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Most oral HRT linked to increased VTE risk
Transdermal hormone replacement therapy is associated with the lowest risk of venous thromboembolism, yet still is relatively underused compared to oral preparations, researchers say.
Writing in the BMJ, Yana Vinogradova, PhD, of the University of Nottingham (England) and her associates reported the results of two nested case-control studies of hormone replacement therapy (HRT) and venous thromboembolism (VTE) from Jan. 1998 to Feb. 2017 that altogether included 80,396 women aged 40-79 years with a primary diagnosis of VTE matched to 391,494 female controls.
Overall, 7% of the women with VTE had been exposed to HRT in the 90 days before the index date versus 5.5% of controls.
The greatest increase in risk of VTE, compared with no exposure, was seen with oral conjugated equine estrogen with medroxyprogesterone acetate, which was associated with a more than twofold increase in risk (odds ratio, 2.10; 95% confidence interval, 1.92-2.31; P less than .01).
However transdermal HRT use was not associated with any increase in risk, compared with no HRT exposure. The data even pointed to a slight decrease in risk, which the authors suggested may be the result of some residual confounding or indication bias.
Oral HRT generally was associated with a 58% increased risk of VTE, which amounted to a number needed to harm of 1,076 and nine extra cases of VTE per 10,000 women taking oral HRT.
Dr. Vinogradova and her colleagues noted that the vast majority of women in the study were being prescribed oral HRT for menopausal symptoms despite previous studies showing transdermal HRT has much lower risk.
“When women with menopausal symptoms already have an increased VTE risk because of comorbidities or obesity, these women and their doctors should give greater consideration to transdermal HRT,” they wrote.
Lubna Pal, MBBS, director of the menopause program and professor of obstetrics, gynecology, and reproductive sciences at Yale University, New Haven, Conn., commented in an interview, “These data are tremendously reassuring. The reported findings are: 1) reaffirm what we have already known , i.e. that advancing age, higher body mass index, and higher doses of exogenous systemic estrogen therapy are associated with increased risk for VTE; 2) offer greater granularity in risk for VTE with different formulations of estrogens and progestins and different regimens than understood thus far, 3) reaffirm that, unlike oral estrogen, transdermal estrogen formulations in doses commonly utilized in clinical practice are not associated with VTE risk, and 4) provide reassurance that the absolute risk, while exaggerated with oral estrogen or combination estrogen and progestin use, is nonetheless small as reflected in the number needed to harm with oral hormone therapy being 1,076, and the number of extra VTE cases attributable to oral HT being 9 per 10,000 woman years.
“The authors are to be commended on this massive analytic undertaking that allows an improved understanding of HRT-related risk for VTE and offers meaningful guidance to the practitioner,” said Dr. Pal, who was not involved in the study.*
Estrogen-only preparations had a 40% higher risk and combined preparations had a 73% higher risk, compared with no exposure.
In estrogen-only preparations, the lowest risk was seen with estradiol, compared with conjugated equine estrogens or combined preparations.
The lowest risk of VTE among oral preparations was seen with estradiol plus dydrogesterone, which only showed a nonsignificant 18% increase in risk.
In an attempt to account for possible increased risk of VTE, the authors conducted a sensitivity analysis in a subgroup of women who had not previously used anticoagulants, but they found similar results to the main analysis.
“This sensitivity analysis indicates that most of the excluded women had probably used anticoagulants because of atrial fibrillation or hip replacement operations rather than an earlier unrecorded VTE,” they wrote.
One author declared directorship of a clinical software company, but no other conflicts of interest were declared. There was no external funding. Dr. Pal reported that she was a coinvestigator in the Kronos Early Estrogen Prevention Study and on an AMAG Pharmaceuticals advisory board and member of their speaker’s bureau.
SOURCE: Vinogradova Y et al. BMJ. 2019 Jan 9. doi: 10.1136/bmj.k4810.
*This article was updated 1/11/19.
Transdermal hormone replacement therapy is associated with the lowest risk of venous thromboembolism, yet still is relatively underused compared to oral preparations, researchers say.
Writing in the BMJ, Yana Vinogradova, PhD, of the University of Nottingham (England) and her associates reported the results of two nested case-control studies of hormone replacement therapy (HRT) and venous thromboembolism (VTE) from Jan. 1998 to Feb. 2017 that altogether included 80,396 women aged 40-79 years with a primary diagnosis of VTE matched to 391,494 female controls.
Overall, 7% of the women with VTE had been exposed to HRT in the 90 days before the index date versus 5.5% of controls.
The greatest increase in risk of VTE, compared with no exposure, was seen with oral conjugated equine estrogen with medroxyprogesterone acetate, which was associated with a more than twofold increase in risk (odds ratio, 2.10; 95% confidence interval, 1.92-2.31; P less than .01).
However transdermal HRT use was not associated with any increase in risk, compared with no HRT exposure. The data even pointed to a slight decrease in risk, which the authors suggested may be the result of some residual confounding or indication bias.
Oral HRT generally was associated with a 58% increased risk of VTE, which amounted to a number needed to harm of 1,076 and nine extra cases of VTE per 10,000 women taking oral HRT.
Dr. Vinogradova and her colleagues noted that the vast majority of women in the study were being prescribed oral HRT for menopausal symptoms despite previous studies showing transdermal HRT has much lower risk.
“When women with menopausal symptoms already have an increased VTE risk because of comorbidities or obesity, these women and their doctors should give greater consideration to transdermal HRT,” they wrote.
Lubna Pal, MBBS, director of the menopause program and professor of obstetrics, gynecology, and reproductive sciences at Yale University, New Haven, Conn., commented in an interview, “These data are tremendously reassuring. The reported findings are: 1) reaffirm what we have already known , i.e. that advancing age, higher body mass index, and higher doses of exogenous systemic estrogen therapy are associated with increased risk for VTE; 2) offer greater granularity in risk for VTE with different formulations of estrogens and progestins and different regimens than understood thus far, 3) reaffirm that, unlike oral estrogen, transdermal estrogen formulations in doses commonly utilized in clinical practice are not associated with VTE risk, and 4) provide reassurance that the absolute risk, while exaggerated with oral estrogen or combination estrogen and progestin use, is nonetheless small as reflected in the number needed to harm with oral hormone therapy being 1,076, and the number of extra VTE cases attributable to oral HT being 9 per 10,000 woman years.
“The authors are to be commended on this massive analytic undertaking that allows an improved understanding of HRT-related risk for VTE and offers meaningful guidance to the practitioner,” said Dr. Pal, who was not involved in the study.*
Estrogen-only preparations had a 40% higher risk and combined preparations had a 73% higher risk, compared with no exposure.
In estrogen-only preparations, the lowest risk was seen with estradiol, compared with conjugated equine estrogens or combined preparations.
The lowest risk of VTE among oral preparations was seen with estradiol plus dydrogesterone, which only showed a nonsignificant 18% increase in risk.
In an attempt to account for possible increased risk of VTE, the authors conducted a sensitivity analysis in a subgroup of women who had not previously used anticoagulants, but they found similar results to the main analysis.
“This sensitivity analysis indicates that most of the excluded women had probably used anticoagulants because of atrial fibrillation or hip replacement operations rather than an earlier unrecorded VTE,” they wrote.
One author declared directorship of a clinical software company, but no other conflicts of interest were declared. There was no external funding. Dr. Pal reported that she was a coinvestigator in the Kronos Early Estrogen Prevention Study and on an AMAG Pharmaceuticals advisory board and member of their speaker’s bureau.
SOURCE: Vinogradova Y et al. BMJ. 2019 Jan 9. doi: 10.1136/bmj.k4810.
*This article was updated 1/11/19.
Transdermal hormone replacement therapy is associated with the lowest risk of venous thromboembolism, yet still is relatively underused compared to oral preparations, researchers say.
Writing in the BMJ, Yana Vinogradova, PhD, of the University of Nottingham (England) and her associates reported the results of two nested case-control studies of hormone replacement therapy (HRT) and venous thromboembolism (VTE) from Jan. 1998 to Feb. 2017 that altogether included 80,396 women aged 40-79 years with a primary diagnosis of VTE matched to 391,494 female controls.
Overall, 7% of the women with VTE had been exposed to HRT in the 90 days before the index date versus 5.5% of controls.
The greatest increase in risk of VTE, compared with no exposure, was seen with oral conjugated equine estrogen with medroxyprogesterone acetate, which was associated with a more than twofold increase in risk (odds ratio, 2.10; 95% confidence interval, 1.92-2.31; P less than .01).
However transdermal HRT use was not associated with any increase in risk, compared with no HRT exposure. The data even pointed to a slight decrease in risk, which the authors suggested may be the result of some residual confounding or indication bias.
Oral HRT generally was associated with a 58% increased risk of VTE, which amounted to a number needed to harm of 1,076 and nine extra cases of VTE per 10,000 women taking oral HRT.
Dr. Vinogradova and her colleagues noted that the vast majority of women in the study were being prescribed oral HRT for menopausal symptoms despite previous studies showing transdermal HRT has much lower risk.
“When women with menopausal symptoms already have an increased VTE risk because of comorbidities or obesity, these women and their doctors should give greater consideration to transdermal HRT,” they wrote.
Lubna Pal, MBBS, director of the menopause program and professor of obstetrics, gynecology, and reproductive sciences at Yale University, New Haven, Conn., commented in an interview, “These data are tremendously reassuring. The reported findings are: 1) reaffirm what we have already known , i.e. that advancing age, higher body mass index, and higher doses of exogenous systemic estrogen therapy are associated with increased risk for VTE; 2) offer greater granularity in risk for VTE with different formulations of estrogens and progestins and different regimens than understood thus far, 3) reaffirm that, unlike oral estrogen, transdermal estrogen formulations in doses commonly utilized in clinical practice are not associated with VTE risk, and 4) provide reassurance that the absolute risk, while exaggerated with oral estrogen or combination estrogen and progestin use, is nonetheless small as reflected in the number needed to harm with oral hormone therapy being 1,076, and the number of extra VTE cases attributable to oral HT being 9 per 10,000 woman years.
