Gynecology

More than half of reproductive-age women who are eligible for tax credits through the Affordable Care Act marketplaces can’t buy a health plan that covers abortion, either because that coverage is banned in their state or it’s simply not offered.

In a new analysis of ACA health plans available in 2015, the Kaiser Family Foundation found that 1.76 million reproductive-age women live in states that have enacted laws banning abortion coverage through health plans sold on the marketplace. Another 123,000 women live in states where there is no ban, but no health plans offer the coverage. That leaves about 1.26 million reproductive-age women whose incomes are low enough to qualify for insurance subsidies with access to health plans that offer abortion.

Overall, 24 states have enacted bans or restrictions on abortion coverage within ACA marketplace plans, and 7 states have no restrictions but the coverage is still not available.

Researchers with the Kaiser Family Foundation said that it is unclear why some ACA health plans do not offer abortion coverage even in states where there are no restrictions. However, they speculated that the complexity of the ACA’s abortion rules could be a factor.

Under the 2010 health law, federal funds are not allowed to be used to pay for abortions, and states have the authority to enact additional bans and restrictions on whether plans can offer the coverage. For those states where bans are not in place, the health plans must collect an additional fee for abortion coverage and keep this funding separate from federal dollars. Aside from the extra administrative work, these plans must also meet additional reporting requirements and undergo audits.

mschneider@frontlinemedcom.com

@maryellenny

More than half of reproductive-age women who are eligible for tax credits through the Affordable Care Act marketplaces can’t buy a health plan that covers abortion, either because that coverage is banned in their state or it’s simply not offered.

In a new analysis of ACA health plans available in 2015, the Kaiser Family Foundation found that 1.76 million reproductive-age women live in states that have enacted laws banning abortion coverage through health plans sold on the marketplace. Another 123,000 women live in states where there is no ban, but no health plans offer the coverage. That leaves about 1.26 million reproductive-age women whose incomes are low enough to qualify for insurance subsidies with access to health plans that offer abortion.

Overall, 24 states have enacted bans or restrictions on abortion coverage within ACA marketplace plans, and 7 states have no restrictions but the coverage is still not available.

Researchers with the Kaiser Family Foundation said that it is unclear why some ACA health plans do not offer abortion coverage even in states where there are no restrictions. However, they speculated that the complexity of the ACA’s abortion rules could be a factor.

Under the 2010 health law, federal funds are not allowed to be used to pay for abortions, and states have the authority to enact additional bans and restrictions on whether plans can offer the coverage. For those states where bans are not in place, the health plans must collect an additional fee for abortion coverage and keep this funding separate from federal dollars. Aside from the extra administrative work, these plans must also meet additional reporting requirements and undergo audits.

mschneider@frontlinemedcom.com

@maryellenny

More than half of reproductive-age women who are eligible for tax credits through the Affordable Care Act marketplaces can’t buy a health plan that covers abortion, either because that coverage is banned in their state or it’s simply not offered.

In a new analysis of ACA health plans available in 2015, the Kaiser Family Foundation found that 1.76 million reproductive-age women live in states that have enacted laws banning abortion coverage through health plans sold on the marketplace. Another 123,000 women live in states where there is no ban, but no health plans offer the coverage. That leaves about 1.26 million reproductive-age women whose incomes are low enough to qualify for insurance subsidies with access to health plans that offer abortion.

Overall, 24 states have enacted bans or restrictions on abortion coverage within ACA marketplace plans, and 7 states have no restrictions but the coverage is still not available.

Researchers with the Kaiser Family Foundation said that it is unclear why some ACA health plans do not offer abortion coverage even in states where there are no restrictions. However, they speculated that the complexity of the ACA’s abortion rules could be a factor.

Under the 2010 health law, federal funds are not allowed to be used to pay for abortions, and states have the authority to enact additional bans and restrictions on whether plans can offer the coverage. For those states where bans are not in place, the health plans must collect an additional fee for abortion coverage and keep this funding separate from federal dollars. Aside from the extra administrative work, these plans must also meet additional reporting requirements and undergo audits.

mschneider@frontlinemedcom.com

@maryellenny

Almost one in five hysterectomies for benign indications were unnecessary, based on 2013 data from 52 Michigan hospitals.

Uterine pathology reports did not match or support the indication for surgery in 18% of the 3,397 hysterectomies reviewed from the Michigan Surgical Quality Collaborative, a state-wide program to improve surgical care. In women under 40 years old, pathology did not support surgery in 38% of hysterectomies for benign indications.

Endometriosis and chronic pain were the most common reasons for unnecessary uterus removal; pathology was unsupportive of surgery in about 40% of those cases. Pathology also was unsupportive in about 14% of women with fibroid or acute uterine bleeding (AUB) and in about 20% of the remaining cases, which were mostly indicated for a blend of bleeding, pain, and other problems (Am. J. Obstet. Gynecol. 2014 Dec 23 [doi:http://dx.doi.org/10.1016/j.ajog.2014.11.031]).

Almost half of the women had no documentation in their charts that alternatives to hysterectomy were tried or even considered. Hormonal management, operative hysteroscopy, endometrial ablation, levonorgestrel intrauterine devices (IUDs), and other approaches were documented in 68% of women under 40 years old, but documentation was less likely in women over 40 years old. Alternatives approaches were more likely in women with larger uteri and in women with endometriosis, but were, overall, “underutilized,” Dr. Daniel Morgan, an associate professor of obstetrics and gynecology at the University of Michigan in Ann Arbor, and his fellow researchers concluded.

Parity, body mass index, insurance, and common medical comorbidities did not seem to influence the use of alternatives in the study.

The researchers noted that checklists for preoperative appropriateness have been shown in previous studies to reduce the rate of benign hysterectomies, and increase the likelihood that pathology will support the reason for the operation.

The checklist approach “could help standardize treatment and ensure appropriate uterine-sparing management has been offered. The use of electronic medical records systems could potentially facilitate this type of standardization with relative ease,” the researchers wrote.

