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What role does the uterine microbiome play in fertility?
Until the second half of the 20th century, it was believed that the uterine cavity was sterile. Since then, technological advances have provided insight into the nature of the microbiome throughout the female reproductive tract. The role of these microorganisms on the fertility of women of reproductive age has been the subject of research. Is there an “optimal microbiome” for fertility? Can changing the microbiome of the uterine cavity affect fertility? There is still no definitive scientific response to these questions.
Several studies describe the healthy state of the uterine microbiota in women of reproductive age, with most of these studies reporting dominance of Lactobacillus species. However, by contrast, some studies did not observe Lactobacillus predominance inside the uterine cavity in cases of healthy uterine microbiomes. The presence of other microorganisms, such as Gardnerella vaginalis, was associated with reduced success in patients attempting in vitro fertilization (IVF) treatment, such as, for example, embryo implantation failure and miscarriage.
It is also possible that a physiologic endometrial microbiome could be considered healthy despite a minor presence of pathogenic bacteria. Importantly, responses from the host also modulate many aspects of human conception. These shifts correlate with parameters such as age, hormonal changes, ethnicity, sexual activity, and intrauterine devices.
Carlos Simón, MD, PhD, is a gynecologist and obstetrician and professor at the University of Valencia in Valencia, Spain; Harvard University, Cambridge, Mass.; and Baylor College of Medicine, Houston. He was in São Paulo at the time of the XXVI Brazilian Congress of Assisted Reproduction and agreed to be interviewed by Medscape Portuguese Edition. Dr. Simón, who is Spanish and is an international reference in uterine microbiome studies, created an endometrial receptivity analysis (ERA).
“What we know is that the human uterus has its own microbiome. Thanks to next-generation sequencing (NGS), we can detect microbial DNA. We’re talking about a microbiome that, if changed, affects [embryo] implantation. We have identified that Lactobacilli are the good [microorganisms], but if there are Streptococci, Gardnerella, or other bacteria, the implantation [of the embryo] is affected.”
In 2018, Dr. Simón’s team published a pilot study assessing the microbiome of 30 patients during fertilization treatment. It was observed that, when there is a change in the microbiome, the implantation rate drops to half and the miscarriage rate doubles.
Following this study, also in 2018, the team published a multicenter, prospective, observational study. A 16S ribosomal RNA (16S rRNA) gene sequencing technique was used to analyze endometrial fluid and biopsy samples before embryo transfer in a cohort of 342 infertile patients asymptomatic for infection. Participants underwent fertilization procedures in 13 centers on three continents.
A dysbiotic endometrial microbiota profile composed of Atopobium, Bifidobacterium, Chryseobacterium, Gardnerella, Haemophilus, Klebsiella, Neisseria, Staphylococcus, and Streptococcus was associated with unsuccessful outcomes. In contrast, Lactobacillus was consistently enriched in patients with live birth outcomes. The authors concluded that endometrial microbiota composition before embryo transfer is a useful biomarker to predict reproductive outcome.
“You see a microbial signature in patients who become pregnant, another in those who do not become pregnant, and yet another in those who miscarry,” Dr. Simón summarized. “By knowing this signature, the microbiome can be analyzed and treated so that it is stabilized before the embryo is transferred.”
What should be done?
Endometrial microbiome profiles do not use microbial cultures. They are obtained by NGS of the endometrial sample. This is because the 16S rRNA gene, which can be found in bacteria, presents hypervariable regions that serve as markers to identify the bacteria present.
If a microbiome is found to be somewhat unhealthy, it is theoretically possible to change its composition, increasing the chances of successful assisted reproduction. The administration of antibiotics and vaginal probiotics are two treatment approaches.
According to Dr. Simón, treatment is specific to the bacterium (metronidazole, and, if that fails, rifampicin for Gardnerella, amoxicillin and clavulanic acid for Streptococci). Once the pathogenic bacterium has been treated, the probiotics can be administered. “If all is well, we can then go ahead with the procedure,” he explained.
Dr. Simón pointed out that, with respect to treatment, knowledge is still limited and primarily based on case reports. “You look for issues in the microbiome when the patient experiences reproductive failure and there are no other causes,” he emphasized. “Microbiology plays a role in reproduction, affecting the human uterus. It’s good to know about it to improve reproductive outcomes. When there are repeated [embryo] implantation failures, we suggest an endometrial biopsy to identify the implantation window and determine whether the uterine microbiome is healthy or not. And if there are any abnormalities in the microbiome, they can be treated.”
There are still many open questions, such as how long the “good microbiome” lasts after antibiotic therapy. “We suggest checking the microbiome after [antibiotic] treatment and before implanting the embryo,” said Dr. Simón.
Although there is no consensus on how the endometrial microbiota relate to reproductive outcomes, the analysis and change in microbiome are already being offered in clinical practice as a way to increase the chances of conception. Márcia Riboldi, PhD, a genetics specialist serving as Country Manager for Igenomix Brasil and Argentina, the company that offers the analyses, provides an idea of the market for such analyses in Brazil. “We perform approximately 500 analyses per month,” she said, adding that most patients have a history of [embryo] implantation failure or miscarriage.
Matheus Roque, MD, PhD, an IVF specialist, shared two IVF case reports from the Mater Prime Human Reproduction Clinic in the southern region of the city of São Paulo. He emphasized that the decision to perform a microbiome analysis was made only after repeated implantation failure.
“With the outcomes the doctors started to see, the paradigm started to shift,” said Dr. Riboldi. “Why wait for the patient to have [an embryo] transfer failure? Let’s study the endometrium, check the ideal moment for the transfer, see whether it’s receptive or not, if there’s any disease and if there are Lactobacilli,” she proposed. “We need medical training and awareness, and we need to use them appropriately. We have the tests. Doctors need to learn about them and know when and how to use them.” The microbiome analysis costs approximately BRL 2,000, plus expenses for the medical procedure.
Is it too early?
Caio Parente Barbosa, MD, PhD, is an obstetrician/gynecologist specializing in human reproduction, as well as the director general and founder of the Fertile Idea Institute for Reproductive Health. He shared a few of his experiences in an interview with this news organization. “I would say it is still too early to confirm that [the microbiome analysis] produces effective outcomes.”
Dr. Barbosa, who is also provost of graduate studies, research, and innovation of the ABC School of Medicine, Santo André, Brazil, emphasized there is still little global experience with these analyses. “There are doubts worldwide regarding whether these analyses produce effective outcomes. Scientific studies are entirely controversial.”
He stated that some professionals recommend the microbiome analysis for “patients who don’t know what else to do,” but also recognized that there is already a demand for patients who don’t fit this category, who research the analyses on social networks and YouTube. “But it is the smallest of demands. Patients are not as worried about this yet.”
Dr. Barbosa recognized that the idea of an increasingly tailored treatment plan is inevitable. He believes that the study and treatment of the microbiome will become more critical in the future, but he thinks it still “does not offer any value.”
Dr. Barbosa emphasized that the financial side of things must also be considered. “If we add all these tests when investigating a patient’s issues, the treatment becomes ridiculously expensive.” He pointed out that health care professionals need to be careful to perform minimal testing. “We have already added some tests, such as the karyotype test, to the minimal testing for all patients.”
Dr. Simón responded to this criticism, stating: “The cost of repeating cycles is always greater than that of being thorough and knowing what’s going on. Nothing is certain, but if my daughter or wife needed it, I would like to have as much information as possible to make this decision.”
Dr. Barbosa and Dr. Simón reported no relevant financial relationships. Dr. Riboldi is Country Manager for Igenomix Brasil and Argentina, the company that offers the analyses.
This article was translated from the Medscape Portuguese edition and appeared on Medscape.com.
Until the second half of the 20th century, it was believed that the uterine cavity was sterile. Since then, technological advances have provided insight into the nature of the microbiome throughout the female reproductive tract. The role of these microorganisms on the fertility of women of reproductive age has been the subject of research. Is there an “optimal microbiome” for fertility? Can changing the microbiome of the uterine cavity affect fertility? There is still no definitive scientific response to these questions.
Several studies describe the healthy state of the uterine microbiota in women of reproductive age, with most of these studies reporting dominance of Lactobacillus species. However, by contrast, some studies did not observe Lactobacillus predominance inside the uterine cavity in cases of healthy uterine microbiomes. The presence of other microorganisms, such as Gardnerella vaginalis, was associated with reduced success in patients attempting in vitro fertilization (IVF) treatment, such as, for example, embryo implantation failure and miscarriage.
It is also possible that a physiologic endometrial microbiome could be considered healthy despite a minor presence of pathogenic bacteria. Importantly, responses from the host also modulate many aspects of human conception. These shifts correlate with parameters such as age, hormonal changes, ethnicity, sexual activity, and intrauterine devices.
Carlos Simón, MD, PhD, is a gynecologist and obstetrician and professor at the University of Valencia in Valencia, Spain; Harvard University, Cambridge, Mass.; and Baylor College of Medicine, Houston. He was in São Paulo at the time of the XXVI Brazilian Congress of Assisted Reproduction and agreed to be interviewed by Medscape Portuguese Edition. Dr. Simón, who is Spanish and is an international reference in uterine microbiome studies, created an endometrial receptivity analysis (ERA).
“What we know is that the human uterus has its own microbiome. Thanks to next-generation sequencing (NGS), we can detect microbial DNA. We’re talking about a microbiome that, if changed, affects [embryo] implantation. We have identified that Lactobacilli are the good [microorganisms], but if there are Streptococci, Gardnerella, or other bacteria, the implantation [of the embryo] is affected.”
In 2018, Dr. Simón’s team published a pilot study assessing the microbiome of 30 patients during fertilization treatment. It was observed that, when there is a change in the microbiome, the implantation rate drops to half and the miscarriage rate doubles.
Following this study, also in 2018, the team published a multicenter, prospective, observational study. A 16S ribosomal RNA (16S rRNA) gene sequencing technique was used to analyze endometrial fluid and biopsy samples before embryo transfer in a cohort of 342 infertile patients asymptomatic for infection. Participants underwent fertilization procedures in 13 centers on three continents.
A dysbiotic endometrial microbiota profile composed of Atopobium, Bifidobacterium, Chryseobacterium, Gardnerella, Haemophilus, Klebsiella, Neisseria, Staphylococcus, and Streptococcus was associated with unsuccessful outcomes. In contrast, Lactobacillus was consistently enriched in patients with live birth outcomes. The authors concluded that endometrial microbiota composition before embryo transfer is a useful biomarker to predict reproductive outcome.
“You see a microbial signature in patients who become pregnant, another in those who do not become pregnant, and yet another in those who miscarry,” Dr. Simón summarized. “By knowing this signature, the microbiome can be analyzed and treated so that it is stabilized before the embryo is transferred.”
What should be done?
Endometrial microbiome profiles do not use microbial cultures. They are obtained by NGS of the endometrial sample. This is because the 16S rRNA gene, which can be found in bacteria, presents hypervariable regions that serve as markers to identify the bacteria present.
If a microbiome is found to be somewhat unhealthy, it is theoretically possible to change its composition, increasing the chances of successful assisted reproduction. The administration of antibiotics and vaginal probiotics are two treatment approaches.
According to Dr. Simón, treatment is specific to the bacterium (metronidazole, and, if that fails, rifampicin for Gardnerella, amoxicillin and clavulanic acid for Streptococci). Once the pathogenic bacterium has been treated, the probiotics can be administered. “If all is well, we can then go ahead with the procedure,” he explained.
Dr. Simón pointed out that, with respect to treatment, knowledge is still limited and primarily based on case reports. “You look for issues in the microbiome when the patient experiences reproductive failure and there are no other causes,” he emphasized. “Microbiology plays a role in reproduction, affecting the human uterus. It’s good to know about it to improve reproductive outcomes. When there are repeated [embryo] implantation failures, we suggest an endometrial biopsy to identify the implantation window and determine whether the uterine microbiome is healthy or not. And if there are any abnormalities in the microbiome, they can be treated.”
There are still many open questions, such as how long the “good microbiome” lasts after antibiotic therapy. “We suggest checking the microbiome after [antibiotic] treatment and before implanting the embryo,” said Dr. Simón.
Although there is no consensus on how the endometrial microbiota relate to reproductive outcomes, the analysis and change in microbiome are already being offered in clinical practice as a way to increase the chances of conception. Márcia Riboldi, PhD, a genetics specialist serving as Country Manager for Igenomix Brasil and Argentina, the company that offers the analyses, provides an idea of the market for such analyses in Brazil. “We perform approximately 500 analyses per month,” she said, adding that most patients have a history of [embryo] implantation failure or miscarriage.
Matheus Roque, MD, PhD, an IVF specialist, shared two IVF case reports from the Mater Prime Human Reproduction Clinic in the southern region of the city of São Paulo. He emphasized that the decision to perform a microbiome analysis was made only after repeated implantation failure.
“With the outcomes the doctors started to see, the paradigm started to shift,” said Dr. Riboldi. “Why wait for the patient to have [an embryo] transfer failure? Let’s study the endometrium, check the ideal moment for the transfer, see whether it’s receptive or not, if there’s any disease and if there are Lactobacilli,” she proposed. “We need medical training and awareness, and we need to use them appropriately. We have the tests. Doctors need to learn about them and know when and how to use them.” The microbiome analysis costs approximately BRL 2,000, plus expenses for the medical procedure.
Is it too early?
Caio Parente Barbosa, MD, PhD, is an obstetrician/gynecologist specializing in human reproduction, as well as the director general and founder of the Fertile Idea Institute for Reproductive Health. He shared a few of his experiences in an interview with this news organization. “I would say it is still too early to confirm that [the microbiome analysis] produces effective outcomes.”
Dr. Barbosa, who is also provost of graduate studies, research, and innovation of the ABC School of Medicine, Santo André, Brazil, emphasized there is still little global experience with these analyses. “There are doubts worldwide regarding whether these analyses produce effective outcomes. Scientific studies are entirely controversial.”
He stated that some professionals recommend the microbiome analysis for “patients who don’t know what else to do,” but also recognized that there is already a demand for patients who don’t fit this category, who research the analyses on social networks and YouTube. “But it is the smallest of demands. Patients are not as worried about this yet.”
Dr. Barbosa recognized that the idea of an increasingly tailored treatment plan is inevitable. He believes that the study and treatment of the microbiome will become more critical in the future, but he thinks it still “does not offer any value.”
Dr. Barbosa emphasized that the financial side of things must also be considered. “If we add all these tests when investigating a patient’s issues, the treatment becomes ridiculously expensive.” He pointed out that health care professionals need to be careful to perform minimal testing. “We have already added some tests, such as the karyotype test, to the minimal testing for all patients.”
Dr. Simón responded to this criticism, stating: “The cost of repeating cycles is always greater than that of being thorough and knowing what’s going on. Nothing is certain, but if my daughter or wife needed it, I would like to have as much information as possible to make this decision.”
Dr. Barbosa and Dr. Simón reported no relevant financial relationships. Dr. Riboldi is Country Manager for Igenomix Brasil and Argentina, the company that offers the analyses.
This article was translated from the Medscape Portuguese edition and appeared on Medscape.com.
Until the second half of the 20th century, it was believed that the uterine cavity was sterile. Since then, technological advances have provided insight into the nature of the microbiome throughout the female reproductive tract. The role of these microorganisms on the fertility of women of reproductive age has been the subject of research. Is there an “optimal microbiome” for fertility? Can changing the microbiome of the uterine cavity affect fertility? There is still no definitive scientific response to these questions.
Several studies describe the healthy state of the uterine microbiota in women of reproductive age, with most of these studies reporting dominance of Lactobacillus species. However, by contrast, some studies did not observe Lactobacillus predominance inside the uterine cavity in cases of healthy uterine microbiomes. The presence of other microorganisms, such as Gardnerella vaginalis, was associated with reduced success in patients attempting in vitro fertilization (IVF) treatment, such as, for example, embryo implantation failure and miscarriage.
It is also possible that a physiologic endometrial microbiome could be considered healthy despite a minor presence of pathogenic bacteria. Importantly, responses from the host also modulate many aspects of human conception. These shifts correlate with parameters such as age, hormonal changes, ethnicity, sexual activity, and intrauterine devices.
Carlos Simón, MD, PhD, is a gynecologist and obstetrician and professor at the University of Valencia in Valencia, Spain; Harvard University, Cambridge, Mass.; and Baylor College of Medicine, Houston. He was in São Paulo at the time of the XXVI Brazilian Congress of Assisted Reproduction and agreed to be interviewed by Medscape Portuguese Edition. Dr. Simón, who is Spanish and is an international reference in uterine microbiome studies, created an endometrial receptivity analysis (ERA).
“What we know is that the human uterus has its own microbiome. Thanks to next-generation sequencing (NGS), we can detect microbial DNA. We’re talking about a microbiome that, if changed, affects [embryo] implantation. We have identified that Lactobacilli are the good [microorganisms], but if there are Streptococci, Gardnerella, or other bacteria, the implantation [of the embryo] is affected.”
In 2018, Dr. Simón’s team published a pilot study assessing the microbiome of 30 patients during fertilization treatment. It was observed that, when there is a change in the microbiome, the implantation rate drops to half and the miscarriage rate doubles.
Following this study, also in 2018, the team published a multicenter, prospective, observational study. A 16S ribosomal RNA (16S rRNA) gene sequencing technique was used to analyze endometrial fluid and biopsy samples before embryo transfer in a cohort of 342 infertile patients asymptomatic for infection. Participants underwent fertilization procedures in 13 centers on three continents.
A dysbiotic endometrial microbiota profile composed of Atopobium, Bifidobacterium, Chryseobacterium, Gardnerella, Haemophilus, Klebsiella, Neisseria, Staphylococcus, and Streptococcus was associated with unsuccessful outcomes. In contrast, Lactobacillus was consistently enriched in patients with live birth outcomes. The authors concluded that endometrial microbiota composition before embryo transfer is a useful biomarker to predict reproductive outcome.
“You see a microbial signature in patients who become pregnant, another in those who do not become pregnant, and yet another in those who miscarry,” Dr. Simón summarized. “By knowing this signature, the microbiome can be analyzed and treated so that it is stabilized before the embryo is transferred.”
What should be done?
Endometrial microbiome profiles do not use microbial cultures. They are obtained by NGS of the endometrial sample. This is because the 16S rRNA gene, which can be found in bacteria, presents hypervariable regions that serve as markers to identify the bacteria present.
If a microbiome is found to be somewhat unhealthy, it is theoretically possible to change its composition, increasing the chances of successful assisted reproduction. The administration of antibiotics and vaginal probiotics are two treatment approaches.
According to Dr. Simón, treatment is specific to the bacterium (metronidazole, and, if that fails, rifampicin for Gardnerella, amoxicillin and clavulanic acid for Streptococci). Once the pathogenic bacterium has been treated, the probiotics can be administered. “If all is well, we can then go ahead with the procedure,” he explained.
Dr. Simón pointed out that, with respect to treatment, knowledge is still limited and primarily based on case reports. “You look for issues in the microbiome when the patient experiences reproductive failure and there are no other causes,” he emphasized. “Microbiology plays a role in reproduction, affecting the human uterus. It’s good to know about it to improve reproductive outcomes. When there are repeated [embryo] implantation failures, we suggest an endometrial biopsy to identify the implantation window and determine whether the uterine microbiome is healthy or not. And if there are any abnormalities in the microbiome, they can be treated.”
There are still many open questions, such as how long the “good microbiome” lasts after antibiotic therapy. “We suggest checking the microbiome after [antibiotic] treatment and before implanting the embryo,” said Dr. Simón.
Although there is no consensus on how the endometrial microbiota relate to reproductive outcomes, the analysis and change in microbiome are already being offered in clinical practice as a way to increase the chances of conception. Márcia Riboldi, PhD, a genetics specialist serving as Country Manager for Igenomix Brasil and Argentina, the company that offers the analyses, provides an idea of the market for such analyses in Brazil. “We perform approximately 500 analyses per month,” she said, adding that most patients have a history of [embryo] implantation failure or miscarriage.
Matheus Roque, MD, PhD, an IVF specialist, shared two IVF case reports from the Mater Prime Human Reproduction Clinic in the southern region of the city of São Paulo. He emphasized that the decision to perform a microbiome analysis was made only after repeated implantation failure.