“The authors are to be commended on this massive analytic undertaking that allows an improved understanding of HRT-related risk for VTE and offers meaningful guidance to the practitioner,” said Dr. Pal, who was not involved in the study.*
Estrogen-only preparations had a 40% higher risk and combined preparations had a 73% higher risk, compared with no exposure.
In estrogen-only preparations, the lowest risk was seen with estradiol, compared with conjugated equine estrogens or combined preparations.
The lowest risk of VTE among oral preparations was seen with estradiol plus dydrogesterone, which only showed a nonsignificant 18% increase in risk.
In an attempt to account for possible increased risk of VTE, the authors conducted a sensitivity analysis in a subgroup of women who had not previously used anticoagulants, but they found similar results to the main analysis.
“This sensitivity analysis indicates that most of the excluded women had probably used anticoagulants because of atrial fibrillation or hip replacement operations rather than an earlier unrecorded VTE,” they wrote.
One author declared directorship of a clinical software company, but no other conflicts of interest were declared. There was no external funding. Dr. Pal reported that she was a coinvestigator in the Kronos Early Estrogen Prevention Study and on an AMAG Pharmaceuticals advisory board and member of their speaker’s bureau.
SOURCE: Vinogradova Y et al. BMJ. 2019 Jan 9. doi: 10.1136/bmj.k4810.
*This article was updated 1/11/19.
FROM THE BMJ
Key clinical point: Transdermal HRT is not associated with any increase in VTE risk.
Major finding: Conjugated equine estrogen with medroxyprogesterone shows a twofold increase in VTE risk.
Study details: Nested case-control study in 80,396 women and 391,494 female controls.
Disclosures: One author declared directorship of a clinical software company, but no other conflicts of interest were declared. There was no external funding. Dr. Pal reported that she was a coinvestigator in the Kronos Early Estrogen Prevention Study and on an AMAG Pharmaceuticals advisory board and member of their speaker’s bureau.
Source: Vinogradova Y et al. BMJ. 2019 Jan 9. doi: 10.1136/bmj.k4810
ACOG updates guidance on chronic hypertension in pregnancy, gestational hypertension
Ob.gyns. will need to focus more on individualized care as they use the two new practice bulletins, one on chronic hypertension in pregnancy and one on gestational hypertension and preeclampsia, released by the American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins–Obstetrics.
The bulletins will replace the 2013 ACOG hypertension in pregnancy task force report and are published in the January issue of Obstetrics & Gynecology.
“The task force was a tour de force in creating a comprehensive view of hypertensive diseases of pregnancy, including research,” Christian M. Pettker, MD, who helped develop both practice bulletins, stated in a press release. “The updated guidance provides clearer recommendations for the management of gestational hypertension with severe-range blood pressure, an emphasis on and instructions for timely treatment of acutely elevated blood pressures, and more defined recommendations for the management of pain in postoperative patients with hypertension.”
“Ob.gyns. will need to focus more on individualized care and may find it’s best to err on the side of caution because the appropriate treatment of hypertensive diseases in pregnancy may be the most important focus of our attempts to improve maternal mortality and morbidity in the United States,” he said.*
Gestational hypertension or preeclampsia
For women with gestational hypertension or preeclampsia at 37 weeks of gestation or later without severe features, the guidelines recommend delivery rather than expectant management.
Those patients with severe features of gestational hypertension or preeclampsia or eclampsia should receive magnesium sulfate to prevent or treat seizures.
Patients should receive low-dose aspirin (81 mg/day) for preeclampsia prophylaxis between 12 weeks and 28 weeks of gestation if they have high-risk factors of preeclampsia such as multifetal gestation, a previous pregnancy with preeclampsia, renal disease, autoimmune disease, type 1 or type 2 diabetes mellitus, chronic hypertension, or a previous pregnancy with preeclampsia; or more than one moderate risk factor such as a family history of preeclampsia, maternal age greater than 35 years, first pregnancy, body mass index greater than 30, personal history factors, or sociodemographic characteristics.
NSAIDs should continue to be used in preference to opioid analgesics.
The guidance also discusses mode of delivery, antihypertensive drugs and thresholds for treatment, management of acute complications for preeclampsia with HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome, the optimal treatment for eclampsia, and postpartum hypertension and headache.
Chronic hypertension
Pregnant women with chronic hypertension also should receive low-dose aspirin between 12 weeks and 28 weeks of gestation. Antihypertensive therapy should be initiated for women with persistent chronic hypertension at systolic pressure of 160 mm Hg or higher and/or diastolic pressure of 110 mm Hg or higher. Consider treating patients at lower blood pressure (BP) thresholds depending on comorbidities or underlying impaired renal function.
ACOG has recommended treating pregnant patients as chronically hypertensive according to recently changed criteria from the American College of Cardiology and the American Heart Association, which call for classifying blood pressure into the following categories:
- Normal. Systolic BP less than 120 mm Hg; diastolic BP less than 80 mm Hg.
- Elevated. Systolic BP greater than or equal to 120-129 mm Hg; diastolic BP greater than 80 mm Hg.
- Stage 1 hypertension. Systolic BP, 130-139 mm Hg; diastolic BP, 80-89 mm Hg.
- Stage 2 hypertension. Systolic BP greater than or equal to 140 mm Hg; diastolic BP greater than or equal to 90 mm Hg.
“The new blood pressure ranges for nonpregnant women have a lower threshold for hypertension diagnosis compared to ACOG’s criteria,” Dr. Pettker said. “This will likely cause a general increase in patients classified as chronic hypertensive and will require shared decision making by the ob.gyn. and the patient regarding appropriate management in pregnancy.”
The guideline also discusses chronic hypertension with superimposed preeclampsia; tests for baseline evaluation of chronic hypertension in pregnancy; common oral antihypertensive agents to use in pregnancy and those to use for urgent blood pressure control in pregnancy; control of acute-onset severe-range hypertension; and postpartum considerations in patients with chronic hypertension.
SOURCE: Gestational hypertension and preeclampsia. ACOG Practice Bulletin No. 202. Obstet Gynecol. 2019;133:e1-25; Chronic hypertension in pregnancy. ACOG Practice Bulletin No. 203. Obstet Gynecol. 2019;133:e26-50.
This article was updated 1/11/19 and 11/19/19.
Ob.gyns. will need to focus more on individualized care as they use the two new practice bulletins, one on chronic hypertension in pregnancy and one on gestational hypertension and preeclampsia, released by the American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins–Obstetrics.
The bulletins will replace the 2013 ACOG hypertension in pregnancy task force report and are published in the January issue of Obstetrics & Gynecology.
“The task force was a tour de force in creating a comprehensive view of hypertensive diseases of pregnancy, including research,” Christian M. Pettker, MD, who helped develop both practice bulletins, stated in a press release. “The updated guidance provides clearer recommendations for the management of gestational hypertension with severe-range blood pressure, an emphasis on and instructions for timely treatment of acutely elevated blood pressures, and more defined recommendations for the management of pain in postoperative patients with hypertension.”
“Ob.gyns. will need to focus more on individualized care and may find it’s best to err on the side of caution because the appropriate treatment of hypertensive diseases in pregnancy may be the most important focus of our attempts to improve maternal mortality and morbidity in the United States,” he said.*
Gestational hypertension or preeclampsia
For women with gestational hypertension or preeclampsia at 37 weeks of gestation or later without severe features, the guidelines recommend delivery rather than expectant management.
Those patients with severe features of gestational hypertension or preeclampsia or eclampsia should receive magnesium sulfate to prevent or treat seizures.
Patients should receive low-dose aspirin (81 mg/day) for preeclampsia prophylaxis between 12 weeks and 28 weeks of gestation if they have high-risk factors of preeclampsia such as multifetal gestation, a previous pregnancy with preeclampsia, renal disease, autoimmune disease, type 1 or type 2 diabetes mellitus, chronic hypertension, or a previous pregnancy with preeclampsia; or more than one moderate risk factor such as a family history of preeclampsia, maternal age greater than 35 years, first pregnancy, body mass index greater than 30, personal history factors, or sociodemographic characteristics.
NSAIDs should continue to be used in preference to opioid analgesics.
The guidance also discusses mode of delivery, antihypertensive drugs and thresholds for treatment, management of acute complications for preeclampsia with HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome, the optimal treatment for eclampsia, and postpartum hypertension and headache.
Chronic hypertension
Pregnant women with chronic hypertension also should receive low-dose aspirin between 12 weeks and 28 weeks of gestation. Antihypertensive therapy should be initiated for women with persistent chronic hypertension at systolic pressure of 160 mm Hg or higher and/or diastolic pressure of 110 mm Hg or higher. Consider treating patients at lower blood pressure (BP) thresholds depending on comorbidities or underlying impaired renal function.
ACOG has recommended treating pregnant patients as chronically hypertensive according to recently changed criteria from the American College of Cardiology and the American Heart Association, which call for classifying blood pressure into the following categories:
- Normal. Systolic BP less than 120 mm Hg; diastolic BP less than 80 mm Hg.
- Elevated. Systolic BP greater than or equal to 120-129 mm Hg; diastolic BP greater than 80 mm Hg.
- Stage 1 hypertension. Systolic BP, 130-139 mm Hg; diastolic BP, 80-89 mm Hg.
- Stage 2 hypertension. Systolic BP greater than or equal to 140 mm Hg; diastolic BP greater than or equal to 90 mm Hg.
“The new blood pressure ranges for nonpregnant women have a lower threshold for hypertension diagnosis compared to ACOG’s criteria,” Dr. Pettker said. “This will likely cause a general increase in patients classified as chronic hypertensive and will require shared decision making by the ob.gyn. and the patient regarding appropriate management in pregnancy.”
