November 2009 Vol. 14 No. 11
From the publishers of
The New England Journal of Medicine
WO MEN’S H EA LT H
of early cancers, some of which might not patients, and to develop tools for shared
NEWS IN CONTEXT be destined to progress or to be lethal. The decision making in breast and prostate
ACS plans to modify its message in early screening. The ACS’s planned modification
Screening for Breast 2010 to indicate that prostate and breast to its previous screening stance is certain to
and Prostate Cancers — screening benefits might have been over- provoke controversy.
Not Living Up to Its Reputation? stated, possibly leading to overtreatment — Wendy S. Biggs, MD
Diagnosis of early breast and prostate cancer of patients with small cancers (New York
Esserman L et al. Rethinking screening for breast
has risen with screening, but the number of Times Oct 10 2009 [http://www.nytimes cancer and prostate cancer. JAMA 2009 Oct 21;
advanced cancers has not fallen. .com/2009/10/21/health/21cancer.htm]). 302:1685.
Breast and prostate cancer account for
more than a quarter of all cancers in the
Explaining “small” cancers to patients is SUMMARY & COMMENT
U.S., and the American Cancer Society
difficult, as simply uttering the word “can-
(ACS) has supported extensive screening
programs for both. A new analysis suggests
cer” can invoke intense anxiety. The au- SERMs for Breast Cancer
that we rethink screening for breast and
thors suggest that minimal-risk lesions Chemoprophylaxis
should not be called “cancer,” but rather a Risks associated with tamoxifen and ralox-
prostate cancer. During the last 20 years,
term such as “indolent lesions of epithelial ifene limit the appeal of these agents.
after screening was introduced, incidence
origin (IDLE).” Patients who are aware
of breast and prostate cancer rose and The selective estrogen receptor modula-
that mortality associated with breast and
never returned to prescreening levels; also, tors (SERMs) tamoxifen (TAM) and ral-
prostate cancers has fallen during the last
more cases were early cancers. However, oxifene (RAL) — and the selective tissue
2 decades might attribute the decrease to
the absolute number of advanced breast estrogenic activity regulator tibolone —
screening instead of to better treatments.
and prostate cancers that were diagnosed are all associated with lower risk for pri-
The authors also point out the importance
during this period has not fallen as pre- mary invasive breast cancer. TAM and
of developing different means (e.g., bio-
dicted. Thus, whereas colon and cervical RAL are approved in the U.S. for chemo-
markers) to determine whether tumors
cancer screening detects precancerous, prophylaxis in high-risk women (RAL in
are likely to progress without treatment; in
treatable conditions (e.g., polyps, cervical postmenopausal women only). In a review
addition, they emphasize the need to put
intraepithelial neoplasia), prostate and of seven placebo-controlled trials and one
a damper on treatment for minimal-risk
breast cancer screening promotes detection head-to-head trial involving women with-
disease, to focus on prevention in high-risk
out histories of breast cancer, investigators
assessed the effectiveness and safety of
CONTENTS these three agents (tibolone is not avail-
able in the U.S.).
SUMMARY & COMMENT What Do LGBTQ Youth Want in Healthcare?
SERMs for Breast Cancer Chemoprophylaxis ...... 81 What We All Want! .................................................. 86 Overall, TAM and RAL lowered the
Mastectomy Instead of BCS: What Is the Ethnicity Affects Attitudes incidence of invasive breast cancer by 7
Role of the Surgeon’s Recommendation? ........... 82 About HPV Vaccination .......................................... 87
to 10 women per 1000 annually (risk ra-
Estrogen-Progestin Therapy Do ICDs Work Better for Men
tios, 0.70 and 0.44, respectively). In both
and Lung Cancer in Menopausal Women .......... 83 Than for Women? ..................................................... 87
Oral Contraceptive Failure Rates ............................. 83
pre- and postmenopausal women, these
NEWS IN CONTEXT
Is Laparoscopic Uterosacral Nerve Ablation Screening for Breast and Prostate Cancers — SERMs reduced risk for estrogen-receptor–
Effective for Chronic Pelvic Pain? ............. 83 Not Living Up to Its Reputation? ............................ 81 positive tumors (but not estrogen-receptor–
Prenatal Exposure to SSRIs Can Adversely Newly Approved Use for the LNG-IUS ................... 88 negative tumors), noninvasive breast can-
Affect Certain Delivery Outcomes ........................ 85 FEATURE cers, and mortality from breast cancer.
Does Repeated Membrane Sweeping Management of Chronic Pain ................................... 84 Both agents also reduced risk for osteo-
for VBAC Make a Difference? ............................... 86 FOR YOUR INFORMATION porotic fractures. TAM and RAL raised
Twins Born Following ART Power over Pain:
Have Higher Risk for Morbidity Gaining Control of Chronic Pain .................. INSERT risk for venous thromboembolic events
Than Spontaneously Conceived Twins ............... 86 (VTEs) by 4 to 7 women per 1000 annually
JOURNAL WATCH (AND ITS DESIGN) IS A REGISTERED TRADEMARK OF THE MASSACHUSETTS MEDICAL SOCIETY.
AN EDITORIALLY INDEPENDENT LITERATURE-SURVEILLANCE NEWSLETTER SUMMARIZING ARTICLES FROM MAJOR MEDICAL JOURNALS. ©2009 MASSACHUSETTS MEDICAL SOCIETY.
ALL RIGHTS RESERVED. DISCLOSURE INFORMATION ABOUT OUR AUTHORS CAN BE FOUND AT http://womens-health.jwatch.org/misc/board_disclosures.dtl
82 WOMEN’S HEALTH Vol. 14 No. 11
(RRs, 1.93 and 1.60, respectively). TAM mastectomy after attempted BCS, investi-
Andrew M. Kaunitz, MD, Professor and Associate
(but not RAL) raised the endometrial gators surveyed women with ductal carci-
Chair, Department of Obstetrics and Gynecology, cancer risk (RR, 2.13) and was also asso- noma in situ or stage I–II breast cancer.
University of Florida Health Science Center — ciated with excess risk for abnormal uter- Participants were asked which procedure
ine bleeding and hysterectomy for benign was recommended by their initial sur-
disease. Both SERMs were associated with geons (and why) and, if applicable, by
Mary A. Nastuk, PhD
Massachusetts Medical Society greater likelihood of hot flashes. second surgeons.
