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Urinary incontinence guidelines recommend nonpharmacologic therapy as first line
Women with stress urinary incontinence should be managed with pelvic floor muscle training as the first-line therapy, according to new guidelines from the American College of Physicians, which also recommended against systemic pharmacologic therapy for the condition.
The review of all English-language literature from 1990 to 2013 on nonsurgical management of urinary incontinence in women found there was high-quality evidence in favor of nonpharmacologic therapy with pelvic floor muscle training as the first-line treatment for both stress and mixed urinary continence.
Defining ‘clinical success’ as a 50% reduction in the frequency of urinary incontinence episodes, the guidelines concluded there was evidence to make a strong recommendation for bladder training in women with urgency urinary incontinence (UI). The addition of pelvic floor muscle training was not found to result in any additional benefit, compared with bladder training alone, for those with urgency incontinence.
While the guidelines advised against pharmacologic therapy for stress incontinence, they did find evidence in favor of pharmacologic therapy as a second-line option for urgency urinary incontinence if bladder training had been unsuccessful, with the choice of agent to be based on tolerability, adverse effect profile, ease of use, and cost.
“Pharmacologic therapies were effective and equally efficacious at managing urgency UI and had a moderate magnitude of benefit in achieving continence rates but were associated with adverse effects,” Dr. Amir Qaseem from the American College of Physicians and his colleagues wrote in the Sept. 15 issue of the Annals of Internal Medicine.
For urgency urinary incontinence, the guidelines found oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, and trospium chloride increased continence rates. However patients were less likely to experience adverse events resulting in discontinuation with solifenacin, and the highest risk of discontinuation was found with oxybutynin.
“Evidence was insufficient to evaluate the comparative effectiveness of nonpharmacologic versus pharmacologic treatments for UI, and nonpharmacologic treatment should be considered first-line therapy.”
The authors also strongly recommended weight loss and exercise to improve continence in obese women, pointing out that the benefits would extend beyond relief of urinary incontinence (Ann. of Intern. Med. 2014 Sept. 15 [doi:10.7326/M13-2410]).
The prevalence of urinary incontinence ranges from one in four women aged 14-21 years, to three-quarters of all women older than 75 years; however, the authors suggested that these figures underestimated the true incidence because at least half of all incontinent women do not tell their physicians.
Because of this fact, the guidelines also suggested that physicians take the lead in routinely asking female patients about troublesome UI symptoms, and following up with a focused history, physical examination, and evaluation of neurologic symptoms.
“Asking such questions as “Do you have a problem with urinary incontinence (of your bladder) that is bothersome enough that you would like to know more about how it could be treated?” as part of a quality-improvement intervention has been shown to increase appropriate care by 15% in patients aged 75 years or older,” the authors wrote.
Some authors declared conflicts of interest including stock options, fees, royalties from a range of private and public organizations. Disclosures can be viewed on the ACP website.
Women with stress urinary incontinence should be managed with pelvic floor muscle training as the first-line therapy, according to new guidelines from the American College of Physicians, which also recommended against systemic pharmacologic therapy for the condition.
The review of all English-language literature from 1990 to 2013 on nonsurgical management of urinary incontinence in women found there was high-quality evidence in favor of nonpharmacologic therapy with pelvic floor muscle training as the first-line treatment for both stress and mixed urinary continence.
Defining ‘clinical success’ as a 50% reduction in the frequency of urinary incontinence episodes, the guidelines concluded there was evidence to make a strong recommendation for bladder training in women with urgency urinary incontinence (UI). The addition of pelvic floor muscle training was not found to result in any additional benefit, compared with bladder training alone, for those with urgency incontinence.
While the guidelines advised against pharmacologic therapy for stress incontinence, they did find evidence in favor of pharmacologic therapy as a second-line option for urgency urinary incontinence if bladder training had been unsuccessful, with the choice of agent to be based on tolerability, adverse effect profile, ease of use, and cost.
“Pharmacologic therapies were effective and equally efficacious at managing urgency UI and had a moderate magnitude of benefit in achieving continence rates but were associated with adverse effects,” Dr. Amir Qaseem from the American College of Physicians and his colleagues wrote in the Sept. 15 issue of the Annals of Internal Medicine.