The guideline also discusses chronic hypertension with superimposed preeclampsia; tests for baseline evaluation of chronic hypertension in pregnancy; common oral antihypertensive agents to use in pregnancy and those to use for urgent blood pressure control in pregnancy; control of acute-onset severe-range hypertension; and postpartum considerations in patients with chronic hypertension.
SOURCE: Gestational hypertension and preeclampsia. ACOG Practice Bulletin No. 202. Obstet Gynecol. 2019;133:e1-25; Chronic hypertension in pregnancy. ACOG Practice Bulletin No. 203. Obstet Gynecol. 2019;133:e26-50.
This article was updated 1/11/19 and 11/19/19.
Ob.gyns. will need to focus more on individualized care as they use the two new practice bulletins, one on chronic hypertension in pregnancy and one on gestational hypertension and preeclampsia, released by the American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins–Obstetrics.
The bulletins will replace the 2013 ACOG hypertension in pregnancy task force report and are published in the January issue of Obstetrics & Gynecology.
“The task force was a tour de force in creating a comprehensive view of hypertensive diseases of pregnancy, including research,” Christian M. Pettker, MD, who helped develop both practice bulletins, stated in a press release. “The updated guidance provides clearer recommendations for the management of gestational hypertension with severe-range blood pressure, an emphasis on and instructions for timely treatment of acutely elevated blood pressures, and more defined recommendations for the management of pain in postoperative patients with hypertension.”
“Ob.gyns. will need to focus more on individualized care and may find it’s best to err on the side of caution because the appropriate treatment of hypertensive diseases in pregnancy may be the most important focus of our attempts to improve maternal mortality and morbidity in the United States,” he said.*
Gestational hypertension or preeclampsia
For women with gestational hypertension or preeclampsia at 37 weeks of gestation or later without severe features, the guidelines recommend delivery rather than expectant management.
Those patients with severe features of gestational hypertension or preeclampsia or eclampsia should receive magnesium sulfate to prevent or treat seizures.
Patients should receive low-dose aspirin (81 mg/day) for preeclampsia prophylaxis between 12 weeks and 28 weeks of gestation if they have high-risk factors of preeclampsia such as multifetal gestation, a previous pregnancy with preeclampsia, renal disease, autoimmune disease, type 1 or type 2 diabetes mellitus, chronic hypertension, or a previous pregnancy with preeclampsia; or more than one moderate risk factor such as a family history of preeclampsia, maternal age greater than 35 years, first pregnancy, body mass index greater than 30, personal history factors, or sociodemographic characteristics.
NSAIDs should continue to be used in preference to opioid analgesics.
The guidance also discusses mode of delivery, antihypertensive drugs and thresholds for treatment, management of acute complications for preeclampsia with HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome, the optimal treatment for eclampsia, and postpartum hypertension and headache.
Chronic hypertension
Pregnant women with chronic hypertension also should receive low-dose aspirin between 12 weeks and 28 weeks of gestation. Antihypertensive therapy should be initiated for women with persistent chronic hypertension at systolic pressure of 160 mm Hg or higher and/or diastolic pressure of 110 mm Hg or higher. Consider treating patients at lower blood pressure (BP) thresholds depending on comorbidities or underlying impaired renal function.
ACOG has recommended treating pregnant patients as chronically hypertensive according to recently changed criteria from the American College of Cardiology and the American Heart Association, which call for classifying blood pressure into the following categories:
- Normal. Systolic BP less than 120 mm Hg; diastolic BP less than 80 mm Hg.
- Elevated. Systolic BP greater than or equal to 120-129 mm Hg; diastolic BP greater than 80 mm Hg.
- Stage 1 hypertension. Systolic BP, 130-139 mm Hg; diastolic BP, 80-89 mm Hg.
- Stage 2 hypertension. Systolic BP greater than or equal to 140 mm Hg; diastolic BP greater than or equal to 90 mm Hg.
“The new blood pressure ranges for nonpregnant women have a lower threshold for hypertension diagnosis compared to ACOG’s criteria,” Dr. Pettker said. “This will likely cause a general increase in patients classified as chronic hypertensive and will require shared decision making by the ob.gyn. and the patient regarding appropriate management in pregnancy.”
The guideline also discusses chronic hypertension with superimposed preeclampsia; tests for baseline evaluation of chronic hypertension in pregnancy; common oral antihypertensive agents to use in pregnancy and those to use for urgent blood pressure control in pregnancy; control of acute-onset severe-range hypertension; and postpartum considerations in patients with chronic hypertension.
SOURCE: Gestational hypertension and preeclampsia. ACOG Practice Bulletin No. 202. Obstet Gynecol. 2019;133:e1-25; Chronic hypertension in pregnancy. ACOG Practice Bulletin No. 203. Obstet Gynecol. 2019;133:e26-50.
This article was updated 1/11/19 and 11/19/19.
FROM OBSTETRICS & GYNECOLOGY
Proposed triple I criteria may overlook febrile women at risk post partum
A large proportion of laboring febrile women are not meeting proposed criteria for intrauterine inflammation or infection or both (triple I), but still may be at risk, according to an analysis of expert recommendations for clinical diagnosis published in Obstetrics & Gynecology.
“Our data suggest caution in universal implementation of the triple I criteria to guide clinical management of febrile women in the intrapartum period,” according to lead author Samsiya Ona, MD, of Brigham and Women’s Hospital in Boston, and her coauthors.
In early 2015, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) established criteria for diagnosing triple I in an effort to “decrease overtreatment of intrapartum women and low-risk newborns.” To assess the validity of those criteria, Dr. Ona and her colleagues analyzed 339 women with a temperature taken of 100.4°F or greater (38.0°C) during labor or within 1 hour post partum from June 2015 to September 2017.
The women were split into two groups: 212 met criteria for suspected triple I (documented fever plus clinical signs of intrauterine infection such as maternal leukocytosis greater than 15,000 per mm3, fetal tachycardia greater than 160 beats per minute, and purulent amniotic fluid) and 127 met criteria for isolated maternal fever. Among the suspected triple I group, incidence of adverse clinical infectious outcomes was 12%, comparable with 10% in the isolated maternal fever group (P = .50). When it came to predicting confirmed triple I, the sensitivity and specificity of the suspected triple I criteria were 71% (95% confidence interval, 61.4%-80.1%) and 41% (95% CI, 33.6%-47.8%), respectively. For predicting adverse clinical infectious outcomes, the sensitivity and specificity of the suspected triple I criteria were 68% (95% CI, 50.2%-82.0%) and 38% (95% CI, 32.6%-43.8%).
The authors cited among study limitations their including only women who had blood cultures sent at initial fever and excluding women who did not have repeat febrile temperature taken within 45 minutes. However, they noted the benefits of working with “a unique, large database with physiologic, laboratory, and microbiological parameters” and emphasized the need for an improved method of diagnosis, suggesting “a simple bedside minimally invasive marker of infection may be ideal.”
The study was supported by an Expanding the Boundaries Faculty Grant from the department of obstetrics, gynecology, and reproductive biology at the Brigham and Women’s Hospital in Boston. No conflicts of interest were reported.
SOURCE: Ona S et al. Obstet Gynecol. 2019 Jan. doi: 10.1097/AOG.0000000000003008.
A large proportion of laboring febrile women are not meeting proposed criteria for intrauterine inflammation or infection or both (triple I), but still may be at risk, according to an analysis of expert recommendations for clinical diagnosis published in Obstetrics & Gynecology.
“Our data suggest caution in universal implementation of the triple I criteria to guide clinical management of febrile women in the intrapartum period,” according to lead author Samsiya Ona, MD, of Brigham and Women’s Hospital in Boston, and her coauthors.
In early 2015, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) established criteria for diagnosing triple I in an effort to “decrease overtreatment of intrapartum women and low-risk newborns.” To assess the validity of those criteria, Dr. Ona and her colleagues analyzed 339 women with a temperature taken of 100.4°F or greater (38.0°C) during labor or within 1 hour post partum from June 2015 to September 2017.
The women were split into two groups: 212 met criteria for suspected triple I (documented fever plus clinical signs of intrauterine infection such as maternal leukocytosis greater than 15,000 per mm3, fetal tachycardia greater than 160 beats per minute, and purulent amniotic fluid) and 127 met criteria for isolated maternal fever. Among the suspected triple I group, incidence of adverse clinical infectious outcomes was 12%, comparable with 10% in the isolated maternal fever group (P = .50). When it came to predicting confirmed triple I, the sensitivity and specificity of the suspected triple I criteria were 71% (95% confidence interval, 61.4%-80.1%) and 41% (95% CI, 33.6%-47.8%), respectively. For predicting adverse clinical infectious outcomes, the sensitivity and specificity of the suspected triple I criteria were 68% (95% CI, 50.2%-82.0%) and 38% (95% CI, 32.6%-43.8%).
The authors cited among study limitations their including only women who had blood cultures sent at initial fever and excluding women who did not have repeat febrile temperature taken within 45 minutes. However, they noted the benefits of working with “a unique, large database with physiologic, laboratory, and microbiological parameters” and emphasized the need for an improved method of diagnosis, suggesting “a simple bedside minimally invasive marker of infection may be ideal.”
The study was supported by an Expanding the Boundaries Faculty Grant from the department of obstetrics, gynecology, and reproductive biology at the Brigham and Women’s Hospital in Boston. No conflicts of interest were reported.
SOURCE: Ona S et al. Obstet Gynecol. 2019 Jan. doi: 10.1097/AOG.0000000000003008.
A large proportion of laboring febrile women are not meeting proposed criteria for intrauterine inflammation or infection or both (triple I), but still may be at risk, according to an analysis of expert recommendations for clinical diagnosis published in Obstetrics & Gynecology.
“Our data suggest caution in universal implementation of the triple I criteria to guide clinical management of febrile women in the intrapartum period,” according to lead author Samsiya Ona, MD, of Brigham and Women’s Hospital in Boston, and her coauthors.
