Both natural and surgical premature menopause before age 40 are associated with a small but statistically significant increased risk for subsequent cardiovascular disease (CVD) compared to that in postmenopausal women without premature menopause, according to a cohort study in 

The composite outcome included coronary artery disease, heart failure, aortic stenosis, mitral regurgitation, atrial fibrillation, ischemic stroke, peripheral artery disease and venous thromboembolism.

The authors noted that although recent guidelines embrace using history of menopause before age 40 to refine atherosclerotic cardiovascular disease (ASCVD) risk assessments in middle-aged women, “robust data on cardiovascular disease risk in this population is lacking.”

The cohort of 144,260 eligible women was from the large-scale, long-term observational UK Biobank study, comprising adult residents of the United Kingdom recruited between 2006 and 2010. 

All included women were 40 to 69 years old (mean age 59.9) and postmenopausal at study enrollment, with median follow-up of 7 years through August 2016. Natural premature menopause was defined as menopause before age 40 without oophorectomy, while surgical premature menopause was bilateral oophorectomy before age 40.

Overall, 3.4% (n = 4,903) of women had natural premature menopause and 0.4% (n = 644) had surgical premature menopause. The primary outcome of incidence of composite CVD was 3.9% (n = 5,415) in women with no prema-ture menopause (5.7/1,000 woman-years) and 6.0% (n = 292) in women with natural premature menopause (8.78/1,000 woman-years), representing a difference vs. no premature menopause of +3.08/1,000 woman-years (95% confidence interval [CI]: 2.06 to 4.10; P < 0.001).

Among the 7.6% of women (n = 49) with surgical premature menopause (11.27/1,000 woman-years), the difference vs. no premature menopause was +5.57/1,000 woman-years (95% CI: 2.41 to 8.73; P < 0.001). 

Overall, natural and surgical premature menopause had hazard ratios of 1.36 (95% CI: 1.19 to 1.56; P < 0.001) and 1.87 (95% CI: 1.36 to 2.58; P < 0.001), respectively, after accounting for conventional CVD risk factors and menopausal hormone therapy.

The Framingham Heart Study found that a higher premenopausal Framingham risk factor was linked to earlier age at menopause. 

The current study, though, concluded that premature menopause may not be limited to comorbid with conventional CVD risk factors, but may separately increase odds of developing these risk factors. In addition, the study found that the CVD risk connected to premature menopause extended beyond ASCVD.

“Postmenopausal state is associated with increase in cytokines and oxidative stress, which may contribute to osteogenesis of valvular interstitial cells,” wrote the authors, noting that it is unknown if this mechanism links premature menopause to aortic stenosis.

Lastly, the form of menopause may be connected to differential cardiovascular risk. Although significant differences in risk between natural and surgical premature menopause were not evident in fully adjusted models, risk differences may arise from differential development of conventional cardiovascular risk facts. There is also the possibility the study had reduced statistical power.

Honigberg MC, Zekavat SM, Aragam K, et al. Association of premature natural and surgical menopause with incident cardio-vascular disease. JAMA. 2019. doi:10.1001/jama.2019.19191

Articles

The authors noted that, although recent guidelines embrace using history of menopause before age 40 to refine atherosclerotic cardiovascular disease (ASCVD) risk assessments in middle-aged women, “robust data on cardio-vascular disease risk in this population is lacking.”

Early menopause and cardiovascular disease

The 46-year-old plaintiff first presented to her primary care physician (PCP) on April 23, 2013, for a cough that had lasted 3 days. She reported incontinence, dribbling, and an inability to hold her urine after heavy menstruation. 

She also reported abdominal pain. Her PCP urged her to go to an ob/gyn for a work-up, with the differential possibly being endometriosis versus ruptured cyst. The impression was that the patient had recurrent stress urinary incontinence but the ob/gyn was concerned that it could turn into physical incontinence, given the woman’s gynecologic issues and age. 

 to send her for an ultrasound (U/S) of the pelvis, which was performed on May 1, 2013. The U/S revealed a very large uterine fibroid (7x7 cm).

On May 5, 2013, the plaintiff presented to nonparty hospital with complaints of lower abdominal pain and vaginal bleeding that had lasted for 2 days. She reported bright red blood with multiple clots that increased throughout the day and her diagnosis with a 7x7-cm uterine fibroid by her PCP but said she did not have an ob/gyn. 