PATIENT INFORMATION EDITOR COMMENT Of 1984 respondents, 66% indicated
Diane E. Judge, APN/CNP, Heartland Health that their first surgeons had recommended
Outreach, Heartland Alliance for Human Needs
In the U.S., tamoxifen is most often pre-
and Human Rights, Chicago scribed as adjuvant endocrine therapy BCS, 17% reported that mastectomy was
following initial treatment for estrogen- initially recommended, and 17% said
Diane J. Angelini, EdD, CNM, FACNM, FAAN, receptor–positive breast cancer in pre- that neither procedure was recommended
NEA-BC, Associate Clinical Professor of Obstetrics and postmenopausal women; raloxifene over the other. In more than two thirds of
and Gynecology and Director, Nurse-Midwifery women who received initial recommenda-
Division, Warren Alpert Medical School of Brown is approved for prevention of osteoporotic
University and Women & Infants Hospital of Rhode fractures in postmenopausal women. Be- tions for mastectomy, BCS was contra-
Island, Providence indicated. Among respondents who did
cause most trial participants were white
Wendy S. Biggs, MD, Assistant Professor, not report contraindications to BCS, only
Department of Family Practice, Michigan State
and relatively healthy, the relevance of
University College of Human Medicine; Associate these findings to women of other ethnic- 6% received surgical recommendations
Director, Midland Family Medicine Residency ities or with comorbidities is uncertain. for mastectomy. Second opinions were
Program, Midland, Michigan sought by 19% of respondents (most often
Risks and side effects associated with
Ann J. Davis, MD, Associate Professor of
SERMs have limited their use for breast when mastectomy was initially recom-
Obstetrics and Gynecology and Pediatrics, Tufts
Medical School, New England Medical Center, cancer chemoprophylaxis in the U.S. In mended); however, 90% of women were
Boston operated on by the first surgeon they con-
particular, VTE risk is an issue in over-
Anna Wald, MD, MPH, Professor, Department of sulted. Among women in whom BCS was
Medicine, Epidemiology, and Laboratory Medicine, weight and older women — and risk for
and Medical Director, Virology Research Clinic, malignant and benign gynecologic disease attempted, no additional surgery was re-
University of Washington, Seattle is cause for concern in premenopausal quired in 62%, reexcision lumpectomy
CONTRIBUTING EDITORS women with intact uteri. Clinicians of was performed in 26%, and subsequent
JoAnne M. Foody, MD, Associate Professor of mastectomy was performed in 12%.
women at risk for breast cancer should
Medicine, Harvard Medical School; Director,
Cardiovascular Wellness Center, Brigham and help those who are considering chemo- COMMENT
Women’s Hospital, Boston prophylaxis to understand the benefits These results indicate that surgeons gen-
Robert W. Rebar, MD, Executive Director, American and risks of SERMs in the context of their
Society for Reproductive Medicine, Birmingham, erally are making appropriate treatment
Alabama own personal circumstances. Moreover, recommendations for stage 0–II breast
MASSACHUSETTS MEDICAL SOCIETY
aromatase inhibitors represent a potential cancer, and that patient preference plays a
Christopher R. Lynch, Vice President for alternative that is now being evaluated. role in the choice of surgery. Such prefer-
Publishing; Alberta L. Fitzpatrick, Publisher — Andrew M. Kaunitz, MD ences — which often arise from fears of
Cara Adler, Diana Montgomery, Lyn Whinston-
Perry, Staff Editors; Martin Jukovsky, Copy Editor; Nelson HD et al. Systematic review: Comparative tumor recurrence and concerns about
Misty Horten, Layout; Matthew O’Rourke, Director, effectiveness of medications to reduce risk of primary radiation therapy — might not be based
Editorial Operations and Development; breast cancer. Ann Intern Med 2009 Sep 14; [e-pub on sound knowledge, underscoring the
Art Wilschek, Christine Miller, Lew Wetzel, ahead of print]. (http://www.annals.org/cgi/
Advertising Sales; William Paige, Publishing content/full/0000605-200911170-00147v1)
importance of candid preoperative coun-
Services; Bette Clancy, Customer Service seling. The authors did not ascertain the
Published 12 times a year. Subscription rates per influence of preoperative magnetic reso-
year: $129 (U.S.), C$163.81 (Canada), US$156 (Intl); Mastectomy Instead of BCS: nance imaging on surgical recommenda-
Residents/Students/Nurses/PAs: $69 (U.S.), C$96.19 What Is the Role of the tions, although this approach could be
(Canada), US$78 (Intl); Institutions: $249 (U.S.),
C$252.38 (Canada), US$216 (Intl); individual print Surgeon’s Recommendation? partially responsible for recent trends
only: $99 (U.S.). Prices do not include GST, HST, Reasons for mastectomy are related to sur- in mastectomy rates (J Clin Oncol 2009;
or VAT. In Canada remit to: Massachusetts Medical
Society C/O #B9162, P.O. Box 9100, Postal Station F,
geon’s recommendation, patient’s preference, 27:4082). Notably, increasing numbers of
Toronto, Ontario, M4Y 3A5. All others remit to: and contraindications to breast-conserving patients are selecting bilateral mastectomy
Journal Watch Women’s Health, P.O. Box 9085, surgery. for initial management of breast cancer
Waltham, MA 02454-9085 or call 1-800-843-6356.
