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					                                                                                                                                                     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

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
                                                        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]. (
 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 Information on our conflict-of-    gery (BCS) have risen substantially dur-                 — Andrew M. Kaunitz, MD
 interest policy can be found at
                                                        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                                                                                                                                 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                    
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 ( 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                                      

                                                                                     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.
    channel your mind away from pain.                            International Association for the Study of Pain.
•   Cognitive-behavioral therapy (CBT) is based on the 
    concept that your thoughts (not uncontrollable outside       National Association of Cognitive-Behavioral Therapists.
    influences, such as people, events, or situations) affect
    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                                                                                                                                    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              (
  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,
                                                Gynecologists (http://www.guideline
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
                                                                                                           illness (51,770).
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                                                                                                                        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]. (
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-
                                                        No part of this newsletter may be reproduced or otherwise incorporated into any information retrieval system without the written
            JW ONLINE CME                               permission of the Massachusetts Medical Society. Printed in the USA. ISSN 1521-4710.

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                                                                                                  Waltham, MA 02451-1413
 from “Is Laparoscopic Uterosacral Nerve
 Ablation Effective for Chronic Pelvic Pain?”
 (p. 83)
 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,
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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. (
     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

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