On exam, she reported that she had a history of heavy menses secondary to the fibroid. Transvaginal (TVUS) confirmed multiple fibroids, the largest being 8.7 cm, and an enlarged uterus (8.5 x 12.2 cm). The impression was leiomyoma of the uterus. The woman was sent home in stable condition that night because she felt better, with a directive to follow up with an ob/gyn that week.

The plaintiff saw her PCP on July 23, 2013, for the start of preoperative medical clearance for a hysterectomy. She was cleared for surgery. 

, she reported incontinence and dribbling and that she could not hold her urine after menstruating. The assessment was vaginal bleeding, with abdominal pain secondary to the abdominal fibroids.

On or about August 26, 2013, the plaintiff presented to Defendant Hospital A for a laparoscopic hysterectomy by 

, secondary to bleeding fibroids. The plaintiff’s history included a cesarean delivery, open cholecystectomy, bilateral breast reduction, and treatment for a miscarriage. During the hysterectomy, she sustained a bladder injury. 

An intraoperative cystoscopy confirmed a 2-cm tear near the vaginal cuff. Two double-J ureteral stents were placed by Defendant urologist, who recommended that she be transferred to Defendant Hospital B. The woman’s bladder was not repaired intraoperatively; instead she was transferred after Defendant ob/gyn A spoke with 

 is a partner at Aaronson, Rappaport, Feinstein & Deutsch, LLP in New York City, specializing in medical malpractice defense and healthcare litigation. This case was handled by one of his partners.

On August 27 at 11:40 p.m., the plaintiff was transferred from Defendant Hospital A to Defendant Hospital B with an admitting diagnosis of injury to the bladder and urethra and open wound. The admitting physician was Defendant ob/gyn B, who attempted conservative management; for 48 hours, the patient was stable without any issues. 

On August 29, a decision was made to perform a cystoscopy to further evaluate the bladder injury. Defendant ob/gyn B’s operative report indicated that informed consent was obtained. A cystogram was performed using 200 mL of fluid without obvious contrast extravasation. The plaintiff’s Foley catheter was removed and the two previously placed double-J stents were identified and noted to be in good position. 

A cystoscopy then was performed, and at the level of the trigone in the posterior portion of the bladder, an area consistent with the intraoperative injury was found. The same was noted to have granulating tissue but no obvious tear or extraperitoneal leak was seen. 

, Defendant ob/gyn B decided “to not proceed with a formal repair” and instead, decided to continue to conservatively manage the plaintiff. 

The Foley catheter was replaced and the report concluded with a comment that the patient was to follow up in the office within the next 2 weeks for a repeat cystoscopy and removal of the double-J stents that had been placed. In the Postoperative Acute Care Unit, she received 2 units of blood. Discharge was on August 30.

A day later, the plaintiff was readmitted to Defendant Hospital B complaining of no urine output from the Foley catheter for 12 hours, lower abdominal pain, and difficulty breathing. The catheter was changed in the ER without relief of symptoms, so the plaintiff was admitted. 

On U/S, her bladder was small with fluid around it. A computed tomography (CT) scan showed that the Foley catheter was out of the bladder and in the peritoneum. The catheter was repositioned and conservative management was attempted. 

 the patient had desaturations in oxygen to the 80s and was found to have bilateral pulmonary embolisms (PEs). Dopplers came back negative for deep vein thrombosis. 

Because of the woman’s history of PEs, a removable inferior vena cava filter was placed by vascular surgery. An intravenous (IV) Heparin drip also was started. The plan was to stabilize the patient medically and then take her to the operating room (OR) for an open bladder repair.

On September 3, repair surgery was undertaken by Defendant ob/gyn B. The procedure was described as an open complex cystorrhaphy with a repair of bladder injury and placement of a suprapubic tube. Per the OR report, “due to the location of the injury at the level of the trigone, a decision was made to perform an intravesical repair.” 

As a result, a cystotomy was performed in the dome of the bladder. The injury was noted to be at the trigone between both ureteral orifices. A suprapubic catheter was placed and the plan was to monitor the patient, transition her back to a heparin drip and eventually warfarin, with the hopes of discharging her a few days thereafter. Postoperatively, the plaintiff had bouts of tachycardia. 