E-mail inquiries or comments via the Contact Us Although rates of breast-conserving sur- (Ann Surg Oncol 2009; 16:2697).
page at JWatch.org. Information on our conflict-of- gery (BCS) have risen substantially dur- — Andrew M. Kaunitz, MD
interest policy can be found at JWatch.org/misc/
ing the last 2 decades, many clinicians Morrow M et al. Surgeon recommendations and
feel that mastectomy is still performed receipt of mastectomy for treatment of breast cancer.
too often. To assess reasons for mastec- JAMA 2009 Oct 14; 302:1551.
tomy as initial treatment and rates of
November 2009 JWatch.org 83
Estrogen-Progestin Therapy Chlebowski RT et al. Oestrogen plus progestin and clinicians to encourage other contraceptive
lung cancer in postmenopausal women (Women’s
and Lung Cancer in options in this age group. Although anti-
Health Initiative trial): A post-hoc analysis of a
Menopausal Women randomised controlled trial. Lancet 2009 Oct 10;
biotic use was associated with a small
Trying to make sense of a puzzle 374:1243. number of OC failures, this observation
Ganti AK. Another nail in the coffin for hormone- is not supported by pharmacokinetic evi-
The Women’s Health Initiative (WHI)
replacement therapy? Lancet 2009 Oct 10; 374:1217. dence. The finding that BMI and weight had
placebo-controlled trial of estrogen-
little effect on OC efficacy differs from U.S.
progestin therapy followed patients for a
findings; furthermore, overall failure rates
mean 5.6 years during hormone therapy Oral Contraceptive Failure Rates are substantially higher in the U.S. If we
and a mean 2.4 years after intervention; The OC failure rate in a large European only knew why European women seem
lung cancer was not among the original cohort was 0.75% in the first year of use. to use OCs so consistently and correctly
study outcomes. In a post-hoc analysis, About 75 million women worldwide use (JW Womens Health Oct 2009, p. 79, and
investigators assessed lung cancer incidence combined oral contraceptives (OCs) to Contraception 2009; 80:142), we could
and mortality rates during treatment and prevent pregnancy. In a secondary analysis encourage that behavior pattern in U.S.
postintervention follow-up. of data from an industry-supported study, women. — Diane E. Judge, APN/CNP
Although the overall incidence of lung researchers assessed OC effectiveness, as
Dinger JC et al. Oral contraceptive effectiveness
cancer (both non–small-cell and small- well as factors that might influence effec- according to body mass index, weight, age, and other
cell) was similar in the HT and placebo tiveness. For as long as 5 years, the investi- factors. Am J Obstet Gynecol 2009 Sep; 201:263.
groups, after about 5 years of follow-up, gators followed 59,000 women (mean base-
more cases of non–small-cell lung cancer line age, 25; mean baseline BMI, 22 kg/m2)
were diagnosed in the HT group than in from seven European countries who re- Is Laparoscopic Uterosacral
the placebo group; moreover, metastatic ceived OC prescriptions (first-time or Nerve Ablation Effective
non–small-cell cancer was substantially switching to new OCs). Only 1400 women for Chronic Pelvic Pain?
more prevalent in the HT group. In general, were lost to follow-up. Data were self- British randomized trial results indicate the
mortality from non–small-cell lung cancer reported at baseline and every 6 months; answer is no.
was more common in the HT group than study physicians verified unplanned preg- Chronic pelvic pain in women is a com-
in the placebo group (hazard ratio, 1.87; nancies and determined their causes by mon condition that impairs quality of life
P=0.004), whereas mortality from small- interview. and often necessitates diagnostic laparos-
cell cancer did not differ between groups. During 112,659 woman-years of OC copy. Nerves in the uterosacral ligaments
use, 545 unplanned pregnancies were re- are believed to carry pain signals from
ported (0.5 pregnancies per 100 woman- pelvic structures. Although laparoscopic
Interpreting these findings is not straight-
years of use). The estimated failure rate uterosacral nerve ablation (LUNA) is an
forward. Both normal and malignant lung
was 0.8% after 1 year of use and 1.7% after option for treating patients with chronic
tissues express estrogen receptors. Obser-
4 years. The most common factors associ- pelvic pain, uncertainty about the pro-
vational data regarding the association be-
ated with failures were inconsistent OC cedure’s efficacy has made this a controver-
tween HT and lung cancer incidence and
use (42.2%), vomiting, diarrhea, or both sial surgery. Investigators at 18 U.K. hos-
mortality are inconsistent. Furthermore,
(18.3%), and antibiotic use (15.6%). Fail- pitals recruited women who were seen in
findings from a recent case-control study
and a Nurse’s Health Study report (JW ure rates were unaffected by BMI, weight, continued on page 85
Womens Health Jun 2009, p. 44, and Obstet or OC formulation (progestin type, estro-
Gynecol 2009; 113:1027) suggest that bilat- gen dose, monophasic vs. multiphasic
JOURNAL WATCH ONLINE
eral oophorectomy is associated with excess dosing), were highest in younger women
risk for lung cancer. Smoking remains (age range, 18–24), and declined mark-
• Listen to interviews of
the foremost risk factor for lung cancer. edly after age 29. Failures were most likely
editorialists and study
Although some will view the present find- during the first year of use and declined
authors as they discuss
ings as a call to discourage smokers with annually thereafter. clinical implications of the
menopausal symptoms from using HT, COMMENT
latest research findings.
women who smoke have more-severe vaso- This cohort of women in Europe had lower • November is national diabetes
motor symptoms and are at higher risk for mean BMI and might have been less racially, month. See our latest diabetes
osteoporotic fractures; for such women, ethnically, and socioeconomically diverse coverage across a variety of
smoking cessation is paramount. In any than women in the U.S. (Nonetheless, the medical specialties.
case, most clinicians would probably agree observation of declining OC failure rates • Sign up for free monthly alerts.
that these findings provide good reason to over time and with increasing user age is Choose from new content in
advise menopausal HT users with non– congruent with U.S. data.) The minimum diabetes, lipid management,
small-cell lung cancer to discontinue HT. age in this cohort was 18; OCs have mark- asthma, and other topics.
— Andrew M. Kaunitz, MD edly higher failure rates in U.S. teenagers
Dr. Kaunitz is a WHI investigator but had no involvement who are younger than 18, leading some JWatch.org/online
in this study.
84 WOMEN’S HEALTH Vol. 14 No. 11
Management of Chronic Pain
Comprehensive treatment for chronic pain must address both physical and psychological aspects.
