Objective: To update and expand The North American Menopause Society's evidence-based position on... more Objective: To update and expand The North American Menopause Society's evidence-based position on nonhormonal management of menopause-associated vasomotor symptoms (VMS), previously a portion of the position statement on the management of VMS. Methods: NAMS enlisted clinical and research experts in the field and a reference librarian to identify and review available evidence. Five different electronic search engines were used to cull relevant literature. Using the literature, experts created a document for final approval by the NAMS Board of Trustees. Results: Nonhormonal management of VMS is an important consideration when hormone therapy is not an option, either because of medical contraindications or a woman's personal choice. Nonhormonal therapies include lifestyle changes, mind-body techniques, dietary management and supplements, prescription therapies, and others. The costs, time, and effort involved as well as adverse effects, lack of long-term studies, and potential interactions with medications all need to be carefully weighed against potential effectiveness during decision making. Conclusions: Clinicians need to be well informed about the level of evidence available for the wide array of nonhormonal management options currently available to midlife women to help prevent underuse of effective therapies or use of inappropriate or ineffective therapies. Recommended: Cognitive-behavioral therapy and, to a lesser extent, clinical hypnosis have been shown to be effective in reducing VMS. Paroxetine salt is the only nonhormonal medication approved by the US Food and Drug Administration for the management of VMS, although other selective serotonin reuptake/norepinephrine reuptake inhibitors, gabapentinoids, and clonidine show evidence of efficacy. Recommend with caution: Some therapies that may be beneficial for alleviating VMS are weight loss, mindfulness-based stress reduction, the S-equol derivatives of soy isoflavones, and stellate ganglion block, but additional studies of these therapies are warranted. Do not recommend at this time: There are negative, insufficient, or inconclusive data suggesting the following should not be recommended as proven therapies for managing VMS: cooling techniques, avoidance of triggers, exercise, yoga, paced respiration, relaxation, over-the-counter supplements and herbal therapies, acupuncture, calibration of neural oscillations, and chiropractic interventions. Incorporating the available evidence into clinical practice will help ensure that women receive evidence-based recommendations along with appropriate cautions for appropriate and timely management of VMS.
Objective The objective of this study is to assess whether the presence of breast arterial calcif... more Objective The objective of this study is to assess whether the presence of breast arterial calcifications (BACs) found on routine mammography is prospectively associated with the development of cardiovascular disease (CVD) events after 10 years of follow-up. Methods Women presenting for screening mammography were enrolled in this prospective cohort. Baseline data were collected including history of CVD and CVD risk factors. Mammograms were assessed for the presence or absence of BAC. Participants completed questionnaires 10 years after baseline that assessed the development of CVD (coronary artery disease [CAD] and stroke) and CVD risk factors. Results Of the 1,995 participants who enrolled at baseline, complete 10-year follow-up data were available for 1,039; of those, 114 (11.0%) were BAC-positive and 925 (89.0%) were BAC-negative at baseline. After controlling for age, BAC-positive women were more likely to develop CAD (odds ratio, 3.14; 95% confidence interval, 1.86-5.27; P <...
Objective The objective of this study is to assess whether the presence of breast arterial calcif... more Objective The objective of this study is to assess whether the presence of breast arterial calcifications (BACs) found on routine mammography is prospectively associated with the development of cardiovascular disease (CVD) events after 10 years of follow-up. Methods Women presenting for screening mammography were enrolled in this prospective cohort. Baseline data were collected including history of CVD and CVD risk factors. Mammograms were assessed for the presence or absence of BAC. Participants completed questionnaires 10 years after baseline that assessed the development of CVD (coronary artery disease [CAD] and stroke) and CVD risk factors. Results Of the 1,995 participants who enrolled at baseline, complete 10-year follow-up data were available for 1,039; of those, 114 (11.0%) were BAC-positive and 925 (89.0%) were BAC-negative at baseline. After controlling for age, BAC-positive women were more likely to develop CAD (odds ratio, 3.14; 95% confidence interval, 1.86-5.27; P <...
Objective This study aimed to assess the variance in menopause education, educational resources, ... more Objective This study aimed to assess the variance in menopause education, educational resources, and the needs of obstetrics and gynecology (ObGyn) residency programs by conducting a national survey of program directors (PDs). Methods In 2022, an institutional review board–approved Web-based Qualtrics survey was designed and distributed electronically to 145 US ObGyn residency PDs. The survey consists of 15 questions. The main outcomes are reported using descriptive statistics. Results The survey was completed by 99 of 145 PDs (68.3%). Almost all participants (92.9%) strongly agreed that residents nationwide should have access to a standardized menopause curriculum that could be utilized in their programs. Only 31.3% reported having a menopause curriculum in their residency program. Of the programs with a menopause curriculum, 96.8% reported using lectures, 77.4% reported assigned readings, and 74.2% had either dedicated menopause clinics or other clinics with a high volume of menop...