“With the outcomes the doctors started to see, the paradigm started to shift,” said Dr. Riboldi. “Why wait for the patient to have [an embryo] transfer failure? Let’s study the endometrium, check the ideal moment for the transfer, see whether it’s receptive or not, if there’s any disease and if there are Lactobacilli,” she proposed. “We need medical training and awareness, and we need to use them appropriately. We have the tests. Doctors need to learn about them and know when and how to use them.” The microbiome analysis costs approximately BRL 2,000, plus expenses for the medical procedure.
Is it too early?
Caio Parente Barbosa, MD, PhD, is an obstetrician/gynecologist specializing in human reproduction, as well as the director general and founder of the Fertile Idea Institute for Reproductive Health. He shared a few of his experiences in an interview with this news organization. “I would say it is still too early to confirm that [the microbiome analysis] produces effective outcomes.”
Dr. Barbosa, who is also provost of graduate studies, research, and innovation of the ABC School of Medicine, Santo André, Brazil, emphasized there is still little global experience with these analyses. “There are doubts worldwide regarding whether these analyses produce effective outcomes. Scientific studies are entirely controversial.”
He stated that some professionals recommend the microbiome analysis for “patients who don’t know what else to do,” but also recognized that there is already a demand for patients who don’t fit this category, who research the analyses on social networks and YouTube. “But it is the smallest of demands. Patients are not as worried about this yet.”
Dr. Barbosa recognized that the idea of an increasingly tailored treatment plan is inevitable. He believes that the study and treatment of the microbiome will become more critical in the future, but he thinks it still “does not offer any value.”
Dr. Barbosa emphasized that the financial side of things must also be considered. “If we add all these tests when investigating a patient’s issues, the treatment becomes ridiculously expensive.” He pointed out that health care professionals need to be careful to perform minimal testing. “We have already added some tests, such as the karyotype test, to the minimal testing for all patients.”
Dr. Simón responded to this criticism, stating: “The cost of repeating cycles is always greater than that of being thorough and knowing what’s going on. Nothing is certain, but if my daughter or wife needed it, I would like to have as much information as possible to make this decision.”
Dr. Barbosa and Dr. Simón reported no relevant financial relationships. Dr. Riboldi is Country Manager for Igenomix Brasil and Argentina, the company that offers the analyses.
This article was translated from the Medscape Portuguese edition and appeared on Medscape.com.
Lasker awardee pioneered prenatal DNA testing
For Yuk Ming Dennis Lo, BM BCh, DPhil, a 1996 paper showing the detection of tumor DNA in blood plasma would prove a turning point.
Since the 1960s, clinicians had been searching for a way to glimpse into a fetus’ genetic makeup without disturbing the pregnancy – a fascination Dr. Lo, at the time a graduate student in the United Kingdom, shared.
But the article triggered a thought. If cancer cells could release their DNA into blood plasma, then maybe fetuses could, too. “I had the strange thought that the cancer growing in the patients is a little bit like the placenta that has implanted into the uterus,” he told The New York Times.
The answer was yes. In 1997, having returned home to Hong Kong, Dr. Lo published a seminal article showing that cell-free fetal DNA could be detected in maternal blood.
He went on to devise methods to detect markers for Down syndrome, creating a noninvasive test that is more than 99% accurate for ruling out the disorder, along with screenings for trisomy 18 (Edwards syndrome), trisomy 13 (Patau syndrome), and other chromosome abnormalities.
With the commercial launch of noninvasive prenatal testing (NIPT) in 2011, health care centers around the world quickly embraced the technology as a safe alternative to more invasive methods, such as amniocentesis, for identifying fetal abnormalities. NIPT is now available in over 60 countries and is widely used by clinicians, according to the Lasker Foundation, which granted him the 2022 Lasker DeBakey Clinical Medical Research Award, along with a $250,000 prize.
“I am pleased that since its launch, noninvasive prenatal testing has become a standard of care,” Dr. Lo, chair of the department of chemical pathology at The Chinese University of Hong Kong, said in a video on the Lasker website. “It has also stimulated a global interest in the diagnostic applications of plasma DNA, especially in the area of cancer liquid biopsies and transplantation monitoring. I look forward to seeing these and other yet to be developed applications improving health care worldwide.”
Dr. Lo’s work has inspired clinical advances and applications, including Rh factor assessments, innovations in cancer technology, transplantation, and beyond, according to Lasker.
Iris Krishna, MD, MPH, director of Perinatal Quality in the Emory Perinatal Center at Emory University School of Medicine, Atlanta, said Dr. Lo’s work has also provided opportunities to screen for other genetic disorders, such as microdeletion syndromes and single gene disorders
“As we continue to learn about the possibilities of this technology, it is imperative for the clinician to be knowledgeable of the benefits and limitations of cell-free DNA screening to be able to counsel their patients appropriately,” Dr. Krishna said.
A COVID clearinghouse
Lauren Gardner, PhD, professor in the department of civil and systems engineering at Johns Hopkins University, Baltimore, received the Lasker Bloomberg Public Service Award for her work on the Johns Hopkins’ COVID-19 dashboard, a critical tool for the dissemination of public health data in real time.
According to the Los Angeles Times, Ensheng Dong, Dr. Gardner’s graduate student, approached her about tracking cases of the emerging infection in his home country of China. Mr. Dong mined Chinese websites for early cases of COVID-19 and created online maps using the information. At Dr. Gardner’s suggestion, he expanded the database to include global data.
At the time, according to Lasker, no other institution was providing this information. The World Health Organization created summaries of daily COVID-19 counts, but the data were not as accessible. Dr. Gardner said timely and obtainable information was crucial to craft nimble and rational strategies for combating the pandemic.
“Given the amount of misinformation in circulation and the highly politicized nature of the COVID-19 public health crisis, our work enabled individuals to access the information they needed to make informed decisions to protect themselves, which was especially critical in those locations with delayed or nonexistent policies in place,” Dr. Gardner said in a statement.
Dr. Gardner said she was excited to pursue additional data-centric projects. “I am optimistic that in the future, timely public health information will become increasingly available, especially in times of crisis,” she said. “Moving forward, I am excited to build on our learnings from COVID-19 and transfer that knowledge to address other problems facing societies.”
New knowledge of cells, immunology, and disease
The 2022 Albert Lasker Basic Research Award honored three scientists who helped identify a family of proteins that connect cells and assist the immune system in attaching to its targets. The proteins, called integrins, are needed for cells to interact with each other to build complex structures in the body. They are also key to the process T cells undergo to recognize and attack cancer cells.
Awardees Richard O. Hynes, MA, PhD, distinguished professor of cancer research at Massachusetts Institute of Technology; Erkki Ruoslahti, MD, PhD, distinguished professor emeritus at Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California; and Timothy A. Springer, PhD, professor of biological chemistry and molecular biology at Boston Children’s Hospital and Harvard Medical School, independently identified a cell-surface–associated protein that helps cells attach to the extracellular matrix.
“Many of the mysteries of how integrins work are only being discovered today,” Dr. Springer said in his acceptance remarks online.
The discoveries related to integrins have led to several clinical advances, including the development of drugs like the eyedrops lifitegrast, the biologic agent vedolizumab (made using integrins Springer discovered), and tirofiban, a medication used to hamper clotting in cardiovascular diseases.
A version of this article first appeared on Medscape.com.
For Yuk Ming Dennis Lo, BM BCh, DPhil, a 1996 paper showing the detection of tumor DNA in blood plasma would prove a turning point.
Since the 1960s, clinicians had been searching for a way to glimpse into a fetus’ genetic makeup without disturbing the pregnancy – a fascination Dr. Lo, at the time a graduate student in the United Kingdom, shared.
But the article triggered a thought. If cancer cells could release their DNA into blood plasma, then maybe fetuses could, too. “I had the strange thought that the cancer growing in the patients is a little bit like the placenta that has implanted into the uterus,” he told The New York Times.
The answer was yes. In 1997, having returned home to Hong Kong, Dr. Lo published a seminal article showing that cell-free fetal DNA could be detected in maternal blood.
He went on to devise methods to detect markers for Down syndrome, creating a noninvasive test that is more than 99% accurate for ruling out the disorder, along with screenings for trisomy 18 (Edwards syndrome), trisomy 13 (Patau syndrome), and other chromosome abnormalities.
With the commercial launch of noninvasive prenatal testing (NIPT) in 2011, health care centers around the world quickly embraced the technology as a safe alternative to more invasive methods, such as amniocentesis, for identifying fetal abnormalities. NIPT is now available in over 60 countries and is widely used by clinicians, according to the Lasker Foundation, which granted him the 2022 Lasker DeBakey Clinical Medical Research Award, along with a $250,000 prize.
“I am pleased that since its launch, noninvasive prenatal testing has become a standard of care,” Dr. Lo, chair of the department of chemical pathology at The Chinese University of Hong Kong, said in a video on the Lasker website. “It has also stimulated a global interest in the diagnostic applications of plasma DNA, especially in the area of cancer liquid biopsies and transplantation monitoring. I look forward to seeing these and other yet to be developed applications improving health care worldwide.”
Dr. Lo’s work has inspired clinical advances and applications, including Rh factor assessments, innovations in cancer technology, transplantation, and beyond, according to Lasker.
Iris Krishna, MD, MPH, director of Perinatal Quality in the Emory Perinatal Center at Emory University School of Medicine, Atlanta, said Dr. Lo’s work has also provided opportunities to screen for other genetic disorders, such as microdeletion syndromes and single gene disorders
“As we continue to learn about the possibilities of this technology, it is imperative for the clinician to be knowledgeable of the benefits and limitations of cell-free DNA screening to be able to counsel their patients appropriately,” Dr. Krishna said.
A COVID clearinghouse
Lauren Gardner, PhD, professor in the department of civil and systems engineering at Johns Hopkins University, Baltimore, received the Lasker Bloomberg Public Service Award for her work on the Johns Hopkins’ COVID-19 dashboard, a critical tool for the dissemination of public health data in real time.
According to the Los Angeles Times, Ensheng Dong, Dr. Gardner’s graduate student, approached her about tracking cases of the emerging infection in his home country of China. Mr. Dong mined Chinese websites for early cases of COVID-19 and created online maps using the information. At Dr. Gardner’s suggestion, he expanded the database to include global data.
At the time, according to Lasker, no other institution was providing this information. The World Health Organization created summaries of daily COVID-19 counts, but the data were not as accessible. Dr. Gardner said timely and obtainable information was crucial to craft nimble and rational strategies for combating the pandemic.
“Given the amount of misinformation in circulation and the highly politicized nature of the COVID-19 public health crisis, our work enabled individuals to access the information they needed to make informed decisions to protect themselves, which was especially critical in those locations with delayed or nonexistent policies in place,” Dr. Gardner said in a statement.
Dr. Gardner said she was excited to pursue additional data-centric projects. “I am optimistic that in the future, timely public health information will become increasingly available, especially in times of crisis,” she said. “Moving forward, I am excited to build on our learnings from COVID-19 and transfer that knowledge to address other problems facing societies.”
New knowledge of cells, immunology, and disease
The 2022 Albert Lasker Basic Research Award honored three scientists who helped identify a family of proteins that connect cells and assist the immune system in attaching to its targets. The proteins, called integrins, are needed for cells to interact with each other to build complex structures in the body. They are also key to the process T cells undergo to recognize and attack cancer cells.
Awardees Richard O. Hynes, MA, PhD, distinguished professor of cancer research at Massachusetts Institute of Technology; Erkki Ruoslahti, MD, PhD, distinguished professor emeritus at Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California; and Timothy A. Springer, PhD, professor of biological chemistry and molecular biology at Boston Children’s Hospital and Harvard Medical School, independently identified a cell-surface–associated protein that helps cells attach to the extracellular matrix.
“Many of the mysteries of how integrins work are only being discovered today,” Dr. Springer said in his acceptance remarks online.
The discoveries related to integrins have led to several clinical advances, including the development of drugs like the eyedrops lifitegrast, the biologic agent vedolizumab (made using integrins Springer discovered), and tirofiban, a medication used to hamper clotting in cardiovascular diseases.
A version of this article first appeared on Medscape.com.
For Yuk Ming Dennis Lo, BM BCh, DPhil, a 1996 paper showing the detection of tumor DNA in blood plasma would prove a turning point.
Since the 1960s, clinicians had been searching for a way to glimpse into a fetus’ genetic makeup without disturbing the pregnancy – a fascination Dr. Lo, at the time a graduate student in the United Kingdom, shared.
But the article triggered a thought. If cancer cells could release their DNA into blood plasma, then maybe fetuses could, too. “I had the strange thought that the cancer growing in the patients is a little bit like the placenta that has implanted into the uterus,” he told The New York Times.
The answer was yes. In 1997, having returned home to Hong Kong, Dr. Lo published a seminal article showing that cell-free fetal DNA could be detected in maternal blood.
He went on to devise methods to detect markers for Down syndrome, creating a noninvasive test that is more than 99% accurate for ruling out the disorder, along with screenings for trisomy 18 (Edwards syndrome), trisomy 13 (Patau syndrome), and other chromosome abnormalities.
With the commercial launch of noninvasive prenatal testing (NIPT) in 2011, health care centers around the world quickly embraced the technology as a safe alternative to more invasive methods, such as amniocentesis, for identifying fetal abnormalities. NIPT is now available in over 60 countries and is widely used by clinicians, according to the Lasker Foundation, which granted him the 2022 Lasker DeBakey Clinical Medical Research Award, along with a $250,000 prize.
“I am pleased that since its launch, noninvasive prenatal testing has become a standard of care,” Dr. Lo, chair of the department of chemical pathology at The Chinese University of Hong Kong, said in a video on the Lasker website. “It has also stimulated a global interest in the diagnostic applications of plasma DNA, especially in the area of cancer liquid biopsies and transplantation monitoring. I look forward to seeing these and other yet to be developed applications improving health care worldwide.”
Dr. Lo’s work has inspired clinical advances and applications, including Rh factor assessments, innovations in cancer technology, transplantation, and beyond, according to Lasker.
Iris Krishna, MD, MPH, director of Perinatal Quality in the Emory Perinatal Center at Emory University School of Medicine, Atlanta, said Dr. Lo’s work has also provided opportunities to screen for other genetic disorders, such as microdeletion syndromes and single gene disorders
“As we continue to learn about the possibilities of this technology, it is imperative for the clinician to be knowledgeable of the benefits and limitations of cell-free DNA screening to be able to counsel their patients appropriately,” Dr. Krishna said.
A COVID clearinghouse
Lauren Gardner, PhD, professor in the department of civil and systems engineering at Johns Hopkins University, Baltimore, received the Lasker Bloomberg Public Service Award for her work on the Johns Hopkins’ COVID-19 dashboard, a critical tool for the dissemination of public health data in real time.
According to the Los Angeles Times, Ensheng Dong, Dr. Gardner’s graduate student, approached her about tracking cases of the emerging infection in his home country of China. Mr. Dong mined Chinese websites for early cases of COVID-19 and created online maps using the information. At Dr. Gardner’s suggestion, he expanded the database to include global data.
At the time, according to Lasker, no other institution was providing this information. The World Health Organization created summaries of daily COVID-19 counts, but the data were not as accessible. Dr. Gardner said timely and obtainable information was crucial to craft nimble and rational strategies for combating the pandemic.
“Given the amount of misinformation in circulation and the highly politicized nature of the COVID-19 public health crisis, our work enabled individuals to access the information they needed to make informed decisions to protect themselves, which was especially critical in those locations with delayed or nonexistent policies in place,” Dr. Gardner said in a statement.
Dr. Gardner said she was excited to pursue additional data-centric projects. “I am optimistic that in the future, timely public health information will become increasingly available, especially in times of crisis,” she said. “Moving forward, I am excited to build on our learnings from COVID-19 and transfer that knowledge to address other problems facing societies.”
New knowledge of cells, immunology, and disease
The 2022 Albert Lasker Basic Research Award honored three scientists who helped identify a family of proteins that connect cells and assist the immune system in attaching to its targets. The proteins, called integrins, are needed for cells to interact with each other to build complex structures in the body. They are also key to the process T cells undergo to recognize and attack cancer cells.
Awardees Richard O. Hynes, MA, PhD, distinguished professor of cancer research at Massachusetts Institute of Technology; Erkki Ruoslahti, MD, PhD, distinguished professor emeritus at Sanford Burnham Prebys Medical Discovery Institute, La Jolla, California; and Timothy A. Springer, PhD, professor of biological chemistry and molecular biology at Boston Children’s Hospital and Harvard Medical School, independently identified a cell-surface–associated protein that helps cells attach to the extracellular matrix.
“Many of the mysteries of how integrins work are only being discovered today,” Dr. Springer said in his acceptance remarks online.
The discoveries related to integrins have led to several clinical advances, including the development of drugs like the eyedrops lifitegrast, the biologic agent vedolizumab (made using integrins Springer discovered), and tirofiban, a medication used to hamper clotting in cardiovascular diseases.
A version of this article first appeared on Medscape.com.
Mouse embryo experiment could teach us about miscarriages
Miscarriages are a devastating, if natural, occurrence. Nearly 1 million pregnant people in the United States experience a miscarriage every year, according to the National Advocates for Pregnant Women. New research could lend insight into the causes of some types of early pregnancy loss and maybe one day help prevent miscarriages.
In the bioengineering breakthrough, scientists created a mouse embryo in a lab without using sperm or eggs. The experimental embryo, called a model, was grown out of stem cells and developed further than any earlier experiments, with a beating heart and the foundation of a brain within a yolk sac, according to the researchers.
The experiment, while conducted with mouse stem cells, could help explain why some human pregnancies fail. Miscarriages occur in up to 15% of pregnancies confirmed by doctors, according to some studies, and also for many pregnant people before they even knew of the pregnancy. This experiment gives researchers a glimpse of a critical developmental stage for the first time.
“We are building mouse embryo models, but they have exactly the same principle as real human embryos,” says lead researcher Magdalena Zernicka-Goetz, PhD, professor in mammalian development and stem cell biology at Cambridge (England) University. “That’s why they tell us about real pregnancy.”
With the new mouse models, the researchers can study implantation, the stage when embryos embed themselves in the mother’s body – a stage that’s often difficult for embryos to survive. The same process happens in mouse embryos, which develop very similarly to human embryos at this early stage of life.
Six years ago, researchers from the University of Cambridge and the California Institute of Technology set out to create models that would allow them to study fetal development in three-dimensional form but without the need for human embryos.
“We are trying to understand the major principles of time and space that have to be fulfilled” to form a successful pregnancy, Dr. Zernicka-Goetz explains. “If those principles are not fulfilled, the pregnancies are terminated, even before women know they’re pregnant.”
There are limits on using human embryos for research, and previous experiments have tended to replicate only one aspect of development. That led to two-dimensional experiments: flat cells on the bottom of a petri dish that lack the structural organization of real tissue.
The new models are three-dimensional with beating hearts and the yolk sacs in which embryos feed and grow. The models even progressed to forming the beginning of a brain – a research first.
The scientists used the foundational cellular “building blocks” called stem cells and managed to get the cells to communicate along a timeline that mimicked natural development, simulating those developmental stages, says Dr. Zernicka-Goetz. Those “building blocks” are actually three types of stem cells: pluripotent stem cells that build body tissue, and two other types of stem cells that build the placenta and the amniotic sac.
Completing the experiment required the right quantity of each stem cell type. The researchers also needed to understand how those cells exchange information before they can begin to grow. The researchers were able to “decipher the code” of how the cells talk to each other, Dr. Zernicka-Goetz says.
Initially, the three types of stem cells combine, almost like a soup, but when the timing is right, they have to recognize each other and sort themselves. Next, each stem cell type must start building a different structure necessary for fetal development. Dr. Zernicka-Goetz thinks of this construction as the architecture of human tissue.
With the new technique, researchers can continue investigating the implantation stage and beyond. And they did – tweaking the experiment to create a genetically flawed embryo on purpose.
Dr. Zernicka-Goetz and her team eliminated a certain gene known to regulate how cells establish their own identities. Doing so resulted in the same brain development flaws as in human embryos, providing “a proof of concept” that the experimental models can be used to study other genetic mysteries, she says.
Scientists are still in the dark about what some genes do, as well as the point when they become critical to brain development.
“Many genes have very early roles in specifying, for example, the position of the head and also how our brain will function,” Dr. Zernicka-Goetz says. “We can now use this model system to assess the function of those genes.”
A version of this article first appeared on WebMD.com.
Miscarriages are a devastating, if natural, occurrence. Nearly 1 million pregnant people in the United States experience a miscarriage every year, according to the National Advocates for Pregnant Women. New research could lend insight into the causes of some types of early pregnancy loss and maybe one day help prevent miscarriages.