Pain is a leading reason that people seek medical care. Annually, thresholds and higher pain ratings in research studies. Such sex
pain is estimated to burden the U.S. economy with $100 billion differences could be secondary to the influence of hormones,
in direct costs and $61 billion in productivity losses. These family history, traditional sex roles, cognitive factors, and how
losses, which amount to a mean of 4.6 hours weekly, are largely the central nervous system processes pain.5
due to diminished performance at work.1 Perhaps more signifi-
INTERDISCIPLINARY TREATMENT OF CHRONIC PAIN
cant, but more difficult to quantify, is the emotional distress
Comprehensive treatment of chronic pain must address both
and diminished quality of life that pain inflicts on individuals
physical and psychological aspects; thus, interdisciplinary ap-
and their loved ones.
proaches to pain management involve medical management,
WHAT IS PAIN? physical therapy, occupational therapy, biofeedback, vocational
Pain, as defined by the International Association for the Study and recreational therapy, and psychological counseling.
of Pain (http://www.iasp-pain.org/AM) is “an unpleasant Rational polypharmacy (evidence-based use of multiple
sensory and emotional experience associated with actual or po- medications) is a cornerstone of medical management of pain
tential tissue damage, or described in terms of such damage.”2 syndromes, which can encompass sleep and mood disorders.
Thus, pain is an experience that comprises a physical sensory Treatment options include nonsteroidal anti-inflammatory
component and an affective cognitive component. The physical agents, antiepileptic drugs such as gabapentin (for neuropathic
element involves a nociceptive, neuropathic, or inflammatory pain), antidepressants, and opioid drugs. Use of chronic opioid
stimulus that is transmitted via the spinal cord to the thalamus therapy has risen substantially, along with concerns about drug
and then to areas of the cerebral cortex, where it is perceived. abuse and addiction; accordingly, treatment recommendations
Acute pain serves a biological purpose as an alert to potential, have been developed by the American Pain Society and the
immediate, or ongoing injury. American Academy of Pain Medicine to provide guidance
Chronic pain is pathologic, serves no biological purpose, about patient selection, risk factors for abuse, and opioid man-
and can result from peripheral sensitization, in which processes agement plans.6 Chronic opioid treatment is appropriate if an-
(such as changes in gene expression in the dorsal root ganglia) algesia is achieved, adverse side effects do not occur, activities
augment the synthesis of various peripheral nociceptors. In of daily living improve, and aberrant behavior or signs of abuse
turn, inputs to the dorsal horn of the spinal cord are amplified, are not present (sometimes referred to as the four A’s). In addi-
leading to activation of N-methyl-d-aspartate (NMDA) recep- tion to documentation of the four A’s, clinicians’ use of opioid
tors and subsequent spinal cord hyperexcitability. Destruction contracts with patients, as well as random urine screens, all
of inhibitory interneurons and sprouting of nerve fibers at the help to justify prescribing these agents as part of therapy for pa-
level of the dorsal horn also can contribute to central sensitiza- tients with chronic pain. Other medical strategies involve ster-
tion; in addition, disruption of descending inhibitory neural oid injections (epidural or delivered directly to affected joints)
pathways can trigger central hypersensitivity and chronic pain.3 to treat pain flares, and, when indicated, surgical approaches.
Chronic pain can persist after an initial injury has healed, Physical therapy serves to allay the patient’s fear of move-
or it can result from ongoing pathologic processes. Although ment; to teach the difference between “hurt” and “harm” sen-
specific periods (typically 6 months) often are used to define sations; to increase endurance, range of motion, and tolerance
chronic pain, a more appropriate definition of the condition is for sitting, standing, and walking; and to improve posture and
simply pain that persists longer than it should. Chronic pain strength. Occupational therapy addresses body mechanics,
often involves neural activity in specific brain areas that are pacing, functional mobility and activities of daily living, and
distinct from those that mediate acute pain; for example, un- ergonomic modifications in the workplace. Biofeedback helps
relenting back pain is processed by areas that also process nega- the patient to master diaphragmatic breathing and progressive
tive emotions.4 In addition, chronic pain can have widespread muscle relaxation with the goals of alleviating muscle tension,
effects on overall brain functioning, thereby causing depres- reducing physical and emotional distress, and encouraging
sion, anxiety, and decision-making difficulties in ways that mindfulness of pain in an effort to divert attention away from it.
acute pain does not. Managing pain largely entails attending to its psychologi-
WOMEN AND PAIN cal features and their impingement on overall emotional status.
Conditions such as headache, pelvic pain, rheumatoid arthritis, Sleep disturbances, anxiety, and depression can be treated with
and facial pain are more common in women than in men; ac- psychotherapy and, when required, pharmacologic agents. Along
cordingly, women are two to three times more likely than men with medical management, cognitive-behavioral therapy (CBT)
to suffer from chronic pain. Compared with men, women also is often a mainstay of treatment.7 CBT is based on the theory
tend to perceive pain as more severe and to report lower pain that thoughts affect feelings and behaviors, which, in turn,
November 2009 JWatch.org
From the publishers of
The New England Journal of Medicine
For Your Information
This patient-education material was prepared by the editors of Journal Watch Women’s Health.
Power over Pain: Gaining Control of Chronic Pain
Treatments aimed at helping you to manage pain by improving your physical
functioning and your ability to control your thoughts, behaviors, and reactions
Although pain is a bad feeling, it usually serves a pur- finding help for this life-altering medical problem.
pose: It warns that harm to your body is occurring or is Research into the causes of and treatments for chronic
about to occur so that you can take action. For instance, pain has led to more-effective therapies and support for
the pain of a burn causes you to quickly remove your women who live with this challenge.
hand from the stove. But what about pain that seems
to have no purpose?
Treatments for Chronic Pain
Chronic pain can be at least partly relieved with com-
Chronic Pain mon medications such as acetaminophen, ibuprofen,
The International Association for the Study of Pain or naproxen. But, in many cases, severe chronic pain
defines pain as “an unpleasant sensory and emotional requires use of strong prescription medications such as
experience associated with actual or potential tissue narcotics — drugs related to opium that dull pain but
damage.” An important part of this definition is the can also dull other senses. Narcotics can be very helpful
acknowledgment that pain has an emotional feature. because they change the way the brain recognizes pain
Acute pain — the kind that occurs to prevent or limit signals. Women often are understandably concerned
injury — goes away when the condition that triggered about using these addictive medications, especially for
it is gone. Unlike acute pain, chronic pain continues long periods of time. In fact, some clinicians are reluc-
but serves no real purpose; it is not a warning that tant to prescribe narcotics because of possible addic-
something harmful is about to happen. tion. However, sometimes the benefits of easing pain
Chronic pain is often defined as pain that lasts longer outweigh the risk for becoming addicted. If narcotics
than 6 months. But a better definition is pain that goes are appropriate for pain control in your situation, your
on longer than it should. Researchers think this might clinician will discuss with you how to use them safely.
