Bob Kronemyer

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According to data from 2012 and 2013, the estimated incidence of metabolic syndrome in Canadian women is 20%, and as high as 38% among women aged 60 to 79.

“Most recently, metabolic syndrome has been associated with an increased risk of breast cancer development, poor prognostic characteristics including triple-negative hormone receptor status, increased likelihood of recurrence, and higher mortality,” wrote the Canadian investigators, who presented their findings in the journal 

The authors evaluated whether menopause is an independent risk factor for the development of metabolic syndrome or its components, including hypertension, central obesity, dyslipidemia, and elevated glycated hemoglobin.

The study cohort consisted of 12,611 women whose baseline data were included in the Canadian Longitudinal Study on Aging Comprehensive Cohort. The data were collected from 2012 to 2015.

Among the cohort, 79.6% had undergone menopause and 20.4% were premenopausal.

Overall, 32.6% of postmenopausal women met the criteria for metabolic syndrome versus 20.5% of premenopausal women (

In both postmenopausal and premenopausal women with a small waist circumference threshold (≥ 80 cm), based on the criteria for metabolic syndrome, the prevalence of metabolic syndrome was higher: 38.2% and 23.2%, respectively (

However, after adjusting for age, body mass index (BMI), and other covariates, the occurrence of menopause was not linked to a significantly higher relative risk of metabolic syndrome when using the unified criteria. For metabolic syndrome: adjusted relative risk (aRR) 1.09; 95% confidence interval (CI): 0.99 to 1.19. (A unified set of criteria were developed in 2009 by organizations including the International Diabetes Federation, the American Heart Association, and the National Heart, Lung, and Blood Institute.)

But women in menopause had a significantly higher relative risk of metabolic syndrome when using criteria for the lower waist circumference: aRR 1.10; 95% CI: 1.01 to 1.19.

The study also found that menopause, rather than the metabolic syndrome, was associated with a higher risk of impaired glucose tolerance (aRR 1.42; 95% CI: 1.26 to 1.59), elevated blood pressure (aRR 1.12; 95% CI: 1.03 to 1.21), and elevated triglycerides (aRR 1.17; 95% CI: 1.08 to 1.26).

Conversely, there was no significant difference in the risk of metabolic syndrome or the occurrence of menopause by age group.

Among postmenopausal women, 38.7% reported using menopausal hormone therapy (MHT), but there was no significant difference in the risk of metabolic syndrome among postmenopausal women on MHT compared to those who were not on therapy.

Premenopausal women reported more weight gain than postmenopausal women. This finding is of particular importance to the Canadian population, “as perhaps women in Canada gain weight earlier, presenting an opportunity to increase awareness among younger women around expected weight change during their upcoming menopause transition,” wrote the authors.

Lifestyle interventions targeted at women with metabolic syndrome can prevent type 2 diabetes mellitus and cardiovascular risk, according to the authors. “Perimenopause may be an important preventative care opportunity to assess metabolic risk factors and improve health and longevity of Canadian women,” they wrote.

Christakis MK, Hasan H, De Souza LR, Shirreff L. The effect of menopause on metabolic syndrome: cross-sectional results from the Canadian Longitudinal Study on Aging. 

. 2020 Sep;27(9):999-1009. doi:10.1097/GME.0000000000001575

Articles

Postmenopausal women are significantly more likely to meet criteria for metabolic syndrome than are premenopausal women, according to a cross-sectional analysis of women aged 45 to 85.

Postmenopausal women more likely to experience metabolic syndrome

Female Pelvic Medicine & Reconstructive Surgery

 has concluded that patients undergoing isolated midurethral sling placement filled a median of 150 cumulative morphine milligram equivalents (MMEs) from 28 days before surgery to 28 days after surgery.

Patients were identified in the Truven Health Analytics MarketScan Commercial Claims and Encounters Database, from which the investigators determined whether sling placement was an isolated procedure or performed in conjunction with other benign gynecologic procedures.

All outpatient prescription drug claims for opioids were recorded from 28 days before surgery to 28 days after surgery. The investigators then flagged the number of prescriptions filled and calculated MMEs in the allotted perioperative window.

The study cohort comprised 153,631 patients, of whom 51.5% underwent an isolated procedure, and the remaining 48.5% multiple benign procedures.

Overall, 72% of the patients who had isolated midurethral sling placement received at least 1 opioid prescription in the allocated perioperative window compared with 79% of those undergoing combined procedures (

The median cumulative MMEs for isolated midurethral sling and midurethral sling + multiple procedures were 150 MMEs and 225 MMEs, respectively (

For the entire study period, the number of prescription opioid claims was 161,471, with hydrocodone (54.4%) and oxycodone (31.8%) representing most (86.2%) of the prescription drug claims.