In the bioengineering breakthrough, scientists created a mouse embryo in a lab without using sperm or eggs. The experimental embryo, called a model, was grown out of stem cells and developed further than any earlier experiments, with a beating heart and the foundation of a brain within a yolk sac, according to the researchers.
The experiment, while conducted with mouse stem cells, could help explain why some human pregnancies fail. Miscarriages occur in up to 15% of pregnancies confirmed by doctors, according to some studies, and also for many pregnant people before they even knew of the pregnancy. This experiment gives researchers a glimpse of a critical developmental stage for the first time.
“We are building mouse embryo models, but they have exactly the same principle as real human embryos,” says lead researcher Magdalena Zernicka-Goetz, PhD, professor in mammalian development and stem cell biology at Cambridge (England) University. “That’s why they tell us about real pregnancy.”
With the new mouse models, the researchers can study implantation, the stage when embryos embed themselves in the mother’s body – a stage that’s often difficult for embryos to survive. The same process happens in mouse embryos, which develop very similarly to human embryos at this early stage of life.
Six years ago, researchers from the University of Cambridge and the California Institute of Technology set out to create models that would allow them to study fetal development in three-dimensional form but without the need for human embryos.
“We are trying to understand the major principles of time and space that have to be fulfilled” to form a successful pregnancy, Dr. Zernicka-Goetz explains. “If those principles are not fulfilled, the pregnancies are terminated, even before women know they’re pregnant.”
There are limits on using human embryos for research, and previous experiments have tended to replicate only one aspect of development. That led to two-dimensional experiments: flat cells on the bottom of a petri dish that lack the structural organization of real tissue.
The new models are three-dimensional with beating hearts and the yolk sacs in which embryos feed and grow. The models even progressed to forming the beginning of a brain – a research first.
The scientists used the foundational cellular “building blocks” called stem cells and managed to get the cells to communicate along a timeline that mimicked natural development, simulating those developmental stages, says Dr. Zernicka-Goetz. Those “building blocks” are actually three types of stem cells: pluripotent stem cells that build body tissue, and two other types of stem cells that build the placenta and the amniotic sac.
Completing the experiment required the right quantity of each stem cell type. The researchers also needed to understand how those cells exchange information before they can begin to grow. The researchers were able to “decipher the code” of how the cells talk to each other, Dr. Zernicka-Goetz says.
Initially, the three types of stem cells combine, almost like a soup, but when the timing is right, they have to recognize each other and sort themselves. Next, each stem cell type must start building a different structure necessary for fetal development. Dr. Zernicka-Goetz thinks of this construction as the architecture of human tissue.
With the new technique, researchers can continue investigating the implantation stage and beyond. And they did – tweaking the experiment to create a genetically flawed embryo on purpose.
Dr. Zernicka-Goetz and her team eliminated a certain gene known to regulate how cells establish their own identities. Doing so resulted in the same brain development flaws as in human embryos, providing “a proof of concept” that the experimental models can be used to study other genetic mysteries, she says.
Scientists are still in the dark about what some genes do, as well as the point when they become critical to brain development.
“Many genes have very early roles in specifying, for example, the position of the head and also how our brain will function,” Dr. Zernicka-Goetz says. “We can now use this model system to assess the function of those genes.”
A version of this article first appeared on WebMD.com.
Miscarriages are a devastating, if natural, occurrence. Nearly 1 million pregnant people in the United States experience a miscarriage every year, according to the National Advocates for Pregnant Women. New research could lend insight into the causes of some types of early pregnancy loss and maybe one day help prevent miscarriages.
In the bioengineering breakthrough, scientists created a mouse embryo in a lab without using sperm or eggs. The experimental embryo, called a model, was grown out of stem cells and developed further than any earlier experiments, with a beating heart and the foundation of a brain within a yolk sac, according to the researchers.
The experiment, while conducted with mouse stem cells, could help explain why some human pregnancies fail. Miscarriages occur in up to 15% of pregnancies confirmed by doctors, according to some studies, and also for many pregnant people before they even knew of the pregnancy. This experiment gives researchers a glimpse of a critical developmental stage for the first time.
“We are building mouse embryo models, but they have exactly the same principle as real human embryos,” says lead researcher Magdalena Zernicka-Goetz, PhD, professor in mammalian development and stem cell biology at Cambridge (England) University. “That’s why they tell us about real pregnancy.”
With the new mouse models, the researchers can study implantation, the stage when embryos embed themselves in the mother’s body – a stage that’s often difficult for embryos to survive. The same process happens in mouse embryos, which develop very similarly to human embryos at this early stage of life.
Six years ago, researchers from the University of Cambridge and the California Institute of Technology set out to create models that would allow them to study fetal development in three-dimensional form but without the need for human embryos.
“We are trying to understand the major principles of time and space that have to be fulfilled” to form a successful pregnancy, Dr. Zernicka-Goetz explains. “If those principles are not fulfilled, the pregnancies are terminated, even before women know they’re pregnant.”
There are limits on using human embryos for research, and previous experiments have tended to replicate only one aspect of development. That led to two-dimensional experiments: flat cells on the bottom of a petri dish that lack the structural organization of real tissue.
The new models are three-dimensional with beating hearts and the yolk sacs in which embryos feed and grow. The models even progressed to forming the beginning of a brain – a research first.
The scientists used the foundational cellular “building blocks” called stem cells and managed to get the cells to communicate along a timeline that mimicked natural development, simulating those developmental stages, says Dr. Zernicka-Goetz. Those “building blocks” are actually three types of stem cells: pluripotent stem cells that build body tissue, and two other types of stem cells that build the placenta and the amniotic sac.
Completing the experiment required the right quantity of each stem cell type. The researchers also needed to understand how those cells exchange information before they can begin to grow. The researchers were able to “decipher the code” of how the cells talk to each other, Dr. Zernicka-Goetz says.
Initially, the three types of stem cells combine, almost like a soup, but when the timing is right, they have to recognize each other and sort themselves. Next, each stem cell type must start building a different structure necessary for fetal development. Dr. Zernicka-Goetz thinks of this construction as the architecture of human tissue.
With the new technique, researchers can continue investigating the implantation stage and beyond. And they did – tweaking the experiment to create a genetically flawed embryo on purpose.
Dr. Zernicka-Goetz and her team eliminated a certain gene known to regulate how cells establish their own identities. Doing so resulted in the same brain development flaws as in human embryos, providing “a proof of concept” that the experimental models can be used to study other genetic mysteries, she says.
Scientists are still in the dark about what some genes do, as well as the point when they become critical to brain development.
“Many genes have very early roles in specifying, for example, the position of the head and also how our brain will function,” Dr. Zernicka-Goetz says. “We can now use this model system to assess the function of those genes.”
A version of this article first appeared on WebMD.com.
The role of repeat uterine curettage in postmolar gestational trophoblastic neoplasia
Trophoblastic tissue is responsible for formation of the placenta during pregnancy. Gestational trophoblastic disease (GTD), a group comprising benign (hydatidiform moles) and malignant tumors, occurs when gestational trophoblastic tissue behaves in an abnormal manner. Hydatidiform moles, which are thought to be caused by errors in fertilization, occur in approximately 1 in 1,200 pregnancies in the United States. Gestational trophoblastic neoplasia (GTN) refers to the subgroup of these trophoblastic or placental tumors with malignant behavior and includes postmolar GTN, invasive mole, gestational choriocarcinoma, placental-site trophoblastic tumor (PSTT), and epithelioid trophoblastic tumor. Postmolar GTN arises after evacuation of a molar pregnancy and is most frequently diagnosed by a plateau or increase in human chorionic gonadotropin (hCG).1 The risk of postmolar GTN is much higher after a complete mole (7%-30%) compared with a partial mole (2.5%-7.5%).2 Once postmolar GTN is diagnosed, a World Health Organization score is assigned to determine if patients have low- or high-risk disease.3 The primary treatment for most GTN is chemotherapy. A patient’s WHO score helps determine whether they would benefit from single-agent or multiagent chemotherapy. The standard of care for low-risk disease is single-agent chemotherapy with either methotrexate or actinomycin D.
The role of a second uterine curettage, after the diagnosis of low-risk postmolar GTN, has been controversial because of the limited data and disparate outcomes reported. In older retrospective series, a second curettage affected treatment or produced remission in only 9%-20% of patients and caused uterine perforation or major hemorrhage in 5%-8% of patients.4,5 Given relatively high rates of major complications compared with surgical cure or decreased chemotherapy cycles needed, only a limited number of patients seemed to benefit from a second procedure. On the other hand, an observational study of 544 patients who underwent second uterine evacuation after a presumed diagnosis of persistent GTD found that up to 60% of patients did not require chemotherapy afterward.6 Those with hCG levels greater than 1,500 IU/L or histologic evidence of GTD were less likely to have a surgical cure after second curettage. The indications for uterine evacuations were varied across these studies and make it nearly impossible to compare their results.
More recently, there have been two prospective trials that have tackled the question of the utility of second uterine evacuation in low-risk, nonmetastatic GTN. The Gynecologic Oncology Group performed a single-arm prospective study in the United States that enrolled patients with postmolar GTN to undergo second curettage as initial treatment of their disease.7 Of 60 eligible patients, 40% had a surgical cure (defined as normalization of hCG followed by at least 6 months of subsequent normal hCG values). Overall, 47% of patients were able to avoid chemotherapy. All surgical cures were seen in patients with WHO scores between 0 and 4. Importantly, three women were diagnosed with PSTT, which tends to be resistant to methotrexate and actinomycin D (treatment for nonmetastatic PSTT is definitive surgery with hysterectomy). The study found that hCG was a poor discriminator for achieving surgical cure. While age appeared to have an association with surgical cure (cure less likely for younger and older ages, younger than 19 and older than 40), patient numbers were too small to make a statistical conclusion. There were no uterine perforations and one patient had a grade 3 hemorrhage (requiring transfusion).
In the second prospective trial, performed in Iran, 62 patients were randomized to either second uterine evacuation or standard treatment after diagnosis of postmolar GTN.8 All patients in the surgical arm received a cervical ripening agent prior to their procedure, had their procedure under ultrasound guidance, and received misoprostol afterward to prevent uterine bleeding. Among those undergoing second uterine evacuation, 50% were cured (no need for chemotherapy). Among those needing chemotherapy after surgery, the mean number of cycles of chemotherapy needed (3.07 vs. 6.69) and the time it took to achieve negative hCG (3.23 vs. 9.19 weeks) were significantly less compared with patients who did not undergo surgery. hCG prior to second uterine evacuation could distinguish response to surgery compared with those needing chemotherapy (hCG of 1,983 IU/L or less was the level determined to best predict response). No complications related to surgery were reported.
Given prospective data available, second uterine evacuation for treatment of nonmetastatic, low-risk postmolar GTN is a reasonable treatment option and one that should be considered and discussed with patients given the potential to avoid chemotherapy or decrease the number of cycles needed. It may be prudent to limit the procedure to patients with an hCG less than 1,500-2,000 IU/L and to those between the ages of 20 and 40. While uterine hemorrhage and perforation have been reported in the literature, more recent data suggest low rates of these complications. Unfortunately, given the rarity of the disease and the historically controversial use of second curettage, little is known about the effects on future fertility that this procedure may have, including the development of uterine synechiae.
Dr. Tucker is assistant professor of gynecologic oncology at the University of North Carolina at Chapel Hill.
References
1. Ngan HY et al, FIGO Committee on Gynecologic Oncology. Int J Gynaecol Obstet. 2003 Oct;83 Suppl 1:175-7. Erratum in: Int J Gynaecol Obstet. 2021 Dec;155(3):563.
2. Soper JT. Obstet Gynecol. 2021 Feb.;137(2):355-70.
3. Ngan HY et al. Int J Gynecol Obstet. 2018;143:79-85.
4. Schlaerth JB et al. Am J Obstet Gynecol. 1990 Jun;162(6):1465-70.
5. van Trommel NE et al. Gynecol Oncol. 2005 Oct;99(1):6-13.
6. Pezeshki M et al. Gynecol Oncol. 2004 Dec;95(3):423-9.
7. Osborne RJ et al. Obstet Gynecol. 2016 Sep;128(3):535-42.
8. Ayatollahi H et al. Int J Womens Health. 2017 Sep 21;9:665-71.
Trophoblastic tissue is responsible for formation of the placenta during pregnancy. Gestational trophoblastic disease (GTD), a group comprising benign (hydatidiform moles) and malignant tumors, occurs when gestational trophoblastic tissue behaves in an abnormal manner. Hydatidiform moles, which are thought to be caused by errors in fertilization, occur in approximately 1 in 1,200 pregnancies in the United States. Gestational trophoblastic neoplasia (GTN) refers to the subgroup of these trophoblastic or placental tumors with malignant behavior and includes postmolar GTN, invasive mole, gestational choriocarcinoma, placental-site trophoblastic tumor (PSTT), and epithelioid trophoblastic tumor. Postmolar GTN arises after evacuation of a molar pregnancy and is most frequently diagnosed by a plateau or increase in human chorionic gonadotropin (hCG).1 The risk of postmolar GTN is much higher after a complete mole (7%-30%) compared with a partial mole (2.5%-7.5%).2 Once postmolar GTN is diagnosed, a World Health Organization score is assigned to determine if patients have low- or high-risk disease.3 The primary treatment for most GTN is chemotherapy. A patient’s WHO score helps determine whether they would benefit from single-agent or multiagent chemotherapy. The standard of care for low-risk disease is single-agent chemotherapy with either methotrexate or actinomycin D.
The role of a second uterine curettage, after the diagnosis of low-risk postmolar GTN, has been controversial because of the limited data and disparate outcomes reported. In older retrospective series, a second curettage affected treatment or produced remission in only 9%-20% of patients and caused uterine perforation or major hemorrhage in 5%-8% of patients.4,5 Given relatively high rates of major complications compared with surgical cure or decreased chemotherapy cycles needed, only a limited number of patients seemed to benefit from a second procedure. On the other hand, an observational study of 544 patients who underwent second uterine evacuation after a presumed diagnosis of persistent GTD found that up to 60% of patients did not require chemotherapy afterward.6 Those with hCG levels greater than 1,500 IU/L or histologic evidence of GTD were less likely to have a surgical cure after second curettage. The indications for uterine evacuations were varied across these studies and make it nearly impossible to compare their results.
More recently, there have been two prospective trials that have tackled the question of the utility of second uterine evacuation in low-risk, nonmetastatic GTN. The Gynecologic Oncology Group performed a single-arm prospective study in the United States that enrolled patients with postmolar GTN to undergo second curettage as initial treatment of their disease.7 Of 60 eligible patients, 40% had a surgical cure (defined as normalization of hCG followed by at least 6 months of subsequent normal hCG values). Overall, 47% of patients were able to avoid chemotherapy. All surgical cures were seen in patients with WHO scores between 0 and 4. Importantly, three women were diagnosed with PSTT, which tends to be resistant to methotrexate and actinomycin D (treatment for nonmetastatic PSTT is definitive surgery with hysterectomy). The study found that hCG was a poor discriminator for achieving surgical cure. While age appeared to have an association with surgical cure (cure less likely for younger and older ages, younger than 19 and older than 40), patient numbers were too small to make a statistical conclusion. There were no uterine perforations and one patient had a grade 3 hemorrhage (requiring transfusion).
In the second prospective trial, performed in Iran, 62 patients were randomized to either second uterine evacuation or standard treatment after diagnosis of postmolar GTN.8 All patients in the surgical arm received a cervical ripening agent prior to their procedure, had their procedure under ultrasound guidance, and received misoprostol afterward to prevent uterine bleeding. Among those undergoing second uterine evacuation, 50% were cured (no need for chemotherapy). Among those needing chemotherapy after surgery, the mean number of cycles of chemotherapy needed (3.07 vs. 6.69) and the time it took to achieve negative hCG (3.23 vs. 9.19 weeks) were significantly less compared with patients who did not undergo surgery. hCG prior to second uterine evacuation could distinguish response to surgery compared with those needing chemotherapy (hCG of 1,983 IU/L or less was the level determined to best predict response). No complications related to surgery were reported.
Given prospective data available, second uterine evacuation for treatment of nonmetastatic, low-risk postmolar GTN is a reasonable treatment option and one that should be considered and discussed with patients given the potential to avoid chemotherapy or decrease the number of cycles needed. It may be prudent to limit the procedure to patients with an hCG less than 1,500-2,000 IU/L and to those between the ages of 20 and 40. While uterine hemorrhage and perforation have been reported in the literature, more recent data suggest low rates of these complications. Unfortunately, given the rarity of the disease and the historically controversial use of second curettage, little is known about the effects on future fertility that this procedure may have, including the development of uterine synechiae.
Dr. Tucker is assistant professor of gynecologic oncology at the University of North Carolina at Chapel Hill.
References
1. Ngan HY et al, FIGO Committee on Gynecologic Oncology. Int J Gynaecol Obstet. 2003 Oct;83 Suppl 1:175-7. Erratum in: Int J Gynaecol Obstet. 2021 Dec;155(3):563.
2. Soper JT. Obstet Gynecol. 2021 Feb.;137(2):355-70.
3. Ngan HY et al. Int J Gynecol Obstet. 2018;143:79-85.
4. Schlaerth JB et al. Am J Obstet Gynecol. 1990 Jun;162(6):1465-70.
5. van Trommel NE et al. Gynecol Oncol. 2005 Oct;99(1):6-13.
6. Pezeshki M et al. Gynecol Oncol. 2004 Dec;95(3):423-9.
7. Osborne RJ et al. Obstet Gynecol. 2016 Sep;128(3):535-42.
8. Ayatollahi H et al. Int J Womens Health. 2017 Sep 21;9:665-71.
Trophoblastic tissue is responsible for formation of the placenta during pregnancy. Gestational trophoblastic disease (GTD), a group comprising benign (hydatidiform moles) and malignant tumors, occurs when gestational trophoblastic tissue behaves in an abnormal manner. Hydatidiform moles, which are thought to be caused by errors in fertilization, occur in approximately 1 in 1,200 pregnancies in the United States. Gestational trophoblastic neoplasia (GTN) refers to the subgroup of these trophoblastic or placental tumors with malignant behavior and includes postmolar GTN, invasive mole, gestational choriocarcinoma, placental-site trophoblastic tumor (PSTT), and epithelioid trophoblastic tumor. Postmolar GTN arises after evacuation of a molar pregnancy and is most frequently diagnosed by a plateau or increase in human chorionic gonadotropin (hCG).1 The risk of postmolar GTN is much higher after a complete mole (7%-30%) compared with a partial mole (2.5%-7.5%).2 Once postmolar GTN is diagnosed, a World Health Organization score is assigned to determine if patients have low- or high-risk disease.3 The primary treatment for most GTN is chemotherapy. A patient’s WHO score helps determine whether they would benefit from single-agent or multiagent chemotherapy. The standard of care for low-risk disease is single-agent chemotherapy with either methotrexate or actinomycin D.
The role of a second uterine curettage, after the diagnosis of low-risk postmolar GTN, has been controversial because of the limited data and disparate outcomes reported. In older retrospective series, a second curettage affected treatment or produced remission in only 9%-20% of patients and caused uterine perforation or major hemorrhage in 5%-8% of patients.4,5 Given relatively high rates of major complications compared with surgical cure or decreased chemotherapy cycles needed, only a limited number of patients seemed to benefit from a second procedure. On the other hand, an observational study of 544 patients who underwent second uterine evacuation after a presumed diagnosis of persistent GTD found that up to 60% of patients did not require chemotherapy afterward.6 Those with hCG levels greater than 1,500 IU/L or histologic evidence of GTD were less likely to have a surgical cure after second curettage. The indications for uterine evacuations were varied across these studies and make it nearly impossible to compare their results.
More recently, there have been two prospective trials that have tackled the question of the utility of second uterine evacuation in low-risk, nonmetastatic GTN. The Gynecologic Oncology Group performed a single-arm prospective study in the United States that enrolled patients with postmolar GTN to undergo second curettage as initial treatment of their disease.7 Of 60 eligible patients, 40% had a surgical cure (defined as normalization of hCG followed by at least 6 months of subsequent normal hCG values). Overall, 47% of patients were able to avoid chemotherapy. All surgical cures were seen in patients with WHO scores between 0 and 4. Importantly, three women were diagnosed with PSTT, which tends to be resistant to methotrexate and actinomycin D (treatment for nonmetastatic PSTT is definitive surgery with hysterectomy). The study found that hCG was a poor discriminator for achieving surgical cure. While age appeared to have an association with surgical cure (cure less likely for younger and older ages, younger than 19 and older than 40), patient numbers were too small to make a statistical conclusion. There were no uterine perforations and one patient had a grade 3 hemorrhage (requiring transfusion).