She remained on a heparin drip. Transthoracic echocardiography showed evidence of some right heart strain. Heparin was changed to enoxaparin sodium. The suprapubic tube eventually drained clear urine and the patient was discharged on September 6 with the suprapubic tube to the Foley catheter and a three-way, 24-French Foley to leg bag.

On September 13, the plaintiff followed up with Defendant ob/gyn B at his office. On exam, the doctor found her to be doing well with a suprapubic tube and the Foley catheter in place. He planned to keep the catheters in for the next 2 weeks and the note indicated she would be following up with her PCP regarding management of her warfarin level. 

Defendant ob/gyn B planned to perform a cystogram at the next visit and perhaps remove the Foley catheter but he intended to leave the suprapubic tube in for another few weeks. 

The plaintiff went to her PCP on September 24 for complaints of a urinary tract infection (UTI) with abrupt onset. 

Her symptoms concluded voiding scant amounts while urinating and the last occurrence was a few weeks before, and burning pain. Diagnosis was acute cystitis, UTI and she was started on sulfamethoxazole/trimethoprim. 

A note written by Defendant ob/gyn B about the patienht’s return visit on September 27, repeated the history and said that the patient is “doing well with no complaints other than minimal pain from the Foley.” 

A cystogram was performed and no evidence of extravasation was noted. The Foley catheter was removed but the suprapubic tube was left in place. When plaintiff returned to Defendant ob/gyn B’s office a week later, a cystogram showed no evidence of extravasation and the suprapubic tube was removed. The bilateral stents were left in place and the patient was directed to return in 3 weeks for their removal. In addition, she was placed on more antibiotics as a result of a complaint of dysuria. 

On October 8, the plaintiff was seen by her PCP for a complaint of 4-day lumbar radicular syndrome, pain 4/10. She also reported frequent urination, incontinence, dribbling, and painful urination. She reported that the pain started after the catheter was removed. 

 that she return to the urologist for catheter placement versus further evaluation. On October 10, the plaintiff was transferred to Defendant Hospital B with complaints of nausea, vomiting, and flank pain and a diagnosis of pyelonephritis. A Foley catheter was placed and she was started on IV antibiotics. A CT scan showed bilateral moderate hydronephrosis with left perinephric stranding.

On October 12, Defendant ob/gyn B brought the patient back to the OR for a cystoscopy, during which he removed the bilateral stents. A cystogram was performed and again no contrast extravasation was seen. 

Thereafter, a cystoscopy was performed. The report noted that the “entire mucosa was extensively observed” and in the area of the previous repair, debris and granulation tissue were noted. Both ureteral orifices were easily identified, and both the right and left ureteral stents were noted to be calcified with debris. 

It was felt that the stents might be a possible source for the UTI, so they were removed. The plan was to monitor the plaintiff over the next 12 hours to see if there was any improvement. The Foley catheter was removed and she passed a trial of void so she was discharged on October 13. 

An appointment with Defendant ob/gyn B was made for October 25 butthen rescheduled to November 22. 

, the plaintiff was 1 month post-removal of the stents, appeared to be doing well save for the complaint of increasing nocturia every 1 1/2 to 2 hours during the evenings as well as frequency throughout the day. Defendant ob/gyn B performed a physical exam and found nothing out of the ordinary except for some costovertebral angle tenderness. 

Under “Impression” he called the plaintiff a woman with “significant lower urinary tract symptoms” and indicated that while a urine dipstick showed some white blood cells, there was no obvious UTI. A culture was sent and the patient was placed on solifenacin to see if this would improve her nocturia. She was directed to return in 4 weeks for a repeat uroflow and postvoid residual (PVR) but she did not.

On August 21, 2014, the plaintiff saw her PCP with complaints of frequent urination as well as vaginal bleeding between periods or after sex. She also reported that this began after surgery. She reported being treated with solifenacin with good results. 

She was given another prescription for the drug, 10 mg daily. The plaintiff returned to Defendant ob/gyn B on September 3 (10 months after her last visit) for the final time. The purpose of the visit was for a new onset of urinary incontinence. In his note, Defendant ob/gyn B recited the woman’s history of the complex bladder injury and repair, the pulmonary embolus. 

He also mentioned her “bleeding issues” (hypercoagulability), for which she was under the care of a hematologist. The plaintiff reported that she had been feeling well over the preceding 6 months and it was only 2 weeks prior when she started to notice the urinary incontinence. 