Also, the levonorgestrel IUD, “a highly effective, cost-saving intervention for women with acute uterine bleeding and pelvic pain, was considered [in] only 12%” of the Michigan cases. Increasing its use is another “important area for quality improvement and cost savings,” they added.

“We are now in the process of developing institution-specific reports ... on use of alternatives prior to hysterectomy and rates of negative pathology. It is our goal that each institution in the Collaborative will see their data and act on it accordingly. We hope that it will lead to more use (or at least consideration) of alternatives to hysterectomy and lower rates of negative pathology.”

The Michigan Surgical Quality Collaborative is funded by Blue Cross and Blue Shield of Michigan/Blue Care Network. Dr. Morgan reported no conflicts of interest.

aotto@frontlinemedcom.com

Almost one in five hysterectomies for benign indications were unnecessary, based on 2013 data from 52 Michigan hospitals.

Uterine pathology reports did not match or support the indication for surgery in 18% of the 3,397 hysterectomies reviewed from the Michigan Surgical Quality Collaborative, a state-wide program to improve surgical care. In women under 40 years old, pathology did not support surgery in 38% of hysterectomies for benign indications.

Endometriosis and chronic pain were the most common reasons for unnecessary uterus removal; pathology was unsupportive of surgery in about 40% of those cases. Pathology also was unsupportive in about 14% of women with fibroid or acute uterine bleeding (AUB) and in about 20% of the remaining cases, which were mostly indicated for a blend of bleeding, pain, and other problems (Am. J. Obstet. Gynecol. 2014 Dec 23 [doi:http://dx.doi.org/10.1016/j.ajog.2014.11.031]).

Almost half of the women had no documentation in their charts that alternatives to hysterectomy were tried or even considered. Hormonal management, operative hysteroscopy, endometrial ablation, levonorgestrel intrauterine devices (IUDs), and other approaches were documented in 68% of women under 40 years old, but documentation was less likely in women over 40 years old. Alternatives approaches were more likely in women with larger uteri and in women with endometriosis, but were, overall, “underutilized,” Dr. Daniel Morgan, an associate professor of obstetrics and gynecology at the University of Michigan in Ann Arbor, and his fellow researchers concluded.

Parity, body mass index, insurance, and common medical comorbidities did not seem to influence the use of alternatives in the study.

The researchers noted that checklists for preoperative appropriateness have been shown in previous studies to reduce the rate of benign hysterectomies, and increase the likelihood that pathology will support the reason for the operation.

The checklist approach “could help standardize treatment and ensure appropriate uterine-sparing management has been offered. The use of electronic medical records systems could potentially facilitate this type of standardization with relative ease,” the researchers wrote.

Also, the levonorgestrel IUD, “a highly effective, cost-saving intervention for women with acute uterine bleeding and pelvic pain, was considered [in] only 12%” of the Michigan cases. Increasing its use is another “important area for quality improvement and cost savings,” they added.

“We are now in the process of developing institution-specific reports ... on use of alternatives prior to hysterectomy and rates of negative pathology. It is our goal that each institution in the Collaborative will see their data and act on it accordingly. We hope that it will lead to more use (or at least consideration) of alternatives to hysterectomy and lower rates of negative pathology.”

The Michigan Surgical Quality Collaborative is funded by Blue Cross and Blue Shield of Michigan/Blue Care Network. Dr. Morgan reported no conflicts of interest.

aotto@frontlinemedcom.com

Almost one in five hysterectomies for benign indications were unnecessary, based on 2013 data from 52 Michigan hospitals.

Uterine pathology reports did not match or support the indication for surgery in 18% of the 3,397 hysterectomies reviewed from the Michigan Surgical Quality Collaborative, a state-wide program to improve surgical care. In women under 40 years old, pathology did not support surgery in 38% of hysterectomies for benign indications.

Endometriosis and chronic pain were the most common reasons for unnecessary uterus removal; pathology was unsupportive of surgery in about 40% of those cases. Pathology also was unsupportive in about 14% of women with fibroid or acute uterine bleeding (AUB) and in about 20% of the remaining cases, which were mostly indicated for a blend of bleeding, pain, and other problems (Am. J. Obstet. Gynecol. 2014 Dec 23 [doi:http://dx.doi.org/10.1016/j.ajog.2014.11.031]).

Almost half of the women had no documentation in their charts that alternatives to hysterectomy were tried or even considered. Hormonal management, operative hysteroscopy, endometrial ablation, levonorgestrel intrauterine devices (IUDs), and other approaches were documented in 68% of women under 40 years old, but documentation was less likely in women over 40 years old. Alternatives approaches were more likely in women with larger uteri and in women with endometriosis, but were, overall, “underutilized,” Dr. Daniel Morgan, an associate professor of obstetrics and gynecology at the University of Michigan in Ann Arbor, and his fellow researchers concluded.

Parity, body mass index, insurance, and common medical comorbidities did not seem to influence the use of alternatives in the study.

The researchers noted that checklists for preoperative appropriateness have been shown in previous studies to reduce the rate of benign hysterectomies, and increase the likelihood that pathology will support the reason for the operation.

The checklist approach “could help standardize treatment and ensure appropriate uterine-sparing management has been offered. The use of electronic medical records systems could potentially facilitate this type of standardization with relative ease,” the researchers wrote.

Also, the levonorgestrel IUD, “a highly effective, cost-saving intervention for women with acute uterine bleeding and pelvic pain, was considered [in] only 12%” of the Michigan cases. Increasing its use is another “important area for quality improvement and cost savings,” they added.

“We are now in the process of developing institution-specific reports ... on use of alternatives prior to hysterectomy and rates of negative pathology. It is our goal that each institution in the Collaborative will see their data and act on it accordingly. We hope that it will lead to more use (or at least consideration) of alternatives to hysterectomy and lower rates of negative pathology.”