In early 2015, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) established criteria for diagnosing triple I in an effort to “decrease overtreatment of intrapartum women and low-risk newborns.” To assess the validity of those criteria, Dr. Ona and her colleagues analyzed 339 women with a temperature taken of 100.4°F or greater (38.0°C) during labor or within 1 hour post partum from June 2015 to September 2017.
The women were split into two groups: 212 met criteria for suspected triple I (documented fever plus clinical signs of intrauterine infection such as maternal leukocytosis greater than 15,000 per mm3, fetal tachycardia greater than 160 beats per minute, and purulent amniotic fluid) and 127 met criteria for isolated maternal fever. Among the suspected triple I group, incidence of adverse clinical infectious outcomes was 12%, comparable with 10% in the isolated maternal fever group (P = .50). When it came to predicting confirmed triple I, the sensitivity and specificity of the suspected triple I criteria were 71% (95% confidence interval, 61.4%-80.1%) and 41% (95% CI, 33.6%-47.8%), respectively. For predicting adverse clinical infectious outcomes, the sensitivity and specificity of the suspected triple I criteria were 68% (95% CI, 50.2%-82.0%) and 38% (95% CI, 32.6%-43.8%).
The authors cited among study limitations their including only women who had blood cultures sent at initial fever and excluding women who did not have repeat febrile temperature taken within 45 minutes. However, they noted the benefits of working with “a unique, large database with physiologic, laboratory, and microbiological parameters” and emphasized the need for an improved method of diagnosis, suggesting “a simple bedside minimally invasive marker of infection may be ideal.”
The study was supported by an Expanding the Boundaries Faculty Grant from the department of obstetrics, gynecology, and reproductive biology at the Brigham and Women’s Hospital in Boston. No conflicts of interest were reported.
SOURCE: Ona S et al. Obstet Gynecol. 2019 Jan. doi: 10.1097/AOG.0000000000003008.
FROM OBSTETRICS & GYNECOLOGY
Key clinical point:
Major finding: The sensitivity and specificity of the suspected triple I criteria to predict an adverse clinical infectious outcome were 68% for the suspected triple I group and 38% for the isolated maternal fever group.
Study details: A retrospective cohort study of 339 women with intrapartum fever from June 2015 to September 2017.
Disclosures: The study was supported by an Expanding the Boundaries Faculty Grant from the department of obstetrics, gynecology, and reproductive biology at the Brigham and Women’s Hospital in Boston. No conflicts of interest were reported.
Source: Ona S et al. Obstet Gynecol. 2019 Jan. doi: 10.1097/AOG.0000000000003008.
Danish study finds reassuring data on pregnancy outcomes in atopic dermatitis patients
PARIS – over an 18-year period, which showed no increased risk of pregnancy and birth problems other than modestly increased risks of premature rupture of membranes and neonatal staphylococcal septicemia, according to Jacob P. Thyssen, MD, PhD.
At a session of the European Task Force of Atopic Dermatitis held in conjunction with the annual congress of the European Academy of Dermatology and Venereology, he presented a case control study of 10,668 births to Danish women with atopic dermatitis (AD) during 1997-2014. They were matched 1:10 by age, parity, and birth year to mothers without AD.
The risk of premature rupture of membranes was 15% higher in mothers with AD. And while the increased relative risk of neonatal staphylococcal septicemia was more substantial – a 145% increase – this was in fact a rare complication, observed Dr. Thyssen, a dermatologist at the University of Copenhagen.
There was no significant difference between women with or without AD in rates of preeclampsia, prematurity, pregnancy-induced hypertension, placenta previa, placental abruption, neonatal nonstaphylococcal septicemia, or other complications. The two groups had a similar number of visits to physicians and midwives during pregnancy.
Moreover, although the body mass index was similar in women with or without AD, the risk of gestational diabetes in women with the disease was significantly reduced by 21%; their risk of having a large-for-gestational-age baby with a birth weight of 4,500 g or more was also significantly lower than in controls.
Women received less treatment for AD during their pregnancy than they did beforehand. While pregnant, their disease was managed predominantly with topical corticosteroids and UV therapy. There was very little use of superpotent topical steroids, topical calcineurin inhibitors, or immunosuppressants, although 10% of pregnant women received systemic corticosteroids for their AD.
Dr. Thyssen reported serving as a scientific adviser and paid speaker for Leo Pharma, Roche, Eli Lilly, and Sanofi-Genzyme, although this study was conducted without commercial support.
PARIS – over an 18-year period, which showed no increased risk of pregnancy and birth problems other than modestly increased risks of premature rupture of membranes and neonatal staphylococcal septicemia, according to Jacob P. Thyssen, MD, PhD.
At a session of the European Task Force of Atopic Dermatitis held in conjunction with the annual congress of the European Academy of Dermatology and Venereology, he presented a case control study of 10,668 births to Danish women with atopic dermatitis (AD) during 1997-2014. They were matched 1:10 by age, parity, and birth year to mothers without AD.
The risk of premature rupture of membranes was 15% higher in mothers with AD. And while the increased relative risk of neonatal staphylococcal septicemia was more substantial – a 145% increase – this was in fact a rare complication, observed Dr. Thyssen, a dermatologist at the University of Copenhagen.
There was no significant difference between women with or without AD in rates of preeclampsia, prematurity, pregnancy-induced hypertension, placenta previa, placental abruption, neonatal nonstaphylococcal septicemia, or other complications. The two groups had a similar number of visits to physicians and midwives during pregnancy.
Moreover, although the body mass index was similar in women with or without AD, the risk of gestational diabetes in women with the disease was significantly reduced by 21%; their risk of having a large-for-gestational-age baby with a birth weight of 4,500 g or more was also significantly lower than in controls.
Women received less treatment for AD during their pregnancy than they did beforehand. While pregnant, their disease was managed predominantly with topical corticosteroids and UV therapy. There was very little use of superpotent topical steroids, topical calcineurin inhibitors, or immunosuppressants, although 10% of pregnant women received systemic corticosteroids for their AD.
Dr. Thyssen reported serving as a scientific adviser and paid speaker for Leo Pharma, Roche, Eli Lilly, and Sanofi-Genzyme, although this study was conducted without commercial support.
PARIS – over an 18-year period, which showed no increased risk of pregnancy and birth problems other than modestly increased risks of premature rupture of membranes and neonatal staphylococcal septicemia, according to Jacob P. Thyssen, MD, PhD.
At a session of the European Task Force of Atopic Dermatitis held in conjunction with the annual congress of the European Academy of Dermatology and Venereology, he presented a case control study of 10,668 births to Danish women with atopic dermatitis (AD) during 1997-2014. They were matched 1:10 by age, parity, and birth year to mothers without AD.
The risk of premature rupture of membranes was 15% higher in mothers with AD. And while the increased relative risk of neonatal staphylococcal septicemia was more substantial – a 145% increase – this was in fact a rare complication, observed Dr. Thyssen, a dermatologist at the University of Copenhagen.
There was no significant difference between women with or without AD in rates of preeclampsia, prematurity, pregnancy-induced hypertension, placenta previa, placental abruption, neonatal nonstaphylococcal septicemia, or other complications. The two groups had a similar number of visits to physicians and midwives during pregnancy.
Moreover, although the body mass index was similar in women with or without AD, the risk of gestational diabetes in women with the disease was significantly reduced by 21%; their risk of having a large-for-gestational-age baby with a birth weight of 4,500 g or more was also significantly lower than in controls.
Women received less treatment for AD during their pregnancy than they did beforehand. While pregnant, their disease was managed predominantly with topical corticosteroids and UV therapy. There was very little use of superpotent topical steroids, topical calcineurin inhibitors, or immunosuppressants, although 10% of pregnant women received systemic corticosteroids for their AD.
Dr. Thyssen reported serving as a scientific adviser and paid speaker for Leo Pharma, Roche, Eli Lilly, and Sanofi-Genzyme, although this study was conducted without commercial support.
REPORTING FROM THE EADV CONGRESS
Key clinical point: Birth complications are uncommon for women with atopic dermatitis in pregnancy.
Major finding: The risk of premature rupture of membranes was increased by 15% in women with atopic dermatitis in pregnancy, but their risk of gestational diabetes was reduced by 21%.
Study details: This case control study included 10,668 births to Danish women with atopic dermatitis and 10 times as many matched controls without the disease.
Disclosures: The study presenter reported serving as a scientific adviser and paid speaker for Leo Pharma, Roche, Eli Lilly, and Sanofi-Genzyme, although this study was conducted without commercial support.
Gender, racial, socioeconomic differences found in obesity-depression link
Association holds for white women across income levels, black men with incomes of $100,000 or higher.
Among white women, obesity is positively associated with depressive symptoms across all income levels. However, among black women, no such associations are found – regardless of income. Meanwhile, among men, the link between obesity and depression appears strong for black men with high household incomes, a cross-sectional analysis of 12,220 adults suggests.
“This work underscores the importance of disentangling the association of race and [socioeconomic status] to gain a better understanding of how each operates to impact health outcomes,” wrote Caryn N. Bell, PhD, and her associates. The report is in Preventive Medicine.
The study comprised 3,755 black subjects, 55.5% of whom were women, and 8,465 white subjects, 51.8% of whom were women. They completed a detailed questionnaire as part of the 2007-2014 National Health and Nutrition Examination Survey and had a physical exam. Depressive symptoms were measured by the Patient Health Questionnaire-9 (PHQ-9), and obesity was defined as a body mass index of 30 kg/m2 or higher. About 1% of both black and white subjects had severe depressive symptoms, meaning a PHQ-9 score ranging from 20 to 27 points.
A greater percentage of black participants were obese (47.3% vs. 34.4%), and black participants were less likely to live in a household earning $100,000 per year or more (10.9% vs. 28.3%). Black participants were a bit younger (mean age 44.8 years vs. 49.2 years), and less likely to be currently married, college graduates, insured, and physically active. A higher percentage reported fair to poor health (23.9% vs. 14.6%). The differences were statistically significant.