For urgency urinary incontinence, the guidelines found oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, and trospium chloride increased continence rates. However patients were less likely to experience adverse events resulting in discontinuation with solifenacin, and the highest risk of discontinuation was found with oxybutynin.
“Evidence was insufficient to evaluate the comparative effectiveness of nonpharmacologic versus pharmacologic treatments for UI, and nonpharmacologic treatment should be considered first-line therapy.”
The authors also strongly recommended weight loss and exercise to improve continence in obese women, pointing out that the benefits would extend beyond relief of urinary incontinence (Ann. of Intern. Med. 2014 Sept. 15 [doi:10.7326/M13-2410]).
The prevalence of urinary incontinence ranges from one in four women aged 14-21 years, to three-quarters of all women older than 75 years; however, the authors suggested that these figures underestimated the true incidence because at least half of all incontinent women do not tell their physicians.
Because of this fact, the guidelines also suggested that physicians take the lead in routinely asking female patients about troublesome UI symptoms, and following up with a focused history, physical examination, and evaluation of neurologic symptoms.
“Asking such questions as “Do you have a problem with urinary incontinence (of your bladder) that is bothersome enough that you would like to know more about how it could be treated?” as part of a quality-improvement intervention has been shown to increase appropriate care by 15% in patients aged 75 years or older,” the authors wrote.
Some authors declared conflicts of interest including stock options, fees, royalties from a range of private and public organizations. Disclosures can be viewed on the ACP website.
Women with stress urinary incontinence should be managed with pelvic floor muscle training as the first-line therapy, according to new guidelines from the American College of Physicians, which also recommended against systemic pharmacologic therapy for the condition.
The review of all English-language literature from 1990 to 2013 on nonsurgical management of urinary incontinence in women found there was high-quality evidence in favor of nonpharmacologic therapy with pelvic floor muscle training as the first-line treatment for both stress and mixed urinary continence.
Defining ‘clinical success’ as a 50% reduction in the frequency of urinary incontinence episodes, the guidelines concluded there was evidence to make a strong recommendation for bladder training in women with urgency urinary incontinence (UI). The addition of pelvic floor muscle training was not found to result in any additional benefit, compared with bladder training alone, for those with urgency incontinence.
While the guidelines advised against pharmacologic therapy for stress incontinence, they did find evidence in favor of pharmacologic therapy as a second-line option for urgency urinary incontinence if bladder training had been unsuccessful, with the choice of agent to be based on tolerability, adverse effect profile, ease of use, and cost.
“Pharmacologic therapies were effective and equally efficacious at managing urgency UI and had a moderate magnitude of benefit in achieving continence rates but were associated with adverse effects,” Dr. Amir Qaseem from the American College of Physicians and his colleagues wrote in the Sept. 15 issue of the Annals of Internal Medicine.
For urgency urinary incontinence, the guidelines found oxybutynin, tolterodine, darifenacin, solifenacin, fesoterodine, and trospium chloride increased continence rates. However patients were less likely to experience adverse events resulting in discontinuation with solifenacin, and the highest risk of discontinuation was found with oxybutynin.
“Evidence was insufficient to evaluate the comparative effectiveness of nonpharmacologic versus pharmacologic treatments for UI, and nonpharmacologic treatment should be considered first-line therapy.”
The authors also strongly recommended weight loss and exercise to improve continence in obese women, pointing out that the benefits would extend beyond relief of urinary incontinence (Ann. of Intern. Med. 2014 Sept. 15 [doi:10.7326/M13-2410]).
The prevalence of urinary incontinence ranges from one in four women aged 14-21 years, to three-quarters of all women older than 75 years; however, the authors suggested that these figures underestimated the true incidence because at least half of all incontinent women do not tell their physicians.
Because of this fact, the guidelines also suggested that physicians take the lead in routinely asking female patients about troublesome UI symptoms, and following up with a focused history, physical examination, and evaluation of neurologic symptoms.
“Asking such questions as “Do you have a problem with urinary incontinence (of your bladder) that is bothersome enough that you would like to know more about how it could be treated?” as part of a quality-improvement intervention has been shown to increase appropriate care by 15% in patients aged 75 years or older,” the authors wrote.