The Michigan Surgical Quality Collaborative is funded by Blue Cross and Blue Shield of Michigan/Blue Care Network. Dr. Morgan reported no conflicts of interest.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – Trendelenburg position does not materially increase ventilator pressures during laparoscopic gynecologic surgery, according to investigators from McMaster University in Hamilton, Ont.

The use of the Trendelenburg position can sometimes cause tension in the operating room. Surgeons need to roll the small bowel out of the pelvis to get access to their gynecologic targets, but anesthesiologists worry that they’ll have to turn up ventilator pressures – and risk barotrauma – if women are placed in a head-down position. It’s unclear from previous studies if pressures really need to be increased when using a moderate Trendelenburg position, Dr. Stephen Bates, a professor of obstetrics and gynecology at McMaster University, said at a meeting sponsored by the AAGL.

To find out, Dr. Bates and his colleagues monitored peak inspiratory pressures (PIP), pneumoperitoneum pressures, degrees of Trendelenburg, and other factors as 100 women underwent laparoscopic hysterectomies performed by a total of seven surgeons. The women were aged 46 years, on average, and had a mean body mass index of 29 kg/m².

The surgeons opted for an average of 10 degrees Trendelenburg, which resulted in a 1.9 cm H₂0 (7%) increase in PIP from horizontal positioning, up from a mean of 26.7 to 28.6 cm H₂0.

“By all anesthesia standards, this is a trivial change and clinically insignificant,” Dr. Bates said in an interview. “The traditional dogma is that if you put patients in Trendelenburg, you’ll increase the difficulty of ventilating them. That was not the case.”

But body mass index, and to a greater degree pneumoperitoneum pressures, did predict increased ventilator pressures among the women.

“The higher pneumoperitoneum pressures are, the harder it is to ventilate,” Dr. Bates said. “There’s [almost] a linear relationship between PnP [pneumoperitoneum pressures] and ventilator pressures.”

When pneumoperitoneum pressures were reduced from 15 to 10 mm Hg, PIP fell by approximately 10%, but the surgeons – all blinded to the reduction in PnP – did not notice any deterioration in their surgical views, he said.

Taken together, the findings suggest a new way to negotiate Trendelenburg positioning in the operating room. “Anesthesiologists and gynecologic surgeons should consider minimizing the pneumoperitoneum pressure rather than reducing the degree of Trendelenburg,” Dr. Bates said.

The researchers also tested an inflatable pillow that lifted women’s buttocks a few inches above the table. The hope was that it would reduce the degree of Trendelenburg needed for their operations, and subsequently reduce PIP. Surgeons were able to decrease Trendelenburg by about 4 degrees with the pillow, but consistent with the study’s overall findings, it made no real difference in PIP. There was a clinically insignificant drop of 0.3 cm H₂0, from a mean of 28.6 to 28.3 cm H₂0, Dr. Bates said.

Dr. Bates reported having no financial disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – Trendelenburg position does not materially increase ventilator pressures during laparoscopic gynecologic surgery, according to investigators from McMaster University in Hamilton, Ont.

The use of the Trendelenburg position can sometimes cause tension in the operating room. Surgeons need to roll the small bowel out of the pelvis to get access to their gynecologic targets, but anesthesiologists worry that they’ll have to turn up ventilator pressures – and risk barotrauma – if women are placed in a head-down position. It’s unclear from previous studies if pressures really need to be increased when using a moderate Trendelenburg position, Dr. Stephen Bates, a professor of obstetrics and gynecology at McMaster University, said at a meeting sponsored by the AAGL.

To find out, Dr. Bates and his colleagues monitored peak inspiratory pressures (PIP), pneumoperitoneum pressures, degrees of Trendelenburg, and other factors as 100 women underwent laparoscopic hysterectomies performed by a total of seven surgeons. The women were aged 46 years, on average, and had a mean body mass index of 29 kg/m².

The surgeons opted for an average of 10 degrees Trendelenburg, which resulted in a 1.9 cm H₂0 (7%) increase in PIP from horizontal positioning, up from a mean of 26.7 to 28.6 cm H₂0.

“By all anesthesia standards, this is a trivial change and clinically insignificant,” Dr. Bates said in an interview. “The traditional dogma is that if you put patients in Trendelenburg, you’ll increase the difficulty of ventilating them. That was not the case.”

But body mass index, and to a greater degree pneumoperitoneum pressures, did predict increased ventilator pressures among the women.

“The higher pneumoperitoneum pressures are, the harder it is to ventilate,” Dr. Bates said. “There’s [almost] a linear relationship between PnP [pneumoperitoneum pressures] and ventilator pressures.”

When pneumoperitoneum pressures were reduced from 15 to 10 mm Hg, PIP fell by approximately 10%, but the surgeons – all blinded to the reduction in PnP – did not notice any deterioration in their surgical views, he said.

Taken together, the findings suggest a new way to negotiate Trendelenburg positioning in the operating room. “Anesthesiologists and gynecologic surgeons should consider minimizing the pneumoperitoneum pressure rather than reducing the degree of Trendelenburg,” Dr. Bates said.

The researchers also tested an inflatable pillow that lifted women’s buttocks a few inches above the table. The hope was that it would reduce the degree of Trendelenburg needed for their operations, and subsequently reduce PIP. Surgeons were able to decrease Trendelenburg by about 4 degrees with the pillow, but consistent with the study’s overall findings, it made no real difference in PIP. There was a clinically insignificant drop of 0.3 cm H₂0, from a mean of 28.6 to 28.3 cm H₂0, Dr. Bates said.

Dr. Bates reported having no financial disclosures.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – Trendelenburg position does not materially increase ventilator pressures during laparoscopic gynecologic surgery, according to investigators from McMaster University in Hamilton, Ont.

The use of the Trendelenburg position can sometimes cause tension in the operating room. Surgeons need to roll the small bowel out of the pelvis to get access to their gynecologic targets, but anesthesiologists worry that they’ll have to turn up ventilator pressures – and risk barotrauma – if women are placed in a head-down position. It’s unclear from previous studies if pressures really need to be increased when using a moderate Trendelenburg position, Dr. Stephen Bates, a professor of obstetrics and gynecology at McMaster University, said at a meeting sponsored by the AAGL.

