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					                                                                                                                                                                     December 2009 Vol. 14 No. 12
                                                                                                                                                                         From the publishers of
                                                                                                                                                                  The New England Journal of Medicine

                                                                           WO MEN’S H EA LT H
                                                                                    accessed on the USPSTF website.) The task                                     women likely will be characterized by con-
                                                                                    force recommends biennial screening mam-                                      fusion and even outrage. Several other U.S.
                                                                                    mography for all middle-aged women (age                                       organizations still endorse annual screening
Breast Cancer Screening:                                                            range, 50–74). B recommendation (The                                          beginning at age 40. Although this discrep-
Who, When, and How?                                                                 USPSTF recommends the service.) However,                                      ancy will add to the confusion, it will also
                                                                                    current evidence is insufficient to assess the                                enable clinicians and patients to choose the
New USPSTF guidelines narrow the proposed
                                                                                    benefits and harms of screening mammogra-                                     guideline that is most consistent with their
age range for screening mammography and
recommend biennial screening.                                                       phy in older women (age, ≥75 [I statement]).                                  preconceptions and preferences.
                                                                                         The task force also found that current                                   — Andrew M. Kaunitz, MD
In 2002, the U.S. Preventive Services Task
Force (USPSTF) recommended screening                                                evidence is insufficient to assess the ben-                                   U.S. Preventive Services Task Force. Screening for
mammography every 1 to 2 years for all                                              efits and risks of clinical breast examina-                                   breast cancer: U.S. Preventive Services Task Force
                                                                                    tion that is performed in addition to mam-                                    Recommendation Statement. Ann Intern Med
women 40 or older. In a 2009 update, the                                                                                                                          2009 Nov 17; 151:716.
task force has revised its guidelines based                                         mography in women age ≥40 (I statement),
                                                                                                                                                                  Mandelblatt JS et al. for the Breast Cancer Working
on: 1) a systematic review of the benefits                                          as well as to assess benefits and harms of
                                                                                                                                                                  Group of the Cancer Intervention and Surveillance
and harms of screening; and 2) statistical                                          digital mammography or magnetic reso-                                         Modeling Network (CISNET). Effects of mammog-
modeling to estimate outcomes associated                                            nance imaging compared with film mam-                                         raphy screening under different screening schedules:
                                                                                    mography. (I statement) Teaching women                                        Model estimates of potential benefits and harms.
with annual versus biennial screening that
                                                                                                                                                                  Ann Intern Med 2009 Nov 17; 151:738.
begins and ends at different ages.                                                  to perform breast self-examination is now
                                                                                    discouraged. D recommendation (The                                            Kerlikowske K. Evidence-based breast cancer pre-
     The USPSTF now recommends against                                                                                                                            vention: The importance of individual risk. Ann
                                                                                    USPSTF recommends against the service.)                                       Intern Med 2009 Nov 17; 151:750.
routine screening of younger women (age
range, 40–49). Decisions about screening                                            COMMENT
women younger than 50 should be individu-                                           Understandably, breast cancer screening
alized. C recommendation (The USPSTF                                                generates anxiety among many women.                                                SUMMARY & COMMENT
recommends against routinely providing the                                          Because these new guidelines specify that
                                                                                                                                                                  Can HPV Vaccination Combat
service; the grading system (http://www                                             mammography be performed in fewer
                                                                                                                                                                  Genital Warts?
.ahrq.gov/clinic/uspstf/grades.htm) can be                                          women — and less often — reactions among
                                                                                                                                                                  Yes — and the benefit extends beyond vacci-
                                                                                                                                                                  nated women to their male sexual partners.
                                                                                                                                                                  In mid-2007, Australia began a free quadri-
                                                                    CONTENTS                                                                                      valent human papillomavirus (HPV) vacci-
  SUMMARY & COMMENT                                                                 Reassuring Pregnancy Outcomes                                                 nation program for schoolgirls and young
  Can HPV Vaccination Combat Genital Warts?....... 89                                in Childhood Cancer Survivors .............................. 94              women (age, ≤26); by the end of 2007, about
  BRCA Testing of Women with Ovarian Cancer:                                        Weigh Less at 18 and Midlife,                                                 70% of the target population had received
   Which Strategy Is Best? ......................................... 90              Live Better After 70................................................... 94   all three doses. Now, investigators have as-
  Breast Tenderness After Starting                                                  Intravenous Bisphosphonate Therapy
                                                                                                                                                                  sessed the initial effect of such immuniza-
   Menopausal HT: An Ominous Sign? ..................... 91                           for Postmenopausal Women
                                                                                      with Low Bone Mass ............................................... 95       tion on the incidence of genital warts at a
  Are Oral Contraceptives Safe for Women
   with Family Histories of Breast Cancer? ............. 91                         Fewer Falls with Vitamin D ........................................ 96        large sexual health clinic in Melbourne.
  Immediate Complications More Common                                               CLINICAL PRACTICE GUIDELINE WATCH                                                 Overall, genital warts were diagnosed in
    After Medical Than Surgical Abortions ............... 91                        Breast Cancer Screening:
                                                                                     Who, When, and How? ........................................... 89
                                                                                                                                                                  11% of 36,055 new patients who presented
  PTSD Is Common in Pregnant Women.................... 92
                                                                                    Major Changes in ACOG Cervical Cytology
                                                                                                                                                                  from 2004 through 2008. The proportion
  Future Fertility After Miscarriage                        .................. 93
                                                                                     Screening Recommendations ............................... 92                 of young women (age, <28) with diagnoses
  Evolving Criteria for Placenta Previa ....................... 93
                                                                                    PRACTICE WATCH                                                                of genital warts declined by 25% each
  Are Antibiotics Warranted
                                                                                    Contraception for Women                                                       quarter of 2008 (P<0.001). The proportion
   for Cesarean Delivery Before
                                                                                     Who Receive Anticoagulant Therapy
   Onset of Labor? ......................................................... 94                                                                                   of heterosexual men diagnosed with genital
                                                                                     for Venous Thrombosis ........................................... 95
                                                                                                                                                                  warts decreased by 5% per quarter that
              ALL RIGHTS RESERVED. DISCLOSURE INFORMATION ABOUT OUR AUTHORS CAN BE FOUND AT http://womens-health.jwatch.org/misc/board_disclosures.dtl
90                                                                 WOMEN’S HEALTH                                                               Vol. 14   No. 12