She denied any other urinary issues but did report that she was having some pelvic pain. A urine dipstick done in the office was within normal limits and the patient was scheduled for further evaluation with flexible cystoscopy. She did not return.

On October 30, the woman saw her PCP with complaints of bladder discomfort and UTI symptoms. 

She did not feel her complaints were socially unacceptable, but had leaking when she laughed, sneezed, and coughed. She also reported urinary frequency but no pain with incontinence. The diagnosis was UTI, acute cystitis. 

The plaintiff went back to her primary doctor on February 27, 2016. His note reported that she presented for urinary incontinence and indicated that the woman was status-post multiple bladder procedures with new incontinence. 

 to reorder medication for incontinence and that she should follow up with urology and urological studies. On July 18, the woman was seen by her primary care physician for lesions found on her rib cage via a CT chest. She had no complaints of dysuria, frequency, urgency, nocturia, hematuria or incontinence. 

 The PCP referred the plaintiff for a bone scan to rule out metastatic disease, which was performed on July 28. On July 29, The PCP notified the woman that the results were normal.

The plaintiff argued that the defendants delayed diagnosing a fibroid uterus, menorrhagia, and anemia and delayed treating fibroids and performing a hysterectomy. 

The plaintiff’s side further alleged that the defendants negligently performed a laparoscopic hysterectomy, delayed timely treatment of complex bladder injury, failed to diagnose said injury intraoperatively, failed to diagnose and treat or prevent bladder damage, delayed surgery, failed to have appropriate surgical specialists available, failed to assess risk factors for a PE, caused a PE, and failed to properly place a Foley catheter.

They contended that the bladder injury was diagnosed by defendants just after the hysterectomy was completed and during the cystoscopy of August 29, 2013. They argued that good and accepted medical practice required immediate repair of the hole in the plaintiff’s bladder. 

They contended that the delay placed the plaintiff at risk for further complications including the worsening of her condition, worsening of the hole, reopening of the hole, incomplete closure, additional procedures, infection, increased risk of urinary incontinence and/or frequency and pain.

Our urology expert was able to defend Defendant ob/gyn B. The plaintiff’s injury, the cystotomy, occurred during the hysterectomy on August 26, 2013. He confirmed that any delay in performing surgery to repair the cystotomy did not cause further injury to the woman. Moreover, incontinence—her alleged injury—pre-existed the surgery. 

, any complaint that she was now at an increased risk because she was treated conservatively made no medical sense. In fact, she would be at an increased risk if she had surgery. Furthermore the repair itself was undertaken in a standard fashion and expertly performed.

The gynecology expert advised that the approximate 2-day delay in repairing the patient’s bladder injury made no difference. On August 29, Defendant ob/gyn B performed a cystogram and a cystoscopy to assess the extent of the plaintiff’s injury. 

The cystogram showed no evidence of leakage and the cystoscopy confirmed the finding. While some healing tissue was found, no perforation was found and there was no extravasation of dye. Defendant ob/gyn B directly visualized the area, and it appeared to be healing. 

Given the complexity of the repair that would have been necessary due to the injury’s location, Defendant ob/gyn B decided to treat the plaintiff conservatively. Our expert opined that the prudent course was to let her continue to heal as she appeared to be healing on her own, and not subject her to a further complicated surgery. 

, although there is variation from patient to patient, but if a patient does not have a leak and is healing, treatment is conservative. Waiting for evidence of a leak for 2 days did not cause or contribute to subsequent urinary issues.

At Defendant ob/gyn B’s deposition, it became evident that the plaintiff really had no claims against him and was hoping, by naming him as a defendant and taking his deposition, that he would implicate the co-defendants. 

To the extent that the plaintiff found it necessary to have him testify that the injury to the bladder occurred at the prior institution, he accomplished his purpose. To the extent he had hoped that ob/gyn B would offer comment that the injury to the bladder was caused by negligence, he was unsuccessful. 

, he testified that he had no knowledge of how the injury occurred other than learning that it happened during the surgery undertaken at the codefendant Hospital.

 as to co Defendant ob/gyn A prior to trial. Ob/gyn B was given a voluntary discontinuance.

This case was interesting because we essentially knew from the time of our client’s deposition forward that the plaintiff was not focusing on his actions or inactions and that so long as we maintained our defense posture, we were likely to extract him from the case if and when our codefendant settled. 