To find out, Dr. Bates and his colleagues monitored peak inspiratory pressures (PIP), pneumoperitoneum pressures, degrees of Trendelenburg, and other factors as 100 women underwent laparoscopic hysterectomies performed by a total of seven surgeons. The women were aged 46 years, on average, and had a mean body mass index of 29 kg/m².

The surgeons opted for an average of 10 degrees Trendelenburg, which resulted in a 1.9 cm H₂0 (7%) increase in PIP from horizontal positioning, up from a mean of 26.7 to 28.6 cm H₂0.

“By all anesthesia standards, this is a trivial change and clinically insignificant,” Dr. Bates said in an interview. “The traditional dogma is that if you put patients in Trendelenburg, you’ll increase the difficulty of ventilating them. That was not the case.”

But body mass index, and to a greater degree pneumoperitoneum pressures, did predict increased ventilator pressures among the women.

“The higher pneumoperitoneum pressures are, the harder it is to ventilate,” Dr. Bates said. “There’s [almost] a linear relationship between PnP [pneumoperitoneum pressures] and ventilator pressures.”

When pneumoperitoneum pressures were reduced from 15 to 10 mm Hg, PIP fell by approximately 10%, but the surgeons – all blinded to the reduction in PnP – did not notice any deterioration in their surgical views, he said.

Taken together, the findings suggest a new way to negotiate Trendelenburg positioning in the operating room. “Anesthesiologists and gynecologic surgeons should consider minimizing the pneumoperitoneum pressure rather than reducing the degree of Trendelenburg,” Dr. Bates said.

The researchers also tested an inflatable pillow that lifted women’s buttocks a few inches above the table. The hope was that it would reduce the degree of Trendelenburg needed for their operations, and subsequently reduce PIP. Surgeons were able to decrease Trendelenburg by about 4 degrees with the pillow, but consistent with the study’s overall findings, it made no real difference in PIP. There was a clinically insignificant drop of 0.3 cm H₂0, from a mean of 28.6 to 28.3 cm H₂0, Dr. Bates said.

Dr. Bates reported having no financial disclosures.

aotto@frontlinemedcom.com

State legislatures enacted fewer restrictions on abortion during 2014 than in the previous year, but that downward trend is unlikely to continue in the new year, according to an analysis from the Guttmacher Institute.

In 2014, state legislatures enacted only 26 of the 341 abortion restrictions introduced. And the total number of laws was down sharply from the 70 provisions enacted in 2013. The new laws included new counseling requirements before an abortion, longer waiting periods, second trimester abortion bans, and parental consent requirements.

But Elizabeth Nash, the senior state issues associate at the Guttmacher Institute, said the number of restrictive laws only looks small in comparision to the spike in legislative activity over the last 4 years, during which states enacted 231 laws limiting access to abortion.

“The scale has changed somewhat,” she said.

Some state legislatures that have been actively targeting abortion access, such as Texas, did not meet in 2014, and others had shortened sessions.

This year could bring more abortion restrictions, Ms. Nash said, as more Republican governors and state legislators take office. In 23 states, Republicans now control both legislative chambers and the governor’s office. An expected debate at the federal level on a 20-week abortion ban could also drive activity at the state level, she said.

For those states that do pursue abortion legislation in 2015, Ms. Nash said she expects them to build on existing restrictions, such as extending the waiting period between mandated counseling and an abortion.

“States will look at existing restrictions and try to make them more burdensome,” she said.

In 2014, Oklahoma enacted a requirement that abortion counseling include information on the availability perinatal hospice when a woman is seeking an abortion because of a fetal abnormality. In Alabama, lawmakers extended the waiting period between counseling and obtaining an abortion from 24 to 48 hours. Meanwhile, Mississippi lawmakers banned abortion at 18 weeks post-fertilization, citing fetal pain.

But other states took action to protect access to abortion in 2014. Following a U.S. Supreme Court ruling striking down a Massachusetts law providing a 35-foot buffer zone around abortion clinics, that state’s lawmakers enacted a new law establishing a 25-foot buffer zone for up to 8 hours after a police officer issues a dispersal order. Similarly, New Hampshire set a 25-foot buffer zone around abortion clinics. And in Utah, the legislature waived some counseling requirements in cases in which a woman is obtaining an abortion because of a diagnosed fetal impairment.

mschneider@frontlinemedcom.com

Twitter @maryellenny

State legislatures enacted fewer restrictions on abortion during 2014 than in the previous year, but that downward trend is unlikely to continue in the new year, according to an analysis from the Guttmacher Institute.

In 2014, state legislatures enacted only 26 of the 341 abortion restrictions introduced. And the total number of laws was down sharply from the 70 provisions enacted in 2013. The new laws included new counseling requirements before an abortion, longer waiting periods, second trimester abortion bans, and parental consent requirements.

But Elizabeth Nash, the senior state issues associate at the Guttmacher Institute, said the number of restrictive laws only looks small in comparision to the spike in legislative activity over the last 4 years, during which states enacted 231 laws limiting access to abortion.

“The scale has changed somewhat,” she said.

Some state legislatures that have been actively targeting abortion access, such as Texas, did not meet in 2014, and others had shortened sessions.

This year could bring more abortion restrictions, Ms. Nash said, as more Republican governors and state legislators take office. In 23 states, Republicans now control both legislative chambers and the governor’s office. An expected debate at the federal level on a 20-week abortion ban could also drive activity at the state level, she said.

For those states that do pursue abortion legislation in 2015, Ms. Nash said she expects them to build on existing restrictions, such as extending the waiting period between mandated counseling and an abortion.

“States will look at existing restrictions and try to make them more burdensome,” she said.

