opening the door to future treatments, results of a recent study suggest.

“We are probably at a turning point in the history of preterm labor diagnosis,” lead author Irina Buhimschi, M.D., of Yale University, New Haven, and her associates wrote (BJOG 2005;112:173-81). She conducted the research with Catalin S. Buhimschi, M.D., also of Yale, and Rob Christner of Ciphergen Biosystems, Fremont, Calif.

“We think this proteomic analysis will be the diagnostic platform of the future from which many diseases will be diagnosed,” Dr. Irina Buhimschi commented in an interview.

The discovery could help identify preterm labor patients who might benefit from intervention “before the battle is completely lost,” she explained.

Although amniotic fluid cultures can detect infection, they have limited clinical utility because results are not quickly available. “By the time you have the result, the patient has already delivered, and the baby is in neonatal intensive care—so the only benefit of the test is to confirm the decision of the physician. In the case of [proteomic analysis], the result can be available within 50 minutes or less and has the potential of being useful for clinical decision making,” she said.

Using proteomic analysis, the team analyzed frozen amniotic fluid samples from 77 women with symptoms of preterm labor or preterm, premature rupture of membranes, and a known outcome (stage 1). The findings were then applied to samples from 24 symptomatic patients whose outcomes were not known to the investigators (stage 2).

The analysis identified a distinctive profile of four proteins present in patients who went on to preterm delivery but absent in patients whose symptoms subsided and who did not give birth prematurely.

This profile consisted of three out of four biomarkers of infection and inflammation, including human neutrophil defensin-1 and -2 and calgranulins A and C.

“If there were just two of the biomarkers present, the symptoms might either spontaneously resolve or get worse. It was only when three or four were present that imminent delivery could be predicted,” Dr. Buhimschi said.

The analysis involved a sophisticated algorithm called mass restricted (MR) analysis, and patients were given an MR score based on their levels of these four proteins.

The scoring system had 100% sensitivity and specificity for predicting which patients would deliver prematurely. Patients with an MR score of 3-4 had a median amniocentesis-to-delivery interval of 2 days, compared with a median of 51 days for patients with MR scores of 0-2.

Although it is generally accepted that a large proportion of preterm deliveries are caused by infection and inflammation, previous attempts at treating all preterm labor patients with antibiotics have failed to reverse the process. This may be partly because patients whose preterm labor is caused by factors other than infection and inflammation do not respond to antibiotic therapy, Dr. Buhimschi said.

“It is reasonable to think that those who respond to antibiotics will be only those in whom the preterm labor is caused by an infection and inflammation—and our approach is able to identify those patients,” she said. In addition, the identification of specific biomarkers of preterm delivery holds potential for research into pathology-specific treatments, she said.

The research was funded by the National Institutes of Health and Ciphergen Biosystems. Dr. Buhimschi said the NIH has agreed to fund further investigations into the application of this research.

Biomarkers of intra-amniotic infection and inflammation can be rapidly detected in amniotic fluid using proteomic analysis. And the identification of a distinctive biomarker profile can predict imminent preterm delivery with 100% accuracy, opening the door to future treatments, results of a recent study suggest.

“We are probably at a turning point in the history of preterm labor diagnosis,” lead author Irina Buhimschi, M.D., of Yale University, New Haven, and her associates wrote (BJOG 2005;112:173-81). She conducted the research with Catalin S. Buhimschi, M.D., also of Yale, and Rob Christner of Ciphergen Biosystems, Fremont, Calif.

“We think this proteomic analysis will be the diagnostic platform of the future from which many diseases will be diagnosed,” Dr. Irina Buhimschi commented in an interview.

The discovery could help identify preterm labor patients who might benefit from intervention “before the battle is completely lost,” she explained.

Although amniotic fluid cultures can detect infection, they have limited clinical utility because results are not quickly available. “By the time you have the result, the patient has already delivered, and the baby is in neonatal intensive care—so the only benefit of the test is to confirm the decision of the physician. In the case of [proteomic analysis], the result can be available within 50 minutes or less and has the potential of being useful for clinical decision making,” she said.

Using proteomic analysis, the team analyzed frozen amniotic fluid samples from 77 women with symptoms of preterm labor or preterm, premature rupture of membranes, and a known outcome (stage 1). The findings were then applied to samples from 24 symptomatic patients whose outcomes were not known to the investigators (stage 2).

The analysis identified a distinctive profile of four proteins present in patients who went on to preterm delivery but absent in patients whose symptoms subsided and who did not give birth prematurely.