We were certainly prepared to defend his care at trial if it came to that. 

 to have the case fully worked up and evaluated to ensure you are in your best position to defend whatever allegations–credible or otherwise–are advanced. 

Ob/gyn B was prepared to not only defend his care but also not to offer opposing counsel any testimony that could implicate his codefendants and further the plaintiff’s somewhat specious claims.

, coordinating defenses should be the primary objective for the trial.

The importance of intervention: When was this baby in trouble? 

 the question of fetal well-being as demonstrated on the FHR tracing is significant. 

Allegations in this complex case include negligence in performing laparoscopic hysterectomy and delaying treatment of bladder injury.

Did delay in bladder repair cause urologic issues?

, also found that the risks were more than twice those of the general population, even for women diagnosed with low or intermediate-grade DCIS.

DCIS can increase a woman’s risk for developing IBC later in life,

 but the long-term risks of IBC and of death from breast cancer after surgery for DCIS had not been previously studied.

This investigation is a result of that. The study’s purpose was to evaluate the long-term risks and explore how those risks may vary in relation to different patient, tumor, and treatment characteristics.

The findings are based on data from 35,024 women in England who had initially been diagnosed with DCIS by the National Health Service (NHS) Breast Screening Program from its inception in 1988 until March 2014. The data included patient-related factors (screening date, date of DCIS diagnosis, age at DCIS diagnosis, any previous cancer diagnoses, and region of residence).

For women screened from April 2000 forward, the data also included tumor-related factors (DCIS tumor size, grade, laterality, estrogen receptor status) and details of treatment (type of surgery, radiotherapy, endocrine treatment).

Researchers found that by December 2014, 2,076 women had developed IBC, an incidence rate of 8.82 per 1,000 per year. That result was more than double the number expected from national rates.1

Of the women with IBC, 310 died from breast cancer with a death rate of 1.26 per 1,000 per year, which was 70% more than expected from national rates. These increases continued for at least 20 years.

This study also showed that breast conserving surgery was associated with a lower rate of invasive breast cancer in women who also had radiotherapy. The lowest rates of IBC were seen in women who had undergone mastectomy.

Larger final surgical margins may also decrease risks of IBC and of death, according to researchers. “Although guidelines recommend that margin widths do not need to be more than 1-2 mm, our study suggests that having margins greater than this may confer some further benefit,” the authors wrote, calling for further studies on margin distances in DCIS.

Mannu G, Wang Z, Broggio J, et al. Invasive breast cancer and breast cancer mortality after ductal carcinoma in situ in women attending for breast screening in England, 1988-2014: population based observational cohort study. 

American Cancer Society. Ductal Carcinoma in Situ (DCIS). July 2, 2020. 

www.cancer.org/cancer/breast-cancer/understanding-a-breast-cancer-diagnosis/types-of-breast-cancer/dcis.html

Women with ductal carcinoma in situ (DCIS) may experience higher risk of developing invasive breast cancer (IBC) and of death from breast cancer than the general population, according to new research. 

Improving risk outcomes: Invasive breast cancer after DCIS

The National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health (NIH), has merged four existing clinical trials networks to create the COVID-19 Prevention Trials Network (CoVPN).

CoVPN was established as a result of President Trump’s Operation Warp Speed, which aims to deliver a safe vaccine for the virus by January 2021.

It is composed of four existing, NIAID-funded clinical trials networks: the HIV Vaccine Trials Network (HVTN); the HIV Prevention Trials Network (HPTN); the Infectious Diseases Clinical Research Consortium (IDCRC); and the AIDS Clinical Trials Group.

“Finding a safe and effective vaccine to prevent infection with SARS-CoV-2 is an urgent public health priority,” said NIAID Director Anthony S. Fauci, M.D. in a recent press release.

 efforts, these networks will continue to perform clinical trials for HIV vaccine and prevention, as well as other infectious diseases.

CoVPN is expected to conduct the first Phase 3 clinical trial this summer. It will use a harmonized vaccine protocol developed by the Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV) public-private partnership. It will involve testing the investigational mRNA-1273 vaccine, developed by NIAID scientists and their collaborators at the biotechnology company Moderna, Inc.

As the CoVPN studies become active, they will reflect on the network’s website under 

NIH launches clinical trials network to test COVID-19 vaccines and other prevention tools. News release. National Institutes of Health; July 8, 2020.