                                                        year (P=0.031). In contrast, the propor-                 personal histories of breast cancer, or
 Andrew M. Kaunitz, MD, Professor and Associate
                                                        tions of older women (age, ≥28), and of                  had family histories of breast or ovarian
 Chair, Department of Obstetrics and Gynecology,        men who have sex with men, who were di-                  cancer (Society of Gynecologic Oncolo-
 University of Florida Health Science Center —          agnosed with genital warts remained stable,              gists [SGO] recommendation)
                                                        as did the proportion of patients who pre-             3. Testing only if index cancer was serous
                                                        sented with genital herpes.                               (the most common form of ovarian
 Mary A. Nastuk, PhD
 Massachusetts Medical Society                                                                                    cancer)
 DEPUTY EDITOR                                          The benefit of the HPV quadrivalent vac-               4. Testing all index cases
 Wendy S. Biggs, MD, Associate Professor,
 Department of Family Practice, Michigan State
                                                        cine extends beyond preventing dysplasia
                                                                                                                    The model was based on the assump-
 University College of Human Medicine; Associate        and cervical cancer — a long-term goal —
                                                                                                               tion that, if index cases tested positive, first-
 Director, Midland Family Medicine Residency            to reducing the burden of genital warts.
 Program, Midland, Michigan                                                                                    degree relatives (FDRs) could be tested and,
                                                        These study findings support benefit of
 PATIENT INFORMATION EDITOR                                                                                    if positive, could undergo prophylactic pro-
                                                        HPV immunization not only to vaccinated
 Diane E. Judge, APN/CNP, Heartland Health                                                                     cedures. Projections were made for two sce-
 Outreach, Heartland Alliance for Human Needs           women but also to their male sexual part-
                                                                                                               narios: the “ideal,” in which all FDRs of
 and Human Rights, Chicago                              ners, and, in turn, to partners’ subsequent
                                                                                                               mutation-positive index cases were tested
 ASSOCIATE EDITORS                                      female partners. Because the vaccine cur-
                                                                                                               and all who were positive underwent pro-
 Diane J. Angelini, EdD, CNM, FACNM, FAAN,              rently is provided only to women, any pro-
 NEA-BC, Associate Clinical Professor of Obstetrics                                                            phylactic surgery; and the “realistic,” in
                                                        tection of men against genital warts is indi-
 and Gynecology and Director, Nurse-Midwifery                                                                  which 50% of FDRs of mutation-positive
 Division, Warren Alpert Medical School of Brown        rect. Clinicians might want to provide these
                                                                                                               cases were tested and ≤70% who were posi-
 University and Women & Infants Hospital of Rhode       emerging data to their patients who are con-
 Island, Providence                                                                                            tive underwent prophylactic surgery.
                                                        sidering immunization. Discussion about
 Ann J. Davis, MD, Associate Professor of                                                                           In the ideal scenario, strategies 2 (i.e.,
 Obstetrics and Gynecology and Pediatrics, Tufts        the benefits of HPV vaccination is likely
 Medical School, New England Medical Center,            to continue, especially given that the FDA             SGO-based), 3, and 4 were associated with
 Boston                                                                                                        approximate costs of US$20,000, $65,000,
                                                        recently approved the quadrivalent vaccine
 Anna Wald, MD, MPH, Professor, Department of                                                                  and $74,000 per life-year gained, respectively,
 Medicine, Epidemiology, and Laboratory Medicine,
                                                        (Gardasil) for preventing genital warts in
 and Medical Director, Virology Research Clinic,        boys (http://www.fda.gov/NewsEvents/                   compared with no testing. In the realistic
 University of Washington, Seattle                      Newsroom/PressAnnouncements/                           scenario, strategies 2, 3, and 4 were asso-
 CONTRIBUTING EDITORS                                   ucm187003.htm) and the bivalent vaccine                ciated with approximate costs of $32,000,
 JoAnne M. Foody, MD, Director, Cardiovascular
                                                        (Cervarix) for preventing cervical cancer              $128,000, and $148,000 per life-year gained,
 Wellness Center, Brigham and Women’s Hospital,
                                                        in girls (http://www.fda.gov/NewsEvents/               respectively, compared with no testing. The
 Robert W. Rebar, MD, Executive Director, American      Newsroom/PressAnnouncements/                           authors concluded that testing ovarian can-
 Society for Reproductive Medicine, Birmingham,         ucm187048.htm). — Anna Wald, MD, MPH                   cer cases according to the SGO strategy rep-
 Alabama                                                                                                       resents a cost-effective approach to lowering
 MASSACHUSETTS MEDICAL SOCIETY                          Fairley CK et al. Rapid decline in presentations of    rates of future breast and ovarian cancers
 Christopher R. Lynch, Vice President for               genital warts after the implementation of a national
                                                        quadrivalent human papillomavirus vaccination          among FDRs and that more-inclusive test-
 Publishing; Alberta L. Fitzpatrick, Publisher
                                                        programme for young women. Sex Transm Infect           ing approaches could prevent more cases
 Cara Adler, Diana Montgomery, Lyn Whinston-
 Perry, Staff Editors; Martin Jukovsky, Copy Editor;    2009 Dec; 85:499.                                      (albeit at substantially higher costs).
 Misty Horten, Layout; Matthew O’Rourke, Director,
 Editorial Operations and Development;                                                                         COMMENT
 Art Wilschek, Christine Miller, Lew Wetzel,            BRCA Testing of Women                                  More women are learning about familial
 Advertising Sales; William Paige, Publishing
 Services; Bette Clancy, Customer Service               with Ovarian Cancer:                                   breast and ovarian cancer and the avail-
                                                        Which Strategy Is Best?                                ability of BRCA testing. When a woman
 Published 12 times a year. Subscription rates per
 year: $129 (U.S.), C$163.81 (Canada), US$156 (Intl);   Testing women of Ashkenazi Jewish ancestry             without a history of cancer informs her cli-
 Residents/Students/Nurses/PAs: $69 (U.S.), C$96.19     or with family histories of breast or ovarian          nician about a first-degree relative who has
 (Canada), US$78 (Intl); Institutions: $249 (U.S.),     cancer was projected to be cost-effective for          ovarian or breast cancer, BRCA testing, if
 C$252.38 (Canada), US$216 (Intl); individual print
 only: $99 (U.S.). Prices do not include GST, HST,
                                                        lowering subsequent cancer rates among                 appropriate, optimally is performed in the
 or VAT. In Canada remit to: Massachusetts Medical      first-degree relatives.                                affected relative. If the test is positive, un-
 Society C/O #B9162, P.O. Box 9100, Postal Station F,
                                                        About 10% of women with ovarian cancer                 affected relatives can be counseled and
 Toronto, Ontario, M4Y 3A5. All others remit to:
 Journal Watch Women’s Health, P.O. Box 9085,           carry BRCA mutations. Investigators devel-             tested. Unfortunately, when I suggest this
 Waltham, MA 02454-9085 or call 1-800-843-6356.         oped a simulation model to estimate costs              strategy to my patients, more often than
 E-mail inquiries or comments via the Contact Us
 page at JWatch.org. Information on our conflict-of-
                                                        and benefits of BRCA testing in women                  not the affected relative does not undergo
 interest policy can be found at JWatch.org/misc/       with ovarian cancer (index cases) using                BRCA testing. This might reflect challenges
 conflict.dtl                                           one of four strategies:                                such as testing costs, reluctance to be test-
                                                        1. No BRCA testing (reference strategy)                ed, and limited access to clinicians who are
                                                                                                               willing to counsel and test. By highlighting
                                                        2. Testing only those index cases who                  the possible benefits and costs associated
                                                           were of Ashkenazi Jewish ancestry, had
December 2009                                                         JWatch.org                                                                            91

