OBG Management

TUESDAY, 6/29/21. DAY 3 AT SGS

The third day of the annual SGS meeting started with several academic roundtables hosted by experts in the field. These authorities shared their knowledge on a range of topics including endometriosis, building an academic career, diversity and equity in the workplace, and scientific publishing. The general session got underway with additional oral and video presentations highlighting advancements in our field. This year’s SGS President Dr. Miles Murphy gave the annual presidential address. He spoke genuinely and humbly about our field. Whitney Ross, MD, (@WRossMD), referred to his speech on Twitter as “Best. Presidential. Address. Ever.” –a sentiment felt by many in the crowd!

This year’s Telinde Lecture was given by Janet Dombrowski, the first ever non-physician to present this lecture. She spoke on resiliency in a lecture titled, “Cultivating Resilience: The Power in Connection & Collaboration.” It was an insightful and wise presentation on the power of connection and how connection bolsters our resiliency. She challenged us to all break down “thinking habits” that isolate us into silos and get in the way of powerful connection and collaboration. She reminded us of the African greeting “Sawubona” (I see you) and “Sikhona” (Because you see me, I am here). A gentle reminder that we feel our existence most tangibly when we are seen by others—an idea consistent with other important themes of this conference, focused on diversity, equity, and inclusion of all.  The morning session was rounded out with a panel discussion on “Novel GYN Office Procedure,” featuring Drs. Cecile Ferrando (@CFerrandoMD), Abbas Shobeiri (@ShobeiriAbbas), Andrea Pezzela, and Eric Sokol.

The afternoon was filled with leisure activities in beautiful Palm Springs, including the SGS Golf Tournament, mountain biking, aerial tramway tour, and hike. The weather even cooperated with slightly cooler temperatures (think 100℉ instead of 120℉)! The evening was filled with food, drinks, and the excitement around the annual “SGS’ Got Talent” show! Everyone was able to let down, show off their dance moves, and enjoy some of that much needed connection time!

Tomorrow is the last day of #SGS2021! Excited to round out the conference with continued learning.

MONDAY, 6/28/21. DAY 2 AT SGS 

 The sun is up and working hard here in Palm Springs, and so are we!  
 
Welcome and introduction of new members 
 
The general session started with a warm welcome to the 12 new SGS members. A special shout out to Dr. Kelly Wright who is a new SGS Member and won the #SGS2021 tweetup! She ranked as a top influencer, prolific tweeter, and made more than 250K impressions leading up to SGS! Way to represent @MigsRunner.  
 
General scientific sessions 
 
There were several excellent oral and video presentations throughout the morning session. A range of topics were discussed, including postoperative pain management, strategies for cost-effective surgery, and how racial and ethnic disparities play into our medical education and patient outcomes. Dr. Eva Welch gave a stellar video presentation on straight-stick sacrocolpopexy techniques for the savvy surgeon. I personally will be incorporating some of her needle management tricks!  
 
After a brief break with some refreshments and a stroll around the exhibit hall, the second scientific session initiated with a transformative lecture. Dr. Mark Walters presented "Insights on Surgical Education: How Can I Help You Get Better" in the inaugural Mark D. Walters Lectureship. Dr. Walters shared his experience and insights on how to transform oneself from a good surgeon to an expert and from a teacher to a coach in the operating room. His dedication to our field, years of experience, and wisdom earned him a standing ovation! Additional oral and video presentations followed. Dr. J. Wong shared correlations between surgeon gender and ergonomic strain with laparoscopic devices. Female surgeons more often reported inappropriate fit and expressed physical discomfort compared with male surgeons. Injuries and ergonomic strain lead to less operating and even disability for some surgeons. It is past time for us to have better--we need instruments that fit our hands!  
 
The afternoon session started with a panel on "Perspectives on Race in GYN Surgery." It was another insightful discussion with thought- and action-provoking knowledge. The afternoon session included the SGS Prize Video by Dr. Angela DiCarlo-Meacham on excision of a vulvar cyst.  
 
Fellows' Pelvic Research Network 
 
After adjourning of the scientific sessions, the fellow-ran, multicenter research network (FPRN) met to give updates. This diverse group of both AUGS-SGS and FMIGS-SGS offers mentorship and relationships that are important for future careers and research. The collaboration allows the study of rare outcomes that may not be feasible at single sites. Dr. Amanda Yunker, fellowship director at Vanderbilt University, gave an amazing history lesson on the fields of OB and GYN, and the evolution of gynecologic surgery. We then had fun assigning a "report card grade" on how MIGS is doing comparatively with other subspecialties in the realms of academics and research.  
 
VideoFest 
 
The late afternoon was concluded with a surgical video session. What an amazing and talented group we are here at SGS!  
 
President's awards ceremony and reception 
The scientific focused day was rounded out with an evening of honors, awards, and social time as we celebrated all the achievements of our peers and colleagues. The president's reception was filled with food, laughter, networking, and reconnecting with friends and colleagues. We are looking forward to another day of education tomorrow! 
 
Follow @JennaRehmerMD, @GynSurgery, and #SGS2021 on Twitter for updates. 

SUNDAY, 6/27/21. DAY 1 AT SGS

Hello live from sunny Palm Spring, CA, and the Annual Scientific Meeting of the Society of Gynecologic Surgeons (SGS)! This year’s conference balances the long-awaited return to in-person events while simultaneously embracing virtual learning with their hybrid meeting format. You can follow me, @JennaRehmerMD, and #SGS2021 in real-time on Twitter. 

Dismantling racism

We were incredibly fortunate to take a deep dive into dismantling racism in our personal and professional spheres. The postgraduate course was well researched and presented by Drs. Oluwateniola “Teni” Brown, Cassandra Carberry, Olivia Cardenas-Trowers (@otrowers_md), Annetta Madsen, Moiuri Siddique, and Blair Washington (@Dr_B_Washington). Each presentation provided a succinct and cohesive flow, taking us through what racism is, the historical and active structural racism in medicine, and the actions and steps of becoming anti-racist. 

Dr. Brown discussed critical race theory. We learned that the engineered system of oppression is so advanced that it is often hidden in plain sight, and that one’s conscious awareness is not necessary in order to uphold the system of oppression. It is reinforced and supported with minimal effort. This is why not being racist is not enough; active anti-racism is needed to bring about change. 

Fibroid management

Across the hall, Drs. Linda Bradley (@BradlelMD), Kimberly Kho (@KimberlyKho1), Cara King (@drcaraking), and Kelly Wright (@MigsRunner) broadened our armamentarium for uterine conservation in fibroid management. Dr. Bradley reviewed medical therapies, including novel treatments, as first-line or adjunct treatment options. Next, the course focused on surgical techniques for hysteroscopic myomectomies, optimization of minilaparotomy for myomectomy, and tissue extraction. Dr. King displayed true grit when giving her lecture from the airport after flight delays prevented her from being in person with us. 

Multidisciplinary care within gyn surgery

In this virtual only postgraduate course, Drs. Risal Djohan (@DjohanMD), Cecile Ferrando (@CFerrandoMD), Marie Fidela Paraiso, Sandip Vasavada (@SandipVasavada), and Sarah Vogler showed us the importance of multidisciplinary care within gynecologic surgery practices. They explored how to streamline the approach so it complements your practice, how to co-bill for shared patient care, and tips and tricks for optimizing the surgical experience for the patient. 

Industry presentations

Over lunch, Dr. Opoku-Akane presented on using ERAS (enhanced recovery after surgery) protocols for endometriosis and chronic pelvic pain and how to optimize the use of alternative surgical modalities for endometriosis. Following this, Drs. Albert Huany and Craig McCoy taught about a new technology using electrical stimulation to optimize visualization of the ureter. 

Harnessing the power of social media

This workshop, organized by SGS Social Media Committee Chair Dr. Amy Park (@dramypark) showed us the importance of having an online identity for the sharing of ideas, networking, professional development, and education. We learned how to optimize our online bios, proper use of GYN ontology for hashtags, and how to maintain professionalism on social media. We reviewed the data on how sharing publications on social media improves altmetric scores and discussed how our social media influence may be tied to performance in the future. 

Lessons in leadership

We rounded out the day with after-dinner dessert and drinks at the evening SGS Women’s Council presentation. We had the great honor of hearing from Lori Ryerker, CEO of Celanese Corporation, a Fortune 500 global company. She provided much wisdom on being a leader. She shared several keys to creating a successful work environment:

• being a leader that “provides an environment where people feel like they can bring their best selves every day” (and that being your best self is being your whole self, without reservations)
• allowing all genders, sexual orientations, races, ethnicities, and ages to show up together without reservations (because only then can people feel safe to be their best, because their best self is their true self). 

It was a wonderful and successful kick-off to the meeting. I look forward to a full day tomorrow! Follow along as this year’s Fellow Scholars, Drs. Tara Brah (@TaraBrah), Amr El Haraki (@drharaki), Sheena Galhotra (@SheenaGalhotra), Meenal Misal (@meenalmisalMD), and yours truly, post live updates daily.

TUESDAY, 6/29/21. DAY 3 AT SGS

The third day of the annual SGS meeting started with several academic roundtables hosted by experts in the field. These authorities shared their knowledge on a range of topics including endometriosis, building an academic career, diversity and equity in the workplace, and scientific publishing. The general session got underway with additional oral and video presentations highlighting advancements in our field. This year’s SGS President Dr. Miles Murphy gave the annual presidential address. He spoke genuinely and humbly about our field. Whitney Ross, MD, (@WRossMD), referred to his speech on Twitter as “Best. Presidential. Address. Ever.” –a sentiment felt by many in the crowd!

This year’s Telinde Lecture was given by Janet Dombrowski, the first ever non-physician to present this lecture. She spoke on resiliency in a lecture titled, “Cultivating Resilience: The Power in Connection & Collaboration.” It was an insightful and wise presentation on the power of connection and how connection bolsters our resiliency. She challenged us to all break down “thinking habits” that isolate us into silos and get in the way of powerful connection and collaboration. She reminded us of the African greeting “Sawubona” (I see you) and “Sikhona” (Because you see me, I am here). A gentle reminder that we feel our existence most tangibly when we are seen by others—an idea consistent with other important themes of this conference, focused on diversity, equity, and inclusion of all.  The morning session was rounded out with a panel discussion on “Novel GYN Office Procedure,” featuring Drs. Cecile Ferrando (@CFerrandoMD), Abbas Shobeiri (@ShobeiriAbbas), Andrea Pezzela, and Eric Sokol.

The afternoon was filled with leisure activities in beautiful Palm Springs, including the SGS Golf Tournament, mountain biking, aerial tramway tour, and hike. The weather even cooperated with slightly cooler temperatures (think 100℉ instead of 120℉)! The evening was filled with food, drinks, and the excitement around the annual “SGS’ Got Talent” show! Everyone was able to let down, show off their dance moves, and enjoy some of that much needed connection time!

Tomorrow is the last day of #SGS2021! Excited to round out the conference with continued learning.

MONDAY, 6/28/21. DAY 2 AT SGS 

 The sun is up and working hard here in Palm Springs, and so are we!  
 
Welcome and introduction of new members 
 
The general session started with a warm welcome to the 12 new SGS members. A special shout out to Dr. Kelly Wright who is a new SGS Member and won the #SGS2021 tweetup! She ranked as a top influencer, prolific tweeter, and made more than 250K impressions leading up to SGS! Way to represent @MigsRunner.  
 
General scientific sessions 
 
There were several excellent oral and video presentations throughout the morning session. A range of topics were discussed, including postoperative pain management, strategies for cost-effective surgery, and how racial and ethnic disparities play into our medical education and patient outcomes. Dr. Eva Welch gave a stellar video presentation on straight-stick sacrocolpopexy techniques for the savvy surgeon. I personally will be incorporating some of her needle management tricks!  
 
After a brief break with some refreshments and a stroll around the exhibit hall, the second scientific session initiated with a transformative lecture. Dr. Mark Walters presented "Insights on Surgical Education: How Can I Help You Get Better" in the inaugural Mark D. Walters Lectureship. Dr. Walters shared his experience and insights on how to transform oneself from a good surgeon to an expert and from a teacher to a coach in the operating room. His dedication to our field, years of experience, and wisdom earned him a standing ovation! Additional oral and video presentations followed. Dr. J. Wong shared correlations between surgeon gender and ergonomic strain with laparoscopic devices. Female surgeons more often reported inappropriate fit and expressed physical discomfort compared with male surgeons. Injuries and ergonomic strain lead to less operating and even disability for some surgeons. It is past time for us to have better--we need instruments that fit our hands!  
 
The afternoon session started with a panel on "Perspectives on Race in GYN Surgery." It was another insightful discussion with thought- and action-provoking knowledge. The afternoon session included the SGS Prize Video by Dr. Angela DiCarlo-Meacham on excision of a vulvar cyst.  
 
Fellows' Pelvic Research Network 
 
After adjourning of the scientific sessions, the fellow-ran, multicenter research network (FPRN) met to give updates. This diverse group of both AUGS-SGS and FMIGS-SGS offers mentorship and relationships that are important for future careers and research. The collaboration allows the study of rare outcomes that may not be feasible at single sites. Dr. Amanda Yunker, fellowship director at Vanderbilt University, gave an amazing history lesson on the fields of OB and GYN, and the evolution of gynecologic surgery. We then had fun assigning a "report card grade" on how MIGS is doing comparatively with other subspecialties in the realms of academics and research.  
 
VideoFest 
 
The late afternoon was concluded with a surgical video session. What an amazing and talented group we are here at SGS!  
 
President's awards ceremony and reception 
The scientific focused day was rounded out with an evening of honors, awards, and social time as we celebrated all the achievements of our peers and colleagues. The president's reception was filled with food, laughter, networking, and reconnecting with friends and colleagues. We are looking forward to another day of education tomorrow! 
 
Follow @JennaRehmerMD, @GynSurgery, and #SGS2021 on Twitter for updates. 

SUNDAY, 6/27/21. DAY 1 AT SGS

Hello live from sunny Palm Spring, CA, and the Annual Scientific Meeting of the Society of Gynecologic Surgeons (SGS)! This year’s conference balances the long-awaited return to in-person events while simultaneously embracing virtual learning with their hybrid meeting format. You can follow me, @JennaRehmerMD, and #SGS2021 in real-time on Twitter. 

Dismantling racism

We were incredibly fortunate to take a deep dive into dismantling racism in our personal and professional spheres. The postgraduate course was well researched and presented by Drs. Oluwateniola “Teni” Brown, Cassandra Carberry, Olivia Cardenas-Trowers (@otrowers_md), Annetta Madsen, Moiuri Siddique, and Blair Washington (@Dr_B_Washington). Each presentation provided a succinct and cohesive flow, taking us through what racism is, the historical and active structural racism in medicine, and the actions and steps of becoming anti-racist. 

Dr. Brown discussed critical race theory. We learned that the engineered system of oppression is so advanced that it is often hidden in plain sight, and that one’s conscious awareness is not necessary in order to uphold the system of oppression. It is reinforced and supported with minimal effort. This is why not being racist is not enough; active anti-racism is needed to bring about change. 