Objective The aim of this study was to examine the association between common menopausal symptoms... more Objective The aim of this study was to examine the association between common menopausal symptoms (MS) and long-term cardiovascular disease (CVD) and all-cause mortality. Methods In an observational cohort of 80,278 postmenopausal women with no known CVD at baseline from the Women's Health Initiative, we assessed individual MS severity (mild vs none; moderate/severe vs none) for night sweats, hot flashes, waking up several times at night, joint pain or stiffness, headaches or migraines, vaginal or genital dryness, heart racing or skipping beats, breast tenderness, dizziness, tremors (shakes), feeling tired, forgetfulness, mood swings, restless or fidgety, and difficulty concentrating. Outcomes included total CVD events (primary) and all-cause mortality (secondary). Associations between specific MS, their severity, and outcomes were assessed during a median of 8.2 years of follow-up. All results were multivariable adjusted, and individual associations were Bonferroni corrected to...
Background Recommended systolic blood pressure targets often do not consider the relationship of ... more Background Recommended systolic blood pressure targets often do not consider the relationship of low diastolic blood pressure (DBP) levels with cardiovascular disease (CVD) and all-cause mortality risk, which is especially relevant for older people with concurrent comorbidities. We examined the relationship of DBP levels to CVD and all-cause mortality in older women in the Women’s Health Initiative Long Life Study (WHI-LLS). Methods The study sample included 7,875 women (mean age: 79 years) who underwent a blood pressure measurement at an in-person home visit conducted in 2012–2013. CVD and all-cause mortality were centrally adjudicated. Hazard ratios (HRs) were obtained from adjusted Cox proportional hazards models. Results After 5 years follow-up, all-cause mortality occurred in 18.4% of women. Compared with a DBP of 80 mm Hg, the fully adjusted HR for mortality was 1.33 (95% confidence interval [CI]: 1.04–1.71) for a DBP of 50 mm Hg and 1.67 (95% CI: 1.29–2.16) for a DBP of 100 m...
Objective: To evaluate the knowledge of and nature of training for menopause management in postgr... more Objective: To evaluate the knowledge of and nature of training for menopause management in postgraduate residents. Participants and Methods: A cross-sectional, anonymous survey was e-mailed to trainees at all postgraduate levels in family medicine, internal medicine, and obstetrics and gynecology at US residency programs between January 11, and July 4, 2017. The survey was adapted from an existing instrument and included questions regarding knowledge of hormone therapy (HT) and other menopause management strategies, availability and type of training in menopause medicine, and demographic information. Results: Of the 703 surveys sent, a total of 183 residents representing 20 US residency programs responded (26.0% response rate). Most trainees were between 26 and 30 years of age (133 of 172 [77.3%]), female (114 of 173 [65.9%]), and believed it was important or very important to be trained to manage menopause (165 of 176 [93.8%]). Although most respondents answered some of the menopause competency questions correctly, important gaps were identified. Of 183 participants, 63 (34.4%) indicated they would not offer HT to a symptomatic, newly menopausal woman without contraindications, and only 71 (38.7%) indicated they would prescribe HT until the natural age of menopause to a prematurely menopausal woman. Of 177 respondents, 36 (20.3%) reported not receiving any menopause lectures during residency, and only 12 of 177 (6.8%) reported feeling adequately prepared to manage women experiencing menopause. Conclusion: Family medicine, internal medicine, and obstetrics and gynecology residency trainees recognize the importance of training in menopause management, but important knowledge gaps exist. Investing in the education of future clinicians to provide evidence-based, comprehensive menopause management for the growing population of midlife women is a priority.
Purpose: Residents in obstetrics and gynecology are deemed to be proficient in transvaginal ultra... more Purpose: Residents in obstetrics and gynecology are deemed to be proficient in transvaginal ultrasound (TVUS) upon graduation, although TVUS education in residency is not standardized. The objective of this study is to assess for improvement in TVUS knowledge among residents after viewing an educational DVD. Methods: This is a multisite prospective randomized controlled trial using an educational DVD ("Gynecology: Beginners Only"), compared to routine education. All participants completed a pretest on TVUS images and principles. The intervention group repeated the test after DVD viewing. During the trial, performing and logging TVUS examinations were encouraged. All enrolled residents repeated the test 6-10 months later. Results: Fifty-seven residents completed the study with a mean pretest score of 9.7 (1st year resident 9.8, 2nd year resident 9.6, 3rd year resident 10.1, 4th year resident 9.4, P = .763), with a mean of 31.5 TVUS examinations logged prior to intervention. The mean score in the intervention group (n = 34) improved significantly after viewing (11.2, P < 0.003). This improvement did not persist 6-10 months later on a follow-up quiz (mean 10.7, P = .894). At completion of the study, participants logged an average of 56.7 TVUS examinations. Conclusion: An educational DVD is easily implemented and demonstrates short-term benefit. Exploration of different teaching modalities in development of a comprehensive training program may improve long-term retention. K E Y W O R D S randomized controlled trial, resident education, transvaginal ultrasound 1 | INTRODUCTION Current practice in obstetrics and gynecology (OB/GYN) requires competent use of transvaginal ultrasound (TVUS), yet formal training during residency is typically limited and not standardized. The Accreditation Council for Graduate Medical Education (ACGME) reported in the September 2012 National Resident Report that graduating OB/GYN residents completed an average of 119.9 TVUS examinations as "surgeon" by the completion of their residency (range 0-623, 95th percentile was 260). 1 While the ACGME advises a resident to perform 50 TVUS examinations before completing residency, there are typically no specific program requirements, nor are there any specific recommendations in regards to how a program might assess competency in TVUS skills. Physicians who have graduated from an ACGME approved OB/GYN residency after 1982 are deemed competent to perform TVUS. Unfortunately, various components of TVUS use, including equipment calibration and transducer reprocessing, may not be part of the residency education. 2 Additionally, the American College of Radiology requires that for a practice to be accredited, the supervising physician must have at least 2 years of US experience during which at least 500 US examinations were performed or supervised and interpreted. 3 This is more The educational DVDs were donated for the study by the American Institute of Ultrasound in Medicine at the corresponding author's request.