happen because parts of your nervous system become Other medications that are not usually thought of
sensitized and continue to send pain messages to your as pain relievers might work for specific types of pain.
brain. Or your body might experience pain even though For example, a medication called gabapentin, which
no obvious medical condition triggered it. was originally used to treat seizures, can be very effec-
Women are two to three more times more likely tive for nerve pain (also known as neuropathic pain).
than men to suffer from chronic pain and are more Medications originally used for depression can be help-
likely to have conditions associated with ongoing pain, ful for treating fibromyalgia and other chronic painful
such as migraines, pelvic pain, rheumatoid arthritis, conditions. In addition to — or instead of — pain medi-
and fibromyalgia. Women can also respond to pain cations that you take by pill or patch, injections of med-
differently than men do, perhaps because of their hor- ications to control pain and swelling can be very useful.
mones, the way their nervous systems process pain, These are most often used for pain in a specific area,
their roles in society, or other factors. In the past, such as the neck, back, or knee.
women with chronic pain sometimes had difficulty
continued on next page
WOMEN’S HEALTH Vol. 14 No. 11
continued from previous page
Having a Team Helps professionals for physical, occupational, biofeedback, and
Medications are usually necessary, but they aren’t the cognitive-behavioral therapies. You can request these indi-
whole story. Chronic pain affects how your brain works. vidual referrals or, instead, ask for a referral to a pain man-
Because of this, women who experience chronic pain often agement program or an experienced clinician with pain
experience depression, anxiety, and difficulty in making management experience. If you do not have a primary care
decisions — problems that do not come with acute pain. provider — or your clinician cannot offer any resources —
This fact does not mean that chronic pain is imaginary. It you can contact teaching hospitals (hospitals associated
is a complex medical problem that affects your whole life: with universities or medical schools) in your area to see
eating, sleeping, relating to friends and family, working, what they have available.
and caring for children. Coping with chronic pain is drain- If you do not have health insurance, or if your insur-
ing physically, emotionally, and financially. It can affect ance does not cover team approaches to chronic pain, con-
your sleep, mood, and mental state. Effective treatments tact your local publicly funded hospital or local health de-
for chronic pain address not just the hurt but also these partments for assistance. The American Pain Foundation
accompanying issues. (see Resources) has information about financial aid.
A basic goal of treating chronic pain is to empower you You might also consider participating in a research
to manage pain by improving your physical functioning as study on chronic pain. Research programs often provide
well as your ability to control your thoughts, behaviors, and treatment at no charge and might be able to refer you to a
reactions. To accomplish this, working with a team of treatment source afterward. If you choose to participate
health professionals is helpful. A clinician (doctor, nurse in a research study, be sure you understand what is being
practitioner, physician assistant) will direct your care and studied and how it will benefit you. You can find studies by
provide necessary prescription medications. Additional checking the National Institute of Neurological Disorders
beneficial strategies include the following: and Stroke website (see Resources).
• Physical therapy teaches you how to move without
causing or worsening pain, helps you develop strength In Conclusion
and endurance, and improves your ability to move
Chronic pain is a condition that can affect every area of
your muscles, bones, and joints without fearing pain.
your life, as well as the life of your family. Effective treat-
• Occupational therapy improves your ability to ac- ment is available and works best when a variety of health-
complish what you need to do each day; such therapy care approaches are used. The goal of chronic pain treatment
might involve assessing any changes that must be made is to empower you with the resources to take back control of
at home and in the workplace so that you can function your body and your life. — Diane E. Judge, APN/CNP
with less pain.
• Biofeedback involves techniques, such as breathing
and progressive muscle relaxation, that help ease mus- Resources
cle tension, lessen physical and emotional distress, and American Pain Foundation. http://www.painfoundation.org
channel your mind away from pain. International Association for the Study of Pain.
• Cognitive-behavioral therapy (CBT) is based on the http://www.iasp-pain.org
concept that your thoughts (not uncontrollable outside National Association of Cognitive-Behavioral Therapists.
influences, such as people, events, or situations) affect http://www.nacbt.org/
your feelings and behavior. By changing the way you
think, you can gain control of how pain affects your National Institute of Neurological Disorders and Stroke
life. CBT teaches you how to identify negative thoughts (Chronic Pain Information Page). http://www.ninds.nih
related to pain and to replace them with coping skills .gov/disorders/chronic_pain/chronic_pain.htm
that you can apply to everyday situations, including
pain flare-ups. CBT allows you to control your pain ©2009 Massachusetts Medical Society. Authorization is hereby granted to
healthcare providers to photocopy For Your Information for noncommercial
rather than having pain control your life. educational use only; not for resale. For more information, please contact
Rights & Permissions, Massachusetts Medical Society, fax: (781) 893-8103.
How to Find Help
Not every community offers the resources needed for a team
approach to pain, and not all health insurers will cover these
programs. Primary care clinicians who are experienced in
treating chronic pain can refer you to additional healthcare
November 2009 JWatch.org 85
influence how one experiences pain. CBT teaches individuals stop ongoing and unnecessary laboratory and radiologic testing
how to identify negative dysfunctional pain-related thoughts after the diagnosis has been made definitively.
and how to replace them with more-adaptive thoughts. Ideally,
one learns coping skills that can be applied to daily situations,
Collaboration among therapists, psychologists, and other
including pain flares.
supportive resources is crucial to delivering effective pain
A key goal of CBT — indeed, of all the therapies for chronic treatments. Helping women with chronic pain to take owner-
pain — is to foster the belief that patients have the power to ship of their conditions and to actively curb physical and
manage their pain by improving their physical abilities and emotional aspects will boost their functional mobility, pro-
by learning how to control their thoughts, behaviors, and reac- ductivity, and quality of life while also shrinking the associated
tions. Having a healthy sense of command of oneself includes financial burden. — Lynn Rader, MD
being both physically and socially active and integrated. Un- Dr. Rader is an attending physician at the Rehabilitation Institute of Chicago Center
remitting pain leads to lower physical activity levels, resulting for Pain Management.
in diminished function and greater likelihood of depression; 1. Stewart WF et al. Lost productive time and cost due to common pain
maintaining higher activity levels leads to less pain, thereby conditions in the US workforce. JAMA 2003 Nov 12; 290:2443.
breaking the cycle. 2. Merskey H and Bogduk N. Part III: Pain terms: A current list with
definitions and notes on usage. In: IASP Task Force on Taxonomy.