Fibroid management

Across the hall, Drs. Linda Bradley (@BradlelMD), Kimberly Kho (@KimberlyKho1), Cara King (@drcaraking), and Kelly Wright (@MigsRunner) broadened our armamentarium for uterine conservation in fibroid management. Dr. Bradley reviewed medical therapies, including novel treatments, as first-line or adjunct treatment options. Next, the course focused on surgical techniques for hysteroscopic myomectomies, optimization of minilaparotomy for myomectomy, and tissue extraction. Dr. King displayed true grit when giving her lecture from the airport after flight delays prevented her from being in person with us. 

Multidisciplinary care within gyn surgery

In this virtual only postgraduate course, Drs. Risal Djohan (@DjohanMD), Cecile Ferrando (@CFerrandoMD), Marie Fidela Paraiso, Sandip Vasavada (@SandipVasavada), and Sarah Vogler showed us the importance of multidisciplinary care within gynecologic surgery practices. They explored how to streamline the approach so it complements your practice, how to co-bill for shared patient care, and tips and tricks for optimizing the surgical experience for the patient. 

Industry presentations

Over lunch, Dr. Opoku-Akane presented on using ERAS (enhanced recovery after surgery) protocols for endometriosis and chronic pelvic pain and how to optimize the use of alternative surgical modalities for endometriosis. Following this, Drs. Albert Huany and Craig McCoy taught about a new technology using electrical stimulation to optimize visualization of the ureter. 

Harnessing the power of social media

This workshop, organized by SGS Social Media Committee Chair Dr. Amy Park (@dramypark) showed us the importance of having an online identity for the sharing of ideas, networking, professional development, and education. We learned how to optimize our online bios, proper use of GYN ontology for hashtags, and how to maintain professionalism on social media. We reviewed the data on how sharing publications on social media improves altmetric scores and discussed how our social media influence may be tied to performance in the future. 

Lessons in leadership

We rounded out the day with after-dinner dessert and drinks at the evening SGS Women’s Council presentation. We had the great honor of hearing from Lori Ryerker, CEO of Celanese Corporation, a Fortune 500 global company. She provided much wisdom on being a leader. She shared several keys to creating a successful work environment:

• being a leader that “provides an environment where people feel like they can bring their best selves every day” (and that being your best self is being your whole self, without reservations)
• allowing all genders, sexual orientations, races, ethnicities, and ages to show up together without reservations (because only then can people feel safe to be their best, because their best self is their true self). 

It was a wonderful and successful kick-off to the meeting. I look forward to a full day tomorrow! Follow along as this year’s Fellow Scholars, Drs. Tara Brah (@TaraBrah), Amr El Haraki (@drharaki), Sheena Galhotra (@SheenaGalhotra), Meenal Misal (@meenalmisalMD), and yours truly, post live updates daily.

TUESDAY, 6/29/21. DAY 3 AT SGS

The third day of the annual SGS meeting started with several academic roundtables hosted by experts in the field. These authorities shared their knowledge on a range of topics including endometriosis, building an academic career, diversity and equity in the workplace, and scientific publishing. The general session got underway with additional oral and video presentations highlighting advancements in our field. This year’s SGS President Dr. Miles Murphy gave the annual presidential address. He spoke genuinely and humbly about our field. Whitney Ross, MD, (@WRossMD), referred to his speech on Twitter as “Best. Presidential. Address. Ever.” –a sentiment felt by many in the crowd!

This year’s Telinde Lecture was given by Janet Dombrowski, the first ever non-physician to present this lecture. She spoke on resiliency in a lecture titled, “Cultivating Resilience: The Power in Connection & Collaboration.” It was an insightful and wise presentation on the power of connection and how connection bolsters our resiliency. She challenged us to all break down “thinking habits” that isolate us into silos and get in the way of powerful connection and collaboration. She reminded us of the African greeting “Sawubona” (I see you) and “Sikhona” (Because you see me, I am here). A gentle reminder that we feel our existence most tangibly when we are seen by others—an idea consistent with other important themes of this conference, focused on diversity, equity, and inclusion of all.  The morning session was rounded out with a panel discussion on “Novel GYN Office Procedure,” featuring Drs. Cecile Ferrando (@CFerrandoMD), Abbas Shobeiri (@ShobeiriAbbas), Andrea Pezzela, and Eric Sokol.

The afternoon was filled with leisure activities in beautiful Palm Springs, including the SGS Golf Tournament, mountain biking, aerial tramway tour, and hike. The weather even cooperated with slightly cooler temperatures (think 100℉ instead of 120℉)! The evening was filled with food, drinks, and the excitement around the annual “SGS’ Got Talent” show! Everyone was able to let down, show off their dance moves, and enjoy some of that much needed connection time!

Tomorrow is the last day of #SGS2021! Excited to round out the conference with continued learning.

MONDAY, 6/28/21. DAY 2 AT SGS 

 The sun is up and working hard here in Palm Springs, and so are we!  
 
Welcome and introduction of new members 
 
The general session started with a warm welcome to the 12 new SGS members. A special shout out to Dr. Kelly Wright who is a new SGS Member and won the #SGS2021 tweetup! She ranked as a top influencer, prolific tweeter, and made more than 250K impressions leading up to SGS! Way to represent @MigsRunner.  
 
General scientific sessions 
 
There were several excellent oral and video presentations throughout the morning session. A range of topics were discussed, including postoperative pain management, strategies for cost-effective surgery, and how racial and ethnic disparities play into our medical education and patient outcomes. Dr. Eva Welch gave a stellar video presentation on straight-stick sacrocolpopexy techniques for the savvy surgeon. I personally will be incorporating some of her needle management tricks!  
 
After a brief break with some refreshments and a stroll around the exhibit hall, the second scientific session initiated with a transformative lecture. Dr. Mark Walters presented "Insights on Surgical Education: How Can I Help You Get Better" in the inaugural Mark D. Walters Lectureship. Dr. Walters shared his experience and insights on how to transform oneself from a good surgeon to an expert and from a teacher to a coach in the operating room. His dedication to our field, years of experience, and wisdom earned him a standing ovation! Additional oral and video presentations followed. Dr. J. Wong shared correlations between surgeon gender and ergonomic strain with laparoscopic devices. Female surgeons more often reported inappropriate fit and expressed physical discomfort compared with male surgeons. Injuries and ergonomic strain lead to less operating and even disability for some surgeons. It is past time for us to have better--we need instruments that fit our hands!  
 
The afternoon session started with a panel on "Perspectives on Race in GYN Surgery." It was another insightful discussion with thought- and action-provoking knowledge. The afternoon session included the SGS Prize Video by Dr. Angela DiCarlo-Meacham on excision of a vulvar cyst.  
 
Fellows' Pelvic Research Network 
 
After adjourning of the scientific sessions, the fellow-ran, multicenter research network (FPRN) met to give updates. This diverse group of both AUGS-SGS and FMIGS-SGS offers mentorship and relationships that are important for future careers and research. The collaboration allows the study of rare outcomes that may not be feasible at single sites. Dr. Amanda Yunker, fellowship director at Vanderbilt University, gave an amazing history lesson on the fields of OB and GYN, and the evolution of gynecologic surgery. We then had fun assigning a "report card grade" on how MIGS is doing comparatively with other subspecialties in the realms of academics and research.  
 
VideoFest 
 
The late afternoon was concluded with a surgical video session. What an amazing and talented group we are here at SGS!  
 
President's awards ceremony and reception 
The scientific focused day was rounded out with an evening of honors, awards, and social time as we celebrated all the achievements of our peers and colleagues. The president's reception was filled with food, laughter, networking, and reconnecting with friends and colleagues. We are looking forward to another day of education tomorrow! 
 
Follow @JennaRehmerMD, @GynSurgery, and #SGS2021 on Twitter for updates. 

SUNDAY, 6/27/21. DAY 1 AT SGS

Hello live from sunny Palm Spring, CA, and the Annual Scientific Meeting of the Society of Gynecologic Surgeons (SGS)! This year’s conference balances the long-awaited return to in-person events while simultaneously embracing virtual learning with their hybrid meeting format. You can follow me, @JennaRehmerMD, and #SGS2021 in real-time on Twitter. 

Dismantling racism

We were incredibly fortunate to take a deep dive into dismantling racism in our personal and professional spheres. The postgraduate course was well researched and presented by Drs. Oluwateniola “Teni” Brown, Cassandra Carberry, Olivia Cardenas-Trowers (@otrowers_md), Annetta Madsen, Moiuri Siddique, and Blair Washington (@Dr_B_Washington). Each presentation provided a succinct and cohesive flow, taking us through what racism is, the historical and active structural racism in medicine, and the actions and steps of becoming anti-racist. 

Dr. Brown discussed critical race theory. We learned that the engineered system of oppression is so advanced that it is often hidden in plain sight, and that one’s conscious awareness is not necessary in order to uphold the system of oppression. It is reinforced and supported with minimal effort. This is why not being racist is not enough; active anti-racism is needed to bring about change. 

Fibroid management

Across the hall, Drs. Linda Bradley (@BradlelMD), Kimberly Kho (@KimberlyKho1), Cara King (@drcaraking), and Kelly Wright (@MigsRunner) broadened our armamentarium for uterine conservation in fibroid management. Dr. Bradley reviewed medical therapies, including novel treatments, as first-line or adjunct treatment options. Next, the course focused on surgical techniques for hysteroscopic myomectomies, optimization of minilaparotomy for myomectomy, and tissue extraction. Dr. King displayed true grit when giving her lecture from the airport after flight delays prevented her from being in person with us. 

Multidisciplinary care within gyn surgery

In this virtual only postgraduate course, Drs. Risal Djohan (@DjohanMD), Cecile Ferrando (@CFerrandoMD), Marie Fidela Paraiso, Sandip Vasavada (@SandipVasavada), and Sarah Vogler showed us the importance of multidisciplinary care within gynecologic surgery practices. They explored how to streamline the approach so it complements your practice, how to co-bill for shared patient care, and tips and tricks for optimizing the surgical experience for the patient. 

Industry presentations

Over lunch, Dr. Opoku-Akane presented on using ERAS (enhanced recovery after surgery) protocols for endometriosis and chronic pelvic pain and how to optimize the use of alternative surgical modalities for endometriosis. Following this, Drs. Albert Huany and Craig McCoy taught about a new technology using electrical stimulation to optimize visualization of the ureter. 

Harnessing the power of social media

This workshop, organized by SGS Social Media Committee Chair Dr. Amy Park (@dramypark) showed us the importance of having an online identity for the sharing of ideas, networking, professional development, and education. We learned how to optimize our online bios, proper use of GYN ontology for hashtags, and how to maintain professionalism on social media. We reviewed the data on how sharing publications on social media improves altmetric scores and discussed how our social media influence may be tied to performance in the future. 

Lessons in leadership

We rounded out the day with after-dinner dessert and drinks at the evening SGS Women’s Council presentation. We had the great honor of hearing from Lori Ryerker, CEO of Celanese Corporation, a Fortune 500 global company. She provided much wisdom on being a leader. She shared several keys to creating a successful work environment:

• being a leader that “provides an environment where people feel like they can bring their best selves every day” (and that being your best self is being your whole self, without reservations)
• allowing all genders, sexual orientations, races, ethnicities, and ages to show up together without reservations (because only then can people feel safe to be their best, because their best self is their true self). 

It was a wonderful and successful kick-off to the meeting. I look forward to a full day tomorrow! Follow along as this year’s Fellow Scholars, Drs. Tara Brah (@TaraBrah), Amr El Haraki (@drharaki), Sheena Galhotra (@SheenaGalhotra), Meenal Misal (@meenalmisalMD), and yours truly, post live updates daily.

Incorporating mobile apps into patient care programs can add immense value. Mobile apps enable data collection when a patient is beyond the walls of a doctor’s office and equip clinicians with new and relevant patient data. Patient engagement apps also provide a mechanism to “nudge” patients to encourage adherence to their care programs. These additional data and increased patient adherence can enable more personalized care,¹ and ultimately can lead to improved outcomes. For example, a meta-analysis of 1,657 patients with diabetes showed a 5% reduction in hemoglobin A_1c (HbA_1c) values for those who used a diabetes-related app.² The literature also shows positive results for heart failure, weight management, smoking reduction, and lifestyle improvement.^3-5 Given their value, why aren’t patient engagement apps more routinely integrated into patient care programs?

From a software development perspective, mobile apps are fairly easy to create. However, from a user retention standpoint, creating an app with a large, sustainable userbase is challenging.⁵ User retention is measured in monthly active users. We are familiar with unused apps collecting digital dust on our smartphone home screens. A 2019 study showed that 25% of people typically use an application only once,⁶ and health care apps are not an exception. There are hundreds of thousands of mobile health apps on the market, but only 7% of these applications have more than 50,000 monthly active users. Further, 62% of digital health apps have less than 1,000 monthly active users.⁷

Using a new app daily or several times weekly requires new habit formation. Anyone who has tried to incorporate a new routine into their daily life knows how difficult habit formation can be. However, ObGyn patients may be particularly well suited to incorporate ObGyn-related apps into their care, given how many women already use mobile applications to track their menstrual cycles. A recent survey found that across all age groups, 47% of women use a mobile phone app to track their menstrual cycle,⁸ compared with 8% of US adults who regularly use an app to measure general health metrics.⁷ This removes one of the largest obstacles of market penetration since the habit of using an app for ObGyn purposes has already been established. As such, it presents an exciting opportunity to capitalize on the userbase already leveraging mobile apps to track their cycles and expand the patient engagement footprint into additional features that can broaden care to create a seamless, holistic patient application for ObGyn patient care.

One can envision a future in which a patient is “prescribed” an ObGyn app during their ObGyn appointment. Within the app, the patient can track their health data, engage with health providers, and gain access to educational materials. The clinician would be able to access data captured in the patient app at an aggregate level to analyze trends over time.

Current, patient-facing ObGyn mobile apps available for download on smartphones are for targeted aspects of ObGyn health. For example, there are separate apps for menstrual cycle tracking, contraception education, and medication adherence tracking. In the future, it would be ideal for clinicians and patients to have access to a single, holistic ObGyn mobile app that supports the end-to-end ObGyn patient journey, one in which clinicians could turn modules on or off given specific patient concerns. The technology for this type of holistic patient engagement platform exists, but unfortunately it is not as simple as downloading a mobile app. Standing up an end-to-end patient engagement platform requires enterprise-wide buy-in, tailoring user workflows, and building out integrations (eg, integrating provider dashboards into the existing electronic health record system). Full-scale solutions are powerful, but they can be expensive and time consuming to stand up. Until there is a more streamlined, outside-the-box ObGyn-tailored solution, there are patientfacing mobile apps available to support your patients for specific concerns.

Continue to: The top 3 recommended menstrual cycle tracking apps...