with BRCA testing, reports such as this one          diagnosed per 10,000 women-years. The                  vised to initiate routine screening mam-
should lead to more candidates being tested          present analysis suggests that, if new-onset           mography earlier than other women. In
appropriately. — Andrew M. Kaunitz, MD               breast tenderness is present, absolute risk            any case, this systematic review provides
                                                     for breast cancer — although greater — is              reassurance that using OCs will not raise
Kwon JS et al. Preventing future cancer by testing
women with ovarian cancer for BRCA mutations.        still relatively modest. Women who are                 breast cancer risk further in women with
J Clin Oncol 2009 Oct 19; [e-pub ahead of print].    considering initiating or continuing E+P               positive family histories of the disease.
(http://dx.doi.org/10.1200/JCO.2008.21.4684)         HT should be counseled about its risks and             — Andrew M. Kaunitz, MD
                                                     benefits (as has long been recommended).
                                                                                                            Gaffield ME et al. Oral contraceptives and family
Breast Tenderness                                    Those women who experience new-onset                   history of breast cancer. Contraception 2009 Oct;
                                                     breast tenderness upon starting E+P HT                 80:372.
After Starting Menopausal HT:
                                                     should discuss this condition with their
An Ominous Sign?
                                                     clinicians, as it could affect decisions about
In the WHI trial, HT users with new-onset                                                                   Immediate Complications More
                                                     HT choice, dose, and duration, as well as
breast tenderness had higher risk for breast
                                                     strategies for breast cancer surveillance.
                                                                                                            Common After Medical Than
cancer than did HT users without this side                                                                  Surgical Abortions
effect.                                              — Andrew M. Kaunitz, MD
                                                                                                            In a Finnish study, overall incidence of ad-
Breast tenderness is a common side effect            Crandall CJ et al. New-onset breast tenderness after   verse events was low within 42 days after
                                                     initiation of estrogen plus progestin therapy and
associated with initiation of menopausal                                                                    abortion but was higher following medical
                                                     breast cancer risk. Arch Intern Med 2009 Oct 12;
hormone therapy. In a report from the                169:1684.
                                                                                                            abortions than after surgical abortions.
Women’s Health Initiative estrogen-plus-                                                                    Although the long-term complication rate
progestin (E+P) trial, investigators assessed                                                               for both medical and surgical abortion is
self-reported breast tenderness at baseline          Are Oral Contraceptives Safe                           low (JW Womens Health Jul 2009, p. 51),
and after 12 months in relation to HT use            for Women with Family                                  we lack information about the immediate
and risk for breast cancer.                          Histories of Breast Cancer?                            consequences of these procedures. In an
     Among women without breast tender-              Systematic review suggests OC use is not               analysis of national registry data, Finnish
ness at baseline, incidence of breast tender-        associated with additional risk for breast             researchers assessed complications that
                                                     cancer in women with family histories of               occurred within the first 42 days in wom-
ness at 12 months was threefold higher in
                                                     the disease.
participants assigned to HT than among                                                                      en who underwent induced abortions
those assigned to placebo (36.1% vs. 11.8%;          Many women with relatives who have had                 (22,368 medical; 20,251 surgical) at ≤63
P<0.001). Women who reported new-onset               breast cancer are concerned that using hor-            days’ gestation. Medical abortions were
breast tenderness were older and more                monal contraception might further raise                performed with mifepristone (alone or
likely to be black or Latina than were women         their risk for this common malignancy. Re-             with misoprostol or other prostaglan-
without this complaint. More than three              searchers from the World Health Organi-                dins); surgical procedures involved vacu-
quarters of participants who reported new-           zation identified 10 case-control or cohort            um aspiration or dilatation and curettage.
onset breast tenderness (most often rated            studies and 1 pooled analysis in which in-             Women who underwent medical abor-
as mild) had been assigned to HT. Users of           vestigators compared breast cancer risk                tions were slightly younger and more like-
HT who reported new-onset breast tender-             in oral contraceptive (OC) users and non-              ly to be single and primigravidas than
ness had 48% higher risk for breast cancer           users with family histories of the disease.            were women in the surgical cohort. Dura-
than did HT users who did not report this                 Seven studies and the pooled analysis             tion of pregnancy was substantially short-
complaint (P=0.02). In contrast, new-                showed no association between OC use and               er in the medical cohort, as surgical pro-
onset breast tenderness in women who                 invasive breast cancer among women with                cedures in Finland usually are performed
were assigned to placebo was not asso-               family histories of the disease. One study             after 42 days’ gestation.
ciated with elevated breast cancer risk.             noted that OC use (compared with never
                                                     use) among women with positive family
COMMENT                                                                                                        JOURNAL WATCH ONLINE
                                                     histories was not associated with excess risk
Breast tenderness has been linked to high
                                                     for ductal carcinoma in situ. Although three
mammographic density, an independent                                                                          • Catch up on news from
                                                     studies showed higher risk among OC users
risk factor for breast cancer. New-onset                                                                        the 2009 American Heart
                                                     than among nonusers, the associations were
breast tenderness is also common among                                                                          Association annual conference,
                                                     primarily among specific subgroups. Thus,
women when they begin HT and generally                                                                          including our physician editors’
                                                     the WHO recommends that no restrictions
is dose-dependent. The results of this analy-                                                                   perspectives.
                                                     be placed on OC use in women with family
sis suggest that new-onset breast tender-                                                                     • “Should We Be Focusing on
                                                     histories of breast cancer.
ness predicts higher risk for breast cancer                                                                     Resident Burnout and Quality
in women who use E+P HT. To put this ex-             COMMENT                                                    of Life?” Read and weigh in via
cess risk in perspective, recall that the origi-     Women with relatives who have breast can-                  Reader Remarks.
nal E+P trial results showed that use of             cer might express concern about the safety
estrogen-progestin HT was associated                 of OC use. Based on the specifics of their                           JWatch.org/online
with eight additional cases of breast cancer         family histories, such women might be ad-
92                                                          WOMEN’S HEALTH                                                                   Vol. 14   No. 12