In the second prospective trial, performed in Iran, 62 patients were randomized to either second uterine evacuation or standard treatment after diagnosis of postmolar GTN.8 All patients in the surgical arm received a cervical ripening agent prior to their procedure, had their procedure under ultrasound guidance, and received misoprostol afterward to prevent uterine bleeding. Among those undergoing second uterine evacuation, 50% were cured (no need for chemotherapy). Among those needing chemotherapy after surgery, the mean number of cycles of chemotherapy needed (3.07 vs. 6.69) and the time it took to achieve negative hCG (3.23 vs. 9.19 weeks) were significantly less compared with patients who did not undergo surgery. hCG prior to second uterine evacuation could distinguish response to surgery compared with those needing chemotherapy (hCG of 1,983 IU/L or less was the level determined to best predict response). No complications related to surgery were reported.
Given prospective data available, second uterine evacuation for treatment of nonmetastatic, low-risk postmolar GTN is a reasonable treatment option and one that should be considered and discussed with patients given the potential to avoid chemotherapy or decrease the number of cycles needed. It may be prudent to limit the procedure to patients with an hCG less than 1,500-2,000 IU/L and to those between the ages of 20 and 40. While uterine hemorrhage and perforation have been reported in the literature, more recent data suggest low rates of these complications. Unfortunately, given the rarity of the disease and the historically controversial use of second curettage, little is known about the effects on future fertility that this procedure may have, including the development of uterine synechiae.
Dr. Tucker is assistant professor of gynecologic oncology at the University of North Carolina at Chapel Hill.
References
1. Ngan HY et al, FIGO Committee on Gynecologic Oncology. Int J Gynaecol Obstet. 2003 Oct;83 Suppl 1:175-7. Erratum in: Int J Gynaecol Obstet. 2021 Dec;155(3):563.
2. Soper JT. Obstet Gynecol. 2021 Feb.;137(2):355-70.
3. Ngan HY et al. Int J Gynecol Obstet. 2018;143:79-85.
4. Schlaerth JB et al. Am J Obstet Gynecol. 1990 Jun;162(6):1465-70.
5. van Trommel NE et al. Gynecol Oncol. 2005 Oct;99(1):6-13.
6. Pezeshki M et al. Gynecol Oncol. 2004 Dec;95(3):423-9.
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8. Ayatollahi H et al. Int J Womens Health. 2017 Sep 21;9:665-71.
Postpartum sexual enjoyment: Does mode of delivery matter?
For some parents, resuming sexual intimacy after having a baby is a top priority. For others, not so much – and late-night feedings and diaper changes may not be the only hang-ups.
Dyspareunia – pain during sex – occurs in a substantial number of women after childbirth, and recent research sheds light on how psychological and biomedical factors relate to this condition.
Mode of delivery, for instance, may have less of an effect on sexual well-being than some people suspect.
Despite a perception that cesarean delivery might affect sexual function less than vaginal delivery does, how mothers delivered did not affect how often they had sex postpartum or the amount of enjoyment they got from it, according to research published in BJOG.
Eleven years after delivery, however, cesarean delivery was associated with a 74% increased likelihood of pain in the vagina during sex, compared with vaginal delivery, the researchers found (odds ratio, 1.74; 95% confidence interval, 1.46-2.08).
The results suggest that cesarean delivery “may not help protect against sexual dysfunction, as previously thought,” Flo Martin, a PhD student in epidemiology at the University of Bristol, United Kingdom, and lead author of the study, said in a news release.
For their study, Ms. Martin and her colleagues analyzed data from more than 10,300 participants in the Avon Longitudinal Study of Parents and Children, which recruited women in the United Kingdom who were pregnant in 1991 and 1992.
The researchers had data about pain during sex at 11 years. They had data about sexual enjoyment and frequency at 33 months, 5 years, 12 years, and 18 years after delivery.
If women experienced pain during sex years after cesarean delivery, uterine scarring might have been a cause, Ms. Martin and colleagues suggested. Alternatively, women with dyspareunia before delivery may be more likely to have cesarean surgery, which also could explain the association.
Other studies have likewise found that different modes of delivery generally lead to similar outcomes of sexual well-being after birth.
“Several of my own longitudinal studies have shown limited associations between mode of delivery and various aspects of sexual well-being, including sexual satisfaction, sexual function, and sexual desire,” said Natalie O. Rosen, PhD, director of the Couples and Sexual Health Laboratory at Dalhousie University, Halifax, N.S.
Nevertheless, other published studies have yielded conflicting results, so the question warrants further study, she said.
Pain catastrophizing
One study by Dr. Rosen’s group, published in Obstetrics & Gynecology, tracked sexual pain in 582 people from mid-pregnancy to 2 years postpartum.
About 21% of participants experienced moderate pain during sex, as determined by an average pain score greater than 4 on scale of 0-10 points. The rest were classified as having “minimal dyspareunia.”
Pain tended to peak at 3 months postpartum and then steadily decrease in both the moderate and minimal pain groups.
Mode of delivery did not affect the odds that a participant would have moderate dyspareunia. Neither did breastfeeding or prior chronic pain.
“But we did find one key thing to look out for: Those who reported a lot of negative thoughts and feelings about pain, something called pain catastrophizing, were more likely to experience moderate persistent pain during sex,” the researchers said in a video about their findings.
Pain catastrophizing 3 months after delivery was associated with significantly increased odds of following a moderate pain trajectory (odds ratio, 1.09; 95% confidence interval, 1.04-1.15).
Let’s talk about #postbabyhankypanky
Caring for a newborn while maintaining a romantic relationship can be challenging, and “there is a lack of evidence-based research aimed at helping couples prevent and navigate changes to their sexual well-being postpartum,” Dr. Rosen said.
During the 2-year study, a growing number of participants reported having sex less often over time. The percentage of women who had engaged in sexual activity in the past 4 weeks was 99% at baseline (20-24 weeks of gestation), 83.5% at 32 weeks of gestation, 73.9% at 3 months postpartum, and 69.6% at 2 years postpartum.
“One crucial way that couples sustain their connection is through their sexuality,” Dr. Rosen said. “Unfortunately, most new parents experience significant disruptions to their sexual function,” such as lower sexual desire or more pain during intercourse.
Dr. Rosen’s group has created a series of videos related to this topic dubbed #postbabyhankypanky to facilitate communication about sex postpartum. She encourages women with dyspareunia to talk with a health care provider because treatments such as cognitive-behavioral therapy, pelvic floor physical therapy, and topical medications can help manage pain.
‘Reassuring’ data
Veronica Gillispie-Bell, MD, MAS, director of quality for women’s services at the Ochsner Health System, New Orleans, said that she sees patients with postpartum sexual pain frequently.
Patients typically are instructed to have pelvic rest from delivery until 6 weeks after.
At the 6-week appointment, she tells patients to make sure that they are using lots of lubrication, because vaginal dryness related to hormonal changes during pregnancy and breastfeeding can make sex more painful, regardless of mode of delivery.
For many patients, she also recommends pelvic floor physical therapy.
As the medical director for the Louisiana Perinatal Quality Collaborative – a network of care providers, public health officials, and advocates that aims to improve outcomes for birthing persons, families, and newborns – Dr. Gillispie-Bell also is focused on reducing the rate of cesarean deliveries in the state. The BJOG study showing an increased risk for dyspareunia after a cesarean surgery serves as a reminder that there may be “long-term effects of having a C-section that may not be as obvious,” she said.
“C-sections are life-saving procedures, but they are not without risk,” Dr. Gillispie-Bell said.
Leila Frodsham, MBChB, a spokesperson for the Royal College of Obstetricians and Gynaecologists, told Medscape UK that it was “reassuring” to see “no difference in sexual enjoyment or sexual frequency at any time point postpartum between women who gave birth via cesarean section and those who delivered vaginally.”
“Women should be supported to make informed decisions about how they plan to give birth, and it is vital that health care professionals respect their preferences,” Dr. Frodsham added.
Clinicians should also remain aware that sexual pain is also common during periods of subfertility, perimenopause, and initiation of sexual activity.
Combinations of biological, psychological, and social factors can influence pain during sex, and there is an interpersonal element to keep in mind as well, Dr. Rosen noted.
“Pain during sex is typically elicited in the context of a partnered relationship,” Dr. Rosen said. “This means that this is an inherently interpersonal issue – let’s not forget about the partner who is both impacted by and can impact the pain through their own responses.”
A version of this article first appeared on Medscape.com.
For some parents, resuming sexual intimacy after having a baby is a top priority. For others, not so much – and late-night feedings and diaper changes may not be the only hang-ups.
Dyspareunia – pain during sex – occurs in a substantial number of women after childbirth, and recent research sheds light on how psychological and biomedical factors relate to this condition.
Mode of delivery, for instance, may have less of an effect on sexual well-being than some people suspect.
Despite a perception that cesarean delivery might affect sexual function less than vaginal delivery does, how mothers delivered did not affect how often they had sex postpartum or the amount of enjoyment they got from it, according to research published in BJOG.
Eleven years after delivery, however, cesarean delivery was associated with a 74% increased likelihood of pain in the vagina during sex, compared with vaginal delivery, the researchers found (odds ratio, 1.74; 95% confidence interval, 1.46-2.08).
The results suggest that cesarean delivery “may not help protect against sexual dysfunction, as previously thought,” Flo Martin, a PhD student in epidemiology at the University of Bristol, United Kingdom, and lead author of the study, said in a news release.
For their study, Ms. Martin and her colleagues analyzed data from more than 10,300 participants in the Avon Longitudinal Study of Parents and Children, which recruited women in the United Kingdom who were pregnant in 1991 and 1992.
The researchers had data about pain during sex at 11 years. They had data about sexual enjoyment and frequency at 33 months, 5 years, 12 years, and 18 years after delivery.
If women experienced pain during sex years after cesarean delivery, uterine scarring might have been a cause, Ms. Martin and colleagues suggested. Alternatively, women with dyspareunia before delivery may be more likely to have cesarean surgery, which also could explain the association.
Other studies have likewise found that different modes of delivery generally lead to similar outcomes of sexual well-being after birth.
“Several of my own longitudinal studies have shown limited associations between mode of delivery and various aspects of sexual well-being, including sexual satisfaction, sexual function, and sexual desire,” said Natalie O. Rosen, PhD, director of the Couples and Sexual Health Laboratory at Dalhousie University, Halifax, N.S.
Nevertheless, other published studies have yielded conflicting results, so the question warrants further study, she said.
Pain catastrophizing
One study by Dr. Rosen’s group, published in Obstetrics & Gynecology, tracked sexual pain in 582 people from mid-pregnancy to 2 years postpartum.
About 21% of participants experienced moderate pain during sex, as determined by an average pain score greater than 4 on scale of 0-10 points. The rest were classified as having “minimal dyspareunia.”
Pain tended to peak at 3 months postpartum and then steadily decrease in both the moderate and minimal pain groups.
Mode of delivery did not affect the odds that a participant would have moderate dyspareunia. Neither did breastfeeding or prior chronic pain.
“But we did find one key thing to look out for: Those who reported a lot of negative thoughts and feelings about pain, something called pain catastrophizing, were more likely to experience moderate persistent pain during sex,” the researchers said in a video about their findings.
Pain catastrophizing 3 months after delivery was associated with significantly increased odds of following a moderate pain trajectory (odds ratio, 1.09; 95% confidence interval, 1.04-1.15).
Let’s talk about #postbabyhankypanky
Caring for a newborn while maintaining a romantic relationship can be challenging, and “there is a lack of evidence-based research aimed at helping couples prevent and navigate changes to their sexual well-being postpartum,” Dr. Rosen said.
During the 2-year study, a growing number of participants reported having sex less often over time. The percentage of women who had engaged in sexual activity in the past 4 weeks was 99% at baseline (20-24 weeks of gestation), 83.5% at 32 weeks of gestation, 73.9% at 3 months postpartum, and 69.6% at 2 years postpartum.
“One crucial way that couples sustain their connection is through their sexuality,” Dr. Rosen said. “Unfortunately, most new parents experience significant disruptions to their sexual function,” such as lower sexual desire or more pain during intercourse.
Dr. Rosen’s group has created a series of videos related to this topic dubbed #postbabyhankypanky to facilitate communication about sex postpartum. She encourages women with dyspareunia to talk with a health care provider because treatments such as cognitive-behavioral therapy, pelvic floor physical therapy, and topical medications can help manage pain.
‘Reassuring’ data
Veronica Gillispie-Bell, MD, MAS, director of quality for women’s services at the Ochsner Health System, New Orleans, said that she sees patients with postpartum sexual pain frequently.
Patients typically are instructed to have pelvic rest from delivery until 6 weeks after.
At the 6-week appointment, she tells patients to make sure that they are using lots of lubrication, because vaginal dryness related to hormonal changes during pregnancy and breastfeeding can make sex more painful, regardless of mode of delivery.
For many patients, she also recommends pelvic floor physical therapy.
As the medical director for the Louisiana Perinatal Quality Collaborative – a network of care providers, public health officials, and advocates that aims to improve outcomes for birthing persons, families, and newborns – Dr. Gillispie-Bell also is focused on reducing the rate of cesarean deliveries in the state. The BJOG study showing an increased risk for dyspareunia after a cesarean surgery serves as a reminder that there may be “long-term effects of having a C-section that may not be as obvious,” she said.
“C-sections are life-saving procedures, but they are not without risk,” Dr. Gillispie-Bell said.
Leila Frodsham, MBChB, a spokesperson for the Royal College of Obstetricians and Gynaecologists, told Medscape UK that it was “reassuring” to see “no difference in sexual enjoyment or sexual frequency at any time point postpartum between women who gave birth via cesarean section and those who delivered vaginally.”
“Women should be supported to make informed decisions about how they plan to give birth, and it is vital that health care professionals respect their preferences,” Dr. Frodsham added.
Clinicians should also remain aware that sexual pain is also common during periods of subfertility, perimenopause, and initiation of sexual activity.
Combinations of biological, psychological, and social factors can influence pain during sex, and there is an interpersonal element to keep in mind as well, Dr. Rosen noted.
“Pain during sex is typically elicited in the context of a partnered relationship,” Dr. Rosen said. “This means that this is an inherently interpersonal issue – let’s not forget about the partner who is both impacted by and can impact the pain through their own responses.”
A version of this article first appeared on Medscape.com.
For some parents, resuming sexual intimacy after having a baby is a top priority. For others, not so much – and late-night feedings and diaper changes may not be the only hang-ups.
Dyspareunia – pain during sex – occurs in a substantial number of women after childbirth, and recent research sheds light on how psychological and biomedical factors relate to this condition.
Mode of delivery, for instance, may have less of an effect on sexual well-being than some people suspect.
Despite a perception that cesarean delivery might affect sexual function less than vaginal delivery does, how mothers delivered did not affect how often they had sex postpartum or the amount of enjoyment they got from it, according to research published in BJOG.
Eleven years after delivery, however, cesarean delivery was associated with a 74% increased likelihood of pain in the vagina during sex, compared with vaginal delivery, the researchers found (odds ratio, 1.74; 95% confidence interval, 1.46-2.08).
The results suggest that cesarean delivery “may not help protect against sexual dysfunction, as previously thought,” Flo Martin, a PhD student in epidemiology at the University of Bristol, United Kingdom, and lead author of the study, said in a news release.
For their study, Ms. Martin and her colleagues analyzed data from more than 10,300 participants in the Avon Longitudinal Study of Parents and Children, which recruited women in the United Kingdom who were pregnant in 1991 and 1992.
The researchers had data about pain during sex at 11 years. They had data about sexual enjoyment and frequency at 33 months, 5 years, 12 years, and 18 years after delivery.
If women experienced pain during sex years after cesarean delivery, uterine scarring might have been a cause, Ms. Martin and colleagues suggested. Alternatively, women with dyspareunia before delivery may be more likely to have cesarean surgery, which also could explain the association.
Other studies have likewise found that different modes of delivery generally lead to similar outcomes of sexual well-being after birth.
“Several of my own longitudinal studies have shown limited associations between mode of delivery and various aspects of sexual well-being, including sexual satisfaction, sexual function, and sexual desire,” said Natalie O. Rosen, PhD, director of the Couples and Sexual Health Laboratory at Dalhousie University, Halifax, N.S.
Nevertheless, other published studies have yielded conflicting results, so the question warrants further study, she said.
Pain catastrophizing
One study by Dr. Rosen’s group, published in Obstetrics & Gynecology, tracked sexual pain in 582 people from mid-pregnancy to 2 years postpartum.
About 21% of participants experienced moderate pain during sex, as determined by an average pain score greater than 4 on scale of 0-10 points. The rest were classified as having “minimal dyspareunia.”
Pain tended to peak at 3 months postpartum and then steadily decrease in both the moderate and minimal pain groups.
Mode of delivery did not affect the odds that a participant would have moderate dyspareunia. Neither did breastfeeding or prior chronic pain.
“But we did find one key thing to look out for: Those who reported a lot of negative thoughts and feelings about pain, something called pain catastrophizing, were more likely to experience moderate persistent pain during sex,” the researchers said in a video about their findings.
Pain catastrophizing 3 months after delivery was associated with significantly increased odds of following a moderate pain trajectory (odds ratio, 1.09; 95% confidence interval, 1.04-1.15).
Let’s talk about #postbabyhankypanky
Caring for a newborn while maintaining a romantic relationship can be challenging, and “there is a lack of evidence-based research aimed at helping couples prevent and navigate changes to their sexual well-being postpartum,” Dr. Rosen said.
During the 2-year study, a growing number of participants reported having sex less often over time. The percentage of women who had engaged in sexual activity in the past 4 weeks was 99% at baseline (20-24 weeks of gestation), 83.5% at 32 weeks of gestation, 73.9% at 3 months postpartum, and 69.6% at 2 years postpartum.
“One crucial way that couples sustain their connection is through their sexuality,” Dr. Rosen said. “Unfortunately, most new parents experience significant disruptions to their sexual function,” such as lower sexual desire or more pain during intercourse.
Dr. Rosen’s group has created a series of videos related to this topic dubbed #postbabyhankypanky to facilitate communication about sex postpartum. She encourages women with dyspareunia to talk with a health care provider because treatments such as cognitive-behavioral therapy, pelvic floor physical therapy, and topical medications can help manage pain.
‘Reassuring’ data
Veronica Gillispie-Bell, MD, MAS, director of quality for women’s services at the Ochsner Health System, New Orleans, said that she sees patients with postpartum sexual pain frequently.
Patients typically are instructed to have pelvic rest from delivery until 6 weeks after.
At the 6-week appointment, she tells patients to make sure that they are using lots of lubrication, because vaginal dryness related to hormonal changes during pregnancy and breastfeeding can make sex more painful, regardless of mode of delivery.
For many patients, she also recommends pelvic floor physical therapy.
As the medical director for the Louisiana Perinatal Quality Collaborative – a network of care providers, public health officials, and advocates that aims to improve outcomes for birthing persons, families, and newborns – Dr. Gillispie-Bell also is focused on reducing the rate of cesarean deliveries in the state. The BJOG study showing an increased risk for dyspareunia after a cesarean surgery serves as a reminder that there may be “long-term effects of having a C-section that may not be as obvious,” she said.
“C-sections are life-saving procedures, but they are not without risk,” Dr. Gillispie-Bell said.
Leila Frodsham, MBChB, a spokesperson for the Royal College of Obstetricians and Gynaecologists, told Medscape UK that it was “reassuring” to see “no difference in sexual enjoyment or sexual frequency at any time point postpartum between women who gave birth via cesarean section and those who delivered vaginally.”
“Women should be supported to make informed decisions about how they plan to give birth, and it is vital that health care professionals respect their preferences,” Dr. Frodsham added.
Clinicians should also remain aware that sexual pain is also common during periods of subfertility, perimenopause, and initiation of sexual activity.
Combinations of biological, psychological, and social factors can influence pain during sex, and there is an interpersonal element to keep in mind as well, Dr. Rosen noted.
“Pain during sex is typically elicited in the context of a partnered relationship,” Dr. Rosen said. “This means that this is an inherently interpersonal issue – let’s not forget about the partner who is both impacted by and can impact the pain through their own responses.”