The top 3 recommended menstrual cycle tracking apps from Moglia and colleagues⁹ are listed in Dr. Chen’s article, “Top free menstrual cycle tracking apps for your patients.”¹⁰ The top 3 recommended contraception education mobile apps from Lunde and colleagues¹¹ are listed in TABLE 1 and are detailed with a shortened version of the APPLICATIONS scoring system, APPLI (app comprehensiveness, price, platform, literature use, important special features).¹² The top 3 recommended patient medication adherence mobile apps from the study by Santo and colleagues¹³ are listed in TABLE 2. The apps in the Stoyanov et al¹⁴ study were evaluated using the 23-item Mobile App Rating System scale. ●

Incorporating mobile apps into patient care programs can add immense value. Mobile apps enable data collection when a patient is beyond the walls of a doctor’s office and equip clinicians with new and relevant patient data. Patient engagement apps also provide a mechanism to “nudge” patients to encourage adherence to their care programs. These additional data and increased patient adherence can enable more personalized care,¹ and ultimately can lead to improved outcomes. For example, a meta-analysis of 1,657 patients with diabetes showed a 5% reduction in hemoglobin A_1c (HbA_1c) values for those who used a diabetes-related app.² The literature also shows positive results for heart failure, weight management, smoking reduction, and lifestyle improvement.^3-5 Given their value, why aren’t patient engagement apps more routinely integrated into patient care programs?

From a software development perspective, mobile apps are fairly easy to create. However, from a user retention standpoint, creating an app with a large, sustainable userbase is challenging.⁵ User retention is measured in monthly active users. We are familiar with unused apps collecting digital dust on our smartphone home screens. A 2019 study showed that 25% of people typically use an application only once,⁶ and health care apps are not an exception. There are hundreds of thousands of mobile health apps on the market, but only 7% of these applications have more than 50,000 monthly active users. Further, 62% of digital health apps have less than 1,000 monthly active users.⁷

Using a new app daily or several times weekly requires new habit formation. Anyone who has tried to incorporate a new routine into their daily life knows how difficult habit formation can be. However, ObGyn patients may be particularly well suited to incorporate ObGyn-related apps into their care, given how many women already use mobile applications to track their menstrual cycles. A recent survey found that across all age groups, 47% of women use a mobile phone app to track their menstrual cycle,⁸ compared with 8% of US adults who regularly use an app to measure general health metrics.⁷ This removes one of the largest obstacles of market penetration since the habit of using an app for ObGyn purposes has already been established. As such, it presents an exciting opportunity to capitalize on the userbase already leveraging mobile apps to track their cycles and expand the patient engagement footprint into additional features that can broaden care to create a seamless, holistic patient application for ObGyn patient care.

One can envision a future in which a patient is “prescribed” an ObGyn app during their ObGyn appointment. Within the app, the patient can track their health data, engage with health providers, and gain access to educational materials. The clinician would be able to access data captured in the patient app at an aggregate level to analyze trends over time.

Current, patient-facing ObGyn mobile apps available for download on smartphones are for targeted aspects of ObGyn health. For example, there are separate apps for menstrual cycle tracking, contraception education, and medication adherence tracking. In the future, it would be ideal for clinicians and patients to have access to a single, holistic ObGyn mobile app that supports the end-to-end ObGyn patient journey, one in which clinicians could turn modules on or off given specific patient concerns. The technology for this type of holistic patient engagement platform exists, but unfortunately it is not as simple as downloading a mobile app. Standing up an end-to-end patient engagement platform requires enterprise-wide buy-in, tailoring user workflows, and building out integrations (eg, integrating provider dashboards into the existing electronic health record system). Full-scale solutions are powerful, but they can be expensive and time consuming to stand up. Until there is a more streamlined, outside-the-box ObGyn-tailored solution, there are patientfacing mobile apps available to support your patients for specific concerns.

Continue to: The top 3 recommended menstrual cycle tracking apps...

The top 3 recommended menstrual cycle tracking apps from Moglia and colleagues⁹ are listed in Dr. Chen’s article, “Top free menstrual cycle tracking apps for your patients.”¹⁰ The top 3 recommended contraception education mobile apps from Lunde and colleagues¹¹ are listed in TABLE 1 and are detailed with a shortened version of the APPLICATIONS scoring system, APPLI (app comprehensiveness, price, platform, literature use, important special features).¹² The top 3 recommended patient medication adherence mobile apps from the study by Santo and colleagues¹³ are listed in TABLE 2. The apps in the Stoyanov et al¹⁴ study were evaluated using the 23-item Mobile App Rating System scale. ●

Incorporating mobile apps into patient care programs can add immense value. Mobile apps enable data collection when a patient is beyond the walls of a doctor’s office and equip clinicians with new and relevant patient data. Patient engagement apps also provide a mechanism to “nudge” patients to encourage adherence to their care programs. These additional data and increased patient adherence can enable more personalized care,¹ and ultimately can lead to improved outcomes. For example, a meta-analysis of 1,657 patients with diabetes showed a 5% reduction in hemoglobin A_1c (HbA_1c) values for those who used a diabetes-related app.² The literature also shows positive results for heart failure, weight management, smoking reduction, and lifestyle improvement.^3-5 Given their value, why aren’t patient engagement apps more routinely integrated into patient care programs?

From a software development perspective, mobile apps are fairly easy to create. However, from a user retention standpoint, creating an app with a large, sustainable userbase is challenging.⁵ User retention is measured in monthly active users. We are familiar with unused apps collecting digital dust on our smartphone home screens. A 2019 study showed that 25% of people typically use an application only once,⁶ and health care apps are not an exception. There are hundreds of thousands of mobile health apps on the market, but only 7% of these applications have more than 50,000 monthly active users. Further, 62% of digital health apps have less than 1,000 monthly active users.⁷

Using a new app daily or several times weekly requires new habit formation. Anyone who has tried to incorporate a new routine into their daily life knows how difficult habit formation can be. However, ObGyn patients may be particularly well suited to incorporate ObGyn-related apps into their care, given how many women already use mobile applications to track their menstrual cycles. A recent survey found that across all age groups, 47% of women use a mobile phone app to track their menstrual cycle,⁸ compared with 8% of US adults who regularly use an app to measure general health metrics.⁷ This removes one of the largest obstacles of market penetration since the habit of using an app for ObGyn purposes has already been established. As such, it presents an exciting opportunity to capitalize on the userbase already leveraging mobile apps to track their cycles and expand the patient engagement footprint into additional features that can broaden care to create a seamless, holistic patient application for ObGyn patient care.

One can envision a future in which a patient is “prescribed” an ObGyn app during their ObGyn appointment. Within the app, the patient can track their health data, engage with health providers, and gain access to educational materials. The clinician would be able to access data captured in the patient app at an aggregate level to analyze trends over time.

Current, patient-facing ObGyn mobile apps available for download on smartphones are for targeted aspects of ObGyn health. For example, there are separate apps for menstrual cycle tracking, contraception education, and medication adherence tracking. In the future, it would be ideal for clinicians and patients to have access to a single, holistic ObGyn mobile app that supports the end-to-end ObGyn patient journey, one in which clinicians could turn modules on or off given specific patient concerns. The technology for this type of holistic patient engagement platform exists, but unfortunately it is not as simple as downloading a mobile app. Standing up an end-to-end patient engagement platform requires enterprise-wide buy-in, tailoring user workflows, and building out integrations (eg, integrating provider dashboards into the existing electronic health record system). Full-scale solutions are powerful, but they can be expensive and time consuming to stand up. Until there is a more streamlined, outside-the-box ObGyn-tailored solution, there are patientfacing mobile apps available to support your patients for specific concerns.

Continue to: The top 3 recommended menstrual cycle tracking apps...

The top 3 recommended menstrual cycle tracking apps from Moglia and colleagues⁹ are listed in Dr. Chen’s article, “Top free menstrual cycle tracking apps for your patients.”¹⁰ The top 3 recommended contraception education mobile apps from Lunde and colleagues¹¹ are listed in TABLE 1 and are detailed with a shortened version of the APPLICATIONS scoring system, APPLI (app comprehensiveness, price, platform, literature use, important special features).¹² The top 3 recommended patient medication adherence mobile apps from the study by Santo and colleagues¹³ are listed in TABLE 2. The apps in the Stoyanov et al¹⁴ study were evaluated using the 23-item Mobile App Rating System scale. ●

Ultrasonography truly has revolutionized the practice of obstetrics and gynecology. Initially, transabdominal ultrasonography was mainly a tool of the obstetrician. Early linear array, real-time equipment had barely enough resolution to perform very limited assessments, such as measure biparietal diameter and identify vertex versus breech presentation, and anterior versus posterior placenta location. The introduction of transvaginal probes, which employ higher frequency and provide closer proximity to structures, yielded a degree of image magnification that was dubbed sonomicroscopy.¹ In other words, we are seeing things with our naked eye that we could not see if we could hold them in our hand at arm’s length and squint at them. An example of this is the cardiac activity clearly visible in a 3-mm embryo at 45 days from the last menstrual period. One would not appreciate this without the low power magnification of the vaginal probe.

The concept of dynamic imaging

As early as 1990, I realized that there is a difference between an ultrasound “examination” performed because of referral for imaging, which generated a report back to the referring health care provider, and “examining” one’s own patient with ultrasonography at the time of bimanual exam. I coined the phrase “the ultrasound-enhanced bimanual exam,” and I believed it should become a routine part of gynecologic care. I put forth this thesis in an article entitled, “Incorporating endovaginal ultrasonography into the overall gynecologic examination.”² The idea is based on thinking: What exactly are we are trying to discern from a bimanual exam?

Clinicians perform the bimanual exam thousands of times. The bimanual examination consists of 2 components, an objective portion and a subjective portion. The objective component attempts to discern information that is totally objective, such as, Is the ovary enlarged? If so, is it cystic or solid? Is this uterus normal in shape and contour? If so, does it feel like leiomyomas or is it globularly enlarged as with adenomyosis? The subjective component of the bimanual examination attempts to determine whether or not tenderness is present or if there is normal mobility of the pelvic organs.

The objective component can be replaced by an image in very little time if the examiner has the equipment and the knowledge and skill. The subjective component, however, depends on the experience and often the nuance of the examiner. That was my original thought process. I wanted, and still want, the examining clinician to use imaging as part of the overall exam. But now, I want the imager to use examination as part of the overall imaging. (VIDEOS 1A and 1B.) This is the concept of dynamic imaging. It involves the liberal use of the abdominal hand as well as an in-and-out motion of the vaginal probe to ascertain aspects of the examination that in the past I deemed “subjective.” Mainly, this involves the aspects of mobility and/or tenderness.

Continue to: Guidelines concerning pelvic ultrasound do not consider dynamic imaging...

Guidelines concerning pelvic ultrasound do not consider dynamic imaging

Until now, most imagers take a myriad of pictures, mostly still snapshots, to illustrate anatomy. Most imaging physicians then look at a series of such pictures and may never even hold the transducer. This is increasingly true in instances of remote teleradiology. Even for the minority of imagers who utilize video clips (VIDEOS 2A–2C), these are still representations of anatomy .

One need look no further than the guidelines that underpin the expectation of those who scan the female pelvis. The American Institute of Ultrasound in Medicine (AIUM) published a practice parameter for the performance of ultrasonography of the female pelvis, developed in collaboration with the American College of Radiology, American College of Obstetricians and Gynecologists, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound. ³ Nowhere does this document mention anything other than what images to obtain, where to look, and how to measure. Nowhere is there any mention of dynamic imaging—the concept of using one’s other hand on the abdomen, eliciting pain with the vaginal probe, checking for mobility, asking the patient to bear down. The document lists indications for pelvic sonography that include but are not limited to 19 different indications, such as pelvic pain, evaluation of dysmenorrhea, evaluation for signs or symptoms of pelvic infection, and evaluation of incontinence or pelvic organ prolapse (TABLE). ³

Dynamic ultrasonography can aid in the diagnosis of certain conditions

Specifically, what can dynamic ultrasonography add to anatomic imaging? The main considerations are pain, adhesions, endometriosis, and pelvic organ prolapse.

Pelvic pain or tenderness

How can you evaluate a patient’s pelvic pain with an anatomic image? Perhaps pain can be corroborated if there is a classic ovarian endometrioma (FIGURE 1) (VIDEOS 3A, 3B) or classic hydrosalpinx (FIGURE 2) (VIDEOS 4A–4C). But can we evaluate pelvic pain with only an anatomic image? No, absolutely not. Evaluating pain requires dynamic assessment. As described above, in a dynamic ultrasound assessment, liberal use of the abdominal hand and the tip of the vaginal probe can elicit where the patient’s pain exists and whether the pain can be recreated.

Adhesions

Pelvic adhesions can be a significant source of pelvic pain and, also, sometimes infertility. The adhesions themselves may not be visible on anatomic imaging. This is where the concept of the sliding organ sign is paramount, a concept first described by Dr. Ilan Timor-Tritsch in his book Transvaginal Sonography . ⁴ He stated, “Diagnosis of pelvic adhesions becomes possible by the ‘sliding organ sign.’ The transducer tip is pointed at the uterus, ovaries or any pelvic finding, and a gentle push-pull movement of several centimeters is started. If no adhesions are present, the organs will move freely in the pelvis. This displacement of organs is perceived on the screen as a sliding movement.” ⁴ Thus, if structures are in fact adherent, they will move in tandem with each other as evidenced by this dynamic assessment. If they are not adherent, they will move slightly but independently of each other ( VIDEOS 5A–5G ).

Continue to: Endometriosis...

Endometriosis

Dynamic ultrasonography can be a significant part of a nonlaparoscopic, presumptive diagnosis of endometriosis when there is no obvious ovarian endometrioma.⁵ The evidence for this comes from a classic paper by Okaro and colleagues, “The use of ultrasound‐based ‘soft markers’ for the prediction of pelvic pathology in women with chronic pelvic pain–can we reduce the need for laparoscopy?”⁶ In that study, 120 consecutive women with chronic pelvic pain scheduled for laparoscopy underwent vaginal ultrasonography. Hard markers were defined as structural abnormalities, such as classic endometriomas or hydrosalpinges.

These markers demonstrated a 100% correlation (24 of 24 women) with laparoscopic findings, as one might have suspected. In addition, soft markers (VIDEOS 6A–6C) were defined as reduced ovarian mobility, site-specific pelvic tenderness, and the presence of loculated peritoneal fluid in the pelvis. These were predictive of pelvic pathology in 73% of these women (37 of 51).⁶

Thus, women who have soft markers on dynamic scanning but no obvious anatomic abnormalities can be treated with a high degree of sensitivity without the need for laparoscopic intervention.

Pelvic organ prolapse and incontinence

With the vaginal probe in place, and even a small amount of urine in the bladder, the patient can be asked to bear down (Valsalva maneuver), and cystocele (VIDEO 7) and/or hypermobility of the urethra (VIDEO 8) is easily discerned with dynamic ultrasonography. This information is not available on static anatomic imaging.