Some authors declared conflicts of interest including stock options, fees, royalties from a range of private and public organizations. Disclosures can be viewed on the ACP website.
FROM ANNALS OF INTERNAL MEDICINE
NHLBI expert panel issues guideline on sickle cell disease
The "much anticipated" guideline to help primary care and emergency clinicians improve the management of sickle cell disease includes a consensus treatment protocol for implementing hydroxyurea therapy and more detailed guidance regarding long-term transfusion therapy, according to a summary report published online September 9 in Journal of the American Medical Association.
Sickle cell disease (SCD), a life-threatening genetically transmitted disorder affecting 70,000-100,000 Americans, is associated with a wide array of complex acute and chronic complications that require immediate medical attention. But high-quality data on which to base management decisions are sorely lacking, and clinicians get little in the way of guidance from existing recommendations. One result is that "the two most widely available disease-modifying therapies, hydroxyurea and long-term transfusions, are underused, and hematopoietic stem cell transplantation, the only curative approach, has been used in only a small proportion of affected individuals," said Dr. Barbara P. Yawn and her associates on the National Heart, Lung, and Blood Institute expert panel that issued the summary report.
Even this guideline is somewhat rudimentary due to the dearth of good data "in virtually every area related to SCD management," and cannot help but leave "many uncertainties for health professionals caring for individuals with SCD." But it is hoped that this guideline will furnish a critical foundation for future research and will now begin "to facilitate improved and more accessible care for all affected individuals," said Dr. Yawn, director of research at Olmsted Medical Center, Rochester, Minn., and her associates.
The guideline is based on an extensive literature review of more than 13,000 abstracts and articles, which was winnowed to 1,583 original studies regarding SCD. From this, a team of health care professionals in family medicine, internal medicine, pediatric and adult hematology, psychiatry and mental health, transfusion medicine, obstetrics and gynecology, maternal/fetal medicine, and emergency department nursing compiled the guideline as well as the summary, entitled Evidence-Based Management of Sickle Cell Disease: Expert Panel Report 2014 (JAMA 2014 September 9 [doi:10.1001/jama.2014.10517]).
In addition to establishing a protocol for implementing hydroxyurea therapy, the guideline addresses changes in pneumococcal vaccination recommendations for adults and children; annual transcranial Doppler screening coupled with long-term transfusion therapy when necessary to prevent stroke in children aged 2-16 years; rapid initiation of opioids for severe pain during vasoocclusive crises; analgesics and physical therapy for avascular necrosis; ACE inhibitor treatment for adults with microalbuminuria; referral to specialists for screening and treatment of proliferative retinopathy; echocardiography to assess signs of pulmonary hypertension; and monitoring for iron overload in patients receiving transfusion therapy.
Both the summary report and the full guideline are available at http://www.nhlbi.nih.gov/health-pro/guidelines/sickle-cell-disease-guidelines/.
Yawn et al. have made a monumental effort to produce practical, evidence-based guidelines, but they were hampered at every turn by a pervasive lack of good quality evidence on which to base their recommendations. Still missing from this guideline are suggestions for how often and when to screen for kidney disease, how to screen for and treat the common clinical problem of asthma-like symptoms (when standard therapies are contraindicated in SCD), how to advocate for patients with the common sequelae of silent cerebral infarcts, or when to consider hematopoietic stem-cell transplantation.
The expert panel also failed to include representatives from the people most affected by SCD: patients and their families. Failure to listen to the perspective of the families, understand which of these recommendations are important to them, and deal with the obstacles families face in implementing the recommendations is a critically important omission.
Dr. Michael R. DeBaun is in the department of pediatrics at the Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Nashville. He made his remarks in an editorial accompanying Dr. Yawn’s report (JAMA 2014:312;1004-5). Dr. DeBaun reported no financial conflicts of interest.