NIH Clinical Trial of investigational Vaccine for COVID-19 Begins. News release. National Institute of Allergy and Infectious Diseases; March 16, 2020.

This new network aims to enroll thousands of volunteers in trials testing investigational vaccines and monoclonal antibodies to fight COVID-19. 

NIH launches clinical trials network to test COVID-19 vaccines and prevention strategies

Journal of Obstetrics, Gynecology and Cancer Research

, the prospective observational study looked at 

 who had been diagnosed with breast cancer and who were experiencing climacteric symptoms. Results included improved quality of life. 

These patients had undergone surgery, radiation otherapy, and/or chemotherapy more than 1 year prior to the study, and were receiving tamoxifen or an AIaromatase inhibitor.

The sample included 57 women who completed a sociodemographic questionnaire, the Blatt-Kupperman Menopausal Index (KI) and the World Health Organization Quality of Life version-bref (WHOQOL-bref) scale.

The median age of patients was 54.4 5.9 years; 86% had ductal carcinoma, 98% had undergone surgery, 70% had received chemotherapy, and 96% had received radiation otherapy.

Patients were divided into two2 groups: 35 patients who used tamoxifen, and 22 patients who took AIaromatase inhibitors. 

Comparison of the KI and WHOQOL-bref scales showed improvement in scores at 6 months in patients who used AIaromatase inhibitors.

In both groups, KI scores declined significantly (

<0.011) over the study. The authors concluded that patients using AIaromatase inhibitors had higher quality-of-life scores than those on tamoxifen. 

 patients with breast cancer found that AIaromatase inhibitors to have a good toxicity profile, with lower rates of hot flashes, nausea, vaginal bleeding, vaginal discharge, endometrial cancer, and thromboembolic events.

Macruz CF, Lima SMRR, Postigo S, Martins MM, Lucarelli AP, de Oliveira VM. Quality of Life and Climacteric Symptoms in Postmenopausal Women Receiving Hormone Therapy for Breast Cancer [published online ahead of print, 2020 Mar 27]. 

. 2020;S1701-2163(20)30262-0. doi:10.1016/j.jogc.2020.02.124

New research shows that, in postmenopausal women undergoing hormone therapy for breast cancer, aromatase inhibitors (AIs) lead to a reduction in climacteric symptoms and significantly improved quality of life.  

Aromatase inhibitors for climacteric symptoms in women with breast cancer

Ben Schwartz is Associate Editor, Contemporary OB/GYN.

Vulvovaginal candidiasis (VVC) is relatively common, and research from 

 indicates a woman’s risk could be increased by certain personal behaviors as well as the composition of her vaginal microbiota. 

 is the most common etiology for VCC and this study looked at what factors are associated with its molecular detection. 

The objective of the study was to better understand epidemiologic factors associated with molecular 

detection and to evaluate how the vaginal microbiota and relative abundance of individual bacterial taxa differ between women with and without 

For the cross-sectional study, vaginal swabs were self-collected by 394 non-pregnant, reproductive-age women. The participants submitted two swabs; one was used to characterize the composition and structure of the vaginal microbiota and the other was used the prepare a smear for Nugent Gram stain scoring.

 using polymerase chain reaction targeting 

 ITS1/2 region. Vaginal microbiota was characterized using 16S rRNA gene amplification sequencing of the V3 to V4 hypervariable regions and then clustered into community state types (CSTs).

Five primary CSTs were identified in this study; four dominated by 

Lactobacillus species (L. iners, L. crispatus, L. gasseri, L. jensenii)

, plus one lacking significant numbers of 

and characterized by higher proportions of strict and facultative anaerobic bacteria (termed CST IV). 

The authors used multiple logistic regression to identify risk factors associated with 

 in 21%of vaginal samples (83 of 394). Women in whom 

 was detected were more likely to report use of tampons, engage in receptive oral sex, and use of over-the-counter (OTC) antifungals to self-treat for vaginal infections before seeing a doctor for examination.

Neither self-reported diagnosis of VVC nor bacterial vaginosis in the prior 60 days were associated with 

Furthermore, detection was not associated with vaginal pH, re-porting any type of vaginal symptom in the past 60 days, age, history of pregnancy, use of hormonal contraception in the past 60 days, number of recent sexual partners, or other forms of sexual activity in the past 60 days.