A tool that enhances patient care

Dynamic ultrasonography is an important and emerging topic in gynecologic imaging. Static images and even cine clips will yield only anatomic information. Increasingly, whoever holds the transducer—whether it be the gynecologist, radiologist, or sonographer—needs to examine the patient with the probe and include liberal use of the abdominal hand as well. Incorporating this concept will enhance the overall diagnostic input of ultrasound scanning, not just imaging, into better and more accurate patient care. ●

Ultrasonography truly has revolutionized the practice of obstetrics and gynecology. Initially, transabdominal ultrasonography was mainly a tool of the obstetrician. Early linear array, real-time equipment had barely enough resolution to perform very limited assessments, such as measure biparietal diameter and identify vertex versus breech presentation, and anterior versus posterior placenta location. The introduction of transvaginal probes, which employ higher frequency and provide closer proximity to structures, yielded a degree of image magnification that was dubbed sonomicroscopy.¹ In other words, we are seeing things with our naked eye that we could not see if we could hold them in our hand at arm’s length and squint at them. An example of this is the cardiac activity clearly visible in a 3-mm embryo at 45 days from the last menstrual period. One would not appreciate this without the low power magnification of the vaginal probe.

The concept of dynamic imaging

As early as 1990, I realized that there is a difference between an ultrasound “examination” performed because of referral for imaging, which generated a report back to the referring health care provider, and “examining” one’s own patient with ultrasonography at the time of bimanual exam. I coined the phrase “the ultrasound-enhanced bimanual exam,” and I believed it should become a routine part of gynecologic care. I put forth this thesis in an article entitled, “Incorporating endovaginal ultrasonography into the overall gynecologic examination.”² The idea is based on thinking: What exactly are we are trying to discern from a bimanual exam?

Clinicians perform the bimanual exam thousands of times. The bimanual examination consists of 2 components, an objective portion and a subjective portion. The objective component attempts to discern information that is totally objective, such as, Is the ovary enlarged? If so, is it cystic or solid? Is this uterus normal in shape and contour? If so, does it feel like leiomyomas or is it globularly enlarged as with adenomyosis? The subjective component of the bimanual examination attempts to determine whether or not tenderness is present or if there is normal mobility of the pelvic organs.

The objective component can be replaced by an image in very little time if the examiner has the equipment and the knowledge and skill. The subjective component, however, depends on the experience and often the nuance of the examiner. That was my original thought process. I wanted, and still want, the examining clinician to use imaging as part of the overall exam. But now, I want the imager to use examination as part of the overall imaging. (VIDEOS 1A and 1B.) This is the concept of dynamic imaging. It involves the liberal use of the abdominal hand as well as an in-and-out motion of the vaginal probe to ascertain aspects of the examination that in the past I deemed “subjective.” Mainly, this involves the aspects of mobility and/or tenderness.

Continue to: Guidelines concerning pelvic ultrasound do not consider dynamic imaging...

Guidelines concerning pelvic ultrasound do not consider dynamic imaging

Until now, most imagers take a myriad of pictures, mostly still snapshots, to illustrate anatomy. Most imaging physicians then look at a series of such pictures and may never even hold the transducer. This is increasingly true in instances of remote teleradiology. Even for the minority of imagers who utilize video clips (VIDEOS 2A–2C), these are still representations of anatomy .

One need look no further than the guidelines that underpin the expectation of those who scan the female pelvis. The American Institute of Ultrasound in Medicine (AIUM) published a practice parameter for the performance of ultrasonography of the female pelvis, developed in collaboration with the American College of Radiology, American College of Obstetricians and Gynecologists, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound. ³ Nowhere does this document mention anything other than what images to obtain, where to look, and how to measure. Nowhere is there any mention of dynamic imaging—the concept of using one’s other hand on the abdomen, eliciting pain with the vaginal probe, checking for mobility, asking the patient to bear down. The document lists indications for pelvic sonography that include but are not limited to 19 different indications, such as pelvic pain, evaluation of dysmenorrhea, evaluation for signs or symptoms of pelvic infection, and evaluation of incontinence or pelvic organ prolapse (TABLE). ³

Dynamic ultrasonography can aid in the diagnosis of certain conditions

Specifically, what can dynamic ultrasonography add to anatomic imaging? The main considerations are pain, adhesions, endometriosis, and pelvic organ prolapse.

Pelvic pain or tenderness

How can you evaluate a patient’s pelvic pain with an anatomic image? Perhaps pain can be corroborated if there is a classic ovarian endometrioma (FIGURE 1) (VIDEOS 3A, 3B) or classic hydrosalpinx (FIGURE 2) (VIDEOS 4A–4C). But can we evaluate pelvic pain with only an anatomic image? No, absolutely not. Evaluating pain requires dynamic assessment. As described above, in a dynamic ultrasound assessment, liberal use of the abdominal hand and the tip of the vaginal probe can elicit where the patient’s pain exists and whether the pain can be recreated.

Adhesions

Pelvic adhesions can be a significant source of pelvic pain and, also, sometimes infertility. The adhesions themselves may not be visible on anatomic imaging. This is where the concept of the sliding organ sign is paramount, a concept first described by Dr. Ilan Timor-Tritsch in his book Transvaginal Sonography . ⁴ He stated, “Diagnosis of pelvic adhesions becomes possible by the ‘sliding organ sign.’ The transducer tip is pointed at the uterus, ovaries or any pelvic finding, and a gentle push-pull movement of several centimeters is started. If no adhesions are present, the organs will move freely in the pelvis. This displacement of organs is perceived on the screen as a sliding movement.” ⁴ Thus, if structures are in fact adherent, they will move in tandem with each other as evidenced by this dynamic assessment. If they are not adherent, they will move slightly but independently of each other ( VIDEOS 5A–5G ).

Continue to: Endometriosis...

Endometriosis

Dynamic ultrasonography can be a significant part of a nonlaparoscopic, presumptive diagnosis of endometriosis when there is no obvious ovarian endometrioma.⁵ The evidence for this comes from a classic paper by Okaro and colleagues, “The use of ultrasound‐based ‘soft markers’ for the prediction of pelvic pathology in women with chronic pelvic pain–can we reduce the need for laparoscopy?”⁶ In that study, 120 consecutive women with chronic pelvic pain scheduled for laparoscopy underwent vaginal ultrasonography. Hard markers were defined as structural abnormalities, such as classic endometriomas or hydrosalpinges.

These markers demonstrated a 100% correlation (24 of 24 women) with laparoscopic findings, as one might have suspected. In addition, soft markers (VIDEOS 6A–6C) were defined as reduced ovarian mobility, site-specific pelvic tenderness, and the presence of loculated peritoneal fluid in the pelvis. These were predictive of pelvic pathology in 73% of these women (37 of 51).⁶

Thus, women who have soft markers on dynamic scanning but no obvious anatomic abnormalities can be treated with a high degree of sensitivity without the need for laparoscopic intervention.

Pelvic organ prolapse and incontinence

With the vaginal probe in place, and even a small amount of urine in the bladder, the patient can be asked to bear down (Valsalva maneuver), and cystocele (VIDEO 7) and/or hypermobility of the urethra (VIDEO 8) is easily discerned with dynamic ultrasonography. This information is not available on static anatomic imaging.

A tool that enhances patient care

Dynamic ultrasonography is an important and emerging topic in gynecologic imaging. Static images and even cine clips will yield only anatomic information. Increasingly, whoever holds the transducer—whether it be the gynecologist, radiologist, or sonographer—needs to examine the patient with the probe and include liberal use of the abdominal hand as well. Incorporating this concept will enhance the overall diagnostic input of ultrasound scanning, not just imaging, into better and more accurate patient care. ●

Ultrasonography truly has revolutionized the practice of obstetrics and gynecology. Initially, transabdominal ultrasonography was mainly a tool of the obstetrician. Early linear array, real-time equipment had barely enough resolution to perform very limited assessments, such as measure biparietal diameter and identify vertex versus breech presentation, and anterior versus posterior placenta location. The introduction of transvaginal probes, which employ higher frequency and provide closer proximity to structures, yielded a degree of image magnification that was dubbed sonomicroscopy.¹ In other words, we are seeing things with our naked eye that we could not see if we could hold them in our hand at arm’s length and squint at them. An example of this is the cardiac activity clearly visible in a 3-mm embryo at 45 days from the last menstrual period. One would not appreciate this without the low power magnification of the vaginal probe.

The concept of dynamic imaging

As early as 1990, I realized that there is a difference between an ultrasound “examination” performed because of referral for imaging, which generated a report back to the referring health care provider, and “examining” one’s own patient with ultrasonography at the time of bimanual exam. I coined the phrase “the ultrasound-enhanced bimanual exam,” and I believed it should become a routine part of gynecologic care. I put forth this thesis in an article entitled, “Incorporating endovaginal ultrasonography into the overall gynecologic examination.”² The idea is based on thinking: What exactly are we are trying to discern from a bimanual exam?

Clinicians perform the bimanual exam thousands of times. The bimanual examination consists of 2 components, an objective portion and a subjective portion. The objective component attempts to discern information that is totally objective, such as, Is the ovary enlarged? If so, is it cystic or solid? Is this uterus normal in shape and contour? If so, does it feel like leiomyomas or is it globularly enlarged as with adenomyosis? The subjective component of the bimanual examination attempts to determine whether or not tenderness is present or if there is normal mobility of the pelvic organs.

The objective component can be replaced by an image in very little time if the examiner has the equipment and the knowledge and skill. The subjective component, however, depends on the experience and often the nuance of the examiner. That was my original thought process. I wanted, and still want, the examining clinician to use imaging as part of the overall exam. But now, I want the imager to use examination as part of the overall imaging. (VIDEOS 1A and 1B.) This is the concept of dynamic imaging. It involves the liberal use of the abdominal hand as well as an in-and-out motion of the vaginal probe to ascertain aspects of the examination that in the past I deemed “subjective.” Mainly, this involves the aspects of mobility and/or tenderness.

Continue to: Guidelines concerning pelvic ultrasound do not consider dynamic imaging...

Guidelines concerning pelvic ultrasound do not consider dynamic imaging

Until now, most imagers take a myriad of pictures, mostly still snapshots, to illustrate anatomy. Most imaging physicians then look at a series of such pictures and may never even hold the transducer. This is increasingly true in instances of remote teleradiology. Even for the minority of imagers who utilize video clips (VIDEOS 2A–2C), these are still representations of anatomy .

One need look no further than the guidelines that underpin the expectation of those who scan the female pelvis. The American Institute of Ultrasound in Medicine (AIUM) published a practice parameter for the performance of ultrasonography of the female pelvis, developed in collaboration with the American College of Radiology, American College of Obstetricians and Gynecologists, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound. ³ Nowhere does this document mention anything other than what images to obtain, where to look, and how to measure. Nowhere is there any mention of dynamic imaging—the concept of using one’s other hand on the abdomen, eliciting pain with the vaginal probe, checking for mobility, asking the patient to bear down. The document lists indications for pelvic sonography that include but are not limited to 19 different indications, such as pelvic pain, evaluation of dysmenorrhea, evaluation for signs or symptoms of pelvic infection, and evaluation of incontinence or pelvic organ prolapse (TABLE). ³

Dynamic ultrasonography can aid in the diagnosis of certain conditions

Specifically, what can dynamic ultrasonography add to anatomic imaging? The main considerations are pain, adhesions, endometriosis, and pelvic organ prolapse.

Pelvic pain or tenderness

How can you evaluate a patient’s pelvic pain with an anatomic image? Perhaps pain can be corroborated if there is a classic ovarian endometrioma (FIGURE 1) (VIDEOS 3A, 3B) or classic hydrosalpinx (FIGURE 2) (VIDEOS 4A–4C). But can we evaluate pelvic pain with only an anatomic image? No, absolutely not. Evaluating pain requires dynamic assessment. As described above, in a dynamic ultrasound assessment, liberal use of the abdominal hand and the tip of the vaginal probe can elicit where the patient’s pain exists and whether the pain can be recreated.

Adhesions

Pelvic adhesions can be a significant source of pelvic pain and, also, sometimes infertility. The adhesions themselves may not be visible on anatomic imaging. This is where the concept of the sliding organ sign is paramount, a concept first described by Dr. Ilan Timor-Tritsch in his book Transvaginal Sonography . ⁴ He stated, “Diagnosis of pelvic adhesions becomes possible by the ‘sliding organ sign.’ The transducer tip is pointed at the uterus, ovaries or any pelvic finding, and a gentle push-pull movement of several centimeters is started. If no adhesions are present, the organs will move freely in the pelvis. This displacement of organs is perceived on the screen as a sliding movement.” ⁴ Thus, if structures are in fact adherent, they will move in tandem with each other as evidenced by this dynamic assessment. If they are not adherent, they will move slightly but independently of each other ( VIDEOS 5A–5G ).

Continue to: Endometriosis...

Endometriosis

Dynamic ultrasonography can be a significant part of a nonlaparoscopic, presumptive diagnosis of endometriosis when there is no obvious ovarian endometrioma.⁵ The evidence for this comes from a classic paper by Okaro and colleagues, “The use of ultrasound‐based ‘soft markers’ for the prediction of pelvic pathology in women with chronic pelvic pain–can we reduce the need for laparoscopy?”⁶ In that study, 120 consecutive women with chronic pelvic pain scheduled for laparoscopy underwent vaginal ultrasonography. Hard markers were defined as structural abnormalities, such as classic endometriomas or hydrosalpinges.

These markers demonstrated a 100% correlation (24 of 24 women) with laparoscopic findings, as one might have suspected. In addition, soft markers (VIDEOS 6A–6C) were defined as reduced ovarian mobility, site-specific pelvic tenderness, and the presence of loculated peritoneal fluid in the pelvis. These were predictive of pelvic pathology in 73% of these women (37 of 51).⁶

Thus, women who have soft markers on dynamic scanning but no obvious anatomic abnormalities can be treated with a high degree of sensitivity without the need for laparoscopic intervention.

Pelvic organ prolapse and incontinence

With the vaginal probe in place, and even a small amount of urine in the bladder, the patient can be asked to bear down (Valsalva maneuver), and cystocele (VIDEO 7) and/or hypermobility of the urethra (VIDEO 8) is easily discerned with dynamic ultrasonography. This information is not available on static anatomic imaging.

A tool that enhances patient care

Dynamic ultrasonography is an important and emerging topic in gynecologic imaging. Static images and even cine clips will yield only anatomic information. Increasingly, whoever holds the transducer—whether it be the gynecologist, radiologist, or sonographer—needs to examine the patient with the probe and include liberal use of the abdominal hand as well. Incorporating this concept will enhance the overall diagnostic input of ultrasound scanning, not just imaging, into better and more accurate patient care. ●

Cardiovascular disease is the leading cause of women’s death in the United States, accounting for 1 in every 5 female deaths per year according to the Centers for Disease Control and Prevention. Most risk factors for cardiovascular disease are modifiable. With a disease so prevalent in women’s health, obstetricians and gynecologists can assist patients in modifying these risk factors. This, however, is easier said than done.