Yawn et al. have made a monumental effort to produce practical, evidence-based guidelines, but they were hampered at every turn by a pervasive lack of good quality evidence on which to base their recommendations. Still missing from this guideline are suggestions for how often and when to screen for kidney disease, how to screen for and treat the common clinical problem of asthma-like symptoms (when standard therapies are contraindicated in SCD), how to advocate for patients with the common sequelae of silent cerebral infarcts, or when to consider hematopoietic stem-cell transplantation.
The expert panel also failed to include representatives from the people most affected by SCD: patients and their families. Failure to listen to the perspective of the families, understand which of these recommendations are important to them, and deal with the obstacles families face in implementing the recommendations is a critically important omission.
Dr. Michael R. DeBaun is in the department of pediatrics at the Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Nashville. He made his remarks in an editorial accompanying Dr. Yawn’s report (JAMA 2014:312;1004-5). Dr. DeBaun reported no financial conflicts of interest.
Yawn et al. have made a monumental effort to produce practical, evidence-based guidelines, but they were hampered at every turn by a pervasive lack of good quality evidence on which to base their recommendations. Still missing from this guideline are suggestions for how often and when to screen for kidney disease, how to screen for and treat the common clinical problem of asthma-like symptoms (when standard therapies are contraindicated in SCD), how to advocate for patients with the common sequelae of silent cerebral infarcts, or when to consider hematopoietic stem-cell transplantation.
The expert panel also failed to include representatives from the people most affected by SCD: patients and their families. Failure to listen to the perspective of the families, understand which of these recommendations are important to them, and deal with the obstacles families face in implementing the recommendations is a critically important omission.
Dr. Michael R. DeBaun is in the department of pediatrics at the Vanderbilt-Meharry Center of Excellence in Sickle Cell Disease, Nashville. He made his remarks in an editorial accompanying Dr. Yawn’s report (JAMA 2014:312;1004-5). Dr. DeBaun reported no financial conflicts of interest.
The "much anticipated" guideline to help primary care and emergency clinicians improve the management of sickle cell disease includes a consensus treatment protocol for implementing hydroxyurea therapy and more detailed guidance regarding long-term transfusion therapy, according to a summary report published online September 9 in Journal of the American Medical Association.
Sickle cell disease (SCD), a life-threatening genetically transmitted disorder affecting 70,000-100,000 Americans, is associated with a wide array of complex acute and chronic complications that require immediate medical attention. But high-quality data on which to base management decisions are sorely lacking, and clinicians get little in the way of guidance from existing recommendations. One result is that "the two most widely available disease-modifying therapies, hydroxyurea and long-term transfusions, are underused, and hematopoietic stem cell transplantation, the only curative approach, has been used in only a small proportion of affected individuals," said Dr. Barbara P. Yawn and her associates on the National Heart, Lung, and Blood Institute expert panel that issued the summary report.
Even this guideline is somewhat rudimentary due to the dearth of good data "in virtually every area related to SCD management," and cannot help but leave "many uncertainties for health professionals caring for individuals with SCD." But it is hoped that this guideline will furnish a critical foundation for future research and will now begin "to facilitate improved and more accessible care for all affected individuals," said Dr. Yawn, director of research at Olmsted Medical Center, Rochester, Minn., and her associates.
The guideline is based on an extensive literature review of more than 13,000 abstracts and articles, which was winnowed to 1,583 original studies regarding SCD. From this, a team of health care professionals in family medicine, internal medicine, pediatric and adult hematology, psychiatry and mental health, transfusion medicine, obstetrics and gynecology, maternal/fetal medicine, and emergency department nursing compiled the guideline as well as the summary, entitled Evidence-Based Management of Sickle Cell Disease: Expert Panel Report 2014 (JAMA 2014 September 9 [doi:10.1001/jama.2014.10517]).
In addition to establishing a protocol for implementing hydroxyurea therapy, the guideline addresses changes in pneumococcal vaccination recommendations for adults and children; annual transcranial Doppler screening coupled with long-term transfusion therapy when necessary to prevent stroke in children aged 2-16 years; rapid initiation of opioids for severe pain during vasoocclusive crises; analgesics and physical therapy for avascular necrosis; ACE inhibitor treatment for adults with microalbuminuria; referral to specialists for screening and treatment of proliferative retinopathy; echocardiography to assess signs of pulmonary hypertension; and monitoring for iron overload in patients receiving transfusion therapy.