A version of this article first appeared on Medscape.com.
Dr. Birds-n-Bees: How physicians are taking up the sex ed slack
An athletic coach stands in front of a packed gym full of high school students.
“Don’t have sex,” he instructs, “because you will get pregnant and die. Don’t have sex in the missionary position. Don’t have sex standing up. Just don’t do it, promise? Okay, everybody take some rubbers.”
Sad to say, this scene from the 2004 movie “Mean Girls” bears a striking resemblance to the actual sex education courses taught in schools across the United States today. In fact, things may have gotten measurably worse.
National data recently published by the Guttmacher Institute showed that adolescents were less likely to receive adequate sex education from 2015 to 2019 than they were in 1995. Only half of kids aged 15-19 received sex education that met minimum standards recommended by the Department of Health & Human Services, and fewer than half were given this information before having sex for the first time. With such a vast learning gap, it is no surprise that the United States has some of the highest rates of teenage pregnancy and sexually transmitted infections in the developed world.
Concerned and motivated by this need for sex education, physicians and other medical professionals are stepping in to fill the void, offering sexual health information through a range of methods to students of all ages (some a lot older than one may think). It is a calling that takes them outside their hospitals and exam rooms into workshops and through educational materials, video, and social media content created from scratch.
“The fact that we’re able to go in and provide factual, scientific, important information that can affect the trajectory of someone’s life is powerful,” said Julia Rossen, part of a contingent of med students at Brown University, Providence, R.I., who now teach sex ed as an elective.
Their goals are not just about protecting health. Many are also teaching about other topics commonly ignored in sex education classes, such as consent, pleasure, LGBTQ+ identities, and cultural competence. There is a mutually beneficial relationship, they say, between their sex education work and their medical practice.
Changing the status quo
A jumble of state laws govern how and when schools should offer sex education courses. Individual school districts often make the final decisions about their content, creating even more inconsistent standards. Only 29 states and the District of Columbia mandate sex education, and 13 of those do not require that it be medically accurate. Abstinence-only education, which has been shown to be ineffective, is exclusively taught in 16 states.
Without formal instruction, many young people must learn about sex from family members, who may be unwilling, or they may share knowledge between themselves, which is often incorrect, or navigate the limitless information and misinformation available on the internet.
The consequences of this were apparent to several medical students at Brown University in 2013. At the time, the rate of teenage pregnancy across Rhode Island was 1 in 100, but in the small city of Central Falls, it was 1 in 25. Aiming to improve this, the group created a comprehensive sex education program for a Central Falls middle school that was taught by medical student volunteers.
The Sex Ed by Brown Med program continues today. It consists of eight in-person sessions. Topics include anatomy, contraception, STIs, sexual decision-making, consent, sexual violence, and sexual and gender identity. Through this program, as well as other factors, the Central Falls teenage pregnancy rate declined to 1.6 in 100 from 2016 to 2020, according to the Rhode Island Department of Health.
“Historically, sexual education has been politicized,” said Ms. Rossen, one of the current program leaders. “It’s been at the discretion of a lot of different factors that aren’t under the control of the communities that are actually receiving the education.”
Among seventh graders, the teachers say they encounter different levels of maturity. But they feel that the kids are more receptive and open with younger adults who, like them, are still students. Some volunteers recall the flaws in their own sex education, particularly regarding topics such as consent and gender and sexual identity, and they believe middle school is the time to begin the sexual health conversation. “By the time you’re talking to college-age students, it’s pretty much too late,” said another group leader, Benjamin Stone.
Mr. Stone feels that practicing having these often-awkward discussions enhances their clinical skills as physicians. “Sex and sexual history are part of the comprehensive medical interview. People want to have these conversations, and they’re looking for someone to open the door. The kids are excited that we’re opening that door for them. And I think patients feel the same way.”
Conquering social media
Opening the door has been more like releasing a floodgate for Danielle Jones, MD, an ob.gyn. physician who is originally from Texas but who moved to New Zealand in 2021. Known on social media as “Mama Doctor Jones,” she has garnered more than 3 million followers across YouTube, TikTok, Twitter, Instagram, and Facebook. Dr. Jones produces short, friendly, entertaining videos on a range of reproductive health and sex education topics. They appeal to an adolescent audience hungry for a trustworthy voice on issues such as,: “5 ‘Strange’ Things Your Vagina Does That Are NORMAL” and “Condom Broke ... Now What?”
Dr. Jones uses her platform to debunk some of the misleading and inaccurate sexual health information being taught in classrooms, by other social media influencers, and that is found on the internet in general. Her no-nonsense-style videos call out such myths as being unable to pee with a tampon in, Plan B emergency contraception causing abortions, and COVID-19 vaccines damaging fertility.
“The way sex ed is done in the U.S. in most places is continuing the taboo by making it a one-time discussion or health class,” said Dr. Jones, “particularly if boys and girls are separated. That doesn’t further communication between people or foster an environment where it’s okay to discuss your body and puberty and changes in sexual health in general. And if you can’t talk about it in educational spaces, you’re certainly not going to be comfortable talking about that in a one-on-one situation with another 16-year-old.”
Taking on other taboos, Dr. Jones has been outspoken about abortion and the consequences of the recent Supreme Court decision, both as an ethical issue and a medical one that endangers lives. Raised in a deeply religious family, Dr. Jones said she was indoctrinated with antiabortion views, and it took time for her thinking to evolve “from a scientific and humanistic standpoint.” While working in a Texas private practice, Dr. Jones described being unable to mention abortion online because of fear of losing her patients and for her own safety.
Now free of those constraints, Dr. Jones feels that her videos can be important resources for teachers who may have little health training. And she is enthusiastic about the complementary relationship between her social media work and her clinical practice. “There are conversations I have all the time in the clinic where patients tell me: ‘Nobody’s ever really had this conversation in this way with me. Thank you for explaining that,’ ” said Dr. Jones. “And then I think: ‘Well, now I’ll have it with a hundred thousand other people too.’ ”
Promoting pleasure
While not an ob.gyn., discussing sexuality with patients has become a focus for Evelin Dacker, MD, a family physician in Salem, Ore. Dr. Dacker is certified in functional medicine, which takes a holistic and integrative approach. During her training she had a sudden realization: Sexuality had not been discussed at any point during her medical education.
“I recognized that this was a huge gap in how we deal with a person as a human,” Dr. Dacker explained. “Since sexuality plays a role in so many aspects of our humanness, not just having sex.”
Dr. Dacker believes in rethinking sexuality as a fundamental part of overall health, as vital as nutrition or blood pressure. Outside her medical practice, she teaches classes and workshops on sexual health and sex positivity for young adults and other physicians. She has also developed an educational framework for sexual health topics. Dr. Dacker said she frequently confronts the idea that sexuality is only about engaging with another person. She disagrees. Using food as a metaphor, she argues that just as the pleasure of eating something is purely for oneself, sexuality belongs to the individual.
Sexuality can also be a tool for pleasure, which Dr. Dacker believes plays an essential role in physical health. “Pleasure is a medicine,” Dr. Dacker said. “I actually prescribe self-pleasure practices to my patients, so they can start owning it within themselves. Make sure you get 7-8 hours of sleep, do some breathing exercises to help bring down your stress, and do self-pleasure so that you can integrate into your body better.”
She added that the impact of prioritizing one’s own desires, needs, and boundaries can transform how people view their sexuality. Her adult students frequently ask: “Why wasn’t I taught this as a teenager?”
Speaking of adult students – An older generation learns new tricks
While the teen cohort is usually the focus, the lack of sex education in previous decades – and the way sexual culture has evolved in that time – have an impact on older groups. Among U.S. adults aged 55 and older, the rate of STIs has more than doubled in the past 10 years, according to the Centers for Disease Control and Prevention. While the majority of STI cases still occur among teenagers and young adults, the consistent increase in STIs among older persons is cause for concern among physicians and researchers.
The issue worries Shannon Dowler, MD, a family physician in western North Carolina and chief medical officer for North Carolina Medicaid. Dr. Dowler, who has practiced in an STI clinic throughout her career, began seeing more and more older adults with chlamydia, herpes, and other STIs. Dowler cites several factors behind the rise, including the growing retirement community population, the availability of pharmaceuticals for sexual dysfunction, and the “hook-up culture” that is active on dating apps, which research shows are regularly used by more than a third of adults older than 55.
Dr. Dowler also sees a lack of communication about sexual health between physicians and their older patients. “Older adults are more likely to be in relationship with their physician outside the exam room, especially if they’re in a small community,” Dr. Dowler said. “Sometimes they aren’t as comfortable sharing what their risks are. But we are guilty in medicine all the time of not asking. We assume someone’s older so they’re not having sex anymore. But, in fact, they are, and we’re not taking the time to say: ‘Let’s talk about your sex life. Are you at risk for anything? Are you having any difficulties with sex?’ We tend to avoid it as a health care culture.”
In contrast, Dr. Dowler said she talks about sexual health with anyone who will listen. She teaches classes in private schools and universities and for church youth groups and other physicians. She often finds that public schools are not interested, which she attributes to fear of her discussing things “outside the rule book.”
Dr. Dowler takes creative approaches. In 2017, she released a hip-hop video, “STD’s Never Get Old,” in which she raps about safe sex for older adults. Her video went viral, was mentioned by several news outlets, and received over 50,000 views on YouTube. Dr. Dowler’s latest project is a book, “Never Too Late: Your Guide to Safer Sex after 60,” which is scheduled for publication on Valentine’s Day, 2023.
“It’s sex ed for seniors,” she explained. “It’s that gym class that some people got – I won’t say everyone got – in high school. This is the version for older adults who didn’t get that. There are new infections now that didn’t exist when they had sex education, if they had sex education.”
A big subject requires a big mission
For others in the sex education field, physicians are allies in their fight against agendas designed to obstruct or erode sex education. Alison Macklin, director of policy and advocacy at SIECUS: Sex Ed for Social Change, formerly the Sexuality Information and Education Council of the United States, sees this struggle playing out in school boards and state legislatures across the country. For every comprehensive sex education bill passed or school district victory, there is yet another blocked proposal or restrictive law somewhere else.
Ms. Macklin urged doctors to get more involved locally and to expand their knowledge of sexual health issues by reaching out to organizations such as Planned Parenthood and to be “hyper vigilant” in their own communities.
“Doctors are trusted. People really respect what they have to say,” Ms. Macklin said. “And this is an important time for them to speak up.”
A version of this article first appeared on Medscape.com.
An athletic coach stands in front of a packed gym full of high school students.
“Don’t have sex,” he instructs, “because you will get pregnant and die. Don’t have sex in the missionary position. Don’t have sex standing up. Just don’t do it, promise? Okay, everybody take some rubbers.”
Sad to say, this scene from the 2004 movie “Mean Girls” bears a striking resemblance to the actual sex education courses taught in schools across the United States today. In fact, things may have gotten measurably worse.
National data recently published by the Guttmacher Institute showed that adolescents were less likely to receive adequate sex education from 2015 to 2019 than they were in 1995. Only half of kids aged 15-19 received sex education that met minimum standards recommended by the Department of Health & Human Services, and fewer than half were given this information before having sex for the first time. With such a vast learning gap, it is no surprise that the United States has some of the highest rates of teenage pregnancy and sexually transmitted infections in the developed world.
Concerned and motivated by this need for sex education, physicians and other medical professionals are stepping in to fill the void, offering sexual health information through a range of methods to students of all ages (some a lot older than one may think). It is a calling that takes them outside their hospitals and exam rooms into workshops and through educational materials, video, and social media content created from scratch.
“The fact that we’re able to go in and provide factual, scientific, important information that can affect the trajectory of someone’s life is powerful,” said Julia Rossen, part of a contingent of med students at Brown University, Providence, R.I., who now teach sex ed as an elective.
Their goals are not just about protecting health. Many are also teaching about other topics commonly ignored in sex education classes, such as consent, pleasure, LGBTQ+ identities, and cultural competence. There is a mutually beneficial relationship, they say, between their sex education work and their medical practice.
Changing the status quo
A jumble of state laws govern how and when schools should offer sex education courses. Individual school districts often make the final decisions about their content, creating even more inconsistent standards. Only 29 states and the District of Columbia mandate sex education, and 13 of those do not require that it be medically accurate. Abstinence-only education, which has been shown to be ineffective, is exclusively taught in 16 states.
Without formal instruction, many young people must learn about sex from family members, who may be unwilling, or they may share knowledge between themselves, which is often incorrect, or navigate the limitless information and misinformation available on the internet.
The consequences of this were apparent to several medical students at Brown University in 2013. At the time, the rate of teenage pregnancy across Rhode Island was 1 in 100, but in the small city of Central Falls, it was 1 in 25. Aiming to improve this, the group created a comprehensive sex education program for a Central Falls middle school that was taught by medical student volunteers.
The Sex Ed by Brown Med program continues today. It consists of eight in-person sessions. Topics include anatomy, contraception, STIs, sexual decision-making, consent, sexual violence, and sexual and gender identity. Through this program, as well as other factors, the Central Falls teenage pregnancy rate declined to 1.6 in 100 from 2016 to 2020, according to the Rhode Island Department of Health.
“Historically, sexual education has been politicized,” said Ms. Rossen, one of the current program leaders. “It’s been at the discretion of a lot of different factors that aren’t under the control of the communities that are actually receiving the education.”
Among seventh graders, the teachers say they encounter different levels of maturity. But they feel that the kids are more receptive and open with younger adults who, like them, are still students. Some volunteers recall the flaws in their own sex education, particularly regarding topics such as consent and gender and sexual identity, and they believe middle school is the time to begin the sexual health conversation. “By the time you’re talking to college-age students, it’s pretty much too late,” said another group leader, Benjamin Stone.
Mr. Stone feels that practicing having these often-awkward discussions enhances their clinical skills as physicians. “Sex and sexual history are part of the comprehensive medical interview. People want to have these conversations, and they’re looking for someone to open the door. The kids are excited that we’re opening that door for them. And I think patients feel the same way.”
Conquering social media
Opening the door has been more like releasing a floodgate for Danielle Jones, MD, an ob.gyn. physician who is originally from Texas but who moved to New Zealand in 2021. Known on social media as “Mama Doctor Jones,” she has garnered more than 3 million followers across YouTube, TikTok, Twitter, Instagram, and Facebook. Dr. Jones produces short, friendly, entertaining videos on a range of reproductive health and sex education topics. They appeal to an adolescent audience hungry for a trustworthy voice on issues such as,: “5 ‘Strange’ Things Your Vagina Does That Are NORMAL” and “Condom Broke ... Now What?”
Dr. Jones uses her platform to debunk some of the misleading and inaccurate sexual health information being taught in classrooms, by other social media influencers, and that is found on the internet in general. Her no-nonsense-style videos call out such myths as being unable to pee with a tampon in, Plan B emergency contraception causing abortions, and COVID-19 vaccines damaging fertility.
“The way sex ed is done in the U.S. in most places is continuing the taboo by making it a one-time discussion or health class,” said Dr. Jones, “particularly if boys and girls are separated. That doesn’t further communication between people or foster an environment where it’s okay to discuss your body and puberty and changes in sexual health in general. And if you can’t talk about it in educational spaces, you’re certainly not going to be comfortable talking about that in a one-on-one situation with another 16-year-old.”
Taking on other taboos, Dr. Jones has been outspoken about abortion and the consequences of the recent Supreme Court decision, both as an ethical issue and a medical one that endangers lives. Raised in a deeply religious family, Dr. Jones said she was indoctrinated with antiabortion views, and it took time for her thinking to evolve “from a scientific and humanistic standpoint.” While working in a Texas private practice, Dr. Jones described being unable to mention abortion online because of fear of losing her patients and for her own safety.
Now free of those constraints, Dr. Jones feels that her videos can be important resources for teachers who may have little health training. And she is enthusiastic about the complementary relationship between her social media work and her clinical practice. “There are conversations I have all the time in the clinic where patients tell me: ‘Nobody’s ever really had this conversation in this way with me. Thank you for explaining that,’ ” said Dr. Jones. “And then I think: ‘Well, now I’ll have it with a hundred thousand other people too.’ ”
Promoting pleasure
While not an ob.gyn., discussing sexuality with patients has become a focus for Evelin Dacker, MD, a family physician in Salem, Ore. Dr. Dacker is certified in functional medicine, which takes a holistic and integrative approach. During her training she had a sudden realization: Sexuality had not been discussed at any point during her medical education.
“I recognized that this was a huge gap in how we deal with a person as a human,” Dr. Dacker explained. “Since sexuality plays a role in so many aspects of our humanness, not just having sex.”
Dr. Dacker believes in rethinking sexuality as a fundamental part of overall health, as vital as nutrition or blood pressure. Outside her medical practice, she teaches classes and workshops on sexual health and sex positivity for young adults and other physicians. She has also developed an educational framework for sexual health topics. Dr. Dacker said she frequently confronts the idea that sexuality is only about engaging with another person. She disagrees. Using food as a metaphor, she argues that just as the pleasure of eating something is purely for oneself, sexuality belongs to the individual.
Sexuality can also be a tool for pleasure, which Dr. Dacker believes plays an essential role in physical health. “Pleasure is a medicine,” Dr. Dacker said. “I actually prescribe self-pleasure practices to my patients, so they can start owning it within themselves. Make sure you get 7-8 hours of sleep, do some breathing exercises to help bring down your stress, and do self-pleasure so that you can integrate into your body better.”
She added that the impact of prioritizing one’s own desires, needs, and boundaries can transform how people view their sexuality. Her adult students frequently ask: “Why wasn’t I taught this as a teenager?”
Speaking of adult students – An older generation learns new tricks
While the teen cohort is usually the focus, the lack of sex education in previous decades – and the way sexual culture has evolved in that time – have an impact on older groups. Among U.S. adults aged 55 and older, the rate of STIs has more than doubled in the past 10 years, according to the Centers for Disease Control and Prevention. While the majority of STI cases still occur among teenagers and young adults, the consistent increase in STIs among older persons is cause for concern among physicians and researchers.
The issue worries Shannon Dowler, MD, a family physician in western North Carolina and chief medical officer for North Carolina Medicaid. Dr. Dowler, who has practiced in an STI clinic throughout her career, began seeing more and more older adults with chlamydia, herpes, and other STIs. Dowler cites several factors behind the rise, including the growing retirement community population, the availability of pharmaceuticals for sexual dysfunction, and the “hook-up culture” that is active on dating apps, which research shows are regularly used by more than a third of adults older than 55.
Dr. Dowler also sees a lack of communication about sexual health between physicians and their older patients. “Older adults are more likely to be in relationship with their physician outside the exam room, especially if they’re in a small community,” Dr. Dowler said. “Sometimes they aren’t as comfortable sharing what their risks are. But we are guilty in medicine all the time of not asking. We assume someone’s older so they’re not having sex anymore. But, in fact, they are, and we’re not taking the time to say: ‘Let’s talk about your sex life. Are you at risk for anything? Are you having any difficulties with sex?’ We tend to avoid it as a health care culture.”
In contrast, Dr. Dowler said she talks about sexual health with anyone who will listen. She teaches classes in private schools and universities and for church youth groups and other physicians. She often finds that public schools are not interested, which she attributes to fear of her discussing things “outside the rule book.”
Dr. Dowler takes creative approaches. In 2017, she released a hip-hop video, “STD’s Never Get Old,” in which she raps about safe sex for older adults. Her video went viral, was mentioned by several news outlets, and received over 50,000 views on YouTube. Dr. Dowler’s latest project is a book, “Never Too Late: Your Guide to Safer Sex after 60,” which is scheduled for publication on Valentine’s Day, 2023.
“It’s sex ed for seniors,” she explained. “It’s that gym class that some people got – I won’t say everyone got – in high school. This is the version for older adults who didn’t get that. There are new infections now that didn’t exist when they had sex education, if they had sex education.”
A big subject requires a big mission
For others in the sex education field, physicians are allies in their fight against agendas designed to obstruct or erode sex education. Alison Macklin, director of policy and advocacy at SIECUS: Sex Ed for Social Change, formerly the Sexuality Information and Education Council of the United States, sees this struggle playing out in school boards and state legislatures across the country. For every comprehensive sex education bill passed or school district victory, there is yet another blocked proposal or restrictive law somewhere else.
Ms. Macklin urged doctors to get more involved locally and to expand their knowledge of sexual health issues by reaching out to organizations such as Planned Parenthood and to be “hyper vigilant” in their own communities.