One of the rate-limiting steps in assisting patients is the process of identifying an individual’s risk factors. This can be a time-consuming task in a women’s health appointment that is already busy with ObGyn-specific concerns, but technology can assist us.

Cardiovascular health app considerations

Many smartphone applications and websites are available that can alleviate the time constraints for identifying these individual modifiable risk factors. When evaluating cardiovascular risk factor apps for patients, keep these qualities (as outlined in the ACOG-recommended rubric) in mind: design, functionality, usefulness, and accuracy.

The patient-centered resources that assist women in identifying cardiovascular risk factors and that provide tools to positively impact these risk factors through lifestyle changes can help women achieve improved cardiovascular health. Recommendations include 1) manage blood pressure, 2) control cholesterol, 3) reduce blood sugar, 4) get active, 5) eat better, 6) lose weight, and 7) stop smoking.

National organizations’ smartphone apps guide the patient through a handful of questions about their current lifestyle, gender, age, and basic laboratory values. Their individual “heart health” results of these questions distribute the 7 risk factors to 3 categories based on the need to focus, improve, or celebrate. Through nonthreatening videos, patients can improve their scores themselves and bring the areas they need to focus, or improve, to their ObGyn’s attention for further assistance.

While adding one more task to an already busy practice can seem daunting, there are great technology resources that can be leveraged to successfully address this important health metric. By using the ACOG-recommended rubric and focusing on the app characteristics identified above, you can find one that works best for you and your patients and incorporate it into your practice today. ●

Cardiovascular disease is the leading cause of women’s death in the United States, accounting for 1 in every 5 female deaths per year according to the Centers for Disease Control and Prevention. Most risk factors for cardiovascular disease are modifiable. With a disease so prevalent in women’s health, obstetricians and gynecologists can assist patients in modifying these risk factors. This, however, is easier said than done.

One of the rate-limiting steps in assisting patients is the process of identifying an individual’s risk factors. This can be a time-consuming task in a women’s health appointment that is already busy with ObGyn-specific concerns, but technology can assist us.

Cardiovascular health app considerations

Many smartphone applications and websites are available that can alleviate the time constraints for identifying these individual modifiable risk factors. When evaluating cardiovascular risk factor apps for patients, keep these qualities (as outlined in the ACOG-recommended rubric) in mind: design, functionality, usefulness, and accuracy.

The patient-centered resources that assist women in identifying cardiovascular risk factors and that provide tools to positively impact these risk factors through lifestyle changes can help women achieve improved cardiovascular health. Recommendations include 1) manage blood pressure, 2) control cholesterol, 3) reduce blood sugar, 4) get active, 5) eat better, 6) lose weight, and 7) stop smoking.

National organizations’ smartphone apps guide the patient through a handful of questions about their current lifestyle, gender, age, and basic laboratory values. Their individual “heart health” results of these questions distribute the 7 risk factors to 3 categories based on the need to focus, improve, or celebrate. Through nonthreatening videos, patients can improve their scores themselves and bring the areas they need to focus, or improve, to their ObGyn’s attention for further assistance.

While adding one more task to an already busy practice can seem daunting, there are great technology resources that can be leveraged to successfully address this important health metric. By using the ACOG-recommended rubric and focusing on the app characteristics identified above, you can find one that works best for you and your patients and incorporate it into your practice today. ●

Cardiovascular disease is the leading cause of women’s death in the United States, accounting for 1 in every 5 female deaths per year according to the Centers for Disease Control and Prevention. Most risk factors for cardiovascular disease are modifiable. With a disease so prevalent in women’s health, obstetricians and gynecologists can assist patients in modifying these risk factors. This, however, is easier said than done.

One of the rate-limiting steps in assisting patients is the process of identifying an individual’s risk factors. This can be a time-consuming task in a women’s health appointment that is already busy with ObGyn-specific concerns, but technology can assist us.

Cardiovascular health app considerations

Many smartphone applications and websites are available that can alleviate the time constraints for identifying these individual modifiable risk factors. When evaluating cardiovascular risk factor apps for patients, keep these qualities (as outlined in the ACOG-recommended rubric) in mind: design, functionality, usefulness, and accuracy.

The patient-centered resources that assist women in identifying cardiovascular risk factors and that provide tools to positively impact these risk factors through lifestyle changes can help women achieve improved cardiovascular health. Recommendations include 1) manage blood pressure, 2) control cholesterol, 3) reduce blood sugar, 4) get active, 5) eat better, 6) lose weight, and 7) stop smoking.

National organizations’ smartphone apps guide the patient through a handful of questions about their current lifestyle, gender, age, and basic laboratory values. Their individual “heart health” results of these questions distribute the 7 risk factors to 3 categories based on the need to focus, improve, or celebrate. Through nonthreatening videos, patients can improve their scores themselves and bring the areas they need to focus, or improve, to their ObGyn’s attention for further assistance.

While adding one more task to an already busy practice can seem daunting, there are great technology resources that can be leveraged to successfully address this important health metric. By using the ACOG-recommended rubric and focusing on the app characteristics identified above, you can find one that works best for you and your patients and incorporate it into your practice today. ●

Diabetes mellitus affects 10% of the US population, and as many as one-third of US adults have prediabetes, according to the National Diabetes Statistics Report 2020 from the Centers for Disease Control and Prevention. While diabetes is associated with significant long-term morbidity and mortality, with early identification and interventions, lifestyle modifications can significantly improve long-term health.

As with obesity (see “Focus on obesity” in OBG Management, May 2021), it is difficult to address lifestyle modifications with patients who have diabetes. However, many apps can be leveraged to aid physicians in this effort.

Diabetes app considerations

Obstetrician-gynecologists can play a pivotal role in helping to screen women for diabetes. When applying the ACOG-recommended rubric to evaluate the quality of an app that is targeted to address screening and diagnosing diabetes, it’s important to consider the app’s timeliness, authority, usefulness, and design.

There are point-of-care apps that include a few simple questions that can quickly identify which women should be screened. Some apps combine screening questions with testing results to streamline screening and diagnosis of diabetes and prediabetes. These apps also provide clinical content to help physicians educate, initiate, and even treat diabetes if they desire.

A wealth of patient-centered apps are available to help patients address a diagnosis of diabetes. Apps that provide real-time feedback, motivational features to engage the user, and links to nutritional, fitness, and diabetic goals provide a woman with a comprehensive and personalized experience that can considerably improve health.

By incorporating apps and engaging with our patients on app technology, ObGyns can successfully partner with women to decrease morbidity with respect to diabetes mellitus and its long-term implications. ●

Diabetes mellitus affects 10% of the US population, and as many as one-third of US adults have prediabetes, according to the National Diabetes Statistics Report 2020 from the Centers for Disease Control and Prevention. While diabetes is associated with significant long-term morbidity and mortality, with early identification and interventions, lifestyle modifications can significantly improve long-term health.

As with obesity (see “Focus on obesity” in OBG Management, May 2021), it is difficult to address lifestyle modifications with patients who have diabetes. However, many apps can be leveraged to aid physicians in this effort.

Diabetes app considerations

Obstetrician-gynecologists can play a pivotal role in helping to screen women for diabetes. When applying the ACOG-recommended rubric to evaluate the quality of an app that is targeted to address screening and diagnosing diabetes, it’s important to consider the app’s timeliness, authority, usefulness, and design.

There are point-of-care apps that include a few simple questions that can quickly identify which women should be screened. Some apps combine screening questions with testing results to streamline screening and diagnosis of diabetes and prediabetes. These apps also provide clinical content to help physicians educate, initiate, and even treat diabetes if they desire.

A wealth of patient-centered apps are available to help patients address a diagnosis of diabetes. Apps that provide real-time feedback, motivational features to engage the user, and links to nutritional, fitness, and diabetic goals provide a woman with a comprehensive and personalized experience that can considerably improve health.

By incorporating apps and engaging with our patients on app technology, ObGyns can successfully partner with women to decrease morbidity with respect to diabetes mellitus and its long-term implications. ●

Diabetes mellitus affects 10% of the US population, and as many as one-third of US adults have prediabetes, according to the National Diabetes Statistics Report 2020 from the Centers for Disease Control and Prevention. While diabetes is associated with significant long-term morbidity and mortality, with early identification and interventions, lifestyle modifications can significantly improve long-term health.

As with obesity (see “Focus on obesity” in OBG Management, May 2021), it is difficult to address lifestyle modifications with patients who have diabetes. However, many apps can be leveraged to aid physicians in this effort.

Diabetes app considerations

Obstetrician-gynecologists can play a pivotal role in helping to screen women for diabetes. When applying the ACOG-recommended rubric to evaluate the quality of an app that is targeted to address screening and diagnosing diabetes, it’s important to consider the app’s timeliness, authority, usefulness, and design.

There are point-of-care apps that include a few simple questions that can quickly identify which women should be screened. Some apps combine screening questions with testing results to streamline screening and diagnosis of diabetes and prediabetes. These apps also provide clinical content to help physicians educate, initiate, and even treat diabetes if they desire.

A wealth of patient-centered apps are available to help patients address a diagnosis of diabetes. Apps that provide real-time feedback, motivational features to engage the user, and links to nutritional, fitness, and diabetic goals provide a woman with a comprehensive and personalized experience that can considerably improve health.

By incorporating apps and engaging with our patients on app technology, ObGyns can successfully partner with women to decrease morbidity with respect to diabetes mellitus and its long-term implications. ●

Among the studies we review in this Update are a follow-up of the US Women’s Health Initiative clinical trials and a large observational study from the United Kingdom, which exlore the impact of different hormone therapies (HTs) on breast cancer risk. We look at the interesting patterns found by authors of a study in Canada that analyzed predictors of unnecessary bilateral salpingo-oophorectomy. In addition, we review a study that investigates whether hormone therapy can be effective, alone or adjunctively, in peri- and postmenopausal women with depression. Finally, Dr. Chrisandra Shufelt and Dr. JoAnn Manson summarize highlights from the recent American Heart Association’s scientific statement on the menopause transition and increasing risk factors for cardiovascular disease, and how this period can be viewed as an opportunity to encourage healthy, cardiovascular risk–reducing behaviors.

Studies clarify menopausal HT’s impact on breast cancer risk

Chlebowski RT, Anderson GL, Aragaki AK, et al. Association of menopausal hormone therapy with breast cancer incidence and mortality during long-term follow-up of the Women’s Health Initiative randomized clinical trials. JAMA. 2020;324:369-380. doi: 10.1001/jama.2020.9482.

Vinogradova Y, Coupland C, Hippisley-Cox J. Use of hormone replacement therapy and risk of breast cancer: nested case-control studies using the QResearch and CPRD databases. BMJ. 2020;371:m3873. doi: 10.1136/bmj.m3873.

For many menopausal women, the most worrisome concern related to the use of HT is that it might increase breast cancer risk. In the summer and fall of 2020, 2 important articles were published that addressed how the use of menopausal HT impacts the risk of breast cancer.

The Women’s Health Initiative (WHI) represents the largest and longest-term randomized trial assessing the health impacts of systemic HT. A 2013 WHI report found that with a median of 13 years’ cumulative follow-up, estrogen-only HT (ET) reduced the risk for breast cancer while estrogen-progestin therapy (EPT) increased the risk.¹ In a July 2020 issue of JAMA, WHI investigators analyzed longer-term data (cumulative median follow-up >20 years), which allowed assessment of whether these trends (breast cancer incidence) persisted and if they led to changes in mortality from breast cancer.²

WHI data on breast cancer risk trends in ET vs EPT users

In the ET trial, in which Chlebowski and colleagues studied 10,739 women with prior hysterectomy, 238 versus 296 new cases of breast cancer were diagnosed in women in the ET versus placebo groups, respectively (annualized incidence, 0.30% [ET] vs 0.37% [placebo]; hazard ratio [HR], 0.78; P = .005). ET also was associated with significantly lower mortality from breast cancer: 30 versus 46 deaths (annualized mortality, 0.031% [ET] vs 0.046% [placebo]; HR, 0.60; P = 0.04).

In the EPT trial, which included 16,608 participants with an intact uterus, EPT compared with placebo was associated with significantly elevated risk for incident breast cancer: 584 versus 447 new cases, respectively (annualized incidence, 0.45% [EPT] vs 0.36% [placebo]; HR, 1.28; P<.001). However, mortality from breast cancer was similar in the EPT and placebo groups: 71 and 53 deaths (annualized mortality, 0.045% [EPT] and 0.035% [placebo]; HR, 1.35; P = .11).²

For women with previous hysterectomy who are considering initiating or continuing ET for treatment of bothersome menopausal symptoms, the breast cancer mortality benefit documented in this long-term WHI analysis could, as editorialists point out, “tip the scales” in favor of ET.³ Furthermore, the mortality benefit raises the possibility that ET could be evaluated as a risk-reduction strategy for selected high-risk menopausal women who have undergone hysterectomy. Although tamoxifen and aromatase inhibitors are approved for breast cancer chemoprophylaxis in high-risk menopausal women, these agents have not been found to lower breast cancer mortality.²

UK data analysis and risk for breast cancer in HT users

In an October 2020 issue of BMJ, Vinogradova and colleagues described their analysis of 2 primary care databases in the United Kingdom that in aggregate included roughly 99,000 women with breast cancer diagnosed between 1998 and 2018 (age range, 50–79; mean age at diagnosis, 63; >95% White); these were matched with more than 450,000 women without breast cancer (controls).⁴ Analyses were adjusted for smoking, body mass index (BMI), ethnicity, and mammography.

In this study, ever-use of EPT was associated with an adjusted odds ratio (OR) for breast cancer of 1.26 (95% confidence interval [CI], 1.24–1.29), while ET had an OR of 1.06 (95% CI, 1.03–1.10). In women aged 50 to 59 who used EPT for 5 years or more, 15 additional breast cancers were diagnosed per 10,000 woman-years; for ET users, the attributable risk was 3. Although risk rose with longer HT duration, this trend was less evident with ET than EPT.

In addition, the increased risk associated with ET use was less pronounced in women with a BMI greater than 30 kg/m². Among EPT users, risks were similar with the progestins medroxyprogesterone acetate (MPA), norethindrone (NET), and levonorgestrel (LNG). Likewise, risks were similar regardless of estrogen dose and route of administration (that is, oral vs transdermal). Vaginal estrogen was not associated with a higher or lower risk for breast cancer. Among past users of ET or EPT (with MPA), no increased risk was noted 5 years or more after stopping HT. For users of EPT (with NET or LNG), risks diminished 5 years or more after stopping HT but remained modestly elevated compared with risk in never-users.⁴

In this large observational UK study, ET was associated with minimally elevated risk for breast cancer, while in the WHI study, ET reduced the risk for breast cancer. For EPT, the excess risk in both studies was identical. As the authors note, mean BMI in the UK study participants was slightly lower than that in the WHI participants, a distinction that might explain the differing findings with ET use.

Continue to: Frequency of nonindicated BSO at the time of hysterectomy in pre- and perimenopausal women...