Both the summary report and the full guideline are available at http://www.nhlbi.nih.gov/health-pro/guidelines/sickle-cell-disease-guidelines/.
The "much anticipated" guideline to help primary care and emergency clinicians improve the management of sickle cell disease includes a consensus treatment protocol for implementing hydroxyurea therapy and more detailed guidance regarding long-term transfusion therapy, according to a summary report published online September 9 in Journal of the American Medical Association.
Sickle cell disease (SCD), a life-threatening genetically transmitted disorder affecting 70,000-100,000 Americans, is associated with a wide array of complex acute and chronic complications that require immediate medical attention. But high-quality data on which to base management decisions are sorely lacking, and clinicians get little in the way of guidance from existing recommendations. One result is that "the two most widely available disease-modifying therapies, hydroxyurea and long-term transfusions, are underused, and hematopoietic stem cell transplantation, the only curative approach, has been used in only a small proportion of affected individuals," said Dr. Barbara P. Yawn and her associates on the National Heart, Lung, and Blood Institute expert panel that issued the summary report.
Even this guideline is somewhat rudimentary due to the dearth of good data "in virtually every area related to SCD management," and cannot help but leave "many uncertainties for health professionals caring for individuals with SCD." But it is hoped that this guideline will furnish a critical foundation for future research and will now begin "to facilitate improved and more accessible care for all affected individuals," said Dr. Yawn, director of research at Olmsted Medical Center, Rochester, Minn., and her associates.
The guideline is based on an extensive literature review of more than 13,000 abstracts and articles, which was winnowed to 1,583 original studies regarding SCD. From this, a team of health care professionals in family medicine, internal medicine, pediatric and adult hematology, psychiatry and mental health, transfusion medicine, obstetrics and gynecology, maternal/fetal medicine, and emergency department nursing compiled the guideline as well as the summary, entitled Evidence-Based Management of Sickle Cell Disease: Expert Panel Report 2014 (JAMA 2014 September 9 [doi:10.1001/jama.2014.10517]).
In addition to establishing a protocol for implementing hydroxyurea therapy, the guideline addresses changes in pneumococcal vaccination recommendations for adults and children; annual transcranial Doppler screening coupled with long-term transfusion therapy when necessary to prevent stroke in children aged 2-16 years; rapid initiation of opioids for severe pain during vasoocclusive crises; analgesics and physical therapy for avascular necrosis; ACE inhibitor treatment for adults with microalbuminuria; referral to specialists for screening and treatment of proliferative retinopathy; echocardiography to assess signs of pulmonary hypertension; and monitoring for iron overload in patients receiving transfusion therapy.
Both the summary report and the full guideline are available at http://www.nhlbi.nih.gov/health-pro/guidelines/sickle-cell-disease-guidelines/.
FROM JAMA
Major finding: The two most widely available disease-modifying therapies for SCD, hydroxyurea and long-term transfusions, are underused, in large part because no evidence-based treatment protocols have been devised until now.
Data source: A review of the literature and compilation of management guidelines "to assist health care professionals in the management of common issues of sickle cell disease."
Disclosures: The National Heart, Lung, and Blood Institute sponsored the development of this guideline. All expert panel members served voluntarily. Many reported numerous ties to industry sources.
USPSTF recommends low-dose aspirin for preeclampsia prevention
The use of low-dose aspirin is advisable after 12 weeks of gestation in asymptomatic pregnant women at high risk for developing preeclampsia, according to a recommendation from the U.S. Preventive Services Task Force.
The recommendation, published online Sept. 8 in the Annals of Internal Medicine, is based on a review of new evidence suggesting that the net benefit of low-dose aspirin for preventing preeclampsia is of substantial magnitude. It updates a 1996 recommendation from the USPSTF, which concluded that there was insufficient evidence at that time to recommend for or against the routine use of aspirin for the prevention of preeclampsia.
The current evidence – including 15 randomized controlled trials used to assess the health benefits of low-dose aspirin, 13 randomized controlled trials used to evaluate preeclampsia incidence, and 19 randomized controlled trials and 2 good-quality observational studies used to evaluate harms associated with low-dose aspirin use – suggests that women at risk may benefit from low-dose aspirin beginning after 12 weeks of gestation.