In 2014, Oklahoma enacted a requirement that abortion counseling include information on the availability perinatal hospice when a woman is seeking an abortion because of a fetal abnormality. In Alabama, lawmakers extended the waiting period between counseling and obtaining an abortion from 24 to 48 hours. Meanwhile, Mississippi lawmakers banned abortion at 18 weeks post-fertilization, citing fetal pain.

But other states took action to protect access to abortion in 2014. Following a U.S. Supreme Court ruling striking down a Massachusetts law providing a 35-foot buffer zone around abortion clinics, that state’s lawmakers enacted a new law establishing a 25-foot buffer zone for up to 8 hours after a police officer issues a dispersal order. Similarly, New Hampshire set a 25-foot buffer zone around abortion clinics. And in Utah, the legislature waived some counseling requirements in cases in which a woman is obtaining an abortion because of a diagnosed fetal impairment.

mschneider@frontlinemedcom.com

Twitter @maryellenny

State legislatures enacted fewer restrictions on abortion during 2014 than in the previous year, but that downward trend is unlikely to continue in the new year, according to an analysis from the Guttmacher Institute.

In 2014, state legislatures enacted only 26 of the 341 abortion restrictions introduced. And the total number of laws was down sharply from the 70 provisions enacted in 2013. The new laws included new counseling requirements before an abortion, longer waiting periods, second trimester abortion bans, and parental consent requirements.

But Elizabeth Nash, the senior state issues associate at the Guttmacher Institute, said the number of restrictive laws only looks small in comparision to the spike in legislative activity over the last 4 years, during which states enacted 231 laws limiting access to abortion.

“The scale has changed somewhat,” she said.

Some state legislatures that have been actively targeting abortion access, such as Texas, did not meet in 2014, and others had shortened sessions.

This year could bring more abortion restrictions, Ms. Nash said, as more Republican governors and state legislators take office. In 23 states, Republicans now control both legislative chambers and the governor’s office. An expected debate at the federal level on a 20-week abortion ban could also drive activity at the state level, she said.

For those states that do pursue abortion legislation in 2015, Ms. Nash said she expects them to build on existing restrictions, such as extending the waiting period between mandated counseling and an abortion.

“States will look at existing restrictions and try to make them more burdensome,” she said.

In 2014, Oklahoma enacted a requirement that abortion counseling include information on the availability perinatal hospice when a woman is seeking an abortion because of a fetal abnormality. In Alabama, lawmakers extended the waiting period between counseling and obtaining an abortion from 24 to 48 hours. Meanwhile, Mississippi lawmakers banned abortion at 18 weeks post-fertilization, citing fetal pain.

But other states took action to protect access to abortion in 2014. Following a U.S. Supreme Court ruling striking down a Massachusetts law providing a 35-foot buffer zone around abortion clinics, that state’s lawmakers enacted a new law establishing a 25-foot buffer zone for up to 8 hours after a police officer issues a dispersal order. Similarly, New Hampshire set a 25-foot buffer zone around abortion clinics. And in Utah, the legislature waived some counseling requirements in cases in which a woman is obtaining an abortion because of a diagnosed fetal impairment.

mschneider@frontlinemedcom.com

Twitter @maryellenny

Are multiple lesion-directed biopsies better than one at detecting cervical cancer precursors?

Yes. In this observational study of 690 women referred to colposcopy for abnormal cervical screening results, the sensitivity of biopsy in the detection of high-grade squamous intraepithelial lesions (HSIL) increased from 60.6% (95% confidence interval [CI], 54.8–66.6) for a single biopsy to 95.6% (95% CI, 91.3–99.2) for three biopsies.

Wentsensen N, Walker JL, Gold MA, et al. Multiple biopsies and detection of cervical cancer precursors at colposcopy [published online ahead of print November 24, 2014]. J Clin Oncol. pii:JCO.2014.55.9948.

Recent updates of cervical cancer screening protocols have altered the way we screen women but have not changed colposcopic practices, which vary widely in the United States. Investigators funded by the National Cancer Institute studied 690 women (median age, 26 years; range, 18–67 years) who underwent as many as four directed biopsies of distinct acetowhite lesions. HSIL (which included cervical intraepithelial neoplasia [CIN] 2 and 3 and ­invasive cancer) represented the gold standard for the sensitivity of the cervical biopsies.

Colposcopists performed a median of one, three, and four biopsies in women with no observed lesions, acetowhite lesions only, and low- or high-grade colposcopic impressions, respectively. More than 95% of HSIL was found in women noted to have a colposcopic impression of at least low-grade disease.

Although multiple biopsies increased the diagnostic yield in all groups, the ­greatest increase in yield was observed in women with HSIL cytology, positivity for HPV 16, and a colposcopic impression suggesting HSIL. Similar trends were observed for each of the six colposcopists (all well trained and highly experienced), each of whom performed at least 60 colposcopies in the study population.

What this evidence means for practice
When HSIL is missed at colposcopy, the patient is subjected to delayed treatment and repeat assessment. Although multiple biopsies can increase patient discomfort and costs, these findings add to other published data underscoring their value. Instead of biopsying only the worst-­appearing lesion, obtain at least two or three biopsies when distinct lesions, including acetowhite areas, are noted.
                                                                                                                                                       —Andrew M. Kaunitz, MD

How useful is random biopsy when no lesions are seen?

Useful. It identifies approximately 20% of otherwise undetected cases of CIN 2, CIN 3, or worse. The absolute risks of disease associated with the random biopsy were higher for women positive for HPV 16 or 18, according to this large post hoc analysis.

Huh WK, Sideri M, Stoler M, Zhang G, Feldman R, Behrens CM. Relevance of random biopsy at the transformation zone when colposcopy is negative. Obstet Gynecol. 2014;124(4):670–678.

When performing colposcopy for abnormal cytology results or high-risk HPV, clinicians often are faced with an absence of visible lesions. This situation prompts the question: Is a random biopsy warranted?