                                           CLINICAL PRACTICE GUIDELINE WATCH

                       Major Changes in ACOG Cervical Cytology Screening Recommendations
              New guidelines recommend less-frequent screening that begins at age 21 regardless of age at onset of sexual activity.

     The American College of Obstetricians and Gynecologists                  •   Cervical cancer screening is unnecessary in women who
     (ACOG) recently recommended important changes in cervi-                      have undergone hysterectomies for benign disease and
     cal cytology screening practices. Revisions to these guidelines,             who have no histories of CIN.
     which are not intended to impose absolute protocols for screen-          •   Discontinuation of screening after age 65 or 70 is reason-
     ing and treatment, largely stem from a better understanding of               able in women with ≥3 negative consecutive tests and no
     the natural history of human papillomavirus (HPV) infections.                cervical abnormalities during the previous decade.
     HPV transmission is very common; however, more than three
                                                                              •   Women with histories of CIN 2, 3 or cancer should
     quarters of women — especially those who are in their early
                                                                                  undergo annual screening for 20 years after treatment.
     20s or younger — clear their HPV infections within 8 to 24
     months. Cervical cancer in young women is extremely rare                 •   HPV vaccination does not change these recommendations.
     (1–2 cases per million women who are 15–19 years of age).                COMMENT
     Evaluations such as colposcopy and excisional procedures often           Although ACOG’s new cervical screening recommendations
     are stressful, especially to young women, in whom cervical ab-           are not linked in any way to the revised breast screening
     normalities are most likely to resolve. Excisional procedures are        recommendations (JW Womens Health this issue, p. 89)
     associated with excess risk for cervical incompetence, which             recently published by the U.S. Preventive Services Task Force,
     can lead to premature births.                                            the temporal proximity of both new positions might fuel added
     Highlights of the revised ACOG guidelines are:                           controversy, especially in light of the ongoing debates about
                                                                              healthcare reform. If patients and clinicians alike agree with
     •   Cervical cancer screening should begin at age 21 regardless
                                                                              these new guidelines, will women access gynecologic care less
         of age at onset of sexual activity.
                                                                              often? The public must understand that annual gynecologic
     •   Cervical cytology screening from age 21 to 29 is recom-              evaluation has other indications: For example, sexually active
         mended every 2 years but should be more frequent in                  women who are ≤24 should undergo annual chlamydia screen-
         women who are HIV-positive, are immunosuppressed,                    ing (JW Womens Health Jun 2009, p. 45, and MMWR Morb
         were exposed in utero to diethylstilbestrol, or have been            Mortal Wkly Rep 2009; 58:362), and any woman with abnormal
         treated for cervical intraepithelial neoplasia (CIN) 2, 3 or         vaginal discharge, pain, or other such concerns should sched-
         cervical cancer.                                                     ule a pelvic exam. We, as women’s healthcare providers, face
     •   Women age ≥30 who have three consecutive negative                    especially difficult decisions as we individualize the line be-
         screens and who do not fit the above criteria for more-              tween doing good and doing no harm. — Ann J. Davis, MD
         frequent screening may be tested every 3 years. Co-testing
                                                                              ACOG Committee on Practice Bulletins — Gynecology. ACOG Practice
         with cervical cytology and high-risk HPV typing is also              Bulletin No. 109: Cervical cytology screening. 2009 Dec; 114:1409. (http://
         appropriate; if both tests are negative, rescreening in 3            journals.lww.com/greenjournal/documents/PB109_Cervical_Cytology_
         years is warranted.                                                  Screening.pdf)