“Doctors are trusted. People really respect what they have to say,” Ms. Macklin said. “And this is an important time for them to speak up.”
A version of this article first appeared on Medscape.com.
An athletic coach stands in front of a packed gym full of high school students.
“Don’t have sex,” he instructs, “because you will get pregnant and die. Don’t have sex in the missionary position. Don’t have sex standing up. Just don’t do it, promise? Okay, everybody take some rubbers.”
Sad to say, this scene from the 2004 movie “Mean Girls” bears a striking resemblance to the actual sex education courses taught in schools across the United States today. In fact, things may have gotten measurably worse.
National data recently published by the Guttmacher Institute showed that adolescents were less likely to receive adequate sex education from 2015 to 2019 than they were in 1995. Only half of kids aged 15-19 received sex education that met minimum standards recommended by the Department of Health & Human Services, and fewer than half were given this information before having sex for the first time. With such a vast learning gap, it is no surprise that the United States has some of the highest rates of teenage pregnancy and sexually transmitted infections in the developed world.
Concerned and motivated by this need for sex education, physicians and other medical professionals are stepping in to fill the void, offering sexual health information through a range of methods to students of all ages (some a lot older than one may think). It is a calling that takes them outside their hospitals and exam rooms into workshops and through educational materials, video, and social media content created from scratch.
“The fact that we’re able to go in and provide factual, scientific, important information that can affect the trajectory of someone’s life is powerful,” said Julia Rossen, part of a contingent of med students at Brown University, Providence, R.I., who now teach sex ed as an elective.
Their goals are not just about protecting health. Many are also teaching about other topics commonly ignored in sex education classes, such as consent, pleasure, LGBTQ+ identities, and cultural competence. There is a mutually beneficial relationship, they say, between their sex education work and their medical practice.
Changing the status quo
A jumble of state laws govern how and when schools should offer sex education courses. Individual school districts often make the final decisions about their content, creating even more inconsistent standards. Only 29 states and the District of Columbia mandate sex education, and 13 of those do not require that it be medically accurate. Abstinence-only education, which has been shown to be ineffective, is exclusively taught in 16 states.
Without formal instruction, many young people must learn about sex from family members, who may be unwilling, or they may share knowledge between themselves, which is often incorrect, or navigate the limitless information and misinformation available on the internet.
The consequences of this were apparent to several medical students at Brown University in 2013. At the time, the rate of teenage pregnancy across Rhode Island was 1 in 100, but in the small city of Central Falls, it was 1 in 25. Aiming to improve this, the group created a comprehensive sex education program for a Central Falls middle school that was taught by medical student volunteers.
The Sex Ed by Brown Med program continues today. It consists of eight in-person sessions. Topics include anatomy, contraception, STIs, sexual decision-making, consent, sexual violence, and sexual and gender identity. Through this program, as well as other factors, the Central Falls teenage pregnancy rate declined to 1.6 in 100 from 2016 to 2020, according to the Rhode Island Department of Health.
“Historically, sexual education has been politicized,” said Ms. Rossen, one of the current program leaders. “It’s been at the discretion of a lot of different factors that aren’t under the control of the communities that are actually receiving the education.”
Among seventh graders, the teachers say they encounter different levels of maturity. But they feel that the kids are more receptive and open with younger adults who, like them, are still students. Some volunteers recall the flaws in their own sex education, particularly regarding topics such as consent and gender and sexual identity, and they believe middle school is the time to begin the sexual health conversation. “By the time you’re talking to college-age students, it’s pretty much too late,” said another group leader, Benjamin Stone.
Mr. Stone feels that practicing having these often-awkward discussions enhances their clinical skills as physicians. “Sex and sexual history are part of the comprehensive medical interview. People want to have these conversations, and they’re looking for someone to open the door. The kids are excited that we’re opening that door for them. And I think patients feel the same way.”
Conquering social media
Opening the door has been more like releasing a floodgate for Danielle Jones, MD, an ob.gyn. physician who is originally from Texas but who moved to New Zealand in 2021. Known on social media as “Mama Doctor Jones,” she has garnered more than 3 million followers across YouTube, TikTok, Twitter, Instagram, and Facebook. Dr. Jones produces short, friendly, entertaining videos on a range of reproductive health and sex education topics. They appeal to an adolescent audience hungry for a trustworthy voice on issues such as,: “5 ‘Strange’ Things Your Vagina Does That Are NORMAL” and “Condom Broke ... Now What?”
Dr. Jones uses her platform to debunk some of the misleading and inaccurate sexual health information being taught in classrooms, by other social media influencers, and that is found on the internet in general. Her no-nonsense-style videos call out such myths as being unable to pee with a tampon in, Plan B emergency contraception causing abortions, and COVID-19 vaccines damaging fertility.
“The way sex ed is done in the U.S. in most places is continuing the taboo by making it a one-time discussion or health class,” said Dr. Jones, “particularly if boys and girls are separated. That doesn’t further communication between people or foster an environment where it’s okay to discuss your body and puberty and changes in sexual health in general. And if you can’t talk about it in educational spaces, you’re certainly not going to be comfortable talking about that in a one-on-one situation with another 16-year-old.”
Taking on other taboos, Dr. Jones has been outspoken about abortion and the consequences of the recent Supreme Court decision, both as an ethical issue and a medical one that endangers lives. Raised in a deeply religious family, Dr. Jones said she was indoctrinated with antiabortion views, and it took time for her thinking to evolve “from a scientific and humanistic standpoint.” While working in a Texas private practice, Dr. Jones described being unable to mention abortion online because of fear of losing her patients and for her own safety.
Now free of those constraints, Dr. Jones feels that her videos can be important resources for teachers who may have little health training. And she is enthusiastic about the complementary relationship between her social media work and her clinical practice. “There are conversations I have all the time in the clinic where patients tell me: ‘Nobody’s ever really had this conversation in this way with me. Thank you for explaining that,’ ” said Dr. Jones. “And then I think: ‘Well, now I’ll have it with a hundred thousand other people too.’ ”
Promoting pleasure
While not an ob.gyn., discussing sexuality with patients has become a focus for Evelin Dacker, MD, a family physician in Salem, Ore. Dr. Dacker is certified in functional medicine, which takes a holistic and integrative approach. During her training she had a sudden realization: Sexuality had not been discussed at any point during her medical education.
“I recognized that this was a huge gap in how we deal with a person as a human,” Dr. Dacker explained. “Since sexuality plays a role in so many aspects of our humanness, not just having sex.”
Dr. Dacker believes in rethinking sexuality as a fundamental part of overall health, as vital as nutrition or blood pressure. Outside her medical practice, she teaches classes and workshops on sexual health and sex positivity for young adults and other physicians. She has also developed an educational framework for sexual health topics. Dr. Dacker said she frequently confronts the idea that sexuality is only about engaging with another person. She disagrees. Using food as a metaphor, she argues that just as the pleasure of eating something is purely for oneself, sexuality belongs to the individual.
Sexuality can also be a tool for pleasure, which Dr. Dacker believes plays an essential role in physical health. “Pleasure is a medicine,” Dr. Dacker said. “I actually prescribe self-pleasure practices to my patients, so they can start owning it within themselves. Make sure you get 7-8 hours of sleep, do some breathing exercises to help bring down your stress, and do self-pleasure so that you can integrate into your body better.”
She added that the impact of prioritizing one’s own desires, needs, and boundaries can transform how people view their sexuality. Her adult students frequently ask: “Why wasn’t I taught this as a teenager?”
Speaking of adult students – An older generation learns new tricks
While the teen cohort is usually the focus, the lack of sex education in previous decades – and the way sexual culture has evolved in that time – have an impact on older groups. Among U.S. adults aged 55 and older, the rate of STIs has more than doubled in the past 10 years, according to the Centers for Disease Control and Prevention. While the majority of STI cases still occur among teenagers and young adults, the consistent increase in STIs among older persons is cause for concern among physicians and researchers.
The issue worries Shannon Dowler, MD, a family physician in western North Carolina and chief medical officer for North Carolina Medicaid. Dr. Dowler, who has practiced in an STI clinic throughout her career, began seeing more and more older adults with chlamydia, herpes, and other STIs. Dowler cites several factors behind the rise, including the growing retirement community population, the availability of pharmaceuticals for sexual dysfunction, and the “hook-up culture” that is active on dating apps, which research shows are regularly used by more than a third of adults older than 55.
Dr. Dowler also sees a lack of communication about sexual health between physicians and their older patients. “Older adults are more likely to be in relationship with their physician outside the exam room, especially if they’re in a small community,” Dr. Dowler said. “Sometimes they aren’t as comfortable sharing what their risks are. But we are guilty in medicine all the time of not asking. We assume someone’s older so they’re not having sex anymore. But, in fact, they are, and we’re not taking the time to say: ‘Let’s talk about your sex life. Are you at risk for anything? Are you having any difficulties with sex?’ We tend to avoid it as a health care culture.”
In contrast, Dr. Dowler said she talks about sexual health with anyone who will listen. She teaches classes in private schools and universities and for church youth groups and other physicians. She often finds that public schools are not interested, which she attributes to fear of her discussing things “outside the rule book.”
Dr. Dowler takes creative approaches. In 2017, she released a hip-hop video, “STD’s Never Get Old,” in which she raps about safe sex for older adults. Her video went viral, was mentioned by several news outlets, and received over 50,000 views on YouTube. Dr. Dowler’s latest project is a book, “Never Too Late: Your Guide to Safer Sex after 60,” which is scheduled for publication on Valentine’s Day, 2023.
“It’s sex ed for seniors,” she explained. “It’s that gym class that some people got – I won’t say everyone got – in high school. This is the version for older adults who didn’t get that. There are new infections now that didn’t exist when they had sex education, if they had sex education.”
A big subject requires a big mission
For others in the sex education field, physicians are allies in their fight against agendas designed to obstruct or erode sex education. Alison Macklin, director of policy and advocacy at SIECUS: Sex Ed for Social Change, formerly the Sexuality Information and Education Council of the United States, sees this struggle playing out in school boards and state legislatures across the country. For every comprehensive sex education bill passed or school district victory, there is yet another blocked proposal or restrictive law somewhere else.
Ms. Macklin urged doctors to get more involved locally and to expand their knowledge of sexual health issues by reaching out to organizations such as Planned Parenthood and to be “hyper vigilant” in their own communities.
“Doctors are trusted. People really respect what they have to say,” Ms. Macklin said. “And this is an important time for them to speak up.”
A version of this article first appeared on Medscape.com.
Early age at hysterectomy ups type 2 diabetes risk
Data from a large French cohort study suggest that women who have a hysterectomy before 40-45 years of age may be at particular risk of subsequently developing type 2 diabetes.
A 20% increase in the risk for incident diabetes was found comparing women of all ages who had and had not had a hysterectomy (P = .0003).
This risk jumped to a 52% increase when only women below the age of 45 were considered (P < .0001) and was still 38% higher if only women under 40 years were analyzed (P = .005).
“Our findings clearly show that hysterectomy is a risk marker for diabetes,” Fabrice Bonnet, MD, PhD, of Centre Hospitalier Universitaire (CHU) de Rennes (France), said at the annual meeting of the European Association for the Study of Diabetes.
Importantly, this risk appears to occur “independently of any hormonal therapy, any reproductive factors, physical activity, and diet,” Dr. Bonnet added.
Findings challenged
“I would like to challenge your findings,” said Peter Nilsson, MD, PhD, a professor at Lund (Sweden) University, during the postpresentation discussion period.
“Could there be a detection bias?” queried Dr. Nilsson. “If you undergo surgery like this, there will be several postoperative visits to a physician and there’s a higher likelihood of somebody taking blood samples and detecting diabetes.
“So, if this is true, it could mean that postoperative controls of goiter or thyroid surgery would bring the same findings,” Dr. Nilsson suggested.
“It is an epidemiological cohort of woman followed for a long time,” Dr. Bonnet responded. “So of course, there probably was more blood testing than in the usual population, but we did not observe the association for another type of surgery and type 2 diabetes.”
Clarifying further, Dr. Bonnet said that they had looked at thyroid surgery but not any other types of abdominal surgery.
Assessing the risk of incident diabetes
Hysterectomy is a common surgery among women – more than 400,000 are estimated to be performed every year in the United States, and 80,000 in France, with a rising rate in developing countries, Dr. Bonnet said in an interview.
“We don’t know exactly why that is, but it could have long-term consequences in terms of metabolic effects and the incidence of diabetes,” he said.
Prior research has linked having a hysterectomy with an increased rate of hypertension and cardiovascular risk, and there have also been a few studies linking it to diabetes.
“Our aim was to analyze the relationship between the past history of hysterectomies and the risk of incident diabetes; and specifically, we assessed the influence of age,” Dr. Bonnet said.
To do so, data on more than 83,000 women who had participated in The French E3N Prospective Cohort Study (E3N) were obtained. This large epidemiologic study is the French component of the long-running EPIC study.
For inclusion in the analysis, women had to have no diabetes at baseline, to have had their uterus, ovaries, or both removed for benign gynecologic reasons, and to have had their surgeries performed before any diagnosis of diabetes had been made. A diagnosis of diabetes was identified through the women’s responses to self-report questionnaires and prescriptions for antidiabetic medications.
In all, 2,672 women were found to have developed diabetes during the 16-year follow-up period.
The hazard ratio for the risk of diabetes in women who had and had not had a hysterectomy was 1.30 (95% confidence interval, 1.17-1.43; P < .0001), taking age into account and stratifying for birth generation.
The association held, when there was adjustment for other factors such as smoking status, physical activity, history of diabetes, weight, and adherence to a Mediterranean diet (HR 1.27; 95% CI 1.02-1.05; P = .02).
And, after adjustment for age at menarche, menopausal status, age at which menopause was reached, oral contraceptive and hormone therapy use, and the number of pregnancies, the risk for type 2 diabetes was still apparent in those who had undergoing a hysterectomy (HR, 1.20; 95% CI, 1.09-1.33; P = .0003).
Risk increased with oophorectomy
“Women who had both hysterectomy with bilateral oophorectomy had the highest rates of incident diabetes, as compared to women without hysterectomy and no oophorectomy,” said Dr. Bonnet (HR, 1.26; 95% CI, 1.11-1.42; P = .0003).
“This suggests preserving ovarian function is of importance,” he added. “Try to keep the ovaries in place, so just have hysterectomy alone,” he suggested might be the advice to fellow clinicians.
“So, identifying women at higher risk could be followed by a prevention program,” he suggested. “We do this for women who have gestational diabetes,” but for women who have had a hysterectomy, “we didn’t pay attention to this until now.”
No increased risk for endometriosis
While hysterectomy appears to up the risk for diabetes, having endometriosis does not. In a separate analysis of data from the E3N cohort, no effect was seen despite the association between endometriosis and other cardiometabolic risk factors.
The HR for incident type 2 diabetes comparing women with and without endometriosis was 10.06 in a fully adjusted statistical model (95% CI, 0.87-1.29). While there was an increase in the risk for diabetes if a woman had endometriosis and had also had a hysterectomy, this was not significant (HR, 1.22; 95% CI, 0.96-1.54).
The E3N study was sponsored by the French Institute for Health and Research. Dr. Bonnet and Dr. Nilsson had no relevant conflicts of interest to disclose.
Data from a large French cohort study suggest that women who have a hysterectomy before 40-45 years of age may be at particular risk of subsequently developing type 2 diabetes.
A 20% increase in the risk for incident diabetes was found comparing women of all ages who had and had not had a hysterectomy (P = .0003).
This risk jumped to a 52% increase when only women below the age of 45 were considered (P < .0001) and was still 38% higher if only women under 40 years were analyzed (P = .005).
“Our findings clearly show that hysterectomy is a risk marker for diabetes,” Fabrice Bonnet, MD, PhD, of Centre Hospitalier Universitaire (CHU) de Rennes (France), said at the annual meeting of the European Association for the Study of Diabetes.
Importantly, this risk appears to occur “independently of any hormonal therapy, any reproductive factors, physical activity, and diet,” Dr. Bonnet added.
Findings challenged
“I would like to challenge your findings,” said Peter Nilsson, MD, PhD, a professor at Lund (Sweden) University, during the postpresentation discussion period.
“Could there be a detection bias?” queried Dr. Nilsson. “If you undergo surgery like this, there will be several postoperative visits to a physician and there’s a higher likelihood of somebody taking blood samples and detecting diabetes.
“So, if this is true, it could mean that postoperative controls of goiter or thyroid surgery would bring the same findings,” Dr. Nilsson suggested.
“It is an epidemiological cohort of woman followed for a long time,” Dr. Bonnet responded. “So of course, there probably was more blood testing than in the usual population, but we did not observe the association for another type of surgery and type 2 diabetes.”
Clarifying further, Dr. Bonnet said that they had looked at thyroid surgery but not any other types of abdominal surgery.
Assessing the risk of incident diabetes
Hysterectomy is a common surgery among women – more than 400,000 are estimated to be performed every year in the United States, and 80,000 in France, with a rising rate in developing countries, Dr. Bonnet said in an interview.
“We don’t know exactly why that is, but it could have long-term consequences in terms of metabolic effects and the incidence of diabetes,” he said.
Prior research has linked having a hysterectomy with an increased rate of hypertension and cardiovascular risk, and there have also been a few studies linking it to diabetes.
“Our aim was to analyze the relationship between the past history of hysterectomies and the risk of incident diabetes; and specifically, we assessed the influence of age,” Dr. Bonnet said.
To do so, data on more than 83,000 women who had participated in The French E3N Prospective Cohort Study (E3N) were obtained. This large epidemiologic study is the French component of the long-running EPIC study.
For inclusion in the analysis, women had to have no diabetes at baseline, to have had their uterus, ovaries, or both removed for benign gynecologic reasons, and to have had their surgeries performed before any diagnosis of diabetes had been made. A diagnosis of diabetes was identified through the women’s responses to self-report questionnaires and prescriptions for antidiabetic medications.
In all, 2,672 women were found to have developed diabetes during the 16-year follow-up period.
The hazard ratio for the risk of diabetes in women who had and had not had a hysterectomy was 1.30 (95% confidence interval, 1.17-1.43; P < .0001), taking age into account and stratifying for birth generation.
The association held, when there was adjustment for other factors such as smoking status, physical activity, history of diabetes, weight, and adherence to a Mediterranean diet (HR 1.27; 95% CI 1.02-1.05; P = .02).
And, after adjustment for age at menarche, menopausal status, age at which menopause was reached, oral contraceptive and hormone therapy use, and the number of pregnancies, the risk for type 2 diabetes was still apparent in those who had undergoing a hysterectomy (HR, 1.20; 95% CI, 1.09-1.33; P = .0003).
Risk increased with oophorectomy
“Women who had both hysterectomy with bilateral oophorectomy had the highest rates of incident diabetes, as compared to women without hysterectomy and no oophorectomy,” said Dr. Bonnet (HR, 1.26; 95% CI, 1.11-1.42; P = .0003).
“This suggests preserving ovarian function is of importance,” he added. “Try to keep the ovaries in place, so just have hysterectomy alone,” he suggested might be the advice to fellow clinicians.
“So, identifying women at higher risk could be followed by a prevention program,” he suggested. “We do this for women who have gestational diabetes,” but for women who have had a hysterectomy, “we didn’t pay attention to this until now.”
No increased risk for endometriosis
While hysterectomy appears to up the risk for diabetes, having endometriosis does not. In a separate analysis of data from the E3N cohort, no effect was seen despite the association between endometriosis and other cardiometabolic risk factors.
The HR for incident type 2 diabetes comparing women with and without endometriosis was 10.06 in a fully adjusted statistical model (95% CI, 0.87-1.29). While there was an increase in the risk for diabetes if a woman had endometriosis and had also had a hysterectomy, this was not significant (HR, 1.22; 95% CI, 0.96-1.54).
The E3N study was sponsored by the French Institute for Health and Research. Dr. Bonnet and Dr. Nilsson had no relevant conflicts of interest to disclose.
Data from a large French cohort study suggest that women who have a hysterectomy before 40-45 years of age may be at particular risk of subsequently developing type 2 diabetes.
A 20% increase in the risk for incident diabetes was found comparing women of all ages who had and had not had a hysterectomy (P = .0003).
This risk jumped to a 52% increase when only women below the age of 45 were considered (P < .0001) and was still 38% higher if only women under 40 years were analyzed (P = .005).
“Our findings clearly show that hysterectomy is a risk marker for diabetes,” Fabrice Bonnet, MD, PhD, of Centre Hospitalier Universitaire (CHU) de Rennes (France), said at the annual meeting of the European Association for the Study of Diabetes.