Maintaining a sense of control is undeniably challenging Classification of Chronic Pain, Second Edition. IASP Press; 1994.
for women who are in continual pain. Isolation and depression (http://www.iasp-pain.org/AM/Template.cfm?Section=Pain_Definitions)
commonly accompany chronic pain conditions, which makes 3. Harvey VL and Dickenson AH. Mechanisms of pain in nonmalignant
treatment difficult. Women must learn to maintain direction disease. Curr Opin Support Palliat Care 2008 Jun; 2:133.
over their own lives and take time to care for themselves while 4. Baliki MN et al. Chronic pain and the emotional brain: Specific brain
also meeting the challenges of employment, caring for their activity associated with spontaneous fluctuations of intensity of chronic back
pain. J Neurosci 2006 Nov 22; 26:12165.
families, and remaining socially integrated. Being able to do all
5. Fillingim RB. Sex-related influences on pain: A review of mechanisms and
of this, in addition to handling a debilitating condition, can be
clinical implications. Rehabil Psychol 2003 Aug; 48:165.
demoralizing and exhausting — physically, emotionally, and fi-
6. Chou R et al. Clinical guidelines for the use of chronic opioid therapy in
nancially. Likewise, managing chronic pain conditions can be chronic noncancer pain. J Pain 2009 Feb; 10:113.
challenging and potentially draining for clinical pain-care
7. Turner JA and Clancy S. Comparison of operant behavioral and cognitive-
teams. The treating clinician has a responsibility not only to behavioral group treatment for chronic low back pain. J Consult Clin
educate the patient that her chronic pain is a disease but also to Psychol 1988 Apr; 56:261.
continued from page 83 COMMENT Prenatal Exposure to SSRIs
This study, which is four times larger Can Adversely Affect
gynecology outpatient clinics and who un-
than any previously published trial in Certain Delivery Outcomes
derwent diagnostic laparoscopies for non-
which LUNA was assessed, provides
cyclic pelvic pain, dysmenorrhea, or dys- In utero SSRI exposure was associated with ex-
clear evidence that LUNA is not effective cess risk for preterm delivery but not for lower
pareunia lasting longer than 6 months.
in alleviating chronic pelvic pain. This birth weight or smaller head circumference.
At laparoscopy, women with moderate or
finding is consistent with positions of the
worse endometriosis, substantial pelvic ad- SSRIs have been prescribed for pregnant
American College of Obstetricians and
hesions, or serious adnexal pathology were women with depression since the 1990s,
excluded; others were randomized to LUNA although prenatal exposure to these
or no LUNA (and were blinded to the as- agents is not without risks (JW Womens
10940&nbr =5720) and findings of a
signment). At 3 and 6 months and at 1, 2, 3, Health Oct 2009, p. 75, and BMJ 2009;
Cochrane review (Cochrane Database
and 5 years, participants provided follow-up 339:b3569, JW Womens Health Jul 2007,
Syst Rev 2005; 4:CD001896) regarding
information about pain (based on a visual p. 51, and N Engl J Med 2007; 356:2684).
surgical treatment of dysmenorrhea.
analog scale [VAS]) and quality of life. In a prospective population-based study,
Moreover, the results indicate that
Danish investigators evaluated delivery
Overall, 487 women (mean age, 30) rigorous evaluation of surgical thera-
outcomes of 57,000 pregnancies from
underwent LUNA or no LUNA. Eight pies for this condition is critical.
August 1989 through November 2006.
cases of mild hemorrhage were reported — Andrew M. Kaunitz, MD
Women were categorized into three cohorts:
during performance of LUNA, and one such
Daniels J et al. Laparoscopic uterosacral nerve those who received at least one SSRI dur-
case was converted to an open procedure. ablation for alleviating chronic pelvic pain: ing pregnancy (329); those with histories
Ureteral injury occurred in one participant A randomized controlled trial. JAMA 2009
of psychiatric illness who did not receive
who was not randomized to LUNA. After a Sep 2; 302:955.
SSRIs during pregnancy (4902); and those
median follow-up of 69 months, VAS and
who reported no histories of psychiatric
quality-of-life scores were not significantly
different between groups.
86 WOMEN’S HEALTH Vol. 14 No. 11
Adjusted analysis showed that risk for or no sweeping beginning at 36 weeks’ To resolve conflicting data, researchers
preterm delivery in women treated with gestation (women in the no-sweep group in Western Australia conducted a cohort
SSRIs was twice that of untreated women underwent weekly vaginal examinations). study using information collected about
with histories of psychiatric illness and The protocol for planned VBAC allowed twins during a 7-year period. To remove
those with no histories of psychiatric for hormonal induction of labor and no bias, the investigators compared outcomes
illness. Infants exposed to SSRIs in utero specific time limit for a trial of labor. in all spontaneously conceived (SC) twins
were more likely to have 5-minute APGAR The sweep and no-sweep groups had as well as the subset of unlike-sex (ULS)
scores <7 compared with infants of women similar rates of spontaneous labor (78% SC twins (i.e., dizygotic twins) with those
without psychiatric histories (odds ratio, and 72%, respectively), induction of labor in ART twins, who are predominantly
4.4) as well as infants of those with un- (12% and 10%), and all-cause cesarean dizygotic.
treated psychiatric illnesses (OR, 6.6). delivery (40% and 44%); mean gestational Analysis that was adjusted for potential
Risk for admission to the neonatal inten- age at delivery was 39.6 weeks for both confounders (e.g., socioeconomic status)
sive care unit (NICU) was more than groups. Post hoc analysis, based on whether showed that, compared with ULS SC twins,
twofold higher in SSRI-exposed infants participants had ever achieved vaginal de- ART twins had higher risks for preterm
than in unexposed infants. Mean head liveries, showed no between-group differ- birth, low birth weight, and death. Mean
circumference and birth weight were ences in spontaneous onset of labor; how- length of hospital stay at birth was 2 days
similar among groups after adjusting ever, all participants with prior vaginal longer for ART twins, who were also 60%
for gestational age and other potential deliveries had better overall outcomes than more likely to be admitted to neonatal
confounders. did those who had never delivered vaginally. intensive care nurseries. Risk for hospital
COMMENT admission during the first 3 years of life
Although these results point to associa- was higher in ART twins than in SC twins.