Details of the study
In a multicenter US study of more than 47,000 women—conducted to assess HPV diagnostics between May 2008 and August 2009—nonpregnant women aged 25 or older with an intact uterus underwent colposcopy after a finding of atypical squamous cells of undetermined significance or higher-grade cytology results or high-risk HPV. Patients and colposcopists were blinded to the results. In women who had satisfactory colposcopy results but no visible lesions, one random biopsy of the squamocolumnar junction was obtained.

Among 2,796 women (mean age, 39.5 years) who underwent random biopsy, the findings were normal, CIN 1, CIN 2, and CIN 3 in 90.0%, 5.7%, 1.3%, and 1.4%, respectively. Among all participants aged 25 and older, random biopsies accounted for 20.9% and 18.9% of the CIN 2 or worse and CIN 3 or worse cases, respectively.

Among women positive for HPV 16 or 18, the likelihood of the random biopsy detecting CIN 2 or worse was 24.7% and 8.6% for those with abnormal cytology or normal cytology, respectively.

What this evidence means for practice
This post hoc analysis underscores the limitations of colposcopy, as have other reports. Just as the findings of Went­sensen and colleagues demonstrate that two or more lesion-directed biopsies increase the diagnostic yield over a single sample, this large study points out the substantial benefit of random biopsy of the squamocolumnar junction when no colposcopic lesions are identified.
                                                                                                                                                      —Andrew M. Kaunitz, MD

Share your thoughts on this article! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Are multiple lesion-directed biopsies better than one at detecting cervical cancer precursors?

Yes. In this observational study of 690 women referred to colposcopy for abnormal cervical screening results, the sensitivity of biopsy in the detection of high-grade squamous intraepithelial lesions (HSIL) increased from 60.6% (95% confidence interval [CI], 54.8–66.6) for a single biopsy to 95.6% (95% CI, 91.3–99.2) for three biopsies.

Wentsensen N, Walker JL, Gold MA, et al. Multiple biopsies and detection of cervical cancer precursors at colposcopy [published online ahead of print November 24, 2014]. J Clin Oncol. pii:JCO.2014.55.9948.

Recent updates of cervical cancer screening protocols have altered the way we screen women but have not changed colposcopic practices, which vary widely in the United States. Investigators funded by the National Cancer Institute studied 690 women (median age, 26 years; range, 18–67 years) who underwent as many as four directed biopsies of distinct acetowhite lesions. HSIL (which included cervical intraepithelial neoplasia [CIN] 2 and 3 and ­invasive cancer) represented the gold standard for the sensitivity of the cervical biopsies.

Colposcopists performed a median of one, three, and four biopsies in women with no observed lesions, acetowhite lesions only, and low- or high-grade colposcopic impressions, respectively. More than 95% of HSIL was found in women noted to have a colposcopic impression of at least low-grade disease.

Although multiple biopsies increased the diagnostic yield in all groups, the ­greatest increase in yield was observed in women with HSIL cytology, positivity for HPV 16, and a colposcopic impression suggesting HSIL. Similar trends were observed for each of the six colposcopists (all well trained and highly experienced), each of whom performed at least 60 colposcopies in the study population.

What this evidence means for practice
When HSIL is missed at colposcopy, the patient is subjected to delayed treatment and repeat assessment. Although multiple biopsies can increase patient discomfort and costs, these findings add to other published data underscoring their value. Instead of biopsying only the worst-­appearing lesion, obtain at least two or three biopsies when distinct lesions, including acetowhite areas, are noted.
                                                                                                                                                       —Andrew M. Kaunitz, MD

How useful is random biopsy when no lesions are seen?

Useful. It identifies approximately 20% of otherwise undetected cases of CIN 2, CIN 3, or worse. The absolute risks of disease associated with the random biopsy were higher for women positive for HPV 16 or 18, according to this large post hoc analysis.

Huh WK, Sideri M, Stoler M, Zhang G, Feldman R, Behrens CM. Relevance of random biopsy at the transformation zone when colposcopy is negative. Obstet Gynecol. 2014;124(4):670–678.

When performing colposcopy for abnormal cytology results or high-risk HPV, clinicians often are faced with an absence of visible lesions. This situation prompts the question: Is a random biopsy warranted?

Details of the study
In a multicenter US study of more than 47,000 women—conducted to assess HPV diagnostics between May 2008 and August 2009—nonpregnant women aged 25 or older with an intact uterus underwent colposcopy after a finding of atypical squamous cells of undetermined significance or higher-grade cytology results or high-risk HPV. Patients and colposcopists were blinded to the results. In women who had satisfactory colposcopy results but no visible lesions, one random biopsy of the squamocolumnar junction was obtained.

Among 2,796 women (mean age, 39.5 years) who underwent random biopsy, the findings were normal, CIN 1, CIN 2, and CIN 3 in 90.0%, 5.7%, 1.3%, and 1.4%, respectively. Among all participants aged 25 and older, random biopsies accounted for 20.9% and 18.9% of the CIN 2 or worse and CIN 3 or worse cases, respectively.

Among women positive for HPV 16 or 18, the likelihood of the random biopsy detecting CIN 2 or worse was 24.7% and 8.6% for those with abnormal cytology or normal cytology, respectively.

What this evidence means for practice
This post hoc analysis underscores the limitations of colposcopy, as have other reports. Just as the findings of Went­sensen and colleagues demonstrate that two or more lesion-directed biopsies increase the diagnostic yield over a single sample, this large study points out the substantial benefit of random biopsy of the squamocolumnar junction when no colposcopic lesions are identified.
                                                                                                                                                      —Andrew M. Kaunitz, MD

Share your thoughts on this article! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

Are multiple lesion-directed biopsies better than one at detecting cervical cancer precursors?

Yes. In this observational study of 690 women referred to colposcopy for abnormal cervical screening results, the sensitivity of biopsy in the detection of high-grade squamous intraepithelial lesions (HSIL) increased from 60.6% (95% confidence interval [CI], 54.8–66.6) for a single biopsy to 95.6% (95% CI, 91.3–99.2) for three biopsies.