For white women, the association between obesity and depression held across all income levels. For black women, this association was not found at any income level. For black men, the link between obesity and depression was limited to those with a household income of $100,000 or more (odds ratio, 4.65; 95% confidence interval, 1.48-14.59). And for white men, the association was limited to those with a household income of $35,000-$74,999 (OR, 1.44; 95% CI, 1.02-2.03).
The effect of race on obesity and depression has been well studied – it’s known, for instance, that the association between obesity and depression is strongest among white women – but the role of income as a modifier has not been well addressed, wrote Dr. Bell, an assistant professor in the department of African American studies at the University of Maryland, College Park, and her associates.
Dr. Bell and her associates wrote.
As for explanations, the authors suggested that strong, antiobesity stigma “may be present among white women at all income levels,” and may drive depression regardless of how much they make.
The prevalence of depressive symptoms at specific income levels among men suggests that something other than stigma is at work. Depression among obese, middle-income white men might be tied to “an unmeasured factor like subjective social status.” Meanwhile, obese black men with high household incomes “have less income and wealth than their white counterparts” because “of various forms of structural racism. ... This may be manifested with higher rates of depression through obesity-related factors like unhealthy coping behaviors and stress,” the investigators said.
Dr. Bell and her associates cited a few limitations. One is that the study looked only at those factors among black and white people. “Results could differ with other ethnic groups,” they wrote. In addition, income was self-reported, and three-way interactions – which are tough to interpret – were used. Nevertheless, they said, the study results have key public health implications.
The study had no financial disclosures, and the investigators reported having no conflicts of interest.
SOURCE: Bell CN et al. Prev Med. 2018 Dec 3. doi: 10.1016/j.ypmed.2018.11.024.
Association holds for white women across income levels, black men with incomes of $100,000 or higher.
Association holds for white women across income levels, black men with incomes of $100,000 or higher.
Among white women, obesity is positively associated with depressive symptoms across all income levels. However, among black women, no such associations are found – regardless of income. Meanwhile, among men, the link between obesity and depression appears strong for black men with high household incomes, a cross-sectional analysis of 12,220 adults suggests.
“This work underscores the importance of disentangling the association of race and [socioeconomic status] to gain a better understanding of how each operates to impact health outcomes,” wrote Caryn N. Bell, PhD, and her associates. The report is in Preventive Medicine.
The study comprised 3,755 black subjects, 55.5% of whom were women, and 8,465 white subjects, 51.8% of whom were women. They completed a detailed questionnaire as part of the 2007-2014 National Health and Nutrition Examination Survey and had a physical exam. Depressive symptoms were measured by the Patient Health Questionnaire-9 (PHQ-9), and obesity was defined as a body mass index of 30 kg/m2 or higher. About 1% of both black and white subjects had severe depressive symptoms, meaning a PHQ-9 score ranging from 20 to 27 points.
A greater percentage of black participants were obese (47.3% vs. 34.4%), and black participants were less likely to live in a household earning $100,000 per year or more (10.9% vs. 28.3%). Black participants were a bit younger (mean age 44.8 years vs. 49.2 years), and less likely to be currently married, college graduates, insured, and physically active. A higher percentage reported fair to poor health (23.9% vs. 14.6%). The differences were statistically significant.
For white women, the association between obesity and depression held across all income levels. For black women, this association was not found at any income level. For black men, the link between obesity and depression was limited to those with a household income of $100,000 or more (odds ratio, 4.65; 95% confidence interval, 1.48-14.59). And for white men, the association was limited to those with a household income of $35,000-$74,999 (OR, 1.44; 95% CI, 1.02-2.03).
The effect of race on obesity and depression has been well studied – it’s known, for instance, that the association between obesity and depression is strongest among white women – but the role of income as a modifier has not been well addressed, wrote Dr. Bell, an assistant professor in the department of African American studies at the University of Maryland, College Park, and her associates.
Dr. Bell and her associates wrote.
As for explanations, the authors suggested that strong, antiobesity stigma “may be present among white women at all income levels,” and may drive depression regardless of how much they make.
The prevalence of depressive symptoms at specific income levels among men suggests that something other than stigma is at work. Depression among obese, middle-income white men might be tied to “an unmeasured factor like subjective social status.” Meanwhile, obese black men with high household incomes “have less income and wealth than their white counterparts” because “of various forms of structural racism. ... This may be manifested with higher rates of depression through obesity-related factors like unhealthy coping behaviors and stress,” the investigators said.
Dr. Bell and her associates cited a few limitations. One is that the study looked only at those factors among black and white people. “Results could differ with other ethnic groups,” they wrote. In addition, income was self-reported, and three-way interactions – which are tough to interpret – were used. Nevertheless, they said, the study results have key public health implications.
The study had no financial disclosures, and the investigators reported having no conflicts of interest.
SOURCE: Bell CN et al. Prev Med. 2018 Dec 3. doi: 10.1016/j.ypmed.2018.11.024.
Among white women, obesity is positively associated with depressive symptoms across all income levels. However, among black women, no such associations are found – regardless of income. Meanwhile, among men, the link between obesity and depression appears strong for black men with high household incomes, a cross-sectional analysis of 12,220 adults suggests.
“This work underscores the importance of disentangling the association of race and [socioeconomic status] to gain a better understanding of how each operates to impact health outcomes,” wrote Caryn N. Bell, PhD, and her associates. The report is in Preventive Medicine.
The study comprised 3,755 black subjects, 55.5% of whom were women, and 8,465 white subjects, 51.8% of whom were women. They completed a detailed questionnaire as part of the 2007-2014 National Health and Nutrition Examination Survey and had a physical exam. Depressive symptoms were measured by the Patient Health Questionnaire-9 (PHQ-9), and obesity was defined as a body mass index of 30 kg/m2 or higher. About 1% of both black and white subjects had severe depressive symptoms, meaning a PHQ-9 score ranging from 20 to 27 points.
A greater percentage of black participants were obese (47.3% vs. 34.4%), and black participants were less likely to live in a household earning $100,000 per year or more (10.9% vs. 28.3%). Black participants were a bit younger (mean age 44.8 years vs. 49.2 years), and less likely to be currently married, college graduates, insured, and physically active. A higher percentage reported fair to poor health (23.9% vs. 14.6%). The differences were statistically significant.
For white women, the association between obesity and depression held across all income levels. For black women, this association was not found at any income level. For black men, the link between obesity and depression was limited to those with a household income of $100,000 or more (odds ratio, 4.65; 95% confidence interval, 1.48-14.59). And for white men, the association was limited to those with a household income of $35,000-$74,999 (OR, 1.44; 95% CI, 1.02-2.03).
The effect of race on obesity and depression has been well studied – it’s known, for instance, that the association between obesity and depression is strongest among white women – but the role of income as a modifier has not been well addressed, wrote Dr. Bell, an assistant professor in the department of African American studies at the University of Maryland, College Park, and her associates.
Dr. Bell and her associates wrote.
As for explanations, the authors suggested that strong, antiobesity stigma “may be present among white women at all income levels,” and may drive depression regardless of how much they make.
The prevalence of depressive symptoms at specific income levels among men suggests that something other than stigma is at work. Depression among obese, middle-income white men might be tied to “an unmeasured factor like subjective social status.” Meanwhile, obese black men with high household incomes “have less income and wealth than their white counterparts” because “of various forms of structural racism. ... This may be manifested with higher rates of depression through obesity-related factors like unhealthy coping behaviors and stress,” the investigators said.
Dr. Bell and her associates cited a few limitations. One is that the study looked only at those factors among black and white people. “Results could differ with other ethnic groups,” they wrote. In addition, income was self-reported, and three-way interactions – which are tough to interpret – were used. Nevertheless, they said, the study results have key public health implications.
The study had no financial disclosures, and the investigators reported having no conflicts of interest.
SOURCE: Bell CN et al. Prev Med. 2018 Dec 3. doi: 10.1016/j.ypmed.2018.11.024.
FROM PREVENTIVE MEDICINE
For pelvic pain, think outside the lower body
LAS VEGAS – An estimated 15%-25% of women aged 18-50 years suffer from chronic pelvic pain, a condition that commonly leads to sick days, reduced activity, and higher medication use. Treatments like surgery and opioids may seem feasible, but an obstetrician-gynecologist who studies pain urged colleagues to think twice.
In some cases, pelvic pain patients may suffer from centralized pain syndromes, conditions linked to the central nervous system that may not respond well to those common treatments, said Sawsan As-Sanie, MD, MPH, director of the University of Michigan Endometriosis Center, Ann Arbor.
“If we have laser vision on the pelvis, we may help some patients, but many of us will do harm,” said Dr. As-Sanie, who spoke at the Pelvic Anatomy and Gynecologic Surgery Symposium.
Endometriosis is frequently linked to pelvic pain. But, she said, the link between the two is fuzzier than has been assumed.
“It would make sense that endometriosis or pelvic adhesions would activate nociceptive pain, and [there are] a lot of data to support that this is, in part, how endometriosis causes pain,” she said. “But I would argue it really isn’t that simple because the relationship between endometriosis and pelvic pain is very complex and not explained entirely by the lesion.” For example, “we know that pain recurs after medical and surgical therapy, often without evidence of recurrent endometriosis.” And, there’s little relationship between pain symptoms and the location or extent of endometriosis.
What’s going on? Dr. As-Sanie suggested central pain syndromes can play a significant role in pelvic pain. These syndromes are 1.5-2 times more common in women than men, and are triggered or exacerbated by stressors.
She also emphasized the wide-ranging effects of these syndromes. “We focus on pain, but it’s clearly not a just a pain disorder,” noting that patients can report fatigue, poor sleep, greater sensitivity to light and sound, and memory difficulties that produce “fibromyalgia fog.”
Research suggests that patients with central pain syndromes experience changes in both brain structure and function, she said. As for pelvic pain specifically, studies have linked it to increased pain sensitivity and altered central nervous system structure and function regardless of whether endometriosis is present.
How should patients with pelvic pain be treated in light of this information? Dr. As-Sanie suggests first trying “gold standard” approaches to treat contributing factors whether they’re gynecologic, urologic, gastrointestinal, musculoskeletal or nerve related.