In addition, 81.9% of all prescriptions included combination narcotics, with 53.0% acetaminophen/hydrocodone and 28.9% acetaminophen/oxycodone.

Among patients undergoing isolated midurethral sling placement, 15.1% filled an opioid prescription during the 28-day presurgical period vs. 19.7% of patients who underwent multiple procedures (

Also, presurgically, patients undergoing an isolated sling procedure received a median of 200 MMEs, whereas patients undergoing multiple procedures received a median of 225 MMEs (

Postsurgically, though, the percentage of patients who filled an opioid prescription rose dramatically: 64.6% of patients undergoing isolated sling placement vs. 69.2% of patients who underwent multiple procedures (

Patients undergoing isolated sling placement received a median of 150 MMEs in the postsurgical period, whereas patients undergoing multiple procedures received 225 MMEs (

“Interestingly, this study revealed that among both isolated and multiple surgery patients who had filled a prescription for an opioid in the 28 days before surgery, approximately half-filled at least one additional prescription in the postsurgical period,” wrote the authors. “Although we acknowledge that this pattern could be secondary to chronic opioid use among some of the study population, it raises the question of possible duplicative or excess prescribing.”

For the total study period, every 1-year increase in the year of surgery was associated with 11% higher odds of filling an opioid prescription: odds ratio (OR) 1.11; 95% confidence interval (CI): 1.10 to 1.12 (

Compared to isolated procedures, multiple procedures had 36% higher odds of filling an opioid prescription during the entire study period: OR 1.36; 95% CI: 1.33 to 1.39; 

 < 0.001). But for the whole study period, there was no significant change in median cumulative MME over time.

There is a continuing need for information on evidence-based use of opioids, given the highly variable prescribing patterns for the drugs, according to the authors. It is hoped that future studies can be done to identify parameters for optimal use of opioids after midurethral sling placement.

Feroz RT, Boyd SS, Schaefer EW, Swailes AL, Long JB. Postoperative opioid filling patterns in women undergoing midurethral sling placement. Female 

. Published online September 4, 2020. doi:10.1097/SPV.0000000000000919

The proportion of patients filling perioperative opioid prescriptions also substantially increased over the study period, which spanned 2005 to 2016.

Perioperative opioid filling for midurethral sling

The Italian retrospective multi-institutional study in the journal 

Oncology found that the 5-year recurrence rate was 8.1% for LEEP and 4% for laser conization (

Patients undergoing LEEP are more likely to be diagnosed with positive margin, which is defined as a histological finding of the cervical intraepithelial neoplasia (CIN) along the specimen margin, in comparison with patients undergoing laser conization.

However, the risk of having persistent human papillomavirus (HPV) was similar between the two groups: 15.0% for LEEP vs. 11.6% for laser conization (

“Many studies have been conducted to investigate the predictors of persistent/recurrent cervical dysplasia,” said principal investigator Giorgio, MD, PhD, a professor of ob/gyn at Fondazione IRCCS Istituto Nazionale dei Tumori in Milano, Italy. “A positive margin after conization and HPV persistence are well-defined predictors of persistent/recurrent disease.”

 that treatment of recurrent disease might significantly impact a patient’s health. “In addition, the second conization might have a detrimental impact on fertility and might be associated with an increased risk of preterm delivery and premature rupture of membranes,” he said. “Therefore, studies aiming to reduce cervical dysplasia recurrence are of paramount importance.”

The current study evaluated the medical records of 2,966 consecutive patients with high-grade cervical dysplasia who underwent primary conization at Dr. Bogani’s institute and in 21 other centers in Italy between 2010 and 2014. The median patient age was 40 years (range 18 to 89)

During the study period, 20% of patients had laser conization and 80% had LEEP.

The reason for conization was CIN2 in 32.7% of patients and CIN3 in 66.9% of patients.

Overall, 175 women received a second conization within the first 5 years after primary treatment, for a recurrence rate of 6%. The median time to recurrence was 18 months, ranging from 5 to 52 months, with most patients developing recurrence within the first 2 years.

Women with a diagnosis of CIN3 were nearly four times as likelyto have recurrence, whereas women with HPV persistence were almost twice as likely.

“To overcome the biases related to the retrospective nature of the study, we applied a propensity-matched algorithm, from which we selected 500 patients undergoing laser conization and 1,000 undergoing LEEP for analysis,” Dr. Bogani said. After applying a propensity-matched algorithm, LEEP was associated with an increased risk of recurrence in comparison to laser conization.