In this group of women with planned
tions between in utero SSRI exposure and vaginal birth after cesarean at term, weekly COMMENT
certain adverse perinatal outcomes, events membrane sweeping did not expedite the These data have important implications for
such as low APGAR scores and NICU onset of spontaneous labor. However, clinicians who provide ART as well as for
admissions have many causes; thus, SSRI the authors included prelabor rupture of those who provide care in the resulting
exposure might not be the crux of this membranes in their definition of sponta- twin pregnancies. The costs of ART to so-
issue. Indeed, pregnant women who re- neous onset of labor; if that criterion had ciety should include the additional burdens
ceived SSRIs were more likely to smoke; been excluded, an effect might have been associated with healthcare for ART twins.
moreover, NICU-admitted infants had seen for membrane sweeping. These results Why ART and ULS SC twins have different
various diagnoses (e.g., jitteriness, sei- differ from those of a Cochrane meta- perinatal outcomes is unclear. As the au-
zures, respiratory problems, infections, analysis, which showed that membrane thors note, this discrepancy could arise
jaundice, hypoglycemia), not all of which sweeping shortened the duration of preg- from parental infertility itself, ART pro-
can be attributed to SSRI withdrawal. nancy; however, the present analysis cen- cedures, greater general scrutiny of infants
Thus, these findings should not be con- ters on women who elected VBAC and born to infertile couples, or a combination
sidered definitive, and decisions to treat might not have experienced prior vaginal of these factors. — Robert W. Rebar, MD
depressed pregnant patients with SSRIs delivery. Larger studies of such women
should be made based on benefits as well Hansen M et al. Twins born following assisted
would be valuable, given their risk for reproductive technology: Perinatal outcome and
as risks (Gen Hosp Psychiatry 2009; repeat cesarean deliveries. admission to hospital. Hum Reprod 2009 Sep;
31:403). — Wendy S. Biggs, MD — Diane J. Angelini, EdD, CNM, FACNM, 24:2321.
Lund N et al. Selective serotonin reuptake inhibitor FAAN, NEA-BC
exposure in utero and pregnancy outcomes. Arch
Pediatr Adolesc Med 2009 Oct; 163:949. Hamdan M et al. Serial membrane sweeping at What Do LGBTQ Youth Want in
term in planned vaginal birth after cesarean: A Healthcare? What We All Want!
randomized controlled trial. Obstet Gynecol
2009 Oct; 114:745. LGBTQ youth ranked competence and
Does Repeated Membrane interpersonal skills among the most im-
Sweeping for VBAC portant qualities of healthcare providers.
Make a Difference? Twins Born Following ART Have Lesbian, gay, bisexual, transgender, and
Weekly membrane sweeping was not ben- Higher Risk for Morbidity Than questioning (LGBTQ) youth are at excess
eficial for women who opted for vaginal Spontaneously Conceived Twins risk for adverse health outcomes, such as
birth after cesarean. ART twins had higher risk for adverse peri- sexually transmitted diseases (STDs),
Membrane sweeping to hasten labor could natal outcomes as well as hospital admissions depression, suicide, and substance abuse;
be advantageous for women who under- during the first 3 years of life. however, information about their health-
go planned vaginal birth after cesarean Twins have higher perinatal morbidity care experiences is lacking. Researchers
(VBAC). To test this approach, investiga- rates than singleton infants — but are developed an internet-based survey to
tors in Malaysia randomized 211 women twins who are conceived following assisted assess healthcare preferences in a diverse
with single transverse lower-segment ce- reproductive technology (ART) at greater sample of >700 LGBTQ youth (mean age,
sarean scars to weekly membrane sweeping risk than those conceived spontaneously? 17 years). Respondents were asked to rank
November 2009 JWatch.org 87
the most important qualities of healthcare ability among 750 women in the six most Marlow LAV et al. Ethnic differences in HPV
providers and offices and to report which populous ethnic minority groups and 200 awareness and vaccine acceptability. J Epidemiol
Community Health 2009 Sep 17; [e-pub ahead of
concerns were most important to discuss white women in the U.K. Data were col- print]. (http://dx.doi.org/10.1136/jech.2008.085886)
with healthcare providers. lected during face-to-face interviews after
Highest-ranked qualities in healthcare provision of appropriate translations of
HPV vaccine informed-consent materials. Do ICDs Work Better for Men
providers were competence, respect, hon-
esty, listening to the patient, treating LGBTQ Overall, 17% of participants were Than for Women?
youth the same as other youth, being non- aware of HPV prior to the interview; how- Implantable cardioverter-defibrillators for
judgmental, and making patients feel com- ever, knowledge varied substantially by preventing sudden cardiac death had no
effect on all-cause mortality in women
fortable. Characteristics viewed as least ethnic group (e.g., 39% of white women,
with advanced heart failure.
important included having the same sex- 8% of African women), age, and religion.
ual orientation as the patient and being the Thirty-eight percent of the 600 partici- Although women constitute a minority of
same sex as the patient. Highly ranked at- pants who had daughters reported that participants in most clinical trials on treat-
tributes of healthcare facilities included they would definitely or probably have ments for cardiovascular disease — and few
cleanliness, acceptance of health insurance, their daughters vaccinated; the remainder such studies are sufficiently powered to ad-
friendliness of office staff, availability of would probably or definitely not accept dress sex-specific outcomes — benefits are
HIV screening, and confidentiality of care. vaccination or were unsure. Acceptability usually assumed to apply equally to men
The most important concerns for discussion varied significantly by ethnicity (range, and women. In a meta-analysis of five ran-
with healthcare providers were depression, 63% of white women–11% of Pakistani domized controlled trials of implantable
side effects of medication, STDs and HIV, women) and by religion (64% of those cardioverter-defibrillators (ICDs) for pre-
suicidal feelings, nutrition, family problems, with no religion, 53% of Christians, 34% of vention of sudden cardiac death (SCD) in
and unsafe sexual behavior. Hindus, and 18% of Muslims), but was un- patients with heart failure, researchers asked
related to age, marital status, and socioeco- whether survival benefits conferred by these
COMMENT devices in men also extend to women.