     The overall incidence of adverse events      gestation (JW Womens Health Mar 2008,                  PTSD Is Common
was low but was substantially higher in the       p. 20, and MMWR Surveill Summ 2007;                    in Pregnant Women
medical cohort (20%) than in the surgical         56:1). The Finnish healthcare system docu-             Among nulliparous women, those with
cohort (6%). Hemorrhage was the most              ments all abortion procedures (whereas the             histories of abuse or difficult miscarriage
common complication (16% medical vs.              U.S. system does not); thus, this study                or abortion had the highest risk for PTSD.
2% surgical); surgical evacuation or re-          provides an especially comprehensive pic-              Post-traumatic stress disorder (PTSD)
evacuation was required after 3% and 1% of        ture of complication rates for both forms              during pregnancy is associated with mater-
medical and surgical abortions, respectively.     of abortion. Women who have a choice of                nal risk behaviors (e.g., smoking, substance
Incomplete abortions occurred in 7% of the        abortion procedures should be counseled                use) and adverse neonatal and maternal
medical group (usually necessitating surgi-       that both procedures have low rates of                 outcomes. Diagnostic criteria for PTSD are
cal intervention) and in 2% of the surgical       serious complications but that bleeding                shown in the table on page 93.
group. Incidence of hemorrhage fell with          and incomplete abortion (requiring fur-
longer gestation in the medical group. In-        ther intervention) are more common fol-                    Researchers conducted a telephone sur-
fection rates were low in both groups.            lowing medical abortions.                              vey to examine the prevalence of and risk
                                                  — Diane E. Judge, APN/CNP
                                                                                                         factors for PTSD among 1581 nulliparous
COMMENT                                                                                                  pregnant women. Participants (age, ≥18;
Most reported abortions in the U.S. are           Niinimäki M et al. Immediate complications after       <28 weeks’ gestation) were racially and eth-
                                                  medical compared with surgical termination of preg-
surgical, and more than half of surgical                                                                 nically diverse (minority women were 45%
                                                  nancy. Obstet Gynecol 2009 Oct; 114:795. (http://
procedures are performed at ≤56 days’             dx.doi.org/10.1097/AOG.0b013e3181b5ccf9)               black, 4% Latina, 7% Asian, 2% Native
December 2009                                                            JWatch.org                                                                       93

American or Alaska Native, and 3% other)                 Future Fertility After                          Smith LFP et al. Incidence of pregnancy after ex-
                                                                                                         pectant, medical, or surgical management of sponta-
and were seen at eight Midwestern mater-                 Miscarriage
                                                                                                         neous first trimester miscarriage: Long term follow-
nity clinics that served primarily privately             About 80% of women had live births within       up of miscarriage treatment (MIST) randomised
or primarily publicly insured patients.                  5 years after miscarriage regardless of         controlled trial. BMJ 2009 Oct 8; 339:b3827.
     Overall, 22% of women reported no                   management mode.                                (http://dx.doi.org/10.1136/bmj.b3827)

histories of trauma, 24% reported trauma                 Management following spontaneous first-
exposures but no PTSD histories, 34%                     trimester miscarriage involves expectant,       Evolving Criteria
reported trauma exposures or histories of                medical, or surgical treatment. Which           for Placenta Previa
PTSD symptoms that did not meet diagnos-                 method is associated with the highest
                                                                                                         How low is low enough to necessitate cesarean
tic criteria (partial PTSD), 12% had histories           subsequent pregnancy rate is unclear. Re-       delivery?
of trauma and PTSD, and 8% met criteria                  searchers randomized 1199 women (mean
                                                                                                         Most obstetric providers use decades-old
for current PTSD. Prevalences of lifetime                age, 31) in England who experienced
                                                                                                         terminology to describe placenta previa as
and current PTSD were higher at primarily                first-trimester (<13 weeks’ gestation) in-
                                                                                                         complete, partial, or marginal. However,
publicly insured sites than at primarily pri-            dex miscarriages between 1997 and 2001
                                                                                                         transvaginal sonography (TVS) has yielded
vately insured sites (lifetime PTSD, 24% vs.             to surgical evacuation, medical treatment
                                                                                                         a more clinically useful measurement: the
17%; current PTSD, 14% vs. 3%). Women                    (mifepristone, misoprostol, or both), or
                                                                                                         distance between the internal cervical os
with current PTSD were younger and initi-                expectant management. From 2005 to
                                                                                                         and the placenta. A distance of ≤20 mm
ated prenatal care later during pregnancy                2007, follow-up questionnaires were sent
                                                                                                         from placental edge to internal cervical os
than did other women regardless of race,                 to participants and their physicians about
                                                                                                         is becoming a new criterion for performing
ethnicity, or socioeconomic and educational              miscarriage management methods and
                                                                                                         term cesarean delivery in women with pla-
levels. Regression analysis showed that                  subsequent pregnancies and live births.
                                                                                                         centa previa. In a retrospective study at a
women who reported abuse or “a difficult                      Having experienced a previous mis-         single Italian hospital, researchers assessed
time due to an abortion or miscarriage” had              carriage predicted lower fertility: 85% of      delivery modes and outcomes of singleton
the highest risk for current PTSD. Each ad-              women with no prior miscarriages delivered      pregnancies among women with placenta
ditional risk factor (e.g., socioeconomic sta-           live infants versus 74%, 67%, and 58% of        previa that was detected with TVS <28 days
tus, type of worst trauma, previous mental               women with 1, 2, or ≥3 previous miscar-         before delivery. Placenta previa was diag-
health treatment, depression or anxiety di-              riages, respectively. Older maternal age also   nosed if the placental edge was within 20
agnosis, family problems) further raised                 predicted lower fertility and longer times      mm of the internal os or overlapped it. La-
risk for PTSD during pregnancy. Prevalence               before subsequent births. Among women           bor was allowed in women who had placen-
of untreated PTSD was 7%.                                who had experienced index miscarriages,         tal edges from 1 mm to 20 mm of the inter-
COMMENT                                                  about 80% had given birth within 5 years,       nal os, cephalic presentation, and no prior
More than 80% of these nulliparous women                 regardless of miscarriage treatment method      cesarean deliveries.
had experienced trauma that could trigger                (79%, 79%, and 82% for expectant, medical,
                                                                                                              In 24 women (group 1), the placental
PTSD, and PTSD was identified even                       and surgical management, respectively).
                                                                                                         edge was from 1 mm to 10 mm of the os;
among lower-risk women. Effective PTSD                   COMMENT                                         in 29 women (group 2), the distance was
treatments are available; prenatal appoint-              Based on these results, clinicians can inform   11 mm to 20 mm. Rates of prelabor bleeding
ments provide an opportunity to evaluate                 women who have miscarried that age and          were higher in group 1 than in group 2 (29%
risk factors, screen, and treat or refer.                the number of previous miscarriages might       vs. 3%; odds ratio, 11.5; 95% confidence in-
Screening tools (www.ncptsd.va.gov/                      affect their future fertility rates, but the    terval, 1.6–76.7) as were rates of cesarean
assessment/screening) are available                      method of miscarriage management will           delivery (75% vs. 31%; OR, 6.7; 95% CI,
online. — Diane E. Judge, APN/CNP                        not. Thus, with her clinician’s guidance, a     2.0–22.0). Rates of postpartum hemorrhage
Seng JS et al. Prevalence, trauma history, and risk      patient can select a miscarriage treatment      were 21% and 10%, respectively, in groups 1
for posttraumatic stress disorder among nulliparous      based on her personal preferences and avail-    and 2; these differences did not reach statis-
women in maternity care. Obstet Gynecol 2009             able resources. — Wendy S. Biggs, MD            tical significance. More than two thirds of
Oct; 4:839.
                                                                                                         placenta previa patients with distances of
                                                                                                         11 mm to 20 mm delivered vaginally. Thus,
                  Diagnostic Criteria for Post-traumatic Stress Disorder                                 a distance of ≥11 mm between the placenta
                                                                                                         and the os predicted lower risk for bleeding
  • Exposure to a traumatic event
                                                                                                         before and during labor as well as greater
  • Persistent reexperiencing of traumatic event in memories or dreams
                                                                                                         likelihood of vaginal birth.
  • Persistent avoidance of stimuli associated with the trauma
  • Persistently heightened arousal and hypervigilance
                                                                                                         Based on their reevaluation of the 20-mm
  • Duration longer than 1 month                                                                         placenta-to-os distance for cesarean deliv-
  • Clinically significant distress or impairment                                                        ery in placenta previa patients, the authors
  Adapted from The Diagnostic and Statistical Manual of Mental Disorders, 4th edition                    advocate a new threshold of ≥11 mm as a
                                                                                                         safe cutoff that allows a woman to advance
94                                                                  WOMEN’S HEALTH                                                               Vol. 14   No. 12