If those strategies don’t work, she said, “consider treating centralized pain” with a blend of approaches: behavioral (such as diet and cognitive-behavior therapy), medical (such as hormone modulation), and interventional (such as physical therapy and surgery).
Also consider pharmacologic therapies, said Dr. As-Sanie, who identified dual reuptake inhibitors (venlafaxine [Effexor] and duloxetine [Cymbalta] are a class of antidepressants that block the reuptake of both serotonin and norepinephrine) and anticonvulsants as drugs with strong evidence as treatments for central pain syndromes.
“Start at low doses and titrate up,” she advised, and “if at any point a given medication doesn’t work, we should try another.”
The Pelvic Anatomy and Gynecologic Surgery Symposium was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
Dr. As-Sanie discloses she is a consultant for AbbVie and Myovant.
LAS VEGAS – An estimated 15%-25% of women aged 18-50 years suffer from chronic pelvic pain, a condition that commonly leads to sick days, reduced activity, and higher medication use. Treatments like surgery and opioids may seem feasible, but an obstetrician-gynecologist who studies pain urged colleagues to think twice.
In some cases, pelvic pain patients may suffer from centralized pain syndromes, conditions linked to the central nervous system that may not respond well to those common treatments, said Sawsan As-Sanie, MD, MPH, director of the University of Michigan Endometriosis Center, Ann Arbor.
“If we have laser vision on the pelvis, we may help some patients, but many of us will do harm,” said Dr. As-Sanie, who spoke at the Pelvic Anatomy and Gynecologic Surgery Symposium.
Endometriosis is frequently linked to pelvic pain. But, she said, the link between the two is fuzzier than has been assumed.
“It would make sense that endometriosis or pelvic adhesions would activate nociceptive pain, and [there are] a lot of data to support that this is, in part, how endometriosis causes pain,” she said. “But I would argue it really isn’t that simple because the relationship between endometriosis and pelvic pain is very complex and not explained entirely by the lesion.” For example, “we know that pain recurs after medical and surgical therapy, often without evidence of recurrent endometriosis.” And, there’s little relationship between pain symptoms and the location or extent of endometriosis.
What’s going on? Dr. As-Sanie suggested central pain syndromes can play a significant role in pelvic pain. These syndromes are 1.5-2 times more common in women than men, and are triggered or exacerbated by stressors.
She also emphasized the wide-ranging effects of these syndromes. “We focus on pain, but it’s clearly not a just a pain disorder,” noting that patients can report fatigue, poor sleep, greater sensitivity to light and sound, and memory difficulties that produce “fibromyalgia fog.”
Research suggests that patients with central pain syndromes experience changes in both brain structure and function, she said. As for pelvic pain specifically, studies have linked it to increased pain sensitivity and altered central nervous system structure and function regardless of whether endometriosis is present.
How should patients with pelvic pain be treated in light of this information? Dr. As-Sanie suggests first trying “gold standard” approaches to treat contributing factors whether they’re gynecologic, urologic, gastrointestinal, musculoskeletal or nerve related.
If those strategies don’t work, she said, “consider treating centralized pain” with a blend of approaches: behavioral (such as diet and cognitive-behavior therapy), medical (such as hormone modulation), and interventional (such as physical therapy and surgery).
Also consider pharmacologic therapies, said Dr. As-Sanie, who identified dual reuptake inhibitors (venlafaxine [Effexor] and duloxetine [Cymbalta] are a class of antidepressants that block the reuptake of both serotonin and norepinephrine) and anticonvulsants as drugs with strong evidence as treatments for central pain syndromes.
“Start at low doses and titrate up,” she advised, and “if at any point a given medication doesn’t work, we should try another.”
The Pelvic Anatomy and Gynecologic Surgery Symposium was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
Dr. As-Sanie discloses she is a consultant for AbbVie and Myovant.
LAS VEGAS – An estimated 15%-25% of women aged 18-50 years suffer from chronic pelvic pain, a condition that commonly leads to sick days, reduced activity, and higher medication use. Treatments like surgery and opioids may seem feasible, but an obstetrician-gynecologist who studies pain urged colleagues to think twice.
In some cases, pelvic pain patients may suffer from centralized pain syndromes, conditions linked to the central nervous system that may not respond well to those common treatments, said Sawsan As-Sanie, MD, MPH, director of the University of Michigan Endometriosis Center, Ann Arbor.
“If we have laser vision on the pelvis, we may help some patients, but many of us will do harm,” said Dr. As-Sanie, who spoke at the Pelvic Anatomy and Gynecologic Surgery Symposium.
Endometriosis is frequently linked to pelvic pain. But, she said, the link between the two is fuzzier than has been assumed.
“It would make sense that endometriosis or pelvic adhesions would activate nociceptive pain, and [there are] a lot of data to support that this is, in part, how endometriosis causes pain,” she said. “But I would argue it really isn’t that simple because the relationship between endometriosis and pelvic pain is very complex and not explained entirely by the lesion.” For example, “we know that pain recurs after medical and surgical therapy, often without evidence of recurrent endometriosis.” And, there’s little relationship between pain symptoms and the location or extent of endometriosis.
What’s going on? Dr. As-Sanie suggested central pain syndromes can play a significant role in pelvic pain. These syndromes are 1.5-2 times more common in women than men, and are triggered or exacerbated by stressors.
She also emphasized the wide-ranging effects of these syndromes. “We focus on pain, but it’s clearly not a just a pain disorder,” noting that patients can report fatigue, poor sleep, greater sensitivity to light and sound, and memory difficulties that produce “fibromyalgia fog.”
Research suggests that patients with central pain syndromes experience changes in both brain structure and function, she said. As for pelvic pain specifically, studies have linked it to increased pain sensitivity and altered central nervous system structure and function regardless of whether endometriosis is present.
How should patients with pelvic pain be treated in light of this information? Dr. As-Sanie suggests first trying “gold standard” approaches to treat contributing factors whether they’re gynecologic, urologic, gastrointestinal, musculoskeletal or nerve related.
If those strategies don’t work, she said, “consider treating centralized pain” with a blend of approaches: behavioral (such as diet and cognitive-behavior therapy), medical (such as hormone modulation), and interventional (such as physical therapy and surgery).
Also consider pharmacologic therapies, said Dr. As-Sanie, who identified dual reuptake inhibitors (venlafaxine [Effexor] and duloxetine [Cymbalta] are a class of antidepressants that block the reuptake of both serotonin and norepinephrine) and anticonvulsants as drugs with strong evidence as treatments for central pain syndromes.
“Start at low doses and titrate up,” she advised, and “if at any point a given medication doesn’t work, we should try another.”
The Pelvic Anatomy and Gynecologic Surgery Symposium was jointly provided by Global Academy for Medical Education and the University of Cincinnati. Global Academy and this news organization are owned by the same company.
Dr. As-Sanie discloses she is a consultant for AbbVie and Myovant.
EXPERT ANALYSIS FROM PAGS
Poor-prognosis cancers linked to highest suicide risk in first year
Suicide risk significantly increases within the first year of a cancer diagnosis, with risk varying by type of cancer, according to investigators who conducted a retrospective analysis representing nearly 4.7 million patients.
Risk of suicide in that first year after diagnosis was especially high in pancreatic and lung cancers, while by contrast, breast and prostate cancer did not increase suicide risk, reported the researchers, led by Hesham Hamoda, MD, MPH, of Boston Children’s Hospital/Harvard Medical School, and Ahmad Alfaar, MBBCh, MSc, of Charité–Universitätsmedizin Berlin.
That variation in suicide risk by cancer type suggests that prognosis and 5-year relative survival play a role in increasing suicide rates, according to Dr. Hamoda, Dr. Alfaar, and their coauthors.
“After the diagnosis, it is important that health care providers be vigilant in screening for suicide and ensuring that patients have access to social and emotional support,” they wrote in a report published in Cancer. Their analysis was based on 4,671,989 patients with a diagnosis of cancer in the Surveillance, Epidemiology, and End Results (SEER) database between 2000 and 2014. Out of 1,005,825 of those patients who died within the first year of diagnosis, the cause of death was suicide for 1,585, or 0.16%.
Overall, the risk of suicide increased significantly among cancer patients versus the general population, with an observed-to-expected (O/E) ratio of 2.51 per 10,000 person-years, the investigators found. The risk was highest in the first 6 months, with an O/E mortality of 3.13 versus 1.8 in the latter 6 months.
The highest ratios were seen for pancreatic cancer, with an O/E ratio of 8.01, and lung cancer, with a ratio of 6.05, the researchers found in further analysis.
Significant increases in suicide risk were also seen for colorectal cancer (2.08) and melanoma (1.45), though rates were not significantly different versus the general population for breast (1.23) and prostate (0.99), according to the reported data.
Suicide risk was relatively high for any cancer with distant metastases (5.63), though still significantly higher at 1.65 in persons with localized/regional disease, the data show.
The increased suicide risk persisted more than 1 year after the cancer diagnosis, though not to the degree observed within that first year, they added.
Most patients with suicide as a cause of death were white (90.2%) and male (87%). Nearly 60% were between the ages of 65 and 84 at the time of suicide.
Social support plays an integral role in suicide prevention among cancer patients, the researchers noted.
Previous studies suggest that support programs may decrease suicide risk by making patients better aware of their prognosis, receptive to decreased social stigma, or less likely to have stress related to cost of care, they said.
“Discussing the quality of life after diagnosis, the effectiveness of therapy, and the prognosis of the disease and maintaining a trusting relationship with health care professionals all decrease the likelihood of suicide immediately after a diagnosis of cancer,” they said.
Dr. Hamoda, Dr. Alfaar, and their coauthors reported no conflicts of interest. Funding for the study came in part from the German Academic Exchange Service (Dr. Alfaar).
SOURCE: Saad AM, et al. Cancer 2019 Jan 7. doi: 10.1002/cncr.31876.
