Ramifications of pelvic exam guidelines

July 29, 2015

Have pelvic guideline changes led to a reduction in other recommended screenings? Plus, how does menopause impact future cardiovascular health? And: Does childhood stress lead to negative obstetric outcomes?

The 2009 change in cervical cancer screening guidelines may have had an unintended consequence: fewer young women are receiving the annual chlamydia screening recommended by the Centers for Disease Control and Prevention (CDC), according to a new study.

More: Whither the annual bimanual pelvic exam?

University of Michigan researchers used a patient population database to identify visits by women aged 15 to 21 years at 5 different family medicine ambulatory clinics at the university. They performed a repeated cross-sectional study comparing women who made visits between January 2009 and February 2009, which was before the guidelines changed, and those who had visits between January 2011 and February 2012, which was after the guideline change. Visits with Pap and chlamydia testing that were likely diagnostic instead of screening were excluded.

The analyses covered 3472 women aged 15 to 21 years for a total of 9852 visits. Overall significantly more patients underwent Pap testing before the guideline change, roughly 24%, than after the guideline change, only 3.9%. Even after adjusting for clinic site, clinician type, and age, the odds of receiving the test were far more significant before the guideline change (odds ratio = 7.13; 95% CI, 5.38–9.43; P <.001).  There was a similar trend with undergoing chlamydia screening before the change versus after the change (odds ratio = 13.97; 95% CI, 9.17–21.29; P <.001). After the change, only 10.8% of chlamydia screens were performed with Pap testing; before the change nearly 62% of chlamydia screens occurred at the same visit as Pap testing.

The investigators concluded that chlamydia screening should be unlinked from pelvic exams and cervical cancer screenings, as the study suggests that they do not serve as opportunities for screening. They also believe that the recent recommendation from the American College of Physicians, which suggested that non-pregnant, asymptomatic women don’t need pelvic exams, could impact chlamydia screening in a similar fashion.

They did note some limitations to their study, including that it covered a single department at a single academic center. The researchers did not have access to demographic information for the patients and the data only showed what tests were completed, not all tests ordered.

NEXT: Menopause's impact on heart health

 

Is menopausal status associated with cardiovascular fat and CHD?

Fat around the heart and aorta may play a role in coronary heart disease (CHD) and a first-of-its-kind report hints at connections between menopause, endogenous hormones, and the increased risk of CVD seen in women after menopause. The findings, published in The Journal of Clinical Endocrinology & Metabolism, are from an ancillary study to the Study of Women’s Health Across the Nation (SWAN), an ongoing community-based longitudinal study of the menopause.

Next: Are common chemicals associated with earlier onset of menopause?

The results reflect data from 456 women with a mean age of 50.75 years, 62% of whom were premenopausal or in early perimenopause and 38% of whom were African-American. Computed tomographic scans were used to quantify cardiovascular fat (CF) deposition in the women. Fat within and outside the pericardial sac was measured, as were the total sum of fat in those two areas and the fat surrounding the descending aorta. Levels of endogenous hormones were measured via blood samples taken from the participants during days 2 to 5 of the menstrual cycle. Menopausal status was determined based on the frequency and regularity of menstrual bleeding.

The goal of the research was to determine the relationship between CF depot, menopausal status, and endogenous sex hormones. Women in late perimenopause or who were postmenopausal had 9.88% more epicardial fat (i.e., enveloped by visceral pericardium, directly adjacent to myocardium and coronary arteries) fat, 20.7% more paracardial fat (i.e., surrounding parietal pericardium), and 11.69% more total heart fat than those in premenopause or early perimenopause (P<.05). The differences were independent of study covariates. Levels of fat in the tissue surrounding the descending thoracic aorta were not associated with menopausal status. Lower estradiol concentrations were associated with higher volumes of paracardial and total heart fat (P<0.05). Women whose estradiol levels decreased the most from baseline had more paracardial fat than those with the least reductions in those hormone levels (P=0.02).

The authors concluded that endogenous sex hormones are associated with CF and that CF may play a role in the higher risk of CHD seen in women after menopause. They believe that theirs is the first study to examine such an association and that the findings “suggest a potential role of E2 in explaining why late peri-/postmenopausal women showed greater volumes of CF depots compared to pre-/early peri-menopausal women in the current study.”

The researchers also acknowledged the limitations of the cross-sectional design and noted that they were unable to adjust for total body fat because that information was not captured in the original SWAN study. Weight management, they said, may be a potential strategy for reducing CF in women at midlife and helping to reduce their CHD risk.

NEXT: Does childhood stress have an impact on pregnancy outcomes?

 

Does childhood stress impact pregnancy outcomes?

The impact of extreme stress in childhood may loom large into adulthood, even increasing the risk of preterm birth, according to a large case-control study.

Next: Obstetric history and CVD risk

Researchers from Edmonton, Canada studied mothers with spontaneous singleton preterm births (<37 weeks) with no preterm premature rupture of membranes (cases) and women who had uncomplicated singleton term births with no history of preterm birth (controls). Medical and sociodemographic data were collected. A telephonic questionnaire was administered postpartum to assess stressors across the mother’s lifespan. Overall 223 women (75 cases, 148 controls) completed the questionnaire. Univariate and multivariate logistic regression were used for analysis.

Analysis showed that being exposed to 2 or more adverse childhood experiences (ACEs) was linked to a two-fold risk of preterm birth. This increased risk occurred regardless of maternal age, smoking status, educational status, or history of miscarriage (adjusted odds ratio, 2.09; 95 % CI, 1.10–3.98; P = 0.024). An adjusted odds ratio of 1.18 for the ACE score seems to suggest that every increase in ACE led to the risk of preterm birth increasing by 18%. A history of lifetime emotional and physical abuse was also tied to spontaneous preterm birth in the study population (adjusted odds ratio, 1.30; 95 % CI, 1.02–1.65; P = 0.033).

The researchers concluded that a strong relationship between ACEs and preterm birth existed in their case study. They believe the 2-fold increased risk of spontaneous preterm birth with a history of 2 or more ACEs was notable and that their data show the impact of childhood stressors on pregnancy outcomes later in life.