to a trial of labor, and thereby avoid unnec-            large study support the regular use of anti-           nonreproductive cancers. The finding that
essary cesarean delivery. Although the                   biotic prophylaxis before cesarean section.            childhood cancer and its treatment did not
thresholds described in this study might                 The greatest benefit can be achieved if anti-          seem to cause germ cell mutations — evi-
help improve safety outcomes for women                   biotics are administered within an hour                denced by the lack of effect on rates of in-
with placenta previa, confirming them in                 before skin incision (Am J Obstet Gynecol              fant death and congenital malformations,
larger obstetric populations would be ap-                2008; 199:301). — Anna Wald, MD, MPH                   as well as sex ratios — is good news that
propriate. — Diane J. Angelini, EdD, CNM,                                                                       should be shared with patients and their
                                                         Dinsmoor MJ et al. Perioperative antibiotics prophy-
FACNM, FAAN, NEA-BC                                      laxis for nonlaboring cesarean delivery. Obstet        families. However, the current study is
                                                         Gynecol 2009 Oct; 114:752.                             only relevant to women who achieved live
Vergani P et al. Placenta previa: Distance to internal
os and mode of delivery. Am J Obstet Gynecol                                                                    births; issues such as ovarian insufficiency
2009 Sep; 201:266.                                                                                              after chemotherapy or radiation were not
                                                         Reassuring Pregnancy Outcomes
                                                                                                                analyzed. — Ann J. Davis, MD
                                                         in Childhood Cancer Survivors
Are Antibiotics Warranted                                Offspring of women with childhood cancer               Mueller BA et al. Pregnancy outcomes in female
                                                                                                                childhood and adolescent cancer survivors: A
for Cesarean Delivery                                    histories were not at excess risk for malfor-
                                                                                                                linked cancer-birth registry analysis. Arch
Before Onset of Labor?                                   mations or infant death; preterm birth and             Pediatr Adolesc Med 2009 Oct; 163:879.
                                                         cesarean delivery were somewhat more
Perioperative antibiotic prophylaxis substan-
                                                         common among childhood cancer survivors.
tially lowered risk for postpartum infection.
                                                         As the number of young cancer survivors                Weigh Less at 18 and Midlife,
Because risk for infection is >50% among
                                                         grows, so do concerns about the effects of             Live Better After 70
women who undergo cesarean delivery
                                                         treatment on reproductive outcomes. In a               Women who were overweight or obese at age
during labor, perioperative antibiotics
                                                         retrospective cohort study based on Surveil-           18 or who gained weight into midlife were
are indicated for such patients. However,
                                                         lance, Epidemiology and End Results cancer             less likely to be healthy after age 70.
whether such prophylaxis is necessary for
women who undergo cesarean delivery                      registries and on birth records, researchers           With more people living longer and the
before the onset of labor is less clear. In a            evaluated outcomes of first live births in             prevalence of obesity on the rise, under-
prospective observational study of 9432                  almost 2000 women with histories of child-             standing the relation between healthy lon-
women who underwent nonlaboring cesar-                   hood or adolescent cancers (genital tract              gevity and body weight is becoming more
ean deliveries at term, investigators evalu-             cancers were analyzed separately) compared             important. In a subanalysis of data from the
ated the efficacy of antibiotic prophylaxis.             with 14,300 women without cancer histories.            Nurses’ Health Study, researchers evaluated
Participants were free of active infection                    Overall, cancer survivors’ offspring              self-reported weight at age 18 and midlife
during pregnancy or at delivery; 64% re-                 were not at excess risk for malformations or           in relation to health status, physical limita-
ceived perioperative antibiotics (most                   infant death; moreover, sex ratios were simi-          tions, and cognitive status among partici-
commonly, a cephalosporin).                              lar to those in children of women who did              pants who survived until at least age 70.
                                                         not have childhood or adolescent cancer his-           Women defined as healthy survivors had
     At study entry, women who received                                                                         none of several conditions (e.g., cancer,
antibiotics were at higher risk for infection            tories. Infants born to cancer survivors were
                                                         more likely to be delivered before 37 weeks’           diabetes, myocardial infarction, conges-
than those who did not. Multivariate analy-                                                                     tive heart failure, stroke, kidney failure,
ses showed that the odds of postpartum                   gestation (relative risk, 1.5) and to weigh
                                                         <2500 g (RR, 1.3); risks for preterm delivery          Parkinson disease, multiple sclerosis) and
endometritis and of wound infection were                                                                        had no major impairments in cognitive or
significantly lower among women who                      and birth weight <2500 g also were modestly
                                                         elevated for offspring of genital tract cancer         physical function or mental health. Those
received peripartum antibiotics (adjusted                                                                       defined as usual survivors did not meet all
odds ratios, 0.4 and 0.5, respectively). The             survivors (RR, 1.3). Cesarean delivery was
                                                         not more common in women with histories                of these criteria.
authors estimated that, to prevent one seri-
ous infection, 113 low-risk women would                  of cancers in the abdomen or pelvis but was                 Women who were healthy survivors
have to receive perioperative antibiotics.               twice as common in bone cancer survivors               (9.9% of all survivors) smoked less and fol-
This high number needed to treat reflects                as in controls.                                        lowed better diets at study entry in 1976
low baseline rates of postpartum endometri-                                                                     (mean age, 50) than did usual survivors.
tis (2.2%) and wound infection (0.7%) in                                                                        Adjusted analysis showed that women with
                                                         The conclusions of this large study are re-
the hospitals that were involved in the study.                                                                  BMI ≥25 kg/m2 at age 18 were 33% less
                                                         assuring. I have found that many parents
                                                                                                                likely to be healthy after age 70 than women
                                                         and their daughters have major concerns
                                                                                                                who were lean (BMI range, 18.5–22.9) at
Cost, as well as the potential for allergic re-          about the effects of cancer treatment (par-
                                                                                                                age 18. Women who were lean at age 18 but
sponses and development of resistance, is a              ticularly if it involves the reproductive
                                                                                                                who had gained >10 kg by study entry were
concern with routine antibiotic use. How-                tract) on later pregnancy outcomes. Pre-
                                                                                                                almost 60% less likely to be healthy survi-
ever, risk for infection incurred during non-            liminary discussions about potential birth
                                                                                                                vors than were women who maintained
laboring cesarean delivery (albeit already               outcomes should be presented in child-
                                                                                                                stable weights until midlife. For every 1-kg
low) can be diminished further with peri-                friendly language at the time of initial
                                                                                                                increase in weight gain since age 18, the
operative antibiotics. The results of this               treatment, whether for reproductive or
                                                                                                                odds of healthy survival fell by 5%.
December 2009                                                      JWatch.org                                                                     95