Suicide risk significantly increases within the first year of a cancer diagnosis, with risk varying by type of cancer, according to investigators who conducted a retrospective analysis representing nearly 4.7 million patients.
Risk of suicide in that first year after diagnosis was especially high in pancreatic and lung cancers, while by contrast, breast and prostate cancer did not increase suicide risk, reported the researchers, led by Hesham Hamoda, MD, MPH, of Boston Children’s Hospital/Harvard Medical School, and Ahmad Alfaar, MBBCh, MSc, of Charité–Universitätsmedizin Berlin.
That variation in suicide risk by cancer type suggests that prognosis and 5-year relative survival play a role in increasing suicide rates, according to Dr. Hamoda, Dr. Alfaar, and their coauthors.
“After the diagnosis, it is important that health care providers be vigilant in screening for suicide and ensuring that patients have access to social and emotional support,” they wrote in a report published in Cancer. Their analysis was based on 4,671,989 patients with a diagnosis of cancer in the Surveillance, Epidemiology, and End Results (SEER) database between 2000 and 2014. Out of 1,005,825 of those patients who died within the first year of diagnosis, the cause of death was suicide for 1,585, or 0.16%.
Overall, the risk of suicide increased significantly among cancer patients versus the general population, with an observed-to-expected (O/E) ratio of 2.51 per 10,000 person-years, the investigators found. The risk was highest in the first 6 months, with an O/E mortality of 3.13 versus 1.8 in the latter 6 months.
The highest ratios were seen for pancreatic cancer, with an O/E ratio of 8.01, and lung cancer, with a ratio of 6.05, the researchers found in further analysis.
Significant increases in suicide risk were also seen for colorectal cancer (2.08) and melanoma (1.45), though rates were not significantly different versus the general population for breast (1.23) and prostate (0.99), according to the reported data.
Suicide risk was relatively high for any cancer with distant metastases (5.63), though still significantly higher at 1.65 in persons with localized/regional disease, the data show.
The increased suicide risk persisted more than 1 year after the cancer diagnosis, though not to the degree observed within that first year, they added.
Most patients with suicide as a cause of death were white (90.2%) and male (87%). Nearly 60% were between the ages of 65 and 84 at the time of suicide.
Social support plays an integral role in suicide prevention among cancer patients, the researchers noted.
Previous studies suggest that support programs may decrease suicide risk by making patients better aware of their prognosis, receptive to decreased social stigma, or less likely to have stress related to cost of care, they said.
“Discussing the quality of life after diagnosis, the effectiveness of therapy, and the prognosis of the disease and maintaining a trusting relationship with health care professionals all decrease the likelihood of suicide immediately after a diagnosis of cancer,” they said.
Dr. Hamoda, Dr. Alfaar, and their coauthors reported no conflicts of interest. Funding for the study came in part from the German Academic Exchange Service (Dr. Alfaar).
SOURCE: Saad AM, et al. Cancer 2019 Jan 7. doi: 10.1002/cncr.31876.
Suicide risk significantly increases within the first year of a cancer diagnosis, with risk varying by type of cancer, according to investigators who conducted a retrospective analysis representing nearly 4.7 million patients.
Risk of suicide in that first year after diagnosis was especially high in pancreatic and lung cancers, while by contrast, breast and prostate cancer did not increase suicide risk, reported the researchers, led by Hesham Hamoda, MD, MPH, of Boston Children’s Hospital/Harvard Medical School, and Ahmad Alfaar, MBBCh, MSc, of Charité–Universitätsmedizin Berlin.
That variation in suicide risk by cancer type suggests that prognosis and 5-year relative survival play a role in increasing suicide rates, according to Dr. Hamoda, Dr. Alfaar, and their coauthors.
“After the diagnosis, it is important that health care providers be vigilant in screening for suicide and ensuring that patients have access to social and emotional support,” they wrote in a report published in Cancer. Their analysis was based on 4,671,989 patients with a diagnosis of cancer in the Surveillance, Epidemiology, and End Results (SEER) database between 2000 and 2014. Out of 1,005,825 of those patients who died within the first year of diagnosis, the cause of death was suicide for 1,585, or 0.16%.
Overall, the risk of suicide increased significantly among cancer patients versus the general population, with an observed-to-expected (O/E) ratio of 2.51 per 10,000 person-years, the investigators found. The risk was highest in the first 6 months, with an O/E mortality of 3.13 versus 1.8 in the latter 6 months.
The highest ratios were seen for pancreatic cancer, with an O/E ratio of 8.01, and lung cancer, with a ratio of 6.05, the researchers found in further analysis.
Significant increases in suicide risk were also seen for colorectal cancer (2.08) and melanoma (1.45), though rates were not significantly different versus the general population for breast (1.23) and prostate (0.99), according to the reported data.
Suicide risk was relatively high for any cancer with distant metastases (5.63), though still significantly higher at 1.65 in persons with localized/regional disease, the data show.
The increased suicide risk persisted more than 1 year after the cancer diagnosis, though not to the degree observed within that first year, they added.
Most patients with suicide as a cause of death were white (90.2%) and male (87%). Nearly 60% were between the ages of 65 and 84 at the time of suicide.
Social support plays an integral role in suicide prevention among cancer patients, the researchers noted.
Previous studies suggest that support programs may decrease suicide risk by making patients better aware of their prognosis, receptive to decreased social stigma, or less likely to have stress related to cost of care, they said.
“Discussing the quality of life after diagnosis, the effectiveness of therapy, and the prognosis of the disease and maintaining a trusting relationship with health care professionals all decrease the likelihood of suicide immediately after a diagnosis of cancer,” they said.
Dr. Hamoda, Dr. Alfaar, and their coauthors reported no conflicts of interest. Funding for the study came in part from the German Academic Exchange Service (Dr. Alfaar).
SOURCE: Saad AM, et al. Cancer 2019 Jan 7. doi: 10.1002/cncr.31876.
FROM CANCER
Key clinical point: A cancer diagnosis significantly increases risk of suicide in comparison to the general population, particularly for poorer-prognosis cancers.
Major finding: The observed-to-expected mortality ratio was substantially higher for pancreatic cancer (8.01), and lung cancer (6.05), but not significantly increased for breast (1.23) and prostate (0.99).
Study details: A retrospective population-based study of 4,671,989 cancer patients.
Disclosures: The authors reported no conflicts of interest. Funding for the study came in part from the German Academic Exchange Service.
Source: Saad AM et al. Cancer. 2019 Jan 7. doi: 10.1002/cncr.31876.
Cerebral small vessel and cognitive impairment
Also today, antidepressants are tied to greater hip fracture incidence, a hospital readmission reduction program may be doing more harm than good, and the flu season rages on with 19 states showing high activity in the final week of 2018.
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Also today, antidepressants are tied to greater hip fracture incidence, a hospital readmission reduction program may be doing more harm than good, and the flu season rages on with 19 states showing high activity in the final week of 2018.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
Also today, antidepressants are tied to greater hip fracture incidence, a hospital readmission reduction program may be doing more harm than good, and the flu season rages on with 19 states showing high activity in the final week of 2018.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
Click for Credit: STIs on the rise; psoriasis & cardiac risk; more
Here are 5 articles from the January issue of Clinician Reviews (individual articles are valid for one year from date of publication—expiration dates below):
1. Can ultrasound screening improve survival in ovarian cancer?
To take the posttest, go to: https://bit.ly/2Vtuc8F
Expires October 17, 2019
2. Higher BMI associated with greater loss of gray matter volume in MS
To take the posttest, go to: https://bit.ly/2ArvFDp
Expires October 29, 2019
3. Psoriasis adds to increased risk of cardiovascular procedures, surgery in patients with hypertension
To take the posttest, go to: https://bit.ly/2sbnkiS
Expires October 31, 2019
4. Fever, intestinal symptoms may delay diagnosis of Kawasaki disease in children
To take the posttest, go to: https://bit.ly/2RdPoBi
Expires October 31, 2019
5. Rate of STIs is rising, and many U.S. teens are sexually active
To take the posttest, go to: https://bit.ly/2CPuYFW
Expires November 8, 2019
Here are 5 articles from the January issue of Clinician Reviews (individual articles are valid for one year from date of publication—expiration dates below):
1. Can ultrasound screening improve survival in ovarian cancer?
To take the posttest, go to: https://bit.ly/2Vtuc8F
Expires October 17, 2019
2. Higher BMI associated with greater loss of gray matter volume in MS
To take the posttest, go to: https://bit.ly/2ArvFDp
Expires October 29, 2019
3. Psoriasis adds to increased risk of cardiovascular procedures, surgery in patients with hypertension
To take the posttest, go to: https://bit.ly/2sbnkiS
Expires October 31, 2019
4. Fever, intestinal symptoms may delay diagnosis of Kawasaki disease in children
To take the posttest, go to: https://bit.ly/2RdPoBi
Expires October 31, 2019
5. Rate of STIs is rising, and many U.S. teens are sexually active
To take the posttest, go to: https://bit.ly/2CPuYFW
Expires November 8, 2019
Here are 5 articles from the January issue of Clinician Reviews (individual articles are valid for one year from date of publication—expiration dates below):
1. Can ultrasound screening improve survival in ovarian cancer?
To take the posttest, go to: https://bit.ly/2Vtuc8F
Expires October 17, 2019
2. Higher BMI associated with greater loss of gray matter volume in MS
To take the posttest, go to: https://bit.ly/2ArvFDp
Expires October 29, 2019
3. Psoriasis adds to increased risk of cardiovascular procedures, surgery in patients with hypertension
To take the posttest, go to: https://bit.ly/2sbnkiS
Expires October 31, 2019
4. Fever, intestinal symptoms may delay diagnosis of Kawasaki disease in children
To take the posttest, go to: https://bit.ly/2RdPoBi
Expires October 31, 2019
5. Rate of STIs is rising, and many U.S. teens are sexually active
To take the posttest, go to: https://bit.ly/2CPuYFW
Expires November 8, 2019
Endometriosis surgery: Women can expect years-long benefits
LAS VEGAS – according to a survey study from the University of Pittsburgh.