-dominated CST had increased, but not statistically significant, oddsof 

 CST IV after cofactor adjustment of receptive oral sex and a history of self-treatment with OTC antifungals (adjusted odds ratio, 2.05%; 95% CI 0.97-4.37, n=323). 

However, using the same model, antifungal use and receptive oral sex were significantly associated with 

detection, with a dose-response trend for increasing frequency of oral sex and escalating odds of 

When assessing individual bacteria to determine if there were taxa that were most likely to be associated with 

Lactobacillus coleohominis, Prevotella oris

 being in higher relative abundance in women in whom 

The authors believe their findings indicate that 

-dominated vaginal microbiota may be associated with increased 

 detection. They also point to receptive oral sex as a risk factor for 

Moura APC, Ribeiro HSAA, Bernardo WM, et al. Accuracy of transvaginal sonography versus magnetic resonance imaging in the diagnosis of rectosigmoid endometriosis: Systematic review and meta-analysis. PLOS One. 2019;14(4):e0214842.

Candida albicans is the most common etiology for VCC and this study looked at what factors are associated with its molecular detection. 

Risk factors for candidiasis

Judith M. Orvos, ELS, is a a BELS-certified medical writer and editor and an editorial consultant for Contemporary OB/GYN.

While urging caution in interpretation of their results, the authors say the findings could be particularly important for management of nulliparas.

Findings from the study—which was stopped early because of a signifi cantly higher rate of peri-natal mortality in the expectant management group—were pub-lished in BMJ. 

SWEPIS (SWEdish Post-term Induction Study) was a multicenter, open-label, random-ized superiority trial conducted at 14 hospitals in Sweden from 2016 to 2018.

Of the 2760 women enrolled, all of whom had low-risk, uncomplicated pregnancies, 1381 were randomized to induction at 41 weeks and 1379 to ex-pectant management with induction at 42 weeks. In many centers in the UK and Scandinavia, induction is com-mon no later than 42 weeks. 

Recent studies have shown a significantly increased risk of perinatal mortality and morbidity at 41 weeks, and of stillbirth beginning at 39 weeks.

The primary outcome of SWEPIS was a composite of perinatal out-come including one or more of still-birth, neonatal mortality, Apgar < 7 at 5 minutes, pH < 7.00 or metabolic aci-dosis in the umbilical artery, hypoxic ischemic encephalopathy, intracranial hemorrhage, convulsions, meconium aspiration syndrome, mechanical ventilation within 72 hours, or obstetric brachial injury. 

The secondary outcome was perinatal mortality. The primary analysis was intent to treat.

In the induction group, there were fewer admissions to a [NICU], lower incidence of neonatal jaundice...and fewer infants with macrosomia.

No perinatal deaths occurred in the group induced at 41 weeks but six occurred in the expectant management group (5 stillbirths, 1 early neonatal death; P = 0.03). No differences were seen between the groups in the composite primary perinatal outcome (2.4% [33/1381] induction group; 2.2% [31/1379] expectant management; RR 1.06, 95% CI 0.6 to 1.73; P = 0.90). 

The proportion of cesarean deliveries, instrumental vaginal deliveries, or major maternal morbidities also did not differ between the groups.

The authors also found that in the induction group, there were fewer admissions to a neonatal intensive care unit, lower incidence of neonatal jaundice requiring therapy, and fewer infants with macrosomia. 

The rate of cesarean delivery did not differ significantly between the two groups. Of note, the researchers said, all perinatal deaths occurred in the nulliparous women. 

“If this finding can be replicated in fu-ture studies,” they indicated, “it could mean that nulliparous women may require particular attention, and interventions such as labor induction might be even more important in this group.” 

The number needed to treat with induction of labor at 41 weeks to prevent one perinatal death was 230, which the authors said was lower than previous estimates.

A nationwide study by Swedish researchers suggests that inducing labor at no later than 41 weeks could be one of the few interventions that reduce stillbirths. 

Inducing labor to reduce stillbirths

 found that more than 95% of the prescriptions were for short-acting opioids (SAOs) only, while 4.1% were for both SAOs and extended-release/long-acting opioids (LAOs).

Only 0.6% of women filled a prescription for LAOs alone.

“Endometriosis is a debilitating disease that can cause significant pelvic pain,” said principal investigator Sawsan As-Sanie, MD, MPH, co-chief of gynecology and director of minimally invasive gynecologic surgery at the University of Michigan in Ann Arbor. 