                                                                                     PRACTICE WATCH
In using BMI at age 18 as a comparator and
excluding women who had chronic diseases
                                                                     Contraception for Women Who Receive
at study entry, the investigators shed light
                                                                  Anticoagulant Therapy for Venous Thrombosis
on body weight as a cause, not a conse-
quence, of chronic disease. Clinicians                              The levonorgestrel IUD and injectable contraception are safe
                                                                       and effective options with noncontraceptive benefits.
should encourage weight-loss efforts in
women of all ages and, with these findings             For women with histories of venous           COMMENT
in mind, should emphasize the impor-                   thromboembolism (VTE) who require            Both pregnancy and use of estrogen-
tance of weight control during adoles-                 anticoagulant therapy, choosing appro-       containing contraceptives are associated
cence and midlife to prevent chronic dis-              priate contraception can be challeng-        with excess risk for VTE; moreover,
eases and health-related limitations later.            ing. WHO investigators reviewed pub-         warfarin use is associated with birth
— Wendy S. Biggs, MD                                   lications that addressed contraceptive       defects as well as heavy menstrual
Sun Q et al. Adiposity and weight change in mid-       use in women who received anticoagu-         bleeding and hemorrhage from post-
life in relation to healthy survival after age 70 in   lant therapy for current VTE, those          ovulatory cysts. Accordingly, effective
women: Prospective cohort study. BMJ 2009 Sep 29;      who received such therapy for other in-      contraception is important for women
339:b3796. (http://dx.doi.org/10.1136/bmj.b3796)                                                    with histories of VTE who receive anti-
                                                       dications (e.g., prosthetic heart valves),
                                                       and those with heavy menstrual bleed-        coagulant therapy. Because progestin-
Intravenous Bisphosphonate                             ing associated with disorders such as        only (“mini”) pills and progestin
Therapy for Postmenopausal                             von Willebrand disease. Highlights of        implants do not predictably diminish
Women with Low Bone Mass                               the WHO observations and recommen-           heavy menstrual bleeding, these methods
                                                       dations are:                                 are less appropriate than DMPA or the
IV zoledronic acid prevented bone loss.
                                                                                                    LNG-IUD for anticoagulated women
Oral bisphosphonate therapy prevents                   •   Progestin-only contraceptives do
                                                                                                    with heavy bleeding (JW Womens
BMD loss in postmenopausal women, but                      not seem to raise risk for VTE.
                                                                                                    Health Oct 2009, p. 73). Preventing
long-term adherence is poor. In a 2-year               •   Women with histories of VTE who          ovulatory hemorrhage in anticoagulated
industry-supported trial, 581 postmeno-                    are on anticoagulant therapy should      women requires an agent that suppresses
pausal women (mean age, 60; 93% white)                     not use estrogen-progestin contra-       ovulation reliably. Hence, DMPA is
with low BMD were randomized to one of                     ceptives (oral, transdermal, or vagi-    appropriate in this context, whereas
three regimens: 5-mg infusion of zoledron-                 nal ring).                               the LNG-IUD, implants, and minipills
ic acid (Reclast) at baseline and at month             •   The levonorgestrel-releasing             (which do not consistently prevent ovu-
12; zoledronic acid infusion at baseline and               intrauterine device (LNG-IUD)            lation) are not. Consistent with these
placebo at month 12; or placebo at baseline                is effective for heavy menstrual         recommendations, most clinicians
and month 12. Low BMD was defined as                       bleeding that is associated with         are reluctant to prescribe estrogen-
BMD T-score <–1.0 and >–2.5 at the lum-                    anticoagulation or bleeding dis-         containing contraceptives for anti-
bar spine and >–2.5 at the femoral neck.                   orders, and might be safer than          coagulated women. However, no evi-
     At 24 months, mean spinal BMD was                     surgical treatment.                      dence suggests thatestrogen-containing
substantially higher, relative to baseline,            •   Suppression of ovulation with de-        contraceptives further raise VTE risk
among women in the single-dose (4.4%                       pot medroxyprogesterone acetate          in women who receive warfarin chron-
change) and two-dose (5.2% change)                         (DMPA) is effective in preventing        ically. If patients will not accept or can-
treatment arms than in the placebo arm                     recurrent hemorrhage from post-          not use the LNG-IUD or DMPA in this
(–1.31% change). Increases in BMD at the                   ovulation cysts.                         setting, use of estrogen-progestin pills,
hip were also significantly greater with ac-           •   Insertion of IUDs and contraceptive      patch, or ring (with ongoing INR mon-
tive treatment than with placebo. Rates of                 implants — and deep injections of        itoring) can be considered.
serious adverse events were similar in the                                                          — Andrew M. Kaunitz, MD
                                                           DMPA — seem to be safe in women
three treatment arms. Pain, fever, chills,                 receiving anticoagulation therapy        Culwell KR and Curtis KM. Use of contracep-
myalgia, and nausea occurred more often                    who have international normalized        tive methods by women with current venous
with zoledronic acid than with placebo;                    ratios (INRs) of 2.0 to 3.0.             thrombosis on anticoagulant therapy: A
most symptoms occurred within 3 days                                                                systematic review. Contraception 2009
                                                       •   Little evidence suggests that hor-       Oct; 80:337.
of infusion and lasted for ≤3 days.
                                                           monal contraceptives interact with
COMMENT                                                    anticoagulation therapies, including
In addition to facilitating treatment adher-               warfarin. Frequent monitoring of
ence, intravenous bisphosphonate therapy                   INRs is important when women on
(which can be administered at infusion cen-                anticoagulation therapy begin hor-
ters) is useful when gastrointestinal con-                 monal contraceptives.
cerns preclude use of oral bisphosphonates.
These trial participants had low bone mass
                                                       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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                                                                                                 Massachusetts Medical Society
  This is one of four questions in a recent Journal
                                                                                                 860 Winter Street
  Watch Online CME exam.
                                                                                                 Waltham, MA 02451-1413
  from “Future Fertility After Miscarriage”
  (p. 93)
  Researchers studied subsequent fertility
  rates among women who had been ran-
  domized to one of three management
  strategies for miscarriage. All of the
  following were associated with di-
  minished live birth rates except:
  A. surgical management of miscarriage.
  B. greater number of previous
  C. longer time between subsequent births.
  D. older maternal age.
  Category: Obstetrics/Fertility
  Exam Title: JW Women’s Health: Miscarriage,
  Pregnancy Weight Gain, Proton-Pump Inhibitors,
  Posted Date: Dec 2 2009
  View this exam and others at http://cme.jwatch.org
  User name and password are required.