Importantly, this risk appears to occur “independently of any hormonal therapy, any reproductive factors, physical activity, and diet,” Dr. Bonnet added.
Findings challenged
“I would like to challenge your findings,” said Peter Nilsson, MD, PhD, a professor at Lund (Sweden) University, during the postpresentation discussion period.
“Could there be a detection bias?” queried Dr. Nilsson. “If you undergo surgery like this, there will be several postoperative visits to a physician and there’s a higher likelihood of somebody taking blood samples and detecting diabetes.
“So, if this is true, it could mean that postoperative controls of goiter or thyroid surgery would bring the same findings,” Dr. Nilsson suggested.
“It is an epidemiological cohort of woman followed for a long time,” Dr. Bonnet responded. “So of course, there probably was more blood testing than in the usual population, but we did not observe the association for another type of surgery and type 2 diabetes.”
Clarifying further, Dr. Bonnet said that they had looked at thyroid surgery but not any other types of abdominal surgery.
Assessing the risk of incident diabetes
Hysterectomy is a common surgery among women – more than 400,000 are estimated to be performed every year in the United States, and 80,000 in France, with a rising rate in developing countries, Dr. Bonnet said in an interview.
“We don’t know exactly why that is, but it could have long-term consequences in terms of metabolic effects and the incidence of diabetes,” he said.
Prior research has linked having a hysterectomy with an increased rate of hypertension and cardiovascular risk, and there have also been a few studies linking it to diabetes.
“Our aim was to analyze the relationship between the past history of hysterectomies and the risk of incident diabetes; and specifically, we assessed the influence of age,” Dr. Bonnet said.
To do so, data on more than 83,000 women who had participated in The French E3N Prospective Cohort Study (E3N) were obtained. This large epidemiologic study is the French component of the long-running EPIC study.
For inclusion in the analysis, women had to have no diabetes at baseline, to have had their uterus, ovaries, or both removed for benign gynecologic reasons, and to have had their surgeries performed before any diagnosis of diabetes had been made. A diagnosis of diabetes was identified through the women’s responses to self-report questionnaires and prescriptions for antidiabetic medications.
In all, 2,672 women were found to have developed diabetes during the 16-year follow-up period.
The hazard ratio for the risk of diabetes in women who had and had not had a hysterectomy was 1.30 (95% confidence interval, 1.17-1.43; P < .0001), taking age into account and stratifying for birth generation.
The association held, when there was adjustment for other factors such as smoking status, physical activity, history of diabetes, weight, and adherence to a Mediterranean diet (HR 1.27; 95% CI 1.02-1.05; P = .02).
And, after adjustment for age at menarche, menopausal status, age at which menopause was reached, oral contraceptive and hormone therapy use, and the number of pregnancies, the risk for type 2 diabetes was still apparent in those who had undergoing a hysterectomy (HR, 1.20; 95% CI, 1.09-1.33; P = .0003).
Risk increased with oophorectomy
“Women who had both hysterectomy with bilateral oophorectomy had the highest rates of incident diabetes, as compared to women without hysterectomy and no oophorectomy,” said Dr. Bonnet (HR, 1.26; 95% CI, 1.11-1.42; P = .0003).
“This suggests preserving ovarian function is of importance,” he added. “Try to keep the ovaries in place, so just have hysterectomy alone,” he suggested might be the advice to fellow clinicians.
“So, identifying women at higher risk could be followed by a prevention program,” he suggested. “We do this for women who have gestational diabetes,” but for women who have had a hysterectomy, “we didn’t pay attention to this until now.”
No increased risk for endometriosis
While hysterectomy appears to up the risk for diabetes, having endometriosis does not. In a separate analysis of data from the E3N cohort, no effect was seen despite the association between endometriosis and other cardiometabolic risk factors.
The HR for incident type 2 diabetes comparing women with and without endometriosis was 10.06 in a fully adjusted statistical model (95% CI, 0.87-1.29). While there was an increase in the risk for diabetes if a woman had endometriosis and had also had a hysterectomy, this was not significant (HR, 1.22; 95% CI, 0.96-1.54).
The E3N study was sponsored by the French Institute for Health and Research. Dr. Bonnet and Dr. Nilsson had no relevant conflicts of interest to disclose.
FROM EASD 2022
Community-level actions could mitigate maternal mortality
Maternal mortality in the United States has been rising for several decades, but actions taken at the community level, as well as larger public health initiatives, have the potential to slow this trend, according to experts at a webinar sponsored by the National Institute for Health Care Management.
Maternal mortality in the United States increased by 14% from 2018 to 2020, according to data from the Centers for Disease Control and Prevention’s National Center for Health Statistics.
However, more than 80% of pregnancy-related deaths are preventable, according to 2017-2019 data from the Maternal Mortality Review Committees published online by the CDC. MMRCs include representatives of diverse clinical and nonclinical backgrounds who review the circumstances of pregnancy-related deaths.
In a webinar presented on Sept. 20, the NIHCM enlisted a panel of experts to discuss maternal mortality, the effect of changes to reproductive rights, and potential strategies to improve maternal health outcomes.
Maternal mortality is defined as “death while pregnant or within 42 days of the end of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to pregnancy or its management,” according to the CDC.
Importantly, mortality rates in the United States are approximately three times higher in Black women compared with White women, said Ndidiamaka Amutah-Onukagha, PhD, MPH, of the Tufts University Center for Black Maternal Health & Reproductive Justice. Dr. Amutah-Onukagha addressed some of the potential issues that appear to drive the disparity in care.
The lack of diversity in the health care workforce has a significant effect on patient outcomes, Dr. Amutah-Onukagha said. Overall, Black newborns are more than twice as likely as White newborns to die during their first year of life, but this number is cut in half when Black infants are cared for by Black physicians, she emphasized.
Other factors that may affect disparities in maternal health care include limited access to prenatal care, discriminatory hospital protocols, and mistreatment by health care professionals, said Dr. Amutah-Onukagha. She cited data showing that maternal mortality rates were higher in rural compared with urban areas. “According to the American Hospital Association, half of rural hospitals have no obstetric care, leaving mothers in maternity care deserts; this exacerbates existing disparities,” she said.
In the webinar, Sindhu Srinivas, MD, a maternal-fetal medicine specialist at the University of Pennsylvania, explained how patient, community, and system factors play a role in the disparities in maternal care.
Overall, Black women have to travel further to receive care, which has implications for high-risk pregnancies, and patients on Medicaid have to wait longer for care, and are less likely to be referred, she added. Black women also have higher rates of preexisting conditions compared with other populations that put them in the high-risk category, such as high blood pressure, diabetes, obesity, or being HIV positive, she said.
Other factors contributing to persistent disparities in maternal care include sociodemographics, patient beliefs and knowledge, and psychological issues including stress, said Dr. Srinivas. Community factors, such as social networks, safety, and poverty, also play a role, as do clinician factors of implicit bias and communication skills, she said.
Strategies to reduce disparity
Dr. Srinivas presented several strategies to reduce disparities at various levels. At the policy level, interventions such as establishing a Maternal Mortality Review Committee, establishing a perinatal quality collaborative, and extending Medicaid for a full year postpartum could help improve outcomes, she said. Dr. Srinivas also encouraged clinicians to report maternal mortality data stratified by race and ethnicity, and to participate in the Alliance for Innovation on Maternal Health program (AIM), an initiative in partnership with the American College of Obstetrics and Gynecology.
Dr. Srinivas also proposed maternal health policies to develop payment models “to sustain and scale innovative solutions, and “preserve access to contraception and abortion care.”
For clinicians looking to have an immediate impact, the panelists agreed that working with community health centers can make a significant difference by improving access to maternal care. Consider opportunities for partnership between hospitals and health care delivery centers in the community, said Dr. Srinivas.
Also, don’t underestimate the value of doulas in the birthing process, Dr. Amutah-Onukagha said. She urged clinicians to advocate for doula reimbursement and to take advantage of opportunities for doulas to work with pregnant individuals at the community levels. Data suggest that doulas are associated with increased maternal care visits and with breastfeeding, she noted.
Adam Myers, MD, of the Blue Cross Blue Shield Association, also contributed to the webinar discussion with a key point: Having financial means and commercial coverage is not a buffer against adverse maternal outcomes for racial minorities.
Dr. Myers cited the latest Health of America Report, which included data up to April 2021 with surveys of Medicaid members and their experiences. According to the report, rates of severe maternal mortality (SMM) increased by 9% for commercially and Medicaid-insured women between 2018 and 2020.
Among commercially insured women, SMM was 53% higher among Black women than White women; among Medicaid-insured women, Black women had a 73% higher rate of SMM, compared with White women.
In addition, the report showed that significantly more mothers of color were not able to complete the recommended series of prenatal visits, mainly for reasons of scheduling and transportation, which were greater barriers than COVID-19, Dr. Myers said.
Based on the data, one specific risk profile rose to the top: “We believe women of color aged 35 or higher with comorbid conditions should be treated as very high risk for SMM,” Dr. Myers emphasized. He stressed the need to focus on transportation and scheduling barriers and expressed support for partnerships and health care delivery centers in the community to mitigate these issues.
Finally, Dr. Srinivas encouraged clinicians to have confidence in their expertise and make themselves heard to help their patients and improve maternal health for all. “Use your voice,” said Dr. Srinivas, “As physicians we don’t think of that as an important aspect of our work, or that we can’t articulate, but remember that we are experts, and sharing stories of patients who are impacted is incredibly powerful,” she said.
The presenters had no relevant financial conflicts to disclose.
Maternal mortality in the United States has been rising for several decades, but actions taken at the community level, as well as larger public health initiatives, have the potential to slow this trend, according to experts at a webinar sponsored by the National Institute for Health Care Management.
Maternal mortality in the United States increased by 14% from 2018 to 2020, according to data from the Centers for Disease Control and Prevention’s National Center for Health Statistics.
However, more than 80% of pregnancy-related deaths are preventable, according to 2017-2019 data from the Maternal Mortality Review Committees published online by the CDC. MMRCs include representatives of diverse clinical and nonclinical backgrounds who review the circumstances of pregnancy-related deaths.
In a webinar presented on Sept. 20, the NIHCM enlisted a panel of experts to discuss maternal mortality, the effect of changes to reproductive rights, and potential strategies to improve maternal health outcomes.
Maternal mortality is defined as “death while pregnant or within 42 days of the end of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to pregnancy or its management,” according to the CDC.
Importantly, mortality rates in the United States are approximately three times higher in Black women compared with White women, said Ndidiamaka Amutah-Onukagha, PhD, MPH, of the Tufts University Center for Black Maternal Health & Reproductive Justice. Dr. Amutah-Onukagha addressed some of the potential issues that appear to drive the disparity in care.
The lack of diversity in the health care workforce has a significant effect on patient outcomes, Dr. Amutah-Onukagha said. Overall, Black newborns are more than twice as likely as White newborns to die during their first year of life, but this number is cut in half when Black infants are cared for by Black physicians, she emphasized.
Other factors that may affect disparities in maternal health care include limited access to prenatal care, discriminatory hospital protocols, and mistreatment by health care professionals, said Dr. Amutah-Onukagha. She cited data showing that maternal mortality rates were higher in rural compared with urban areas. “According to the American Hospital Association, half of rural hospitals have no obstetric care, leaving mothers in maternity care deserts; this exacerbates existing disparities,” she said.
In the webinar, Sindhu Srinivas, MD, a maternal-fetal medicine specialist at the University of Pennsylvania, explained how patient, community, and system factors play a role in the disparities in maternal care.
Overall, Black women have to travel further to receive care, which has implications for high-risk pregnancies, and patients on Medicaid have to wait longer for care, and are less likely to be referred, she added. Black women also have higher rates of preexisting conditions compared with other populations that put them in the high-risk category, such as high blood pressure, diabetes, obesity, or being HIV positive, she said.
Other factors contributing to persistent disparities in maternal care include sociodemographics, patient beliefs and knowledge, and psychological issues including stress, said Dr. Srinivas. Community factors, such as social networks, safety, and poverty, also play a role, as do clinician factors of implicit bias and communication skills, she said.
Strategies to reduce disparity
Dr. Srinivas presented several strategies to reduce disparities at various levels. At the policy level, interventions such as establishing a Maternal Mortality Review Committee, establishing a perinatal quality collaborative, and extending Medicaid for a full year postpartum could help improve outcomes, she said. Dr. Srinivas also encouraged clinicians to report maternal mortality data stratified by race and ethnicity, and to participate in the Alliance for Innovation on Maternal Health program (AIM), an initiative in partnership with the American College of Obstetrics and Gynecology.
Dr. Srinivas also proposed maternal health policies to develop payment models “to sustain and scale innovative solutions, and “preserve access to contraception and abortion care.”
For clinicians looking to have an immediate impact, the panelists agreed that working with community health centers can make a significant difference by improving access to maternal care. Consider opportunities for partnership between hospitals and health care delivery centers in the community, said Dr. Srinivas.
Also, don’t underestimate the value of doulas in the birthing process, Dr. Amutah-Onukagha said. She urged clinicians to advocate for doula reimbursement and to take advantage of opportunities for doulas to work with pregnant individuals at the community levels. Data suggest that doulas are associated with increased maternal care visits and with breastfeeding, she noted.
Adam Myers, MD, of the Blue Cross Blue Shield Association, also contributed to the webinar discussion with a key point: Having financial means and commercial coverage is not a buffer against adverse maternal outcomes for racial minorities.
Dr. Myers cited the latest Health of America Report, which included data up to April 2021 with surveys of Medicaid members and their experiences. According to the report, rates of severe maternal mortality (SMM) increased by 9% for commercially and Medicaid-insured women between 2018 and 2020.
Among commercially insured women, SMM was 53% higher among Black women than White women; among Medicaid-insured women, Black women had a 73% higher rate of SMM, compared with White women.
In addition, the report showed that significantly more mothers of color were not able to complete the recommended series of prenatal visits, mainly for reasons of scheduling and transportation, which were greater barriers than COVID-19, Dr. Myers said.
Based on the data, one specific risk profile rose to the top: “We believe women of color aged 35 or higher with comorbid conditions should be treated as very high risk for SMM,” Dr. Myers emphasized. He stressed the need to focus on transportation and scheduling barriers and expressed support for partnerships and health care delivery centers in the community to mitigate these issues.
Finally, Dr. Srinivas encouraged clinicians to have confidence in their expertise and make themselves heard to help their patients and improve maternal health for all. “Use your voice,” said Dr. Srinivas, “As physicians we don’t think of that as an important aspect of our work, or that we can’t articulate, but remember that we are experts, and sharing stories of patients who are impacted is incredibly powerful,” she said.
The presenters had no relevant financial conflicts to disclose.
Maternal mortality in the United States has been rising for several decades, but actions taken at the community level, as well as larger public health initiatives, have the potential to slow this trend, according to experts at a webinar sponsored by the National Institute for Health Care Management.
Maternal mortality in the United States increased by 14% from 2018 to 2020, according to data from the Centers for Disease Control and Prevention’s National Center for Health Statistics.
However, more than 80% of pregnancy-related deaths are preventable, according to 2017-2019 data from the Maternal Mortality Review Committees published online by the CDC. MMRCs include representatives of diverse clinical and nonclinical backgrounds who review the circumstances of pregnancy-related deaths.
In a webinar presented on Sept. 20, the NIHCM enlisted a panel of experts to discuss maternal mortality, the effect of changes to reproductive rights, and potential strategies to improve maternal health outcomes.
Maternal mortality is defined as “death while pregnant or within 42 days of the end of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to pregnancy or its management,” according to the CDC.
Importantly, mortality rates in the United States are approximately three times higher in Black women compared with White women, said Ndidiamaka Amutah-Onukagha, PhD, MPH, of the Tufts University Center for Black Maternal Health & Reproductive Justice. Dr. Amutah-Onukagha addressed some of the potential issues that appear to drive the disparity in care.
The lack of diversity in the health care workforce has a significant effect on patient outcomes, Dr. Amutah-Onukagha said. Overall, Black newborns are more than twice as likely as White newborns to die during their first year of life, but this number is cut in half when Black infants are cared for by Black physicians, she emphasized.
Other factors that may affect disparities in maternal health care include limited access to prenatal care, discriminatory hospital protocols, and mistreatment by health care professionals, said Dr. Amutah-Onukagha. She cited data showing that maternal mortality rates were higher in rural compared with urban areas. “According to the American Hospital Association, half of rural hospitals have no obstetric care, leaving mothers in maternity care deserts; this exacerbates existing disparities,” she said.
In the webinar, Sindhu Srinivas, MD, a maternal-fetal medicine specialist at the University of Pennsylvania, explained how patient, community, and system factors play a role in the disparities in maternal care.
Overall, Black women have to travel further to receive care, which has implications for high-risk pregnancies, and patients on Medicaid have to wait longer for care, and are less likely to be referred, she added. Black women also have higher rates of preexisting conditions compared with other populations that put them in the high-risk category, such as high blood pressure, diabetes, obesity, or being HIV positive, she said.
Other factors contributing to persistent disparities in maternal care include sociodemographics, patient beliefs and knowledge, and psychological issues including stress, said Dr. Srinivas. Community factors, such as social networks, safety, and poverty, also play a role, as do clinician factors of implicit bias and communication skills, she said.
Strategies to reduce disparity
Dr. Srinivas presented several strategies to reduce disparities at various levels. At the policy level, interventions such as establishing a Maternal Mortality Review Committee, establishing a perinatal quality collaborative, and extending Medicaid for a full year postpartum could help improve outcomes, she said. Dr. Srinivas also encouraged clinicians to report maternal mortality data stratified by race and ethnicity, and to participate in the Alliance for Innovation on Maternal Health program (AIM), an initiative in partnership with the American College of Obstetrics and Gynecology.
Dr. Srinivas also proposed maternal health policies to develop payment models “to sustain and scale innovative solutions, and “preserve access to contraception and abortion care.”
For clinicians looking to have an immediate impact, the panelists agreed that working with community health centers can make a significant difference by improving access to maternal care. Consider opportunities for partnership between hospitals and health care delivery centers in the community, said Dr. Srinivas.
Also, don’t underestimate the value of doulas in the birthing process, Dr. Amutah-Onukagha said. She urged clinicians to advocate for doula reimbursement and to take advantage of opportunities for doulas to work with pregnant individuals at the community levels. Data suggest that doulas are associated with increased maternal care visits and with breastfeeding, she noted.
Adam Myers, MD, of the Blue Cross Blue Shield Association, also contributed to the webinar discussion with a key point: Having financial means and commercial coverage is not a buffer against adverse maternal outcomes for racial minorities.
Dr. Myers cited the latest Health of America Report, which included data up to April 2021 with surveys of Medicaid members and their experiences. According to the report, rates of severe maternal mortality (SMM) increased by 9% for commercially and Medicaid-insured women between 2018 and 2020.
Among commercially insured women, SMM was 53% higher among Black women than White women; among Medicaid-insured women, Black women had a 73% higher rate of SMM, compared with White women.
In addition, the report showed that significantly more mothers of color were not able to complete the recommended series of prenatal visits, mainly for reasons of scheduling and transportation, which were greater barriers than COVID-19, Dr. Myers said.
Based on the data, one specific risk profile rose to the top: “We believe women of color aged 35 or higher with comorbid conditions should be treated as very high risk for SMM,” Dr. Myers emphasized. He stressed the need to focus on transportation and scheduling barriers and expressed support for partnerships and health care delivery centers in the community to mitigate these issues.
Finally, Dr. Srinivas encouraged clinicians to have confidence in their expertise and make themselves heard to help their patients and improve maternal health for all. “Use your voice,” said Dr. Srinivas, “As physicians we don’t think of that as an important aspect of our work, or that we can’t articulate, but remember that we are experts, and sharing stories of patients who are impacted is incredibly powerful,” she said.
The presenters had no relevant financial conflicts to disclose.
‘Cracking’ technology shows promise for reducing environmental inhaled nitrous oxide impacts during labor
New evidence indicates that the use of “cracking” technology can significantly reduce the ambient levels of inhaled nitrous oxide (N2O) during labor, especially when women are coached on how best to use it.
The findings, from a quality improvement study conducted by anesthetists and midwives in the United Kingdom, appear to have implications for minimizing staff exposures and for lowering N2O’s environmental effect overall. The potent greenhouse gas has a carbon footprint that is 265 times larger than carbon dioxide.