Preeclampsia complicates 2%-8% of pregnancies worldwide, and accounts for 15% of preterm births and 12% of maternal deaths in the United States, according to the task force.
"The USPSTF found adequate evidence of a reduction in risk for preeclampsia, preterm birth, and IUGR [intrauterine growth restriction] in women at increased risk for preeclampsia who received low-dose aspirin, thus demonstrating substantial benefit. Low-dose aspirin (range, 60-150 mg/day) reduced the risk for preeclampsia by 24% in clinical trials [pooled relative risk, 0.76] and reduced the risk for preterm birth by 14% and IUGR by 20% [pooled relative risk, 0.86 and 0.80, respectively]," the updated recommendation stated (Ann. Intern. Med. 2014 Sept. 8 [doi:10.7326/m14-1884]).
Adequate evidence also indicates that low-dose aspirin is not associated with any increase in the risk of placental abruption, postpartum hemorrhage, fetal intracranial bleeding, or perinatal mortality.
"Evidence on long-term outcomes in offspring exposed in utero to low-dose aspirin is limited, but no developmental harms were identified by age 18 months in the one study reviewed," the task force wrote, concluding – with moderate certainty – that there is a substantial net benefit of daily low-dose aspirin use to reduce the risk for preeclampsia, preterm birth, and IUGR in women at high risk.
The decision to initiate low-dose aspirin therapy in this population is typically based on medical history; there are no validated methods for identifying women at high risk based on biomarkers, clinical diagnostic tests, or medical history. However, as part of the recommendation, the USPSTF provided a pragmatic approach that may help identify those at risk.
"Women with one or more risk factors should receive low-dose aspirin. Women with several moderate risk factors may also benefit from low-dose aspirin," the task force noted, adding that the evidence for the latter approach is less certain, and that clinicians should use clinical judgment and discuss the risks and benefits with patients.
The recommendation applies to asymptomatic women at risk in whom low-dose aspirin is not contraindicated, and defines women at high risk as those with a history of preeclampsia, especially those with an adverse outcome; chronic hypertension, renal disease, type 1 or 2 diabetes, or an autoimmune disease; and those with multifetal gestation, according to the updated recommendation.
Moderate risk factors include nulliparity, obesity, a family history of preeclampsia, age greater than or equal to 35 years, African American race, low socioeconomic status, low birth rate or small for gestational age, greater than 10-year pregnancy interval, or previous adverse pregnancy outcome.
As for appropriate dosing, the most common dosage across studies was 100 mg, but the two largest trials contributing to benefit estimates used 60 mg.
An 81-mg dose was not specifically evaluated, but is commonly available in the United States in tablet form, and is a reasonable dosage for preeclampsia prophylaxis, the task force said.
The updated recommendation is generally in keeping with those of other organizations, including the American College of Obstetricians and Gynecologists, the World Health Organization, the National Institute for Health and Clinical Excellence, the American Heart Association/American Stroke Association, and the American Academy of Family Physicians. For example, ACOG recommends initiating daily low-dose aspirin during the late first trimester in those with a history of early-onset preeclampsia and preterm delivery, or with a history of preeclampsia in more than one prior pregnancy (<cf number="\"2\"">“</cf>American College of Obstetricians and Gynecologists: Hypertension in Pregnancy [Washington, D.C.: American College of Obstetricians and Gynecologists, 2013]), and WHO recommends daily low-dose aspirin as early as 12 weeks for those at high risk ("WHO Recommendations for Prevention and Treatment of Pre-Eclampsia and Eclampsia" [Geneva: World Health Organization, 2011]).
The review by the USPSTF identified several research needs. For example, additional study is needed on the effects of low-dose aspirin on the development of preeclampsia and how patient response is affected by various risk factors. Research is also needed on how to improve clinicians’ ability to identify those at risk, and particularly those who would benefit most from prophylaxis. Study is needed on risk assessment tools, and on populations at particular risk, such as African American and nulliparous women.
Future trials