“However, currently available treatments are not consistently effective for all women, and some may resort to opioids to manage their pain, despite the fact that opioids are not recommended for the treatment of endometriosis pain or any other chronic non-malignant pain condition. Long-term opioid use can be associated with significant harm.”

The investigators, who sought to better understand the scope of opioid prescribing patterns in women with endometriosis, performed a retrospective cohort analysis of data from the Truven MarketScan Commercial database for the period January 2011 to December 2016.

Women who filled an opioid prescription within 12 months of their first endometriosis diagnosis were compared to women who did not fill an opioid prescription during the study period.

The dataset comprised 58,472 women with endometriosis, of whom 61.7% filled an opioid prescription within the first year. While only 10% of women did not have any surgery in the first year after the first listed endometriosis diagnosis, the prevalence of patients who received an opioid prescription remained high, even after excluding opioids prescribed in the perioperative period (defined as anytime between 14 days before or 30 days after surgery). 

After excluding prescriptions in the perioperative period, 49% of women with endometriosis filled at least one opioid prescription.

Compared to endometriosis patients who did not fill an opioid prescription, endometriosis patients who filled an opioid prescription had significantly higher baseline comorbidities (especially gynecological and chronic pain comorbidities), endometriosis-related medication use, mental health disorders and substance abuse.

“I expected that this would be common after surgery, but was especially surprised that these patterns persisted, even after excluding opioid prescribing outside of the surgical period.” 

Patients who filled both LAO and SAO prescriptions had the highest total days' supply of opioids, proportion of days covered by prescriptions and morphine equivalent daily dose.

Baseline opioid abuse, opioid dependence, and opioid overdose were also significantly higher in the SAO and LAO-SAO groups compared to the non-opioid group: SAO: 0.3%, 2.2%, 0.2% respectively; LAO-SAO: 2.5%, 15.8%, 2.4% respectively; non-opioid: 0.2%, 1.2%, 0.1% respectively (

These patients also had the highest proportions of opioid switching and dose augmentation.

“While I do not recommend the use of opioids for the management of chronic pain in my practice, I was surprised by how commonly opioids are prescribed in women with endometriosis,” Dr. As-Sanie told 

Dr. As-Sanie said an important next step in understanding and optimizing endometriosis care is further research into when opioids are prescribed relative to the diagnosis and treatment timeline, and the reasons surrounding the use of opioids in relation to other recommended treatments, such as combined hormonal contraceptives, gonadotrophin-releasing hormone agonists (GnRHa), progestins, and surgical excision.

Dr. As-Sanie receives royalties from UpToDate, and is a consultant to AbbVie, Myovant Sciences, Bayer, and Merck.

As-Sanie S, Soliman AM, Evans K, et al. Short-acting and long-acting opioids utilization among women diagnosed with endometriosis in the United States: a population-based claims study. 

. Published online June 9, 2020. doi:10.1016/j.jmig.2020.05.029

Nearly two-thirds of women newly diagnosed with endometriosis filled an opioid prescription within the first year, according to a US population-based claims study. 

Opioid use in women with endometriosis

A significant positive association exists between hormone replacement therapy (HRT) and mammographic density (MD), according to a systematic literature review in the journal 

The review concluded that the highest increase in MD is among current users of HRT, particularly those taking continuous estrogen plus progestin (CEP).

“HRT has been used as an effective treatment for alleviating the climacteric symptoms of menopause, such as hot flushes, sleeping disturbance, depressive mood, and muscle and joint pain for many years,” said senior author Shadi Azam, PhD, a breast cancer epidemiologist at Karolinska Institute in Stockholm, Sweden.

 that various papers and reviews have evaluated the effect of different HRT regimes, state of exposure and risk of breast cancer. 

“However, ours is the first systematic review to assess the impact of HRT regimens on MD, which is an important risk factor for breast cancer,” she said.

Articles published between 2002 and 2019 from PubMed, Embase and Ovid were reviewed. Among the 22 studies that met the inclusion criteria, six studies showed that using estrogen plus progestin (E + P) HRT was associated with higher MD than estrogen alone.

Four studies reported that CEP was connected to higher MD than sequential estrogen plus progestin (SEP) or estrogen alone, but two studies showed that SEP caused slightly higher MD than CEP or estrogen alone.