“Our results indicate that cracking technology can reduce ambient nitrous oxide levels in the obstetric setting, with potential for reductions in environmental impacts and occupational exposure,” reported Annie Pinder, MBChB, a fellow in sustainable anesthesia at North West School of Anaesthesia, Manchester, England, and colleagues in Anaesthesia.
Proportionally, the United Kingdom is one of the largest users of inhaled N2O during labor, often for first-line pain control. A 2017 survey by the Care Quality Commission estimated that 77% of women in labor used inhaled N2O for pain, and that it didn’t preclude them from using other types of analgesia, including opioids, epidurals, and nonpharmacologic approaches.
Previous research has established the effectiveness of cracking, which uses a catalyst to convert N2O into nitrogen and oxygen. However, little is known about the effectiveness of scavenging devices that minimize waste N2O in a real-world setting, the authors said.
For the study, median ambient N2O levels were recorded for 36 women during the final 30 minutes of uncomplicated labor. Ambient N2O levels were initially recorded in 12 patients without use of three N2O scavenging devices, and then in three groups of eight patients using either a mouthpiece, a facemask with an air-filled cushion, or a low-profile facemask. Women were also coached on how to use the devices, and given feedback.
“Given that a similar magnitude of reduction in nitrous oxide levels was seen with mouthpieces and low-profile face masks, we suggest that pregnant women should be offered the option of either device when cracking is used,” the study authors wrote.
Staff feedback was generally positive, but some found use of the technology cumbersome. Sufficient staff engagement is the key to successful implementation, the researchers pointed out.
The results showed that when women consistently exhaled into the mouthpiece, median ambient N2O levels were 71% lower compared with levels recorded prior to use of the scavenging device. When women exhaled into a lightweight face mask with a flexible seal, median ambient N2O levels were 81% lower compared with baseline.
These data are consistent with the United Kingdom’s goal of achieving a net zero carbon footprint for the National Health Service by 2040, the researchers said. The study findings are also in keeping with predictions that cracking technology could reduce greenhouse gas emissions associated with N2O by an estimated 75%.
“Although cracking may make nitrous oxide ‘greener,’ it does not make it ‘green,’ ” noted Dr. Pinder and coauthor Cliff Shelton, MBChB, in an interview. Dr. Shelton is a senior clinical lecturer in anesthesia at Lancaster (England) University and a consultant anesthetist at Wythenshawe Hospital, Manchester.
Even with the use of cracking technology, the occupational effect of inhaled N2O is likely to remain higher than for other, more effective forms of anesthesia, such as epidurals and remifentanil (Ultiva), Dr. Pinder and Dr. Shelton said. Furthermore, ambient N2O levels are not a direct measure of the proportion of nitrous oxide cracked, “so there is scope for further work to more precisely understand the ‘carbon footprint’ impacts,” they pointed out.
Inhaled N20 is widely used for labor pain in the Scandinavian countries, as well as in Canada, Australia, and New Zealand. It’s also making a comeback in the United States, facilitated by the Food and Drug Administration’s (FDA) approval of a portable N2O delivery system in 2012.
The system, which delivers a mixture of 50% nitrous oxide and 50% oxygen, has offered a new option for laboring mothers, said Robert L. Barbieri, MD, chair of obstetrics and gynecology at Brigham and Women’s Hospital, Boston, and coauthors in a 2014 report.
“Nitrous oxide works really well as an adjunct to other analgesia,” said Laura Goetzl, MD, MPH, professor of obstetrics, gynecology, and reproductive sciences at University of Texas at Houston Health Science Center. Women in labor really like having the option of inhaled N2O to manage pain, she said in an interview. “The more options that we have to offer, the better for women.”
“Not only does nitrous oxide help with perception of pain, it’s also highly effective for reducing patient anxiety,” Dr. Goetzl explained. “If a patient is waiting for an epidural, the use of nitrous oxide can be particularly helpful.”
Dr. Shelton reported that he is executive editor of Anaesthesia Reports. Dr. Pinder and the remaining coauthors disclosed having no conflicts of interest. Dr. Goetzl reported that she is on the medical advisory board of Mirvie.
This story was updated on Sept. 27, 2022.
New evidence indicates that the use of “cracking” technology can significantly reduce the ambient levels of inhaled nitrous oxide (N2O) during labor, especially when women are coached on how best to use it.
The findings, from a quality improvement study conducted by anesthetists and midwives in the United Kingdom, appear to have implications for minimizing staff exposures and for lowering N2O’s environmental effect overall. The potent greenhouse gas has a carbon footprint that is 265 times larger than carbon dioxide.
“Our results indicate that cracking technology can reduce ambient nitrous oxide levels in the obstetric setting, with potential for reductions in environmental impacts and occupational exposure,” reported Annie Pinder, MBChB, a fellow in sustainable anesthesia at North West School of Anaesthesia, Manchester, England, and colleagues in Anaesthesia.
Proportionally, the United Kingdom is one of the largest users of inhaled N2O during labor, often for first-line pain control. A 2017 survey by the Care Quality Commission estimated that 77% of women in labor used inhaled N2O for pain, and that it didn’t preclude them from using other types of analgesia, including opioids, epidurals, and nonpharmacologic approaches.
Previous research has established the effectiveness of cracking, which uses a catalyst to convert N2O into nitrogen and oxygen. However, little is known about the effectiveness of scavenging devices that minimize waste N2O in a real-world setting, the authors said.
For the study, median ambient N2O levels were recorded for 36 women during the final 30 minutes of uncomplicated labor. Ambient N2O levels were initially recorded in 12 patients without use of three N2O scavenging devices, and then in three groups of eight patients using either a mouthpiece, a facemask with an air-filled cushion, or a low-profile facemask. Women were also coached on how to use the devices, and given feedback.
“Given that a similar magnitude of reduction in nitrous oxide levels was seen with mouthpieces and low-profile face masks, we suggest that pregnant women should be offered the option of either device when cracking is used,” the study authors wrote.
Staff feedback was generally positive, but some found use of the technology cumbersome. Sufficient staff engagement is the key to successful implementation, the researchers pointed out.
The results showed that when women consistently exhaled into the mouthpiece, median ambient N2O levels were 71% lower compared with levels recorded prior to use of the scavenging device. When women exhaled into a lightweight face mask with a flexible seal, median ambient N2O levels were 81% lower compared with baseline.
These data are consistent with the United Kingdom’s goal of achieving a net zero carbon footprint for the National Health Service by 2040, the researchers said. The study findings are also in keeping with predictions that cracking technology could reduce greenhouse gas emissions associated with N2O by an estimated 75%.
“Although cracking may make nitrous oxide ‘greener,’ it does not make it ‘green,’ ” noted Dr. Pinder and coauthor Cliff Shelton, MBChB, in an interview. Dr. Shelton is a senior clinical lecturer in anesthesia at Lancaster (England) University and a consultant anesthetist at Wythenshawe Hospital, Manchester.
Even with the use of cracking technology, the occupational effect of inhaled N2O is likely to remain higher than for other, more effective forms of anesthesia, such as epidurals and remifentanil (Ultiva), Dr. Pinder and Dr. Shelton said. Furthermore, ambient N2O levels are not a direct measure of the proportion of nitrous oxide cracked, “so there is scope for further work to more precisely understand the ‘carbon footprint’ impacts,” they pointed out.
Inhaled N20 is widely used for labor pain in the Scandinavian countries, as well as in Canada, Australia, and New Zealand. It’s also making a comeback in the United States, facilitated by the Food and Drug Administration’s (FDA) approval of a portable N2O delivery system in 2012.
The system, which delivers a mixture of 50% nitrous oxide and 50% oxygen, has offered a new option for laboring mothers, said Robert L. Barbieri, MD, chair of obstetrics and gynecology at Brigham and Women’s Hospital, Boston, and coauthors in a 2014 report.
“Nitrous oxide works really well as an adjunct to other analgesia,” said Laura Goetzl, MD, MPH, professor of obstetrics, gynecology, and reproductive sciences at University of Texas at Houston Health Science Center. Women in labor really like having the option of inhaled N2O to manage pain, she said in an interview. “The more options that we have to offer, the better for women.”
“Not only does nitrous oxide help with perception of pain, it’s also highly effective for reducing patient anxiety,” Dr. Goetzl explained. “If a patient is waiting for an epidural, the use of nitrous oxide can be particularly helpful.”
Dr. Shelton reported that he is executive editor of Anaesthesia Reports. Dr. Pinder and the remaining coauthors disclosed having no conflicts of interest. Dr. Goetzl reported that she is on the medical advisory board of Mirvie.
This story was updated on Sept. 27, 2022.
New evidence indicates that the use of “cracking” technology can significantly reduce the ambient levels of inhaled nitrous oxide (N2O) during labor, especially when women are coached on how best to use it.
The findings, from a quality improvement study conducted by anesthetists and midwives in the United Kingdom, appear to have implications for minimizing staff exposures and for lowering N2O’s environmental effect overall. The potent greenhouse gas has a carbon footprint that is 265 times larger than carbon dioxide.
“Our results indicate that cracking technology can reduce ambient nitrous oxide levels in the obstetric setting, with potential for reductions in environmental impacts and occupational exposure,” reported Annie Pinder, MBChB, a fellow in sustainable anesthesia at North West School of Anaesthesia, Manchester, England, and colleagues in Anaesthesia.
Proportionally, the United Kingdom is one of the largest users of inhaled N2O during labor, often for first-line pain control. A 2017 survey by the Care Quality Commission estimated that 77% of women in labor used inhaled N2O for pain, and that it didn’t preclude them from using other types of analgesia, including opioids, epidurals, and nonpharmacologic approaches.
Previous research has established the effectiveness of cracking, which uses a catalyst to convert N2O into nitrogen and oxygen. However, little is known about the effectiveness of scavenging devices that minimize waste N2O in a real-world setting, the authors said.
For the study, median ambient N2O levels were recorded for 36 women during the final 30 minutes of uncomplicated labor. Ambient N2O levels were initially recorded in 12 patients without use of three N2O scavenging devices, and then in three groups of eight patients using either a mouthpiece, a facemask with an air-filled cushion, or a low-profile facemask. Women were also coached on how to use the devices, and given feedback.
“Given that a similar magnitude of reduction in nitrous oxide levels was seen with mouthpieces and low-profile face masks, we suggest that pregnant women should be offered the option of either device when cracking is used,” the study authors wrote.
Staff feedback was generally positive, but some found use of the technology cumbersome. Sufficient staff engagement is the key to successful implementation, the researchers pointed out.
The results showed that when women consistently exhaled into the mouthpiece, median ambient N2O levels were 71% lower compared with levels recorded prior to use of the scavenging device. When women exhaled into a lightweight face mask with a flexible seal, median ambient N2O levels were 81% lower compared with baseline.
These data are consistent with the United Kingdom’s goal of achieving a net zero carbon footprint for the National Health Service by 2040, the researchers said. The study findings are also in keeping with predictions that cracking technology could reduce greenhouse gas emissions associated with N2O by an estimated 75%.
“Although cracking may make nitrous oxide ‘greener,’ it does not make it ‘green,’ ” noted Dr. Pinder and coauthor Cliff Shelton, MBChB, in an interview. Dr. Shelton is a senior clinical lecturer in anesthesia at Lancaster (England) University and a consultant anesthetist at Wythenshawe Hospital, Manchester.
Even with the use of cracking technology, the occupational effect of inhaled N2O is likely to remain higher than for other, more effective forms of anesthesia, such as epidurals and remifentanil (Ultiva), Dr. Pinder and Dr. Shelton said. Furthermore, ambient N2O levels are not a direct measure of the proportion of nitrous oxide cracked, “so there is scope for further work to more precisely understand the ‘carbon footprint’ impacts,” they pointed out.
Inhaled N20 is widely used for labor pain in the Scandinavian countries, as well as in Canada, Australia, and New Zealand. It’s also making a comeback in the United States, facilitated by the Food and Drug Administration’s (FDA) approval of a portable N2O delivery system in 2012.
The system, which delivers a mixture of 50% nitrous oxide and 50% oxygen, has offered a new option for laboring mothers, said Robert L. Barbieri, MD, chair of obstetrics and gynecology at Brigham and Women’s Hospital, Boston, and coauthors in a 2014 report.
“Nitrous oxide works really well as an adjunct to other analgesia,” said Laura Goetzl, MD, MPH, professor of obstetrics, gynecology, and reproductive sciences at University of Texas at Houston Health Science Center. Women in labor really like having the option of inhaled N2O to manage pain, she said in an interview. “The more options that we have to offer, the better for women.”
“Not only does nitrous oxide help with perception of pain, it’s also highly effective for reducing patient anxiety,” Dr. Goetzl explained. “If a patient is waiting for an epidural, the use of nitrous oxide can be particularly helpful.”
Dr. Shelton reported that he is executive editor of Anaesthesia Reports. Dr. Pinder and the remaining coauthors disclosed having no conflicts of interest. Dr. Goetzl reported that she is on the medical advisory board of Mirvie.
This story was updated on Sept. 27, 2022.
FROM ANAESTHESIA
Early or delayed menopause and irregular periods tied to new-onset atrial fibrillation
Takeaway
- Early or delayed menopause and a history of irregular menstrual cycles were significantly associated with a greater risk of new-onset atrial fibrillation (AF) in women.
- Women with nulliparity and multiparity had a greater risk of new-onset AF compared with those with one to two live births.
Why this matters
- Findings highlight the significance of considering the reproductive history of women while developing tailored screening and prevention strategies for AF.
Study design
- A population-based cohort study of 235,191 women (age, 40-69 years) without AF and a history of hysterectomy and/or bilateral oophorectomy, identified from the UK Biobank (2006-2010).
- Funding: Gender and Prevention Grant from ZonMw and other.
Key results
- During a median follow-up of 11.6 years, 4,629 (2.0%) women were diagnosed with new-onset AF.
- A history of irregular menstrual cycle was associated with higher risk of new-onset AF (adjusted HR, 1.34; 95% confidence interval, 1.01-1.79; P = .04).
- Compared with women who experienced menarche at the age of 12 years, the risk of new-onset AF was significantly higher in those who experienced menarche:
- –Earlier between the ages of 7 and 11 years (aHR, 1.10; 95% CI, 1.00-1.21; P = .04) and
- –Later between the ages of 13 and 18 years (aHR, 1.08; 95% CI, 1.00-1.17; P = .05).
- The risk of new-onset AF was significantly higher in women who experienced menopause:
- –At the age of < 35 years (aHR, 2.25; 95% CI, 1.48-3.43; P < .001);
- –Between the ages of 35 and 44 years (aHR, 1.24; 95% CI, 1.10-1.39; P < .001); and
- –At the age of ≥ 60 years (aHR, 1.34; 95% CI, 1.10-1.78; P = .04).
- Women with no live births (aHR, 1.13; 95% CI, 1.04-1.24; P < .01), four to six live births (aHR, 1.12; 95% CI, 1.01-1.24; P = .04), and ≥ seven live births (aHR, 1.67; 95% CI, 1.03-2.70; P = .03) vs. those with one to two live births had a significantly higher risk of new-onset AF.
Limitations
- Observational design.
A version of this article first appeared on Medscape UK.
Reference
Lu Z, Aribas E, Geurts S, Roeters van Lennep JE, Ikram MA, Bos MM, de Groot NMS, Kavousi M. Association Between Sex-Specific Risk Factors and Risk of New-Onset Atrial Fibrillation Among Women. JAMA Netw Open. 2022;5(9):e2229716. doi: 10.1001/jamanetworkopen.2022.29716. PMID: 36048441.
Takeaway
- Early or delayed menopause and a history of irregular menstrual cycles were significantly associated with a greater risk of new-onset atrial fibrillation (AF) in women.
- Women with nulliparity and multiparity had a greater risk of new-onset AF compared with those with one to two live births.
Why this matters
- Findings highlight the significance of considering the reproductive history of women while developing tailored screening and prevention strategies for AF.
Study design
- A population-based cohort study of 235,191 women (age, 40-69 years) without AF and a history of hysterectomy and/or bilateral oophorectomy, identified from the UK Biobank (2006-2010).
- Funding: Gender and Prevention Grant from ZonMw and other.
Key results
- During a median follow-up of 11.6 years, 4,629 (2.0%) women were diagnosed with new-onset AF.
- A history of irregular menstrual cycle was associated with higher risk of new-onset AF (adjusted HR, 1.34; 95% confidence interval, 1.01-1.79; P = .04).
- Compared with women who experienced menarche at the age of 12 years, the risk of new-onset AF was significantly higher in those who experienced menarche:
- –Earlier between the ages of 7 and 11 years (aHR, 1.10; 95% CI, 1.00-1.21; P = .04) and
- –Later between the ages of 13 and 18 years (aHR, 1.08; 95% CI, 1.00-1.17; P = .05).
- The risk of new-onset AF was significantly higher in women who experienced menopause:
- –At the age of < 35 years (aHR, 2.25; 95% CI, 1.48-3.43; P < .001);
- –Between the ages of 35 and 44 years (aHR, 1.24; 95% CI, 1.10-1.39; P < .001); and
- –At the age of ≥ 60 years (aHR, 1.34; 95% CI, 1.10-1.78; P = .04).
- Women with no live births (aHR, 1.13; 95% CI, 1.04-1.24; P < .01), four to six live births (aHR, 1.12; 95% CI, 1.01-1.24; P = .04), and ≥ seven live births (aHR, 1.67; 95% CI, 1.03-2.70; P = .03) vs. those with one to two live births had a significantly higher risk of new-onset AF.
Limitations
- Observational design.
A version of this article first appeared on Medscape UK.
Reference
Lu Z, Aribas E, Geurts S, Roeters van Lennep JE, Ikram MA, Bos MM, de Groot NMS, Kavousi M. Association Between Sex-Specific Risk Factors and Risk of New-Onset Atrial Fibrillation Among Women. JAMA Netw Open. 2022;5(9):e2229716. doi: 10.1001/jamanetworkopen.2022.29716. PMID: 36048441.
Takeaway
- Early or delayed menopause and a history of irregular menstrual cycles were significantly associated with a greater risk of new-onset atrial fibrillation (AF) in women.
- Women with nulliparity and multiparity had a greater risk of new-onset AF compared with those with one to two live births.
Why this matters
- Findings highlight the significance of considering the reproductive history of women while developing tailored screening and prevention strategies for AF.
Study design
- A population-based cohort study of 235,191 women (age, 40-69 years) without AF and a history of hysterectomy and/or bilateral oophorectomy, identified from the UK Biobank (2006-2010).
- Funding: Gender and Prevention Grant from ZonMw and other.
Key results
- During a median follow-up of 11.6 years, 4,629 (2.0%) women were diagnosed with new-onset AF.
- A history of irregular menstrual cycle was associated with higher risk of new-onset AF (adjusted HR, 1.34; 95% confidence interval, 1.01-1.79; P = .04).
- Compared with women who experienced menarche at the age of 12 years, the risk of new-onset AF was significantly higher in those who experienced menarche:
- –Earlier between the ages of 7 and 11 years (aHR, 1.10; 95% CI, 1.00-1.21; P = .04) and
- –Later between the ages of 13 and 18 years (aHR, 1.08; 95% CI, 1.00-1.17; P = .05).
- The risk of new-onset AF was significantly higher in women who experienced menopause:
- –At the age of < 35 years (aHR, 2.25; 95% CI, 1.48-3.43; P < .001);
- –Between the ages of 35 and 44 years (aHR, 1.24; 95% CI, 1.10-1.39; P < .001); and
- –At the age of ≥ 60 years (aHR, 1.34; 95% CI, 1.10-1.78; P = .04).
- Women with no live births (aHR, 1.13; 95% CI, 1.04-1.24; P < .01), four to six live births (aHR, 1.12; 95% CI, 1.01-1.24; P = .04), and ≥ seven live births (aHR, 1.67; 95% CI, 1.03-2.70; P = .03) vs. those with one to two live births had a significantly higher risk of new-onset AF.
Limitations
- Observational design.
A version of this article first appeared on Medscape UK.
Reference
Lu Z, Aribas E, Geurts S, Roeters van Lennep JE, Ikram MA, Bos MM, de Groot NMS, Kavousi M. Association Between Sex-Specific Risk Factors and Risk of New-Onset Atrial Fibrillation Among Women. JAMA Netw Open. 2022;5(9):e2229716. doi: 10.1001/jamanetworkopen.2022.29716. PMID: 36048441.
FROM JAMA NETWORK OPEN