Wentsensen N, Walker JL, Gold MA, et al. Multiple biopsies and detection of cervical cancer precursors at colposcopy [published online ahead of print November 24, 2014]. J Clin Oncol. pii:JCO.2014.55.9948.

Recent updates of cervical cancer screening protocols have altered the way we screen women but have not changed colposcopic practices, which vary widely in the United States. Investigators funded by the National Cancer Institute studied 690 women (median age, 26 years; range, 18–67 years) who underwent as many as four directed biopsies of distinct acetowhite lesions. HSIL (which included cervical intraepithelial neoplasia [CIN] 2 and 3 and ­invasive cancer) represented the gold standard for the sensitivity of the cervical biopsies.

Colposcopists performed a median of one, three, and four biopsies in women with no observed lesions, acetowhite lesions only, and low- or high-grade colposcopic impressions, respectively. More than 95% of HSIL was found in women noted to have a colposcopic impression of at least low-grade disease.

Although multiple biopsies increased the diagnostic yield in all groups, the ­greatest increase in yield was observed in women with HSIL cytology, positivity for HPV 16, and a colposcopic impression suggesting HSIL. Similar trends were observed for each of the six colposcopists (all well trained and highly experienced), each of whom performed at least 60 colposcopies in the study population.

What this evidence means for practice
When HSIL is missed at colposcopy, the patient is subjected to delayed treatment and repeat assessment. Although multiple biopsies can increase patient discomfort and costs, these findings add to other published data underscoring their value. Instead of biopsying only the worst-­appearing lesion, obtain at least two or three biopsies when distinct lesions, including acetowhite areas, are noted.
                                                                                                                                                       —Andrew M. Kaunitz, MD

How useful is random biopsy when no lesions are seen?

Useful. It identifies approximately 20% of otherwise undetected cases of CIN 2, CIN 3, or worse. The absolute risks of disease associated with the random biopsy were higher for women positive for HPV 16 or 18, according to this large post hoc analysis.

Huh WK, Sideri M, Stoler M, Zhang G, Feldman R, Behrens CM. Relevance of random biopsy at the transformation zone when colposcopy is negative. Obstet Gynecol. 2014;124(4):670–678.

When performing colposcopy for abnormal cytology results or high-risk HPV, clinicians often are faced with an absence of visible lesions. This situation prompts the question: Is a random biopsy warranted?

Details of the study
In a multicenter US study of more than 47,000 women—conducted to assess HPV diagnostics between May 2008 and August 2009—nonpregnant women aged 25 or older with an intact uterus underwent colposcopy after a finding of atypical squamous cells of undetermined significance or higher-grade cytology results or high-risk HPV. Patients and colposcopists were blinded to the results. In women who had satisfactory colposcopy results but no visible lesions, one random biopsy of the squamocolumnar junction was obtained.

Among 2,796 women (mean age, 39.5 years) who underwent random biopsy, the findings were normal, CIN 1, CIN 2, and CIN 3 in 90.0%, 5.7%, 1.3%, and 1.4%, respectively. Among all participants aged 25 and older, random biopsies accounted for 20.9% and 18.9% of the CIN 2 or worse and CIN 3 or worse cases, respectively.

Among women positive for HPV 16 or 18, the likelihood of the random biopsy detecting CIN 2 or worse was 24.7% and 8.6% for those with abnormal cytology or normal cytology, respectively.

What this evidence means for practice
This post hoc analysis underscores the limitations of colposcopy, as have other reports. Just as the findings of Went­sensen and colleagues demonstrate that two or more lesion-directed biopsies increase the diagnostic yield over a single sample, this large study points out the substantial benefit of random biopsy of the squamocolumnar junction when no colposcopic lesions are identified.
                                                                                                                                                      —Andrew M. Kaunitz, MD

Share your thoughts on this article! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

VANCOUVER, B.C. – A medical cocktail of tranexamic acid, gonadotropin-releasing hormone agonist, and an aromatase inhibitor stops bleeding from uterine arteriovenous malformations and eliminates the malformations on Doppler ultrasound within a few months, according to a small case series from Western University in London, Ont.

The finding could be a “game changer,” if it holds up under further testing, since it appears to resolve uterine arteriovenous malformations (AVMs) without compromising fertility, unlike uterine artery embolization or hysterectomy, said Dr. Angelos Vilos of Western University, the study’s lead investigator.

“We believe that we have come up with a novel and advantageous cocktail [that is] accessible to all physicians,” he said. “It eliminates uterine bleeding and AVMs. We know it’s safe, and all these medications are readily available.”

Dr. Vilos said he plans to use the drug cocktail as a first-line therapy in patients with uterine bleeding from AVMs.

The investigators used uterine tamponade, as needed, to control bleeding in nine women, then gave them oral tranexamic acid (Cyklokapron) 1 g three times daily for 5 days to clot AVM bleeders. The women also received gonadotropin-releasing hormone (GnRH) agonist injections to shrink the uterus and its vasculature – usually one shot of leuprolide, but goserelin was used for one woman – plus oral letrozole 2.5 mg/day for 5 days after the first injection to prevent GnRH flare.

The uterine AVMs “disappeared” on Doppler ultrasound within 3 months, Dr. Vilos said.

Four of the women went on to conceive spontaneously and have live births. Four others are on oral contraceptives. The ninth woman opted for a subsequent tubal ligation.

“We were able to preserve fertility and the uterus in all of these women,” he said.

The patients had been bleeding from uterine AVMs for up to 6 months, most following spontaneous or therapeutic abortions. They all had negative beta–human chorionic gonadotropin and Doppler-confirmed AVMs in the myometrium. Retained products were ruled out in all of the patients. Two women had failed embolization with coils and gel foam, and two women required transfusions before treatment. One woman required uterine tamponade before the protocol.

“These women weren’t resolving on their own,” Dr. Vilos said at the meeting sponsored by AAGL.