Frequency of nonindicated BSO at the time of hysterectomy in pre- and perimenopausal women

Wong J, Murji A, Sunderji Z, et al. Unnecessary bilateral salpingo-oophorectomy at the time of hysterectomy and potential for ovarian preservation. Menopause. 2020;28:8-11. doi: 10.1097/GME.0000000000001652.

While prevention of ovarian cancer is an important benefit of bilateral salpingo-oophorectomy (BSO), performing a BSO at the time of hysterectomy in pre- or perimenopausal patients not only will induce surgical menopause but also is associated with significantly increased overall mortality and an increased risk of mortality due to cardiovascular disease in patients younger than age 45.^5,6 Earlier BSO also has been associated with diabetes, accelerated bone density loss, sexual dysfunction, mood disorders, and decreased cognitive function.⁷

BSO at hysterectomy: How many procedures are not indicated?

To evaluate the prevalence and predictors of unnecessary BSO at the time of hysterectomy, Wong and colleagues conducted a multicenter retrospective review of hysterectomy procedures completed at 6 Canadian hospitals.⁸ Criteria for unnecessary BSO included age younger than 51 years; benign preoperative diagnosis (other than endometriosis, premenstrual dysphoric disorder, and gender dysphoria); and absence of endometriosis and pelvic adhesions.

A total of 2,656 hysterectomies were performed by 75 surgeons (28 fellowship trained and 47 generalists) across 3 community and 3 tertiary care hospitals between 2016 and 2018. At the time of hysterectomy, 749 patients (28%) underwent BSO. Of these, 509 women (68%) had at least 1 indication for concurrent BSO based on preoperative diagnosis.

Key study findings. Concurrent BSO procedures performed at academic hospitals were more likely to have a preoperative indication compared with BSO performed at community sites (70% vs 63%; OR, 1.42; 95% CI, 1.02–1.97; P = .04). BSO was more likely to be indicated when performed by fellowship-trained surgeons compared with surgeries performed by generalist surgeons (75% vs 63%; OR, 1.76; 95% CI, 1.26–2.44, P = .001). BSO procedures performed with vaginal hysterectomy were less likely to be indicated (3 of 20, 15%) when compared with open hysterectomy (74 of 154, 48%) and laparoscopic hysterectomy (432 of 575, 75%).

Of the patients who lacked a preoperative indication for concomitant BSO, 105 of 239 (43.9%) were younger than age 51. Overall, 8% (59 of 749) of patients in the study cohort had an unnecessary BSO based on a combination of preoperative diagnosis, age younger than age 51, and intraoperative factors including absence of endometriosis and adhesions.

Continue to: HT for menopausal depression: Which patients may benefit?

HT for menopausal depression: Which patients may benefit?

Dwyer JB, Aftab A, Radhakrishnan R, et al; APA Council of Research Task Force on Novel Biomarkers and Treatments. Hormonal treatments for major depressive disorder: state of the art. Am J Psychiatry. 2020;177:686- 705. doi:10.1176/appi.ajp.2020.19080848.

The cumulative lifetime prevalence of major depression in US women is 21%.9 An increased risk of mood symptoms and major depressive disorder occurs with the cessation of ovarian hormone production during menopause. In a review of both physiology and clinical studies, an American Psychiatric Association task force found support for several hormone-related strategies for treating depression and highlighted the rapidly advancing, but mixed, findings in this field.¹⁰

Clinical trials that examined mood in peri- and postmenopausal women treated with HT have produced mixed results for a variety of reasons, including differences in psychiatric symptomatology across studies and differences in treatment timing in relation to menopause onset.

HT effectiveness for depression depends on menopausal status

Five studies included in a meta-analysis by Rubinow and colleagues examined the use of ET and EPT as antidepressant monotherapy in peri- or postmenopausal women with major depression.¹¹ Of the 3 higher-quality studies, 2 conducted in perimenopausal women demonstrated the antidepressant efficacy of transdermal estrogen patches compared with placebo. The third study included a mixed population of both peri- and postmenopausal women, and it found that increased estradiol levels (spontaneously occurring or due to ET) were associated with improvement in depression in perimenopausal women but not in postmenopausal women.¹¹

ET also has been investigated as a potential adjunctive treatment to selective serotonin reuptake inhibitors (SSRIs). In a retrospective analysis of a multicenter randomized controlled trial of fluoxetine in patients with depression, women who received ET and fluoxetine demonstrated a greater improvement than those who received fluoxetine monotherapy.¹² One small study that prospectively assessed ET in combination with an antidepressant in postmenopausal women demonstrated no benefit of ET in treating depression.¹³ Another small trial found that while combining transdermal ET with an SSRI accelerated symptom improvement, by the end of the 10-week study, treatment efficacy in the HT plus SSRI group was no greater than that observed in the SSRI-only group.¹⁴

Nineteen studies included in the metaanalysis by Rubinow and colleagues, which examined mood after ET or EPT treatment in nondepressed women, found little evidence of benefit, particularly in women without other physical symptoms of menopause.¹¹

The Kronos Early Estrogen Prevention Study (KEEPS) followed 661 women who received either oral estrogen plus progesterone, transdermal estrogen plus progesterone, or placebo over 4 years.¹⁵ Women with clinical depression were excluded from the study; however, women with mild to moderate mood symptoms who were being treated with an antidepressant were included. Improvements in depressive symptoms and anxiety were observed only in the oral estrogen plus progesterone group compared with the placebo group.¹⁵

In a study of 172 euthymic peri- and postmenopausal women treated for 12 months with transdermal estrogen plus oral progesterone, investigators found that, unlike postmenopausal women and those in the late perimenopausal transition, only women in the early perimenopausal transition had a lower risk of developing depressive symptoms.¹⁶

Bottom line

This complex literature suggests that ET/HT interventions are most likely to be successful when implemented early in the menopausal transition. The clearest indication for the use of HT is for perimenopausal women experiencing depression who are also experiencing menopausal symptoms (for example, bothersome hot flashes). There is little evidence that the use of ET/HT in late perimenopausal or postmenopausal women effectively treats depression; accordingly, HT is not recommended for the treatment of mood disorders in this population. The more ambiguous cases are those of perimenopausal women who are depressed but do not have classic vasomotor symptoms; some evidence supports the antidepressant efficacy of HT in this setting.¹¹ Although some studies suggest that HT can be effective in preventing depression in perimenopausal women, more evidence is needed.¹⁶

 

The menopause transition: A key period for strategizing CVD risk factor reduction

---

Chrisandra L. Shufelt, MD, MS, NCMP

Dr. Shufelt is Associate Director of the Barbra
Streisand Women’s Heart Center, Smidt
Heart Institute, Cedars-Sinai Medical Center,
Los Angeles, California.

JoAnn E. Manson, MD, DrPH, NCMP

Dr. Manson is Professor of Medicine and the
Michael and Lee Bell Professor of Women’s
Health at Harvard Medical School; Professor
in the Department of Epidemiology, Harvard
T.H. Chan School of Public Health; and Chief
of the Division of Preventive Medicine
at Brigham and Women’s Hospital, Boston,
Massachusetts.

The authors report no financial relationships relevant to this article. Dr. Manson is a coauthor of the AHA Scientific Statement discussed in this article.

In the United States, nearly one-half of a woman’s life, on average, will be lived after menopause. For women with natural menopause, the menopause transition (MT) can begin 2 to 7 years before and may extend 1 year past the final menstrual period, which occurs at an average age of 51 years. For women with surgical menopause, the MT occurs abruptly with the sudden loss of endogenous ovarian hormones. Both types of transitions mark a critical time period when reproduction and endogenous sex hormone levels diminish and when cardiovascular disease (CVD) risk factors begin to rise.

The 2020 American Heart Association (AHA) scientific statement, “Menopause transition and cardiovascular disease risk: Implications for timing of early prevention,” highlights the MT as a window of opportunity for CVD prevention.¹

CVD risk factors associated with ovarian aging

In the AHA scientific statement, data from several longitudinal women’s health studies were used to identify which CVD risk factor changes during the MT are related to ovarian aging as opposed to chronologic aging. Independent of aging, those associated with reproductive or ovarian aging included an increase in serum total cholesterol, low-density lipoprotein cholesterol (LDL-C), and apolipoprotein B. Changes in high-density lipoprotein cholesterol (HDL-C) particles and function also occur during the MT, which may explain why higher HDL-C levels during the MT and the postmenopausal years are not as cardioprotective as during the premenopausal period.

Changes in body composition and adipose tissue distribution also are associated with ovarian aging, with reduction in muscle mass and lean body mass and an increase in abdominal/visceral fat and subcutaneous adipose tissue. Although these body composition changes reflect ovarian aging, midlife weight gain is more closely related to chronologic aging.

The risk of the metabolic syndrome constellation of risk factors was found to be more closely associated with ovarian aging, whereas changes in blood pressure, insulin, and glucose individually tracked more closely with chronologic aging. Additionally, the AHA statement notes the research that identified several symptoms during the MT—including vasomotor symptoms, sleep disturbance, and depression—as being associated with more adverse CVD risk factor status and with subclinical measures of atherosclerosis. Additional research on the mechanistic basis for these associations is needed.

Chronologic age and type of menopause

Notably, a woman’s age and type of menopause matter with respect to CVD risk. Higher CVD risk is seen in women with premature onset (age < 40 years) or early onset (age < 45 years) of menopause and in women undergoing surgical menopause (bilateral oophorectomy) before age 45. In general, menopausal hormone therapy (HT) is recommended for women with premature or early menopause, whether natural or surgical, with continuation through at least the average age of natural menopause. In other women, although not recommended for the express purpose of CVD prevention, menopausal HT is appropriate for the treatment of bothersome vasomotor or other menopausal symptoms, especially when therapy is started before age 60 or within 10 years of menopause among women who are not at elevated risk of CVD.

While the AHA statement suggests that some women who begin estrogen early in menopause may experience reduced coronary heart disease risk, major research gaps remain with regard to HT dose, formulation, route of delivery, and recommended duration of treatment.

An opportunity to promote healthy lifestyle behaviors

Translating the AHA’s first-of-its-kind scientific statement into clinical practice requires recognition and awareness of the MT as a unique phase in a woman’s life associated with myriad changes in CVD risk factors. The statement underscores that the MT is an important time to target behavioral changes to promote CVD risk reduction, including lifestyle modifications in the AHA’s Life’s Simple 7 components (increased physical activity, smoking cessation, healthy diet, avoidance of weight gain) as well as vigilant control of blood pressure, cholesterol, and glucose levels. The MT is truly a window of opportunity for reinvigorated efforts to lower women’s CVD risk. ●

Reference

1. El Khoudary SR, Aggarwal B, Beckie TM, et al; American Heart Association Prevention Science Committee of the Council on Epidemiology and Prevention; and Council on Cardiovascular and Stroke Nursing. Menopause transition and cardiovascular disease risk: implications for timing of early prevention: a scientific statement from the American Heart Association. Circulation. 2020;142:e506-e532. doi: 10.1161/CIR.000000000000912.

Among the studies we review in this Update are a follow-up of the US Women’s Health Initiative clinical trials and a large observational study from the United Kingdom, which exlore the impact of different hormone therapies (HTs) on breast cancer risk. We look at the interesting patterns found by authors of a study in Canada that analyzed predictors of unnecessary bilateral salpingo-oophorectomy. In addition, we review a study that investigates whether hormone therapy can be effective, alone or adjunctively, in peri- and postmenopausal women with depression. Finally, Dr. Chrisandra Shufelt and Dr. JoAnn Manson summarize highlights from the recent American Heart Association’s scientific statement on the menopause transition and increasing risk factors for cardiovascular disease, and how this period can be viewed as an opportunity to encourage healthy, cardiovascular risk–reducing behaviors.

Studies clarify menopausal HT’s impact on breast cancer risk

Chlebowski RT, Anderson GL, Aragaki AK, et al. Association of menopausal hormone therapy with breast cancer incidence and mortality during long-term follow-up of the Women’s Health Initiative randomized clinical trials. JAMA. 2020;324:369-380. doi: 10.1001/jama.2020.9482.

Vinogradova Y, Coupland C, Hippisley-Cox J. Use of hormone replacement therapy and risk of breast cancer: nested case-control studies using the QResearch and CPRD databases. BMJ. 2020;371:m3873. doi: 10.1136/bmj.m3873.

For many menopausal women, the most worrisome concern related to the use of HT is that it might increase breast cancer risk. In the summer and fall of 2020, 2 important articles were published that addressed how the use of menopausal HT impacts the risk of breast cancer.

The Women’s Health Initiative (WHI) represents the largest and longest-term randomized trial assessing the health impacts of systemic HT. A 2013 WHI report found that with a median of 13 years’ cumulative follow-up, estrogen-only HT (ET) reduced the risk for breast cancer while estrogen-progestin therapy (EPT) increased the risk.¹ In a July 2020 issue of JAMA, WHI investigators analyzed longer-term data (cumulative median follow-up >20 years), which allowed assessment of whether these trends (breast cancer incidence) persisted and if they led to changes in mortality from breast cancer.²

WHI data on breast cancer risk trends in ET vs EPT users

In the ET trial, in which Chlebowski and colleagues studied 10,739 women with prior hysterectomy, 238 versus 296 new cases of breast cancer were diagnosed in women in the ET versus placebo groups, respectively (annualized incidence, 0.30% [ET] vs 0.37% [placebo]; hazard ratio [HR], 0.78; P = .005). ET also was associated with significantly lower mortality from breast cancer: 30 versus 46 deaths (annualized mortality, 0.031% [ET] vs 0.046% [placebo]; HR, 0.60; P = 0.04).

In the EPT trial, which included 16,608 participants with an intact uterus, EPT compared with placebo was associated with significantly elevated risk for incident breast cancer: 584 versus 447 new cases, respectively (annualized incidence, 0.45% [EPT] vs 0.36% [placebo]; HR, 1.28; P<.001). However, mortality from breast cancer was similar in the EPT and placebo groups: 71 and 53 deaths (annualized mortality, 0.045% [EPT] and 0.035% [placebo]; HR, 1.35; P = .11).²

For women with previous hysterectomy who are considering initiating or continuing ET for treatment of bothersome menopausal symptoms, the breast cancer mortality benefit documented in this long-term WHI analysis could, as editorialists point out, “tip the scales” in favor of ET.³ Furthermore, the mortality benefit raises the possibility that ET could be evaluated as a risk-reduction strategy for selected high-risk menopausal women who have undergone hysterectomy. Although tamoxifen and aromatase inhibitors are approved for breast cancer chemoprophylaxis in high-risk menopausal women, these agents have not been found to lower breast cancer mortality.²

UK data analysis and risk for breast cancer in HT users

In an October 2020 issue of BMJ, Vinogradova and colleagues described their analysis of 2 primary care databases in the United Kingdom that in aggregate included roughly 99,000 women with breast cancer diagnosed between 1998 and 2018 (age range, 50–79; mean age at diagnosis, 63; >95% White); these were matched with more than 450,000 women without breast cancer (controls).⁴ Analyses were adjusted for smoking, body mass index (BMI), ethnicity, and mammography.