OBJECTIVE: To determine whether there is a correlation between COMLEX and USMLE scores for osteop... more OBJECTIVE: To determine whether there is a correlation between COMLEX and USMLE scores for osteopathic students applying to the obstetrics and gynecology residency program at Reading Hospital. METHODS: Participant selection included osteopathic applicants to the Reading Health System's obstetrics and gynecology residency from 2010 to 2014, including both those students who took only the COMLEX and those who took both the COMLEX and the USMLE. After institutional review board approval, these data were abstracted from ERAS applications and de-identified for analysis. RESULTS: Eighty-two students took both COMLEX level 1 and USMLE step 1, with mean (standard deviation [SD]) scores of 528.5 (58.4) and 207.5 (14.4), respectively. Seventy-two students took both COMLEX level 2 CE and USMLE step 2 CK, with mean (SD) scores of 543.1 (83.9) and 222.7 (19.2), respectively. USMLE step 1 scores are positively correlated to COMLEX level 1 scores by Spearman correlation (r=0.74, P<.0001). This gives a predictive equation of USMLE step 1 score=108.89+0.1866×COMLEX level 1 score. USMLE step 2 scores are positively correlated to COMLEX level 2 scores by Spearman correlation (r=0.70, P<.0001). This gives a predictive equation of USMLE step 2 CK score=134.1+0.1631×COMLEX level 2 CE score. CONCLUSION: These results may suggest that both steps of USMLE scores are strongly correlated with both levels of COMLEX scores. Further research is indicated at other programs to gauge whether these results may be generalizable to a larger group than just the applicants to Reading Hospital.
Objective: To analyze vitamin D 3 plasma concentrations among monkeys randomized to oral conjugat... more Objective: To analyze vitamin D 3 plasma concentrations among monkeys randomized to oral conjugated equine estrogen (CEE) versus control and the association with coronary artery atherosclerosis (CAA). Methods: Surgically postmenopausal monkeys (N ¼ 50) were fed an atherogenic diet containing a woman's equivalent of 1000 IU/day of vitamin D 3. The monkeys were randomized at baseline to receive CEE (equivalent of 0.45 mg/d, n ¼ 25) or placebo (n ¼ 25). 25-hydroxyvitamin D 3 (25OHD 3) was measured at baseline and 20 months later. At 20 months, CAA evidence of coronary artery remodeling, and American Heart Association (AHA) severity scores were assessed. Results: The percent change in 25OHD 3 concentrations from baseline to 20 months postrandomization was inversely correlated with plaque area of the right coronary artery (P ¼ 0.048), left circumflex artery (P ¼ 0.039), left anterior descending artery (P ¼ 0.017), and AHA severity score (AHA LADmax) (P ¼ 0.016). Those with increased 25OHD 3 concentrations who were taking CEE also had significantly lower AHA scores compared with those who were not taking CEE and did not have an increase in 25OHD 3 (P ¼ 0.01). Conclusions: Monkeys with increases in 25OHD 3 concentrations had significantly less severe CAA. Those with increases in 25OHD 3 with CEE were associated with significantly decreased AHA lesion scores, decreased plaque, and greater coronary artery remodeling. If these findings are present in women, achieving higher 25OHD 3 concentrations (or being a vitamin D supplementation ''responder'') may be associated with cardioprotection, and further studies to evaluate a synergistic effect with CEE and vitamin D on cardiovascular health are needed.