This profile consisted of three out of four biomarkers of infection and inflammation, including human neutrophil defensin-1 and -2 and calgranulins A and C.

“If there were just two of the biomarkers present, the symptoms might either spontaneously resolve or get worse. It was only when three or four were present that imminent delivery could be predicted,” Dr. Buhimschi said.

The analysis involved a sophisticated algorithm called mass restricted (MR) analysis, and patients were given an MR score based on their levels of these four proteins.

The scoring system had 100% sensitivity and specificity for predicting which patients would deliver prematurely. Patients with an MR score of 3-4 had a median amniocentesis-to-delivery interval of 2 days, compared with a median of 51 days for patients with MR scores of 0-2.

Although it is generally accepted that a large proportion of preterm deliveries are caused by infection and inflammation, previous attempts at treating all preterm labor patients with antibiotics have failed to reverse the process. This may be partly because patients whose preterm labor is caused by factors other than infection and inflammation do not respond to antibiotic therapy, Dr. Buhimschi said.

“It is reasonable to think that those who respond to antibiotics will be only those in whom the preterm labor is caused by an infection and inflammation—and our approach is able to identify those patients,” she said. In addition, the identification of specific biomarkers of preterm delivery holds potential for research into pathology-specific treatments, she said.

The research was funded by the National Institutes of Health and Ciphergen Biosystems. Dr. Buhimschi said the NIH has agreed to fund further investigations into the application of this research.

Biomarkers of intra-amniotic infection and inflammation can be rapidly detected in amniotic fluid using proteomic analysis. And the identification of a distinctive biomarker profile can predict imminent preterm delivery with 100% accuracy, opening the door to future treatments, results of a recent study suggest.

“We are probably at a turning point in the history of preterm labor diagnosis,” lead author Irina Buhimschi, M.D., of Yale University, New Haven, and her associates wrote (BJOG 2005;112:173-81). She conducted the research with Catalin S. Buhimschi, M.D., also of Yale, and Rob Christner of Ciphergen Biosystems, Fremont, Calif.

“We think this proteomic analysis will be the diagnostic platform of the future from which many diseases will be diagnosed,” Dr. Irina Buhimschi commented in an interview.

The discovery could help identify preterm labor patients who might benefit from intervention “before the battle is completely lost,” she explained.

Although amniotic fluid cultures can detect infection, they have limited clinical utility because results are not quickly available. “By the time you have the result, the patient has already delivered, and the baby is in neonatal intensive care—so the only benefit of the test is to confirm the decision of the physician. In the case of [proteomic analysis], the result can be available within 50 minutes or less and has the potential of being useful for clinical decision making,” she said.

Using proteomic analysis, the team analyzed frozen amniotic fluid samples from 77 women with symptoms of preterm labor or preterm, premature rupture of membranes, and a known outcome (stage 1). The findings were then applied to samples from 24 symptomatic patients whose outcomes were not known to the investigators (stage 2).

The analysis identified a distinctive profile of four proteins present in patients who went on to preterm delivery but absent in patients whose symptoms subsided and who did not give birth prematurely.

This profile consisted of three out of four biomarkers of infection and inflammation, including human neutrophil defensin-1 and -2 and calgranulins A and C.

“If there were just two of the biomarkers present, the symptoms might either spontaneously resolve or get worse. It was only when three or four were present that imminent delivery could be predicted,” Dr. Buhimschi said.

The analysis involved a sophisticated algorithm called mass restricted (MR) analysis, and patients were given an MR score based on their levels of these four proteins.

The scoring system had 100% sensitivity and specificity for predicting which patients would deliver prematurely. Patients with an MR score of 3-4 had a median amniocentesis-to-delivery interval of 2 days, compared with a median of 51 days for patients with MR scores of 0-2.

Although it is generally accepted that a large proportion of preterm deliveries are caused by infection and inflammation, previous attempts at treating all preterm labor patients with antibiotics have failed to reverse the process. This may be partly because patients whose preterm labor is caused by factors other than infection and inflammation do not respond to antibiotic therapy, Dr. Buhimschi said.

“It is reasonable to think that those who respond to antibiotics will be only those in whom the preterm labor is caused by an infection and inflammation—and our approach is able to identify those patients,” she said. In addition, the identification of specific biomarkers of preterm delivery holds potential for research into pathology-specific treatments, she said.

The research was funded by the National Institutes of Health and Ciphergen Biosystems. Dr. Buhimschi said the NIH has agreed to fund further investigations into the application of this research.