  CME FACULTY: Allison Oler, MD

96                                                                  WOMEN’S HEALTH                                                                                 Vol. 14     No. 12

(the authors do not use the term “osteope-             Fewer Falls with Vitamin D                                        COMMENT
nia,” which might inappropriately connote              High-dose vitamin D lowered risk for falls                        These results confirm those of a 2004
high fracture risk). Updated guidelines                in older individuals.                                             meta-analysis that showed that vitamin D
from the National Osteoporosis Foundation                                                                                supplementation lowered fall risk by 22%
                                                       Every year, one in three older adults
(http://www.nof.org/professionals/NOF_                                                                                   (JAMA 2004; 291:1999) and emphasize
                                                       (age, ≥65) experiences at least one fall,
Clinicians_Guide.pdf) recommend that                                                                                     the importance of daily high-dose vita-
                                                       which makes fall prevention an impor-
prescription therapy be considered for post-                                                                             min D. Clinicians routinely recommend
                                                       tant public health issue. Researchers per-
menopausal women who do not have osteo-                                                                                  calcium supplementation for osteoporosis
                                                       formed a meta-analysis of eight double-
porosis but who have moderate or high frac-                                                                              prevention, but they might not recom-
                                                       blind randomized controlled trials to
ture risk based on a combination of BMD                                                                                  mend high-dose vitamin D supplementa-
                                                       evaluate the effect of oral vitamin D
and clinical risk factors. The authors note                                                                              tion. Because fall prevention is crucial to
                                                       supplementation on risk for falls in
that, based on WHO FRAX assessment                                                                                       averting hip fractures, clinicians should
                                                       2624 older adults (81% women).
(http://www.shef.ac.uk/FRAX), which was                                                                                  recommend 700–1000 IU of supplemen-
not available when the study began, many of                 High-dose vitamin D (700–1000 IU                             tal vitamin D daily to maintain patients’
these participants would not be considered             daily) was associated with 19% lower fall                         serum 25(OH)D concentrations at
candidates for prescription therapy. Zole-             risk (number needed to treat, 11 people                           ≥60 nmol/L, especially in women who
dronic acid prevents fractures in osteoporotic         for 2–36 months). Low-dose vitamin D                              are older than 65.
women; these results indicate that it is also          (200–600 IU daily) did not attenuate risk                         — Wendy S. Biggs, MD
suitable for preventing loss of BMD in                 significantly. Serum 25-hydroxyvitamin D3
                                                                                                                         Bischoff-Ferrari HA et al. Fall prevention with
women with low bone mass who are appro-                (25[OH]D) levels of ≥60 nmol/L lowered
                                                                                                                         supplemental and active forms of vitamin D:
priate candidates for pharmacologic therapy.           fall risk by 23%, whereas concentrations                          A meta-analysis of randomised controlled trials.
— Andrew M. Kaunitz, MD                                <60 nmol/L had no significant effect. Sub-                        BMJ 2009 Oct 1; 339:b3692. (http://dx.doi.org/
                                                       group analysis suggested that the effect of                       10.1136/bmj.b3692)
McClung M et al. Zoledronic acid for the prevention    vitamin D was independent of calcium
of bone loss in postmenopausal women with low
bone mass: A randomized controlled trial. Obstet
Gynecol 2009 Nov; 114:999.

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