One reason why laser conization is associated with a lower rate of recurrence than LEEP is that “similar to cold knife with conization, laser allows us to perform a step-by-step conization, following the geometry of the lesions, thus tailoring the radicality of the procedure,” Dr. Bogani said.

The extensive vaporization of the surgical margins caused by laser CO2 might also provide a higher rate of local control than diathermocoagulation.

HPV persistence was the only factor associated with 5-year recurrence after either laser conization (

 = 0.001). “This finding highlights the importance of HPV persistence as one of the main prognostic factors for recurrence,” Dr. Bogani said.

The author and his colleagues are now studying the long-term effect of vaccination against HPV in women who under conization. “We anticipate that vaccination against HPV in adolescent and young adults will reduce the burden of HPV-related diseases,” Dr. Bogani said.

Dr. Bogani reports no relevant financial disclosures.

Bogani G, Di Donato V, Sopracordevole F. Recurrence rate after loop electrosurgical excision procedure (LEEP) and laser conization: a 5-year follow-up study. 

. Published online on September 3, 2020. doi:10.1016/j.ygyno.2020.08.025

Women with high-grade cervical dysplasia are much less likely to have recurrence after primary conization if they undergo laser conization than a loop electrosurgical excision procedure (LEEP), according to a 5-year follow-up study.

Recurrence of high-grade cervical dysplasia

was part of the Swiss Perimenopause Study: a large prospective, 1-year longitudinal research project conducted at the Department of Clinical Psychology and Psychotherapy at the University of Zurich.

The population-based sample for the cross-sectional analysis consisted of 135 perimenopausal women, aged 40 to 56 years, who participated in the study. Subjects were recruited between June 2018 and December 2019 through various channels, such as mailing lists, social media, and newsletter articles.

A good to excellent self-reported health status at study enrollment was required.

Among the 135 women, 43.7% were early perimenopausal and 56.3% were late perimenopausal. In addition, slightly more than half of the cohort (56.3%) was married.

All women were either Swiss (n = 105), German (n = 8) or Austrian (n = 1). However, despite efforts to recruit women from different socioeconomic backgrounds, participants were overall well-educated, with 54.5% reporting an academic degree, compared with 44.5% in the Swiss population, and had a higher socioeconomic status.

A history of depression was surmised if a woman had been previously diagnosed by a mental health expert such as a psychiatrist or a psychotherapist, or as a self-report complying with the criteria for major depression according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

A wide range of validated psychosocial questionnaires were used to compare women with and without prior depression.

Overall, 40% of the study group had experienced at least one depressive episode in the past, whereas 60% did not indicate a history of depression.

Women with prior depression showed significantly more depressive symptoms (Mann-Whitney U-test [U]= 1215.5; 

 < 0.01), more menopausal symptoms (U = 1395.0; 

 < 0.01) and more sleep disturbances (U = 1583.5; 

 < 0.05) than women without prior depression.

Women with a history of depression also rated their own mental health worse (U = 1573.0; 

 < 0.05) and felt more isolated (U = 1524.0; 

 < 0.05) than those without prior depression.

“We assumed that females with prior depression would struggle significantly more during the menopausal transition, as reflected by greater levels of suffering in the perimenopause, more frequent negative health outcomes, and limited subjective well-being,” wrote the authors. “Indeed, we found increased burdensome symptoms in women with a history of depression.”

However, there were no significant differences in perceived stress, coping or self-esteem between women with and without prior depression.

Noteworthy, though, is that women with prior depression reported higher scores on instrumental social support compared with women without prior depression; hence, social isolation and helplessness during past depressive episodes might have increased the perceived social support.

The study’s findings underscore the need to consider a woman's mental health history during evaluation, education, and treatment of symptoms linked to the menopausal transition.

Moreover, because a woman's sensitivity to hormonal changes has been suggested as an influential factor in the relationship between depression and perimenopause, endocrinological factors as predictors of depressive symptoms should be considered for future research, according to the authors.

Willi J, Süss H, Grub J, et al. Prior depression affects the experience of the perimenopause - findings from the Swiss Perimenopause Study. 

. Published online September 2, 2020. doi:10.1016/j.jad.2020.08.062

Perimenopausal women with prior depression exhibit significantly more depressive symptoms, more menopausal symptoms, and more sleep disturbances than perimenopausal women without prior depression, according to a study from Switzerland.

Author | Bob Kronemyer

Articles

Postmenopausal women more likely to experience metabolic syndrome

Perioperative opioid filling for midurethral sling

Recurrence of high-grade cervical dysplasia

Research finds link between prior depression and severity of symptoms during perimenopause