New guidelines for when to initiate cervical cancer screening have recently been revised. The American Cancer Society now recommends that screening be initiated within 3 years of the onset of vaginal intercourse but no later than 21 years of age. Natural history studies of human papillomavirus (HPV; the cause of abnormal cytology and cervical cancer) suggest that there is little risk of a significant precancerous lesion going undetected within the first 3 to 5 years after the onset of sexual activity. The new recommendations will assist in the over-referral and overtreatment of adolescents with HPV.
Recurrent miscarriage is defined as the occurrence of three consecutive pregnancy losses during the first trimester. Although it affects only 1% of all couples, it is a most frustrating experience for the patient as well as for the clinician. Frustrating for the couple because they rarely obtain clear-cut reasons for the repeated failure to sustain a pregnancy, nor the prospect of a fail-safe treatment; frustrating for the clinician, too, because it is extremely difficult to disentangle the causes of sporadic and unavoidable miscarriage--most of which have a genetic background--from those of recurrent miscarriage. In the latter case, an underlying defect can potentially be detected and, ideally, should be amenable to treatment. Unfortunately, however, this is rather exceptional. In this paper, literature on genetic, anatomic, endocrine, metabolic, and autoimmune aspects of recurrent miscarriage are reviewed, and a survey of meaningful investigations and treatment is provided.
In this paper, the evolution of postmenopausal hormone replacement is reviewed, with an evidence-based approach and particular emphasis on the Heart and Estrogen/Progestin Replacement Study and Women's Health Initiative reports. This therapy will continue to evolve and have pertinence for women with menopausal symptoms and for osteoporosis prevention in selected patients.
The intrauterine device (IUD) has experienced a resurgence of popularity. Much of this popularity is attributable to reassessments of the association between IUD use and pelvic inflammatory disease (PID) in which authors conclude that the association is attributable to factors other than the IUD. This article examines recent studies that assess the risk of PID with IUD use, explains why some of the assumptions on which the arguments regarding a lack of an association between IUD use and PID are based might not be correct, and recommends additional trials to evaluate IUDs as one of several contraceptive options.
Women who are in a low socioeconomic status are most vulnerable to genital ulcer disease (GUD). GUD is recognized as an important co-factor for acquisition of HIV. GUD etiology has been elucidated in the past decade, with the availability of multiplex polymerase chain reaction. Worldwide, herpes simplex virus-2 (HSV-2) is the leading cause of GUD. However, mainly in women in developed countries, the incidence of GUD causation by HSV-1 is rising, owing to adolescents who are HSV-1 naïve and to increased oral sex practices. Especially in some African countries, the still high prevalence of chancroid should decrease in the next decade, because chancroid can easily be avoided and treated. Syphilitic ulcers seemed to be almost extinct, but recently there has been a resurgence of syphilis worldwide with the availability of effective HIV treatment. Development of herpes and chancroid vaccines, condom use, and the provision of education and accessible treatment facilities should help those women who now suffer from recurrent GUD infections.
Fetal cells in maternal blood represent the future of prenatal screening and diagnosis. The possibility of analyzing fetal cells recovered from maternal blood could provide screening and diagnostic protocols characterized by high sensitivity and specificity with no direct risk to the developing fetus. Years of investigation have thus far not led to the development of reliable and consistent protocols; nonetheless, fetal cell recovery promises to be an attractive addition to noninvasive prenatal diagnosis.
Congestive heart failure represents a growing health issue with significant morbidity, expense, and mortality. Unfortunately, despite heart failure affecting men and women equally, women historically have represented a minority in heart failure trials. Despite this disparity, treatment decisions rely heavily on these trials. Women with heart failure often have different clinical features than men, such as age of onset and comorbidities. Compared with men, women also demonstrate differences in remodeling and the response to injury, such as volume or pressure overload and myocardial infarction. We are only beginning to understand the clinical implications of these gender differences and their impact on pharmacologic treatments. After discussing these differences, a review of the agents useful in systolic failure is made, including angiotensin-converting enzyme inhibitors, b-blockers, digoxin, and aldosterone inhibition. Treatment of diastolic heart failure with empiric guidelines follows.
: The rate of congenital syphilis is declining in the United States, but congenital syphilis is still a significant public health problem. Maternal serum screening is the mainstay of diagnosis. Maternal treatment will prevent most, but not all, cases of congenital syphilis. Access to prenatal care is critical to further reduce the rate of congenital syphilis.
Due to the high incidence of breast cancer and the excessively high false-positive rate of current screening technologies, adjunctive risk assessment measures are needed. Nipple aspiration cytologic analysis and random fine-needle aspirations have been proposed; however, ductal lavage and cytologic analysis of the effluent is a more sensitive and specific test. The dilemma lies in what should be done subsequent to a ductal lavage yielding malignant or atypical cells. The procedures and potential management strategies are discussed.
The stage and tumor remnants after radical surgery are the most important prognostic factors in patients with ovarian cancer. Because the incidence of ovarian cancer is highest in elderly women, and mostly advanced stages occur, radical surgery is necessary in this population as well as in younger patients. Age and the surgeon's expertise are the factors that influence the quality of surgical treatment of ovarian cancer. Surgical treatment of ovarian cancer should therefore be confined to centers with the required infrastructure and expertise.
The emerging understanding of gender differences among ethnic minorities in the rates, etiology, course, and treatment of substance abuse and common comorbid mental health disorders has significant scientific and practical implications. Growing recognition of these differences and their implications for treatment and policy decisions has highlighted research gaps and the need for more thoughtful application of the knowledge gained from existing research findings. In this brief review, we outline some of the unique aspects of substance abuse and comorbid mental health problems for women, as well as for women of various ethnic/cultural groups, including specific barriers to obtaining and remaining in treatment. Research challenges to improving limited knowledge about the rates, course, and treatment of substance abuse disorders among ethnic minority women are highlighted.
Magnetic resonance imaging (MRI) of the pelvic floor specifically to evaluate causes of fecal incontinence is relatively new. Along with physical examination and endoanal ultrasound, recently developed MRI techniques can be used to more accurately diagnose and characterize pelvic floor disorders leading to fecal incontinence. All three compartments of the pelvic floor can be evaluated simultaneously using MRI. During an MRI study, images are rapidly obtained in the sagittal plane at rest and during strain, and in the axial plane at rest. In symptomatic patients, abnormal descent of pelvic viscera is indicative of muscle or fascial weakness. Abnormal descent of pelvic viscera is readily detected on sagittal MR images. Muscle and sphincter tears can also be visualized, although most fascial damage is incurred secondarily. The detailed information gained from an MRI can be used to plan optimal treatment, surgical or otherwise.
Sexually transmitted diseases (STDs) impose a tremendous health burden on women, and adolescent females are the group at the highest risk. Universal annual screening of all women younger than 25 years of age has been a best practice recommendation since 1997. When implemented, such screening leads to a decrease in disease prevalence and of serious sequelae, such as pelvic inflammatory disease (PID). However, STD screening rates in actual clinical practice fail to approach recommendations. In this review, we summarize findings from recent surveys of providers and adolescents, discuss barriers to STD screening, and offer strategies for individual clinicians to improve STD screening rates in practice.
Uterovaginal anomalies in the adolescent can be a challenging group of conditions. Not only is the understanding of normal embryologic development essential but also the appreciation that her immaturity and budding sexuality will influence the nature and success of her treatment is important. The ideal care for these young females requires a team approach of both medical and supportive professionals. Normalizing her reproductive tract surgically and supporting her psychologically can usually be accomplished and, in most situations, reproductive capacity is preserved.
The incidence of hip fractures in the elderly is increasing worldwide, with 650,000 fractures expected in the United States by the year 2050. The mechanism of injury is typically a ground-level fall. Efforts at prevention focus on reducing risk factors by aggressive medical management of comorbidities, use of protective garments, and modification of the individual's environment to lessen the chance of falling. Treatment is associated with an elevated mortality rate and compromised functional outcome.
Approximately 50% of all pregnant women experience back pain during pregnancy. The causes and risk factors associated with the back pain encountered during pregnancy continue to be evaluated. The key to evaluating and managing these patients is the history and physical examination. Recognizing characteristics of the frequently encountered back pain of pregnancy as well as uncommon sources of back pain during pregnancy is essential in establishing an accurate diagnosis and initiating prompt and effective management.
Medical abortion using mifepristone and a prostaglandin analogue is a highly effective option for early abortion. Since the clinical introduction of mifepristone to the world in 1988, millions of women have had the opportunity to have a safe abortion without primary surgical intervention. The standard method of providing medical abortion has evolved through well-done studies to develop regimens that decrease cost and time to abortion. Currently, mifepristone with misoprostol is the most widely used medical abortion regimen. The most effective option available involves mifepristone 200 mg followed at least 24 hours later by misoprostol 800 microg vaginally. Women can self-administer the misoprostol, with complete abortion rates exceeding 95%. Researchers continue to refine the available regimens to improve outcomes and acceptability.
Osteopenia is a progressive condition that places patients at risk for increased morbidity and mortality if untreated. Patients with bone loss of at least 1.0 standard deviation (SD) from normal are considered osteopenic, whereas those with bone loss of at least 2.5 SDs are considered osteoporotic. Osteoporotic patients are treated to stop bone loss and restore bone mineral density. Patients with bone loss in the osteopenic range, even osteopenic patients with additional risk factors, might not receive treatment. National Osteoporosis Foundation guidelines recommend treatment when bone loss is 2.0 SDs, or less when additional risk factors are present. This is supported by the literature; treatments for bone loss are approved for the prevention of osteoporosis.