BACKGROUND: Residency training is associated with a significant degree of burnout in single insti... more BACKGROUND: Residency training is associated with a significant degree of burnout in single institution studies. OBJECTIVE: To assess the rate of burnout in a national sample of obstetrics and gynecology residents. METHODS: A web link to a 50-item, online, nonobligatory survey was distributed to all Accreditation Council for Graduate Medical Education–accredited obstetrics and gynecology residents through program coordinators and directors. The survey was open for responses from March 11, 2014 to June 5, 2014. RESULTS: Of 892 who responded to the survey, 790 (88.6%) were valid for analysis. Of 790, 26% were noted to have high burnout. Residents with burnout also had higher rates of depression and anxiety (P<.001). There were no statistically significant differences in burnout between men and women, single compared with married, university compared with nonuniversity programs, and size of programs (more than 20 compared with 20 or fewer residents). Burnout rates were not associated with either the number of children or year of training. However, burnout rates were higher for residents who worked more than 70 hours/week. Residents with burnout felt there was a lack of “strong support” by the faculty (P=.001) and fellow residents (P=.006), that faculty were not committed to teaching (P<.001), perceived a greater emphasis on “service over education” (P<.001), and were less satisfied with the hospital's benefits and facilities (P=.023). Furthermore, as frequency of poor clinical outcomes increased, the severity of the depression also increased (P=.021). CONCLUSION: Nationally, about 25% of obstetrics and gynecology residents have high burnout. It is important to recognize factors associated with burnout in residents, so we may institute changes to better accommodate our future physicians and assure patient safety.
INTRODUCTION: Adolescents in sub-Saharan Africa report an unmet need for contraception with some ... more INTRODUCTION: Adolescents in sub-Saharan Africa report an unmet need for contraception with some adolescents using periodic abstinence as their current contraceptive method. Undesired pregnancies in sub-Saharan African adolescents are associated with significant maternal and neonatal morbidity, and fertility awareness in this population needs to be further explored. METHODS: Nationally representative Demographic and Health Surveys (USAID) interviewed 45,054 adolescents (aged 15–19 years) from 18 least developed sub-Saharan African nations regarding contraception and fertility awareness. Analyses evaluated fertility awareness, contraceptive use, and unwanted pregnancies. RESULTS: Adolescents using contraception (n=3,384) reported periodic abstinence (n=596, 17.6%) as their current contraceptive method. All adolescents (n=45,054) were queried regarding timing of ovulation, but only 18.4% (n=8,306) were able to correctly identify this as occurring in the middle of her cycle. Adolescents using periodic abstinence were significantly more likely (68.2% compared with 33.5% of those using another method, P<.001) to correctly identify timing of ovulation. Adolescents who had completed secondary or higher education (n=269) were significantly more likely to be able to correctly identify timing of ovulation (secondary odds ratio [OR] 2.888, 95% confidence interval [CI] 2.193–3.805, higher OR 7.866, 95% CI 3.433–18.021). CONCLUSION: A majority of adolescents in sub-Saharan Africa are unaware of timing of ovulation in regard to their menstrual cycles, and a significant number are using periodic abstinence as their contraceptive method. A multidisciplinary approach is key because education regarding fertility awareness and contraceptive options may be a key step in decreasing unintended pregnancies.
Journal of lower genital tract disease, Jan 8, 2015
To assess the risk of endometrial cancer (EC) associated with atypical glandular cells of endomet... more To assess the risk of endometrial cancer (EC) associated with atypical glandular cells of endometrial origin (AGC-EM) in 2 age groups (age younger than 51 vs 51 years or older). A retrospective case series was assembled identifying AGC from a pathology database between January 1, 2005 and January 1, 2009. Demographics, cervical cytology results, and final diagnoses (including clinically significant diseases and cancers) were recorded from the initial AGC diagnosis until August 30, 2011. Data were analyzed using the χ test to compare rates of disease between age groups. Among the 444 patients with AGC, 41% (183/444) had AGC-EM. Women younger than 51 years, compared to those 51 years or older, had significantly lower rates of AGC-EM (35% [105/296] vs 53% [78/148]; p < .001; odds ratio, 0.49; 95% confidence interval, 0.33-0.74). The rate of EC was significantly lower in those younger than 51 years, compared to those aged 51 or older (5% [8/158] vs 19% [18/95]; p < .001; odds rati...
Osteoporosis is most prevalent in women over the age of 50 as the hormonal influence of estrogen ... more Osteoporosis is most prevalent in women over the age of 50 as the hormonal influence of estrogen on bone health dissipates with the onset of menopause. The progressive changes in bone structure, quality and density lead to pathological fractures and an increase in morbidity and mortality among menopausal women. This review will examine the 2010 North American Menopause Society (NAMS) position statement and other recent publications to summarize the data and combinations of therapies used to treat women 50 years or older with osteoporosis. To review the latest research and guidelines for osteoporosis management we performed a PubMed search using the parameters Linked to free full text, Humans, Female, Review, English, Middle Age (45-64 years and 45+ years), Age 65+ years, and published in the last five years. Articles were sorted by relevance and hand searching of these articles was done to further increase the yield. While a perfect treatment has yet to be discovered to completely c...
Background: While most diagnoses associated with atypical glandular cells (AGCs) are localized to... more Background: While most diagnoses associated with atypical glandular cells (AGCs) are localized to the uterus, a small number of extrauterine malignancies have been reported in connection with this finding. The current case report describes a malignant melanoma of ...
Objective: To update and expand The North American Menopause Society's evidence-based position on... more Objective: To update and expand The North American Menopause Society's evidence-based position on nonhormonal management of menopause-associated vasomotor symptoms (VMS), previously a portion of the position statement on the management of VMS. Methods: NAMS enlisted clinical and research experts in the field and a reference librarian to identify and review available evidence. Five different electronic search engines were used to cull relevant literature. Using the literature, experts created a document for final approval by the NAMS Board of Trustees. Results: Nonhormonal management of VMS is an important consideration when hormone therapy is not an option, either because of medical contraindications or a woman's personal choice. Nonhormonal therapies include lifestyle changes, mind-body techniques, dietary management and supplements, prescription therapies, and others. The costs, time, and effort involved as well as adverse effects, lack of long-term studies, and potential interactions with medications all need to be carefully weighed against potential effectiveness during decision making. Conclusions: Clinicians need to be well informed about the level of evidence available for the wide array of nonhormonal management options currently available to midlife women to help prevent underuse of effective therapies or use of inappropriate or ineffective therapies. Recommended: Cognitive-behavioral therapy and, to a lesser extent, clinical hypnosis have been shown to be effective in reducing VMS. Paroxetine salt is the only nonhormonal medication approved by the US Food and Drug Administration for the management of VMS, although other selective serotonin reuptake/norepinephrine reuptake inhibitors, gabapentinoids, and clonidine show evidence of efficacy. Recommend with caution: Some therapies that may be beneficial for alleviating VMS are weight loss, mindfulness-based stress reduction, the S-equol derivatives of soy isoflavones, and stellate ganglion block, but additional studies of these therapies are warranted. Do not recommend at this time: There are negative, insufficient, or inconclusive data suggesting the following should not be recommended as proven therapies for managing VMS: cooling techniques, avoidance of triggers, exercise, yoga, paced respiration, relaxation, over-the-counter supplements and herbal therapies, acupuncture, calibration of neural oscillations, and chiropractic interventions. Incorporating the available evidence into clinical practice will help ensure that women receive evidence-based recommendations along with appropriate cautions for appropriate and timely management of VMS.
Objective The objective of this study is to assess whether the presence of breast arterial calcif... more Objective The objective of this study is to assess whether the presence of breast arterial calcifications (BACs) found on routine mammography is prospectively associated with the development of cardiovascular disease (CVD) events after 10 years of follow-up. Methods Women presenting for screening mammography were enrolled in this prospective cohort. Baseline data were collected including history of CVD and CVD risk factors. Mammograms were assessed for the presence or absence of BAC. Participants completed questionnaires 10 years after baseline that assessed the development of CVD (coronary artery disease [CAD] and stroke) and CVD risk factors. Results Of the 1,995 participants who enrolled at baseline, complete 10-year follow-up data were available for 1,039; of those, 114 (11.0%) were BAC-positive and 925 (89.0%) were BAC-negative at baseline. After controlling for age, BAC-positive women were more likely to develop CAD (odds ratio, 3.14; 95% confidence interval, 1.86-5.27; P <...
Objective The objective of this study is to assess whether the presence of breast arterial calcif... more Objective The objective of this study is to assess whether the presence of breast arterial calcifications (BACs) found on routine mammography is prospectively associated with the development of cardiovascular disease (CVD) events after 10 years of follow-up. Methods Women presenting for screening mammography were enrolled in this prospective cohort. Baseline data were collected including history of CVD and CVD risk factors. Mammograms were assessed for the presence or absence of BAC. Participants completed questionnaires 10 years after baseline that assessed the development of CVD (coronary artery disease [CAD] and stroke) and CVD risk factors. Results Of the 1,995 participants who enrolled at baseline, complete 10-year follow-up data were available for 1,039; of those, 114 (11.0%) were BAC-positive and 925 (89.0%) were BAC-negative at baseline. After controlling for age, BAC-positive women were more likely to develop CAD (odds ratio, 3.14; 95% confidence interval, 1.86-5.27; P <...
Objective This study aimed to assess the variance in menopause education, educational resources, ... more Objective This study aimed to assess the variance in menopause education, educational resources, and the needs of obstetrics and gynecology (ObGyn) residency programs by conducting a national survey of program directors (PDs). Methods In 2022, an institutional review board–approved Web-based Qualtrics survey was designed and distributed electronically to 145 US ObGyn residency PDs. The survey consists of 15 questions. The main outcomes are reported using descriptive statistics. Results The survey was completed by 99 of 145 PDs (68.3%). Almost all participants (92.9%) strongly agreed that residents nationwide should have access to a standardized menopause curriculum that could be utilized in their programs. Only 31.3% reported having a menopause curriculum in their residency program. Of the programs with a menopause curriculum, 96.8% reported using lectures, 77.4% reported assigned readings, and 74.2% had either dedicated menopause clinics or other clinics with a high volume of menop...
Objective The aim of this study was to examine the association between common menopausal symptoms... more Objective The aim of this study was to examine the association between common menopausal symptoms (MS) and long-term cardiovascular disease (CVD) and all-cause mortality. Methods In an observational cohort of 80,278 postmenopausal women with no known CVD at baseline from the Women's Health Initiative, we assessed individual MS severity (mild vs none; moderate/severe vs none) for night sweats, hot flashes, waking up several times at night, joint pain or stiffness, headaches or migraines, vaginal or genital dryness, heart racing or skipping beats, breast tenderness, dizziness, tremors (shakes), feeling tired, forgetfulness, mood swings, restless or fidgety, and difficulty concentrating. Outcomes included total CVD events (primary) and all-cause mortality (secondary). Associations between specific MS, their severity, and outcomes were assessed during a median of 8.2 years of follow-up. All results were multivariable adjusted, and individual associations were Bonferroni corrected to...
Background Recommended systolic blood pressure targets often do not consider the relationship of ... more Background Recommended systolic blood pressure targets often do not consider the relationship of low diastolic blood pressure (DBP) levels with cardiovascular disease (CVD) and all-cause mortality risk, which is especially relevant for older people with concurrent comorbidities. We examined the relationship of DBP levels to CVD and all-cause mortality in older women in the Women’s Health Initiative Long Life Study (WHI-LLS). Methods The study sample included 7,875 women (mean age: 79 years) who underwent a blood pressure measurement at an in-person home visit conducted in 2012–2013. CVD and all-cause mortality were centrally adjudicated. Hazard ratios (HRs) were obtained from adjusted Cox proportional hazards models. Results After 5 years follow-up, all-cause mortality occurred in 18.4% of women. Compared with a DBP of 80 mm Hg, the fully adjusted HR for mortality was 1.33 (95% confidence interval [CI]: 1.04–1.71) for a DBP of 50 mm Hg and 1.67 (95% CI: 1.29–2.16) for a DBP of 100 m...
Objective: To evaluate the knowledge of and nature of training for menopause management in postgr... more Objective: To evaluate the knowledge of and nature of training for menopause management in postgraduate residents. Participants and Methods: A cross-sectional, anonymous survey was e-mailed to trainees at all postgraduate levels in family medicine, internal medicine, and obstetrics and gynecology at US residency programs between January 11, and July 4, 2017. The survey was adapted from an existing instrument and included questions regarding knowledge of hormone therapy (HT) and other menopause management strategies, availability and type of training in menopause medicine, and demographic information. Results: Of the 703 surveys sent, a total of 183 residents representing 20 US residency programs responded (26.0% response rate). Most trainees were between 26 and 30 years of age (133 of 172 [77.3%]), female (114 of 173 [65.9%]), and believed it was important or very important to be trained to manage menopause (165 of 176 [93.8%]). Although most respondents answered some of the menopause competency questions correctly, important gaps were identified. Of 183 participants, 63 (34.4%) indicated they would not offer HT to a symptomatic, newly menopausal woman without contraindications, and only 71 (38.7%) indicated they would prescribe HT until the natural age of menopause to a prematurely menopausal woman. Of 177 respondents, 36 (20.3%) reported not receiving any menopause lectures during residency, and only 12 of 177 (6.8%) reported feeling adequately prepared to manage women experiencing menopause. Conclusion: Family medicine, internal medicine, and obstetrics and gynecology residency trainees recognize the importance of training in menopause management, but important knowledge gaps exist. Investing in the education of future clinicians to provide evidence-based, comprehensive menopause management for the growing population of midlife women is a priority.
Purpose: Residents in obstetrics and gynecology are deemed to be proficient in transvaginal ultra... more Purpose: Residents in obstetrics and gynecology are deemed to be proficient in transvaginal ultrasound (TVUS) upon graduation, although TVUS education in residency is not standardized. The objective of this study is to assess for improvement in TVUS knowledge among residents after viewing an educational DVD. Methods: This is a multisite prospective randomized controlled trial using an educational DVD ("Gynecology: Beginners Only"), compared to routine education. All participants completed a pretest on TVUS images and principles. The intervention group repeated the test after DVD viewing. During the trial, performing and logging TVUS examinations were encouraged. All enrolled residents repeated the test 6-10 months later. Results: Fifty-seven residents completed the study with a mean pretest score of 9.7 (1st year resident 9.8, 2nd year resident 9.6, 3rd year resident 10.1, 4th year resident 9.4, P = .763), with a mean of 31.5 TVUS examinations logged prior to intervention. The mean score in the intervention group (n = 34) improved significantly after viewing (11.2, P < 0.003). This improvement did not persist 6-10 months later on a follow-up quiz (mean 10.7, P = .894). At completion of the study, participants logged an average of 56.7 TVUS examinations. Conclusion: An educational DVD is easily implemented and demonstrates short-term benefit. Exploration of different teaching modalities in development of a comprehensive training program may improve long-term retention. K E Y W O R D S randomized controlled trial, resident education, transvaginal ultrasound 1 | INTRODUCTION Current practice in obstetrics and gynecology (OB/GYN) requires competent use of transvaginal ultrasound (TVUS), yet formal training during residency is typically limited and not standardized. The Accreditation Council for Graduate Medical Education (ACGME) reported in the September 2012 National Resident Report that graduating OB/GYN residents completed an average of 119.9 TVUS examinations as "surgeon" by the completion of their residency (range 0-623, 95th percentile was 260). 1 While the ACGME advises a resident to perform 50 TVUS examinations before completing residency, there are typically no specific program requirements, nor are there any specific recommendations in regards to how a program might assess competency in TVUS skills. Physicians who have graduated from an ACGME approved OB/GYN residency after 1982 are deemed competent to perform TVUS. Unfortunately, various components of TVUS use, including equipment calibration and transducer reprocessing, may not be part of the residency education. 2 Additionally, the American College of Radiology requires that for a practice to be accredited, the supervising physician must have at least 2 years of US experience during which at least 500 US examinations were performed or supervised and interpreted. 3 This is more The educational DVDs were donated for the study by the American Institute of Ultrasound in Medicine at the corresponding author's request.
OBJECTIVE: To determine whether there is a correlation between COMLEX and USMLE scores for osteop... more OBJECTIVE: To determine whether there is a correlation between COMLEX and USMLE scores for osteopathic students applying to the obstetrics and gynecology residency program at Reading Hospital. METHODS: Participant selection included osteopathic applicants to the Reading Health System's obstetrics and gynecology residency from 2010 to 2014, including both those students who took only the COMLEX and those who took both the COMLEX and the USMLE. After institutional review board approval, these data were abstracted from ERAS applications and de-identified for analysis. RESULTS: Eighty-two students took both COMLEX level 1 and USMLE step 1, with mean (standard deviation [SD]) scores of 528.5 (58.4) and 207.5 (14.4), respectively. Seventy-two students took both COMLEX level 2 CE and USMLE step 2 CK, with mean (SD) scores of 543.1 (83.9) and 222.7 (19.2), respectively. USMLE step 1 scores are positively correlated to COMLEX level 1 scores by Spearman correlation (r=0.74, P<.0001). This gives a predictive equation of USMLE step 1 score=108.89+0.1866×COMLEX level 1 score. USMLE step 2 scores are positively correlated to COMLEX level 2 scores by Spearman correlation (r=0.70, P<.0001). This gives a predictive equation of USMLE step 2 CK score=134.1+0.1631×COMLEX level 2 CE score. CONCLUSION: These results may suggest that both steps of USMLE scores are strongly correlated with both levels of COMLEX scores. Further research is indicated at other programs to gauge whether these results may be generalizable to a larger group than just the applicants to Reading Hospital.
Objective: To analyze vitamin D 3 plasma concentrations among monkeys randomized to oral conjugat... more Objective: To analyze vitamin D 3 plasma concentrations among monkeys randomized to oral conjugated equine estrogen (CEE) versus control and the association with coronary artery atherosclerosis (CAA). Methods: Surgically postmenopausal monkeys (N ¼ 50) were fed an atherogenic diet containing a woman's equivalent of 1000 IU/day of vitamin D 3. The monkeys were randomized at baseline to receive CEE (equivalent of 0.45 mg/d, n ¼ 25) or placebo (n ¼ 25). 25-hydroxyvitamin D 3 (25OHD 3) was measured at baseline and 20 months later. At 20 months, CAA evidence of coronary artery remodeling, and American Heart Association (AHA) severity scores were assessed. Results: The percent change in 25OHD 3 concentrations from baseline to 20 months postrandomization was inversely correlated with plaque area of the right coronary artery (P ¼ 0.048), left circumflex artery (P ¼ 0.039), left anterior descending artery (P ¼ 0.017), and AHA severity score (AHA LADmax) (P ¼ 0.016). Those with increased 25OHD 3 concentrations who were taking CEE also had significantly lower AHA scores compared with those who were not taking CEE and did not have an increase in 25OHD 3 (P ¼ 0.01). Conclusions: Monkeys with increases in 25OHD 3 concentrations had significantly less severe CAA. Those with increases in 25OHD 3 with CEE were associated with significantly decreased AHA lesion scores, decreased plaque, and greater coronary artery remodeling. If these findings are present in women, achieving higher 25OHD 3 concentrations (or being a vitamin D supplementation ''responder'') may be associated with cardioprotection, and further studies to evaluate a synergistic effect with CEE and vitamin D on cardiovascular health are needed.