The work was likely the first to assess long-term outcomes after laparoscopic endometriosis excision with a disease-specific questionnaire, the Endometriosis Health Profile-30 (EHP-30). The findings should reassure both surgeons and patients. “I really feel these results can help us as endometriosis providers” to counsel women, said lead investigator Nicole M. Donnellan, MD, a gynecologic surgeon at the University of Pittsburgh.
Surgery “offers lasting improvement in all quality of life domains ... measured by the EHP-30”: pain; control/powerlessness; emotional well-being; social support; and self-image, with supplemental questions about work, sexual function, and other matters. Because “definitive surgery was not associated with improved outcomes when compared with fertility-sparing surgery ... fertility preservation should continue to be offered as first-line surgery for treatment of symptomatic disease,” Dr. Donnellan and her team concluded at a meeting sponsored by AAGL.
Surgery is the gold standard for endometriosis, but there just hasn’t been much data on long-term outcomes until now, especially with a potent questionnaire like the EHP-30. The gap left surgeons in the lurch on what to tell women how they’ll do, especially because results from previous, shorter, and less-rigorous studies have been mixed. The Pittsburgh results mean that competent surgeons can breathe easier and be confident in telling women what to expect.
The team administered EHP-30 to 61 women before surgery and at 4 weeks postoperatively; 45 patients (74%) had fertility-sparing excisions, 7 (11%) had hysterectomy with adnexa preservation, and 9 (15%) had hysterectomy with bilateral salpingo-oophorectomy. The women were contacted again in 2017 to fill out the survey anywhere from 3 to 7 years after their operation; 45 women agreed, a response rate of 74%.
There was a definitive, statistically significant reduction in scores across all five domains of the survey, both at 4 weeks and out to 7 years, and the improvements did not vary by endometriosis stage or the type of surgery women had.
The overall score – a combination of the five domains – fell from a preoperative median of 50 points out of a possible 100, with 100 being the worst possible score, to a median of about 20 points 4 weeks after surgery, and a median of about 10 points at long-term follow-up. Pain scores fell about the same amount; the greatest improvements were on questions that focused on sense of control and empowerment.
At long-term follow-up, overall scores improved a median of 43 points in women with American Society for Reproductive Medicine stage 1 endometriosis and 28 points among women with stage 4 disease (P = .705). Although the differences were not statistically significant, women with stage 1 disease generally reported the greatest improvements, except on the control and empowerment scale, where women reported the same improvement across all four stages, about 50 points out of 100.
Long-term score improvements were pretty much identical among women who had fertility-sparing surgery and those who had hysterectomies, with, for instance, both groups reporting about a 33-point improvement in pain scores. The two groups separated out only on emotional well-being scores, a 38-point improvement in the hysterectomy group versus 21 points, but the difference was not statistically significant (P = .525).
The long-term results remained the same when eight women who had subsequent gynecologic surgery were excluded.
In the end, the take home is that “all of these women improved,” Dr. Donnellan said.
The investigators didn’t report any disclosures.
SOURCE: Donnellan NM et al. 2018 AAGL Global Congress, Abstract 82.
LAS VEGAS – according to a survey study from the University of Pittsburgh.
The work was likely the first to assess long-term outcomes after laparoscopic endometriosis excision with a disease-specific questionnaire, the Endometriosis Health Profile-30 (EHP-30). The findings should reassure both surgeons and patients. “I really feel these results can help us as endometriosis providers” to counsel women, said lead investigator Nicole M. Donnellan, MD, a gynecologic surgeon at the University of Pittsburgh.
Surgery “offers lasting improvement in all quality of life domains ... measured by the EHP-30”: pain; control/powerlessness; emotional well-being; social support; and self-image, with supplemental questions about work, sexual function, and other matters. Because “definitive surgery was not associated with improved outcomes when compared with fertility-sparing surgery ... fertility preservation should continue to be offered as first-line surgery for treatment of symptomatic disease,” Dr. Donnellan and her team concluded at a meeting sponsored by AAGL.
Surgery is the gold standard for endometriosis, but there just hasn’t been much data on long-term outcomes until now, especially with a potent questionnaire like the EHP-30. The gap left surgeons in the lurch on what to tell women how they’ll do, especially because results from previous, shorter, and less-rigorous studies have been mixed. The Pittsburgh results mean that competent surgeons can breathe easier and be confident in telling women what to expect.
The team administered EHP-30 to 61 women before surgery and at 4 weeks postoperatively; 45 patients (74%) had fertility-sparing excisions, 7 (11%) had hysterectomy with adnexa preservation, and 9 (15%) had hysterectomy with bilateral salpingo-oophorectomy. The women were contacted again in 2017 to fill out the survey anywhere from 3 to 7 years after their operation; 45 women agreed, a response rate of 74%.
There was a definitive, statistically significant reduction in scores across all five domains of the survey, both at 4 weeks and out to 7 years, and the improvements did not vary by endometriosis stage or the type of surgery women had.
The overall score – a combination of the five domains – fell from a preoperative median of 50 points out of a possible 100, with 100 being the worst possible score, to a median of about 20 points 4 weeks after surgery, and a median of about 10 points at long-term follow-up. Pain scores fell about the same amount; the greatest improvements were on questions that focused on sense of control and empowerment.
At long-term follow-up, overall scores improved a median of 43 points in women with American Society for Reproductive Medicine stage 1 endometriosis and 28 points among women with stage 4 disease (P = .705). Although the differences were not statistically significant, women with stage 1 disease generally reported the greatest improvements, except on the control and empowerment scale, where women reported the same improvement across all four stages, about 50 points out of 100.
Long-term score improvements were pretty much identical among women who had fertility-sparing surgery and those who had hysterectomies, with, for instance, both groups reporting about a 33-point improvement in pain scores. The two groups separated out only on emotional well-being scores, a 38-point improvement in the hysterectomy group versus 21 points, but the difference was not statistically significant (P = .525).
The long-term results remained the same when eight women who had subsequent gynecologic surgery were excluded.
In the end, the take home is that “all of these women improved,” Dr. Donnellan said.
The investigators didn’t report any disclosures.
SOURCE: Donnellan NM et al. 2018 AAGL Global Congress, Abstract 82.
LAS VEGAS – according to a survey study from the University of Pittsburgh.
The work was likely the first to assess long-term outcomes after laparoscopic endometriosis excision with a disease-specific questionnaire, the Endometriosis Health Profile-30 (EHP-30). The findings should reassure both surgeons and patients. “I really feel these results can help us as endometriosis providers” to counsel women, said lead investigator Nicole M. Donnellan, MD, a gynecologic surgeon at the University of Pittsburgh.
Surgery “offers lasting improvement in all quality of life domains ... measured by the EHP-30”: pain; control/powerlessness; emotional well-being; social support; and self-image, with supplemental questions about work, sexual function, and other matters. Because “definitive surgery was not associated with improved outcomes when compared with fertility-sparing surgery ... fertility preservation should continue to be offered as first-line surgery for treatment of symptomatic disease,” Dr. Donnellan and her team concluded at a meeting sponsored by AAGL.
Surgery is the gold standard for endometriosis, but there just hasn’t been much data on long-term outcomes until now, especially with a potent questionnaire like the EHP-30. The gap left surgeons in the lurch on what to tell women how they’ll do, especially because results from previous, shorter, and less-rigorous studies have been mixed. The Pittsburgh results mean that competent surgeons can breathe easier and be confident in telling women what to expect.
The team administered EHP-30 to 61 women before surgery and at 4 weeks postoperatively; 45 patients (74%) had fertility-sparing excisions, 7 (11%) had hysterectomy with adnexa preservation, and 9 (15%) had hysterectomy with bilateral salpingo-oophorectomy. The women were contacted again in 2017 to fill out the survey anywhere from 3 to 7 years after their operation; 45 women agreed, a response rate of 74%.
There was a definitive, statistically significant reduction in scores across all five domains of the survey, both at 4 weeks and out to 7 years, and the improvements did not vary by endometriosis stage or the type of surgery women had.
The overall score – a combination of the five domains – fell from a preoperative median of 50 points out of a possible 100, with 100 being the worst possible score, to a median of about 20 points 4 weeks after surgery, and a median of about 10 points at long-term follow-up. Pain scores fell about the same amount; the greatest improvements were on questions that focused on sense of control and empowerment.
At long-term follow-up, overall scores improved a median of 43 points in women with American Society for Reproductive Medicine stage 1 endometriosis and 28 points among women with stage 4 disease (P = .705). Although the differences were not statistically significant, women with stage 1 disease generally reported the greatest improvements, except on the control and empowerment scale, where women reported the same improvement across all four stages, about 50 points out of 100.
Long-term score improvements were pretty much identical among women who had fertility-sparing surgery and those who had hysterectomies, with, for instance, both groups reporting about a 33-point improvement in pain scores. The two groups separated out only on emotional well-being scores, a 38-point improvement in the hysterectomy group versus 21 points, but the difference was not statistically significant (P = .525).
The long-term results remained the same when eight women who had subsequent gynecologic surgery were excluded.
In the end, the take home is that “all of these women improved,” Dr. Donnellan said.
The investigators didn’t report any disclosures.
SOURCE: Donnellan NM et al. 2018 AAGL Global Congress, Abstract 82.
REPORTING FROM THE AAGL GLOBAL CONGRESS
Key clinical point: Endometriosis excision improves quality of life for at least 7 years, even when women have conservative, fertility-sparing surgery.
Major finding: The overall score on the Endometriosis Health Profile-30 fell from a preoperative median of 50 points out of a possible 100, with 100 being the worst possible score, to a median of about 20 points 4 weeks after surgery, and a median of about 10 points at the 7-year follow-up.
Study details: A review of 61 cases
Disclosures: The investigators didn’t report any disclosures.
Source: Donnellan NM et al. 2018 AAGL Global Congress, Abstract 82.