Based on previous work, Dr. Vilos said he and his team were comfortable using GnRH agonists and letrozole for endometriosis, and they frequently use tranexamic acid for acute bleeding. “So we kind of put these ideas together,” he said.

Several of the women were hemorrhaging in the middle of the night, and the community hospitals where they were being treated couldn’t do embolization. The hospitals called Western University, a tertiary care center, for assistance. “We initiated the protocol, and they resolved,” Dr. Vilos said. “[It’s] an effective management strategy.”

Dr. Vilos is an advisor for Bayer Healthcare and Actavis. The investigators did not receive outside funding for the work.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – A medical cocktail of tranexamic acid, gonadotropin-releasing hormone agonist, and an aromatase inhibitor stops bleeding from uterine arteriovenous malformations and eliminates the malformations on Doppler ultrasound within a few months, according to a small case series from Western University in London, Ont.

The finding could be a “game changer,” if it holds up under further testing, since it appears to resolve uterine arteriovenous malformations (AVMs) without compromising fertility, unlike uterine artery embolization or hysterectomy, said Dr. Angelos Vilos of Western University, the study’s lead investigator.

“We believe that we have come up with a novel and advantageous cocktail [that is] accessible to all physicians,” he said. “It eliminates uterine bleeding and AVMs. We know it’s safe, and all these medications are readily available.”

Dr. Vilos said he plans to use the drug cocktail as a first-line therapy in patients with uterine bleeding from AVMs.

The investigators used uterine tamponade, as needed, to control bleeding in nine women, then gave them oral tranexamic acid (Cyklokapron) 1 g three times daily for 5 days to clot AVM bleeders. The women also received gonadotropin-releasing hormone (GnRH) agonist injections to shrink the uterus and its vasculature – usually one shot of leuprolide, but goserelin was used for one woman – plus oral letrozole 2.5 mg/day for 5 days after the first injection to prevent GnRH flare.

The uterine AVMs “disappeared” on Doppler ultrasound within 3 months, Dr. Vilos said.

Four of the women went on to conceive spontaneously and have live births. Four others are on oral contraceptives. The ninth woman opted for a subsequent tubal ligation.

“We were able to preserve fertility and the uterus in all of these women,” he said.

The patients had been bleeding from uterine AVMs for up to 6 months, most following spontaneous or therapeutic abortions. They all had negative beta–human chorionic gonadotropin and Doppler-confirmed AVMs in the myometrium. Retained products were ruled out in all of the patients. Two women had failed embolization with coils and gel foam, and two women required transfusions before treatment. One woman required uterine tamponade before the protocol.

“These women weren’t resolving on their own,” Dr. Vilos said at the meeting sponsored by AAGL.

Based on previous work, Dr. Vilos said he and his team were comfortable using GnRH agonists and letrozole for endometriosis, and they frequently use tranexamic acid for acute bleeding. “So we kind of put these ideas together,” he said.

Several of the women were hemorrhaging in the middle of the night, and the community hospitals where they were being treated couldn’t do embolization. The hospitals called Western University, a tertiary care center, for assistance. “We initiated the protocol, and they resolved,” Dr. Vilos said. “[It’s] an effective management strategy.”

Dr. Vilos is an advisor for Bayer Healthcare and Actavis. The investigators did not receive outside funding for the work.

aotto@frontlinemedcom.com

VANCOUVER, B.C. – A medical cocktail of tranexamic acid, gonadotropin-releasing hormone agonist, and an aromatase inhibitor stops bleeding from uterine arteriovenous malformations and eliminates the malformations on Doppler ultrasound within a few months, according to a small case series from Western University in London, Ont.

The finding could be a “game changer,” if it holds up under further testing, since it appears to resolve uterine arteriovenous malformations (AVMs) without compromising fertility, unlike uterine artery embolization or hysterectomy, said Dr. Angelos Vilos of Western University, the study’s lead investigator.

“We believe that we have come up with a novel and advantageous cocktail [that is] accessible to all physicians,” he said. “It eliminates uterine bleeding and AVMs. We know it’s safe, and all these medications are readily available.”

Dr. Vilos said he plans to use the drug cocktail as a first-line therapy in patients with uterine bleeding from AVMs.

The investigators used uterine tamponade, as needed, to control bleeding in nine women, then gave them oral tranexamic acid (Cyklokapron) 1 g three times daily for 5 days to clot AVM bleeders. The women also received gonadotropin-releasing hormone (GnRH) agonist injections to shrink the uterus and its vasculature – usually one shot of leuprolide, but goserelin was used for one woman – plus oral letrozole 2.5 mg/day for 5 days after the first injection to prevent GnRH flare.

The uterine AVMs “disappeared” on Doppler ultrasound within 3 months, Dr. Vilos said.

Four of the women went on to conceive spontaneously and have live births. Four others are on oral contraceptives. The ninth woman opted for a subsequent tubal ligation.

“We were able to preserve fertility and the uterus in all of these women,” he said.

The patients had been bleeding from uterine AVMs for up to 6 months, most following spontaneous or therapeutic abortions. They all had negative beta–human chorionic gonadotropin and Doppler-confirmed AVMs in the myometrium. Retained products were ruled out in all of the patients. Two women had failed embolization with coils and gel foam, and two women required transfusions before treatment. One woman required uterine tamponade before the protocol.

“These women weren’t resolving on their own,” Dr. Vilos said at the meeting sponsored by AAGL.

Based on previous work, Dr. Vilos said he and his team were comfortable using GnRH agonists and letrozole for endometriosis, and they frequently use tranexamic acid for acute bleeding. “So we kind of put these ideas together,” he said.

Several of the women were hemorrhaging in the middle of the night, and the community hospitals where they were being treated couldn’t do embolization. The hospitals called Western University, a tertiary care center, for assistance. “We initiated the protocol, and they resolved,” Dr. Vilos said. “[It’s] an effective management strategy.”

Dr. Vilos is an advisor for Bayer Healthcare and Actavis. The investigators did not receive outside funding for the work.

aotto@frontlinemedcom.com