BACKGROUND: Residency training is associated with a significant degree of burnout in single insti... more BACKGROUND: Residency training is associated with a significant degree of burnout in single institution studies. OBJECTIVE: To assess the rate of burnout in a national sample of obstetrics and gynecology residents. METHODS: A web link to a 50-item, online, nonobligatory survey was distributed to all Accreditation Council for Graduate Medical Education–accredited obstetrics and gynecology residents through program coordinators and directors. The survey was open for responses from March 11, 2014 to June 5, 2014. RESULTS: Of 892 who responded to the survey, 790 (88.6%) were valid for analysis. Of 790, 26% were noted to have high burnout. Residents with burnout also had higher rates of depression and anxiety (P<.001). There were no statistically significant differences in burnout between men and women, single compared with married, university compared with nonuniversity programs, and size of programs (more than 20 compared with 20 or fewer residents). Burnout rates were not associated with either the number of children or year of training. However, burnout rates were higher for residents who worked more than 70 hours/week. Residents with burnout felt there was a lack of “strong support” by the faculty (P=.001) and fellow residents (P=.006), that faculty were not committed to teaching (P<.001), perceived a greater emphasis on “service over education” (P<.001), and were less satisfied with the hospital's benefits and facilities (P=.023). Furthermore, as frequency of poor clinical outcomes increased, the severity of the depression also increased (P=.021). CONCLUSION: Nationally, about 25% of obstetrics and gynecology residents have high burnout. It is important to recognize factors associated with burnout in residents, so we may institute changes to better accommodate our future physicians and assure patient safety.
INTRODUCTION: Adolescents in sub-Saharan Africa report an unmet need for contraception with some ... more INTRODUCTION: Adolescents in sub-Saharan Africa report an unmet need for contraception with some adolescents using periodic abstinence as their current contraceptive method. Undesired pregnancies in sub-Saharan African adolescents are associated with significant maternal and neonatal morbidity, and fertility awareness in this population needs to be further explored. METHODS: Nationally representative Demographic and Health Surveys (USAID) interviewed 45,054 adolescents (aged 15–19 years) from 18 least developed sub-Saharan African nations regarding contraception and fertility awareness. Analyses evaluated fertility awareness, contraceptive use, and unwanted pregnancies. RESULTS: Adolescents using contraception (n=3,384) reported periodic abstinence (n=596, 17.6%) as their current contraceptive method. All adolescents (n=45,054) were queried regarding timing of ovulation, but only 18.4% (n=8,306) were able to correctly identify this as occurring in the middle of her cycle. Adolescents using periodic abstinence were significantly more likely (68.2% compared with 33.5% of those using another method, P<.001) to correctly identify timing of ovulation. Adolescents who had completed secondary or higher education (n=269) were significantly more likely to be able to correctly identify timing of ovulation (secondary odds ratio [OR] 2.888, 95% confidence interval [CI] 2.193–3.805, higher OR 7.866, 95% CI 3.433–18.021). CONCLUSION: A majority of adolescents in sub-Saharan Africa are unaware of timing of ovulation in regard to their menstrual cycles, and a significant number are using periodic abstinence as their contraceptive method. A multidisciplinary approach is key because education regarding fertility awareness and contraceptive options may be a key step in decreasing unintended pregnancies.
Journal of lower genital tract disease, Jan 8, 2015
To assess the risk of endometrial cancer (EC) associated with atypical glandular cells of endomet... more To assess the risk of endometrial cancer (EC) associated with atypical glandular cells of endometrial origin (AGC-EM) in 2 age groups (age younger than 51 vs 51 years or older). A retrospective case series was assembled identifying AGC from a pathology database between January 1, 2005 and January 1, 2009. Demographics, cervical cytology results, and final diagnoses (including clinically significant diseases and cancers) were recorded from the initial AGC diagnosis until August 30, 2011. Data were analyzed using the χ test to compare rates of disease between age groups. Among the 444 patients with AGC, 41% (183/444) had AGC-EM. Women younger than 51 years, compared to those 51 years or older, had significantly lower rates of AGC-EM (35% [105/296] vs 53% [78/148]; p < .001; odds ratio, 0.49; 95% confidence interval, 0.33-0.74). The rate of EC was significantly lower in those younger than 51 years, compared to those aged 51 or older (5% [8/158] vs 19% [18/95]; p < .001; odds rati...
Osteoporosis is most prevalent in women over the age of 50 as the hormonal influence of estrogen ... more Osteoporosis is most prevalent in women over the age of 50 as the hormonal influence of estrogen on bone health dissipates with the onset of menopause. The progressive changes in bone structure, quality and density lead to pathological fractures and an increase in morbidity and mortality among menopausal women. This review will examine the 2010 North American Menopause Society (NAMS) position statement and other recent publications to summarize the data and combinations of therapies used to treat women 50 years or older with osteoporosis. To review the latest research and guidelines for osteoporosis management we performed a PubMed search using the parameters Linked to free full text, Humans, Female, Review, English, Middle Age (45-64 years and 45+ years), Age 65+ years, and published in the last five years. Articles were sorted by relevance and hand searching of these articles was done to further increase the yield. While a perfect treatment has yet to be discovered to completely c...
Background: While most diagnoses associated with atypical glandular cells (AGCs) are localized to... more Background: While most diagnoses associated with atypical glandular cells (AGCs) are localized to the uterus, a small number of extrauterine malignancies have been reported in connection with this finding. The current case report describes a malignant melanoma of ...
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Papers by Peter Schnatz