nomic characteristics. Among all ethnicities,
Internet surveys have certain limitations
the most common reasons for accepting In a pooled population of 934 women
(e.g., socioeconomic bias); moreover, this
vaccination were HPV or cervical cancer and 3810 men, investigators compared out-
particular survey was conducted only in
protection, general health reasons, or posi- comes of ICDs versus medical therapy in pa-
English. Nonetheless, the findings provide
tive feelings about the vaccine. The most tients with low left ventricular ejection frac-
some important data on a very hard to
common reasons for not vaccinating were tion with or without histories of arrhythmia.
reach youth population. Sometimes, clini-
need for more information and concerns The hazard ratio for the effect of ICD im-
cians assume that healthcare of LGBTQ
about safety or promoting sexual activity. plantation on all-cause mortality was 0.78
youth is best provided by those with the
in men (P<0.001) and 1.01 in women.
same sexual orientation and with signifi- COMMENT
cant experience in caring for this popula- U.S. studies have also revealed ethnic and COMMENT
tion. These survey results show that pro- racial differences in attitudes about HPV These results suggest that the benefits of
vider competence and interpersonal skills vaccination, even though the racial mix ICDs for primary prevention of sudden car-
were viewed as much more important. In differs from that in the U.K. Acknowledg- diac death in women are questionable. As an
listening, being nonjudgmental, and word- ing and responding to such differences in editorialist notes, what’s good for the gander
ing questions carefully (e.g., using the term our own practices is worth pursuing, per- might not be good for the goose, at least re-
“partner”), we can provide the best possible haps by inviting mothers to express their garding ICDs. Clearly, we need additional
care to all youth, regardless of their sexual concerns and asking what information they sex-specific data — not only about ICDs,
orientation. — Ann J. Davis, MD need. A broader public-health approach but also about cardiovascular interventions
would involve identifying and working in general. For now, clinicians should in-
Hoffman ND et al. Healthcare preferences of lesbian,
gay, bisexual, transgender and questioning youth. with trusted information sources in vari- form women that the proven benefits of
J Adolesc Health 2009 Sep; 45:222. ous communities to promote awareness ICDs for the primary prevention of SCD
and informed decision-making (in much seem to be limited to men.
the same way that religion-based groups — JoAnne M. Foody, MD
Ethnicity Affects Attitudes
in some black communities have raised
About HPV Vaccination awareness and acceptance of breast cancer
Ghanbari H et al. Effectiveness of implantable car-
dioverter-defibrillators for the primary prevention
Ethnic minority women in the U.K. were screening). The possibility that a vaccine of sudden cardiac death in women with advanced
less likely than white women to know about against a sexually transmitted infection heart failure: A meta-analysis of randomized
HPV and to view vaccination as acceptable. controlled trials. Arch Intern Med 2009
might promote sexual activity among ado-
The human papillomavirus (HPV) vac- Sep 14; 169:1500.
lescents is a concern for many women, re-
cine is routinely recommended for 11- to Redberg RF. Is what is good for the gander really
gardless of ethnicity. This concern can be
good for the goose? Arch Intern Med 2009 Sep 14;
12-year-old girls in the U.S.; however, pa- directly addressed: HPV vaccination has 169:1460.
rental acceptance of the vaccine can vary not been shown to promote sexual activity.
with ethnicity. Researchers assessed HPV — Diane E. Judge, APN/CNP
vaccine knowledge, attitudes, and accept-
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from “Is Laparoscopic Uterosacral Nerve
Ablation Effective for Chronic Pelvic Pain?”
Women with chronic pelvic pain under-
going laparoscopy were randomized to
laparoscopic uterosacral nerve ablation
(LUNA) or no LUNA. Compared with no
LUNA, LUNA was associated with:
A. improved quality of life.
B. excess risk for ureteral injury.
C. excess risk for bleeding.
D. both B and C.
Category: Women’s Health
Exam Title: JW Women’s Health: Chronic Pelvic
Pain, Incontinence, Cervical Biopsy Pain,
Posted Date: Nov 4 2009
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CME FACULTY: Allison Oler, MD
88 WOMEN’S HEALTH Vol. 14 No. 11
NEWS IN CONTEXT
Newly Approved Use for the LNG-IUS
FDA approves the LNG-IUS for treating patients with menorrhagia.
The FDA has approved the levonorgestrel intrauterine system make the LNG-IUS a desirable treatment option for some
(LNG-IUS; Mirena) for treating heavy menstrual bleeding women. Use of the LNG-IUS to control menorrhagia in
in women who also use the device for pregnancy prevention. women who do not need contraception or who use other
In a news release, the FDA cited a manufacturer-sponsored contraceptive methods remains off-label.
study (recently published as an abstract) showing that, com- — Diane E. Judge, APN/CNP
pared with medroxyprogesterone acetate, the LNG-IUS Dr. Andrew M. Kaunitz, Editor-in-Chief of Journal Watch Women’s Health,
was associated with statistically significant reductions in did not contribute to the summation of this information for Journal Watch.
menstrual-blood loss in parous women whose excessive FDA approves additional use for IUD Mirena to treat heavy menstrual
bleeding did not have clear etiologies (except for small bleeding in IUD users. [press release]. Silver Spring, MD: U.S. Food and
Drug Administration; October 1, 2009. (http://www.fda.gov/NewsEvents/
uterine fibroids in some cases). Newsroom/PressAnnouncements/ucm184747.htm)
COMMENT Kaunitz AM et al. Levonorgestrel intrauterine system and medroxyproges-
terone acetate for treatment of heavy menstrual bleeding. Contraception
A small meta-analysis (JW Womens Health Jul 2009, p. 49,
2009 Aug; 80:212.
and Obstet Gynecol 2009; 113:1104) showed the LNG-IUS to
be as effective as endometrial ablation in controlling menor-
rhagia for at least 2 years. The convenience and lower cost of
intrauterine device insertion compared with more-invasive
interventions (endometrial ablation or hysterectomy) should