In this study, ever-use of EPT was associated with an adjusted odds ratio (OR) for breast cancer of 1.26 (95% confidence interval [CI], 1.24–1.29), while ET had an OR of 1.06 (95% CI, 1.03–1.10). In women aged 50 to 59 who used EPT for 5 years or more, 15 additional breast cancers were diagnosed per 10,000 woman-years; for ET users, the attributable risk was 3. Although risk rose with longer HT duration, this trend was less evident with ET than EPT.

In addition, the increased risk associated with ET use was less pronounced in women with a BMI greater than 30 kg/m². Among EPT users, risks were similar with the progestins medroxyprogesterone acetate (MPA), norethindrone (NET), and levonorgestrel (LNG). Likewise, risks were similar regardless of estrogen dose and route of administration (that is, oral vs transdermal). Vaginal estrogen was not associated with a higher or lower risk for breast cancer. Among past users of ET or EPT (with MPA), no increased risk was noted 5 years or more after stopping HT. For users of EPT (with NET or LNG), risks diminished 5 years or more after stopping HT but remained modestly elevated compared with risk in never-users.⁴

In this large observational UK study, ET was associated with minimally elevated risk for breast cancer, while in the WHI study, ET reduced the risk for breast cancer. For EPT, the excess risk in both studies was identical. As the authors note, mean BMI in the UK study participants was slightly lower than that in the WHI participants, a distinction that might explain the differing findings with ET use.

Continue to: Frequency of nonindicated BSO at the time of hysterectomy in pre- and perimenopausal women...

Frequency of nonindicated BSO at the time of hysterectomy in pre- and perimenopausal women

Wong J, Murji A, Sunderji Z, et al. Unnecessary bilateral salpingo-oophorectomy at the time of hysterectomy and potential for ovarian preservation. Menopause. 2020;28:8-11. doi: 10.1097/GME.0000000000001652.

While prevention of ovarian cancer is an important benefit of bilateral salpingo-oophorectomy (BSO), performing a BSO at the time of hysterectomy in pre- or perimenopausal patients not only will induce surgical menopause but also is associated with significantly increased overall mortality and an increased risk of mortality due to cardiovascular disease in patients younger than age 45.^5,6 Earlier BSO also has been associated with diabetes, accelerated bone density loss, sexual dysfunction, mood disorders, and decreased cognitive function.⁷

BSO at hysterectomy: How many procedures are not indicated?

To evaluate the prevalence and predictors of unnecessary BSO at the time of hysterectomy, Wong and colleagues conducted a multicenter retrospective review of hysterectomy procedures completed at 6 Canadian hospitals.⁸ Criteria for unnecessary BSO included age younger than 51 years; benign preoperative diagnosis (other than endometriosis, premenstrual dysphoric disorder, and gender dysphoria); and absence of endometriosis and pelvic adhesions.

A total of 2,656 hysterectomies were performed by 75 surgeons (28 fellowship trained and 47 generalists) across 3 community and 3 tertiary care hospitals between 2016 and 2018. At the time of hysterectomy, 749 patients (28%) underwent BSO. Of these, 509 women (68%) had at least 1 indication for concurrent BSO based on preoperative diagnosis.

Key study findings. Concurrent BSO procedures performed at academic hospitals were more likely to have a preoperative indication compared with BSO performed at community sites (70% vs 63%; OR, 1.42; 95% CI, 1.02–1.97; P = .04). BSO was more likely to be indicated when performed by fellowship-trained surgeons compared with surgeries performed by generalist surgeons (75% vs 63%; OR, 1.76; 95% CI, 1.26–2.44, P = .001). BSO procedures performed with vaginal hysterectomy were less likely to be indicated (3 of 20, 15%) when compared with open hysterectomy (74 of 154, 48%) and laparoscopic hysterectomy (432 of 575, 75%).

Of the patients who lacked a preoperative indication for concomitant BSO, 105 of 239 (43.9%) were younger than age 51. Overall, 8% (59 of 749) of patients in the study cohort had an unnecessary BSO based on a combination of preoperative diagnosis, age younger than age 51, and intraoperative factors including absence of endometriosis and adhesions.

Continue to: HT for menopausal depression: Which patients may benefit?

HT for menopausal depression: Which patients may benefit?

Dwyer JB, Aftab A, Radhakrishnan R, et al; APA Council of Research Task Force on Novel Biomarkers and Treatments. Hormonal treatments for major depressive disorder: state of the art. Am J Psychiatry. 2020;177:686- 705. doi:10.1176/appi.ajp.2020.19080848.

The cumulative lifetime prevalence of major depression in US women is 21%.9 An increased risk of mood symptoms and major depressive disorder occurs with the cessation of ovarian hormone production during menopause. In a review of both physiology and clinical studies, an American Psychiatric Association task force found support for several hormone-related strategies for treating depression and highlighted the rapidly advancing, but mixed, findings in this field.¹⁰

Clinical trials that examined mood in peri- and postmenopausal women treated with HT have produced mixed results for a variety of reasons, including differences in psychiatric symptomatology across studies and differences in treatment timing in relation to menopause onset.

HT effectiveness for depression depends on menopausal status

Five studies included in a meta-analysis by Rubinow and colleagues examined the use of ET and EPT as antidepressant monotherapy in peri- or postmenopausal women with major depression.¹¹ Of the 3 higher-quality studies, 2 conducted in perimenopausal women demonstrated the antidepressant efficacy of transdermal estrogen patches compared with placebo. The third study included a mixed population of both peri- and postmenopausal women, and it found that increased estradiol levels (spontaneously occurring or due to ET) were associated with improvement in depression in perimenopausal women but not in postmenopausal women.¹¹

ET also has been investigated as a potential adjunctive treatment to selective serotonin reuptake inhibitors (SSRIs). In a retrospective analysis of a multicenter randomized controlled trial of fluoxetine in patients with depression, women who received ET and fluoxetine demonstrated a greater improvement than those who received fluoxetine monotherapy.¹² One small study that prospectively assessed ET in combination with an antidepressant in postmenopausal women demonstrated no benefit of ET in treating depression.¹³ Another small trial found that while combining transdermal ET with an SSRI accelerated symptom improvement, by the end of the 10-week study, treatment efficacy in the HT plus SSRI group was no greater than that observed in the SSRI-only group.¹⁴

Nineteen studies included in the metaanalysis by Rubinow and colleagues, which examined mood after ET or EPT treatment in nondepressed women, found little evidence of benefit, particularly in women without other physical symptoms of menopause.¹¹

The Kronos Early Estrogen Prevention Study (KEEPS) followed 661 women who received either oral estrogen plus progesterone, transdermal estrogen plus progesterone, or placebo over 4 years.¹⁵ Women with clinical depression were excluded from the study; however, women with mild to moderate mood symptoms who were being treated with an antidepressant were included. Improvements in depressive symptoms and anxiety were observed only in the oral estrogen plus progesterone group compared with the placebo group.¹⁵

In a study of 172 euthymic peri- and postmenopausal women treated for 12 months with transdermal estrogen plus oral progesterone, investigators found that, unlike postmenopausal women and those in the late perimenopausal transition, only women in the early perimenopausal transition had a lower risk of developing depressive symptoms.¹⁶

Bottom line

This complex literature suggests that ET/HT interventions are most likely to be successful when implemented early in the menopausal transition. The clearest indication for the use of HT is for perimenopausal women experiencing depression who are also experiencing menopausal symptoms (for example, bothersome hot flashes). There is little evidence that the use of ET/HT in late perimenopausal or postmenopausal women effectively treats depression; accordingly, HT is not recommended for the treatment of mood disorders in this population. The more ambiguous cases are those of perimenopausal women who are depressed but do not have classic vasomotor symptoms; some evidence supports the antidepressant efficacy of HT in this setting.¹¹ Although some studies suggest that HT can be effective in preventing depression in perimenopausal women, more evidence is needed.¹⁶

 

The menopause transition: A key period for strategizing CVD risk factor reduction

---

Chrisandra L. Shufelt, MD, MS, NCMP

Dr. Shufelt is Associate Director of the Barbra
Streisand Women’s Heart Center, Smidt
Heart Institute, Cedars-Sinai Medical Center,
Los Angeles, California.

JoAnn E. Manson, MD, DrPH, NCMP

Dr. Manson is Professor of Medicine and the
Michael and Lee Bell Professor of Women’s
Health at Harvard Medical School; Professor
in the Department of Epidemiology, Harvard
T.H. Chan School of Public Health; and Chief
of the Division of Preventive Medicine
at Brigham and Women’s Hospital, Boston,
Massachusetts.

The authors report no financial relationships relevant to this article. Dr. Manson is a coauthor of the AHA Scientific Statement discussed in this article.

In the United States, nearly one-half of a woman’s life, on average, will be lived after menopause. For women with natural menopause, the menopause transition (MT) can begin 2 to 7 years before and may extend 1 year past the final menstrual period, which occurs at an average age of 51 years. For women with surgical menopause, the MT occurs abruptly with the sudden loss of endogenous ovarian hormones. Both types of transitions mark a critical time period when reproduction and endogenous sex hormone levels diminish and when cardiovascular disease (CVD) risk factors begin to rise.

The 2020 American Heart Association (AHA) scientific statement, “Menopause transition and cardiovascular disease risk: Implications for timing of early prevention,” highlights the MT as a window of opportunity for CVD prevention.¹

CVD risk factors associated with ovarian aging

In the AHA scientific statement, data from several longitudinal women’s health studies were used to identify which CVD risk factor changes during the MT are related to ovarian aging as opposed to chronologic aging. Independent of aging, those associated with reproductive or ovarian aging included an increase in serum total cholesterol, low-density lipoprotein cholesterol (LDL-C), and apolipoprotein B. Changes in high-density lipoprotein cholesterol (HDL-C) particles and function also occur during the MT, which may explain why higher HDL-C levels during the MT and the postmenopausal years are not as cardioprotective as during the premenopausal period.

Changes in body composition and adipose tissue distribution also are associated with ovarian aging, with reduction in muscle mass and lean body mass and an increase in abdominal/visceral fat and subcutaneous adipose tissue. Although these body composition changes reflect ovarian aging, midlife weight gain is more closely related to chronologic aging.

The risk of the metabolic syndrome constellation of risk factors was found to be more closely associated with ovarian aging, whereas changes in blood pressure, insulin, and glucose individually tracked more closely with chronologic aging. Additionally, the AHA statement notes the research that identified several symptoms during the MT—including vasomotor symptoms, sleep disturbance, and depression—as being associated with more adverse CVD risk factor status and with subclinical measures of atherosclerosis. Additional research on the mechanistic basis for these associations is needed.

Chronologic age and type of menopause

Notably, a woman’s age and type of menopause matter with respect to CVD risk. Higher CVD risk is seen in women with premature onset (age < 40 years) or early onset (age < 45 years) of menopause and in women undergoing surgical menopause (bilateral oophorectomy) before age 45. In general, menopausal hormone therapy (HT) is recommended for women with premature or early menopause, whether natural or surgical, with continuation through at least the average age of natural menopause. In other women, although not recommended for the express purpose of CVD prevention, menopausal HT is appropriate for the treatment of bothersome vasomotor or other menopausal symptoms, especially when therapy is started before age 60 or within 10 years of menopause among women who are not at elevated risk of CVD.

While the AHA statement suggests that some women who begin estrogen early in menopause may experience reduced coronary heart disease risk, major research gaps remain with regard to HT dose, formulation, route of delivery, and recommended duration of treatment.

An opportunity to promote healthy lifestyle behaviors

Translating the AHA’s first-of-its-kind scientific statement into clinical practice requires recognition and awareness of the MT as a unique phase in a woman’s life associated with myriad changes in CVD risk factors. The statement underscores that the MT is an important time to target behavioral changes to promote CVD risk reduction, including lifestyle modifications in the AHA’s Life’s Simple 7 components (increased physical activity, smoking cessation, healthy diet, avoidance of weight gain) as well as vigilant control of blood pressure, cholesterol, and glucose levels. The MT is truly a window of opportunity for reinvigorated efforts to lower women’s CVD risk. ●

Reference

1. El Khoudary SR, Aggarwal B, Beckie TM, et al; American Heart Association Prevention Science Committee of the Council on Epidemiology and Prevention; and Council on Cardiovascular and Stroke Nursing. Menopause transition and cardiovascular disease risk: implications for timing of early prevention: a scientific statement from the American Heart Association. Circulation. 2020;142:e506-e532. doi: 10.1161/CIR.000000000000912.

Among the studies we review in this Update are a follow-up of the US Women’s Health Initiative clinical trials and a large observational study from the United Kingdom, which exlore the impact of different hormone therapies (HTs) on breast cancer risk. We look at the interesting patterns found by authors of a study in Canada that analyzed predictors of unnecessary bilateral salpingo-oophorectomy. In addition, we review a study that investigates whether hormone therapy can be effective, alone or adjunctively, in peri- and postmenopausal women with depression. Finally, Dr. Chrisandra Shufelt and Dr. JoAnn Manson summarize highlights from the recent American Heart Association’s scientific statement on the menopause transition and increasing risk factors for cardiovascular disease, and how this period can be viewed as an opportunity to encourage healthy, cardiovascular risk–reducing behaviors.

Studies clarify menopausal HT’s impact on breast cancer risk

Chlebowski RT, Anderson GL, Aragaki AK, et al. Association of menopausal hormone therapy with breast cancer incidence and mortality during long-term follow-up of the Women’s Health Initiative randomized clinical trials. JAMA. 2020;324:369-380. doi: 10.1001/jama.2020.9482.

Vinogradova Y, Coupland C, Hippisley-Cox J. Use of hormone replacement therapy and risk of breast cancer: nested case-control studies using the QResearch and CPRD databases. BMJ. 2020;371:m3873. doi: 10.1136/bmj.m3873.

For many menopausal women, the most worrisome concern related to the use of HT is that it might increase breast cancer risk. In the summer and fall of 2020, 2 important articles were published that addressed how the use of menopausal HT impacts the risk of breast cancer.

The Women’s Health Initiative (WHI) represents the largest and longest-term randomized trial assessing the health impacts of systemic HT. A 2013 WHI report found that with a median of 13 years’ cumulative follow-up, estrogen-only HT (ET) reduced the risk for breast cancer while estrogen-progestin therapy (EPT) increased the risk.¹ In a July 2020 issue of JAMA, WHI investigators analyzed longer-term data (cumulative median follow-up >20 years), which allowed assessment of whether these trends (breast cancer incidence) persisted and if they led to changes in mortality from breast cancer.²

WHI data on breast cancer risk trends in ET vs EPT users

In the ET trial, in which Chlebowski and colleagues studied 10,739 women with prior hysterectomy, 238 versus 296 new cases of breast cancer were diagnosed in women in the ET versus placebo groups, respectively (annualized incidence, 0.30% [ET] vs 0.37% [placebo]; hazard ratio [HR], 0.78; P = .005). ET also was associated with significantly lower mortality from breast cancer: 30 versus 46 deaths (annualized mortality, 0.031% [ET] vs 0.046% [placebo]; HR, 0.60; P = 0.04).

In the EPT trial, which included 16,608 participants with an intact uterus, EPT compared with placebo was associated with significantly elevated risk for incident breast cancer: 584 versus 447 new cases, respectively (annualized incidence, 0.45% [EPT] vs 0.36% [placebo]; HR, 1.28; P<.001). However, mortality from breast cancer was similar in the EPT and placebo groups: 71 and 53 deaths (annualized mortality, 0.045% [EPT] and 0.035% [placebo]; HR, 1.35; P = .11).²

For women with previous hysterectomy who are considering initiating or continuing ET for treatment of bothersome menopausal symptoms, the breast cancer mortality benefit documented in this long-term WHI analysis could, as editorialists point out, “tip the scales” in favor of ET.³ Furthermore, the mortality benefit raises the possibility that ET could be evaluated as a risk-reduction strategy for selected high-risk menopausal women who have undergone hysterectomy. Although tamoxifen and aromatase inhibitors are approved for breast cancer chemoprophylaxis in high-risk menopausal women, these agents have not been found to lower breast cancer mortality.²

UK data analysis and risk for breast cancer in HT users

In an October 2020 issue of BMJ, Vinogradova and colleagues described their analysis of 2 primary care databases in the United Kingdom that in aggregate included roughly 99,000 women with breast cancer diagnosed between 1998 and 2018 (age range, 50–79; mean age at diagnosis, 63; >95% White); these were matched with more than 450,000 women without breast cancer (controls).⁴ Analyses were adjusted for smoking, body mass index (BMI), ethnicity, and mammography.

In this study, ever-use of EPT was associated with an adjusted odds ratio (OR) for breast cancer of 1.26 (95% confidence interval [CI], 1.24–1.29), while ET had an OR of 1.06 (95% CI, 1.03–1.10). In women aged 50 to 59 who used EPT for 5 years or more, 15 additional breast cancers were diagnosed per 10,000 woman-years; for ET users, the attributable risk was 3. Although risk rose with longer HT duration, this trend was less evident with ET than EPT.

In addition, the increased risk associated with ET use was less pronounced in women with a BMI greater than 30 kg/m². Among EPT users, risks were similar with the progestins medroxyprogesterone acetate (MPA), norethindrone (NET), and levonorgestrel (LNG). Likewise, risks were similar regardless of estrogen dose and route of administration (that is, oral vs transdermal). Vaginal estrogen was not associated with a higher or lower risk for breast cancer. Among past users of ET or EPT (with MPA), no increased risk was noted 5 years or more after stopping HT. For users of EPT (with NET or LNG), risks diminished 5 years or more after stopping HT but remained modestly elevated compared with risk in never-users.⁴

In this large observational UK study, ET was associated with minimally elevated risk for breast cancer, while in the WHI study, ET reduced the risk for breast cancer. For EPT, the excess risk in both studies was identical. As the authors note, mean BMI in the UK study participants was slightly lower than that in the WHI participants, a distinction that might explain the differing findings with ET use.

Continue to: Frequency of nonindicated BSO at the time of hysterectomy in pre- and perimenopausal women...

Frequency of nonindicated BSO at the time of hysterectomy in pre- and perimenopausal women

Wong J, Murji A, Sunderji Z, et al. Unnecessary bilateral salpingo-oophorectomy at the time of hysterectomy and potential for ovarian preservation. Menopause. 2020;28:8-11. doi: 10.1097/GME.0000000000001652.

While prevention of ovarian cancer is an important benefit of bilateral salpingo-oophorectomy (BSO), performing a BSO at the time of hysterectomy in pre- or perimenopausal patients not only will induce surgical menopause but also is associated with significantly increased overall mortality and an increased risk of mortality due to cardiovascular disease in patients younger than age 45.^5,6 Earlier BSO also has been associated with diabetes, accelerated bone density loss, sexual dysfunction, mood disorders, and decreased cognitive function.⁷

BSO at hysterectomy: How many procedures are not indicated?

To evaluate the prevalence and predictors of unnecessary BSO at the time of hysterectomy, Wong and colleagues conducted a multicenter retrospective review of hysterectomy procedures completed at 6 Canadian hospitals.⁸ Criteria for unnecessary BSO included age younger than 51 years; benign preoperative diagnosis (other than endometriosis, premenstrual dysphoric disorder, and gender dysphoria); and absence of endometriosis and pelvic adhesions.

A total of 2,656 hysterectomies were performed by 75 surgeons (28 fellowship trained and 47 generalists) across 3 community and 3 tertiary care hospitals between 2016 and 2018. At the time of hysterectomy, 749 patients (28%) underwent BSO. Of these, 509 women (68%) had at least 1 indication for concurrent BSO based on preoperative diagnosis.

Key study findings. Concurrent BSO procedures performed at academic hospitals were more likely to have a preoperative indication compared with BSO performed at community sites (70% vs 63%; OR, 1.42; 95% CI, 1.02–1.97; P = .04). BSO was more likely to be indicated when performed by fellowship-trained surgeons compared with surgeries performed by generalist surgeons (75% vs 63%; OR, 1.76; 95% CI, 1.26–2.44, P = .001). BSO procedures performed with vaginal hysterectomy were less likely to be indicated (3 of 20, 15%) when compared with open hysterectomy (74 of 154, 48%) and laparoscopic hysterectomy (432 of 575, 75%).

Of the patients who lacked a preoperative indication for concomitant BSO, 105 of 239 (43.9%) were younger than age 51. Overall, 8% (59 of 749) of patients in the study cohort had an unnecessary BSO based on a combination of preoperative diagnosis, age younger than age 51, and intraoperative factors including absence of endometriosis and adhesions.

Continue to: HT for menopausal depression: Which patients may benefit?

HT for menopausal depression: Which patients may benefit?

Dwyer JB, Aftab A, Radhakrishnan R, et al; APA Council of Research Task Force on Novel Biomarkers and Treatments. Hormonal treatments for major depressive disorder: state of the art. Am J Psychiatry. 2020;177:686- 705. doi:10.1176/appi.ajp.2020.19080848.

The cumulative lifetime prevalence of major depression in US women is 21%.9 An increased risk of mood symptoms and major depressive disorder occurs with the cessation of ovarian hormone production during menopause. In a review of both physiology and clinical studies, an American Psychiatric Association task force found support for several hormone-related strategies for treating depression and highlighted the rapidly advancing, but mixed, findings in this field.¹⁰

Clinical trials that examined mood in peri- and postmenopausal women treated with HT have produced mixed results for a variety of reasons, including differences in psychiatric symptomatology across studies and differences in treatment timing in relation to menopause onset.

HT effectiveness for depression depends on menopausal status

Five studies included in a meta-analysis by Rubinow and colleagues examined the use of ET and EPT as antidepressant monotherapy in peri- or postmenopausal women with major depression.¹¹ Of the 3 higher-quality studies, 2 conducted in perimenopausal women demonstrated the antidepressant efficacy of transdermal estrogen patches compared with placebo. The third study included a mixed population of both peri- and postmenopausal women, and it found that increased estradiol levels (spontaneously occurring or due to ET) were associated with improvement in depression in perimenopausal women but not in postmenopausal women.¹¹

ET also has been investigated as a potential adjunctive treatment to selective serotonin reuptake inhibitors (SSRIs). In a retrospective analysis of a multicenter randomized controlled trial of fluoxetine in patients with depression, women who received ET and fluoxetine demonstrated a greater improvement than those who received fluoxetine monotherapy.¹² One small study that prospectively assessed ET in combination with an antidepressant in postmenopausal women demonstrated no benefit of ET in treating depression.¹³ Another small trial found that while combining transdermal ET with an SSRI accelerated symptom improvement, by the end of the 10-week study, treatment efficacy in the HT plus SSRI group was no greater than that observed in the SSRI-only group.¹⁴

Nineteen studies included in the metaanalysis by Rubinow and colleagues, which examined mood after ET or EPT treatment in nondepressed women, found little evidence of benefit, particularly in women without other physical symptoms of menopause.¹¹

The Kronos Early Estrogen Prevention Study (KEEPS) followed 661 women who received either oral estrogen plus progesterone, transdermal estrogen plus progesterone, or placebo over 4 years.¹⁵ Women with clinical depression were excluded from the study; however, women with mild to moderate mood symptoms who were being treated with an antidepressant were included. Improvements in depressive symptoms and anxiety were observed only in the oral estrogen plus progesterone group compared with the placebo group.¹⁵

In a study of 172 euthymic peri- and postmenopausal women treated for 12 months with transdermal estrogen plus oral progesterone, investigators found that, unlike postmenopausal women and those in the late perimenopausal transition, only women in the early perimenopausal transition had a lower risk of developing depressive symptoms.¹⁶

Bottom line

This complex literature suggests that ET/HT interventions are most likely to be successful when implemented early in the menopausal transition. The clearest indication for the use of HT is for perimenopausal women experiencing depression who are also experiencing menopausal symptoms (for example, bothersome hot flashes). There is little evidence that the use of ET/HT in late perimenopausal or postmenopausal women effectively treats depression; accordingly, HT is not recommended for the treatment of mood disorders in this population. The more ambiguous cases are those of perimenopausal women who are depressed but do not have classic vasomotor symptoms; some evidence supports the antidepressant efficacy of HT in this setting.¹¹ Although some studies suggest that HT can be effective in preventing depression in perimenopausal women, more evidence is needed.¹⁶

 

The menopause transition: A key period for strategizing CVD risk factor reduction

---

Chrisandra L. Shufelt, MD, MS, NCMP

Dr. Shufelt is Associate Director of the Barbra
Streisand Women’s Heart Center, Smidt
Heart Institute, Cedars-Sinai Medical Center,
Los Angeles, California.

JoAnn E. Manson, MD, DrPH, NCMP

Dr. Manson is Professor of Medicine and the
Michael and Lee Bell Professor of Women’s
Health at Harvard Medical School; Professor
in the Department of Epidemiology, Harvard
T.H. Chan School of Public Health; and Chief
of the Division of Preventive Medicine
at Brigham and Women’s Hospital, Boston,
Massachusetts.

The authors report no financial relationships relevant to this article. Dr. Manson is a coauthor of the AHA Scientific Statement discussed in this article.

In the United States, nearly one-half of a woman’s life, on average, will be lived after menopause. For women with natural menopause, the menopause transition (MT) can begin 2 to 7 years before and may extend 1 year past the final menstrual period, which occurs at an average age of 51 years. For women with surgical menopause, the MT occurs abruptly with the sudden loss of endogenous ovarian hormones. Both types of transitions mark a critical time period when reproduction and endogenous sex hormone levels diminish and when cardiovascular disease (CVD) risk factors begin to rise.

The 2020 American Heart Association (AHA) scientific statement, “Menopause transition and cardiovascular disease risk: Implications for timing of early prevention,” highlights the MT as a window of opportunity for CVD prevention.¹

CVD risk factors associated with ovarian aging

In the AHA scientific statement, data from several longitudinal women’s health studies were used to identify which CVD risk factor changes during the MT are related to ovarian aging as opposed to chronologic aging. Independent of aging, those associated with reproductive or ovarian aging included an increase in serum total cholesterol, low-density lipoprotein cholesterol (LDL-C), and apolipoprotein B. Changes in high-density lipoprotein cholesterol (HDL-C) particles and function also occur during the MT, which may explain why higher HDL-C levels during the MT and the postmenopausal years are not as cardioprotective as during the premenopausal period.

Changes in body composition and adipose tissue distribution also are associated with ovarian aging, with reduction in muscle mass and lean body mass and an increase in abdominal/visceral fat and subcutaneous adipose tissue. Although these body composition changes reflect ovarian aging, midlife weight gain is more closely related to chronologic aging.

The risk of the metabolic syndrome constellation of risk factors was found to be more closely associated with ovarian aging, whereas changes in blood pressure, insulin, and glucose individually tracked more closely with chronologic aging. Additionally, the AHA statement notes the research that identified several symptoms during the MT—including vasomotor symptoms, sleep disturbance, and depression—as being associated with more adverse CVD risk factor status and with subclinical measures of atherosclerosis. Additional research on the mechanistic basis for these associations is needed.

Chronologic age and type of menopause

Notably, a woman’s age and type of menopause matter with respect to CVD risk. Higher CVD risk is seen in women with premature onset (age < 40 years) or early onset (age < 45 years) of menopause and in women undergoing surgical menopause (bilateral oophorectomy) before age 45. In general, menopausal hormone therapy (HT) is recommended for women with premature or early menopause, whether natural or surgical, with continuation through at least the average age of natural menopause. In other women, although not recommended for the express purpose of CVD prevention, menopausal HT is appropriate for the treatment of bothersome vasomotor or other menopausal symptoms, especially when therapy is started before age 60 or within 10 years of menopause among women who are not at elevated risk of CVD.

While the AHA statement suggests that some women who begin estrogen early in menopause may experience reduced coronary heart disease risk, major research gaps remain with regard to HT dose, formulation, route of delivery, and recommended duration of treatment.

An opportunity to promote healthy lifestyle behaviors

Translating the AHA’s first-of-its-kind scientific statement into clinical practice requires recognition and awareness of the MT as a unique phase in a woman’s life associated with myriad changes in CVD risk factors. The statement underscores that the MT is an important time to target behavioral changes to promote CVD risk reduction, including lifestyle modifications in the AHA’s Life’s Simple 7 components (increased physical activity, smoking cessation, healthy diet, avoidance of weight gain) as well as vigilant control of blood pressure, cholesterol, and glucose levels. The MT is truly a window of opportunity for reinvigorated efforts to lower women’s CVD risk. ●

Reference

1. El Khoudary SR, Aggarwal B, Beckie TM, et al; American Heart Association Prevention Science Committee of the Council on Epidemiology and Prevention; and Council on Cardiovascular and Stroke Nursing. Menopause transition and cardiovascular disease risk: implications for timing of early prevention: a scientific statement from the American Heart Association. Circulation. 2020;142:e506-e532. doi: 10.1161/CIR.000000000000912.

Vaginal dryness, encompassed in the modern term genitourinary syndrome of menopause (GSM) affects up to 40% of menopausal women and up to 60% of postmenopausal breast cancer survivors.^1,2 Premenopausal women also can have vulvovaginal dryness while breastfeeding (lactational amenorrhea) and while taking low-dose contraceptives.³ Vaginal moisturizers and lubricants are the first-line treatment options for vaginal dryness, dyspareunia, and GSM.^4,5 In fact, approximately two-thirds of women have reported using a vaginal lubricant in their lifetime.⁶ Despite such ubiquitous use, many health care providers and patients have questions about the difference between vaginal moisturizers and lubricants and how to best choose a product.

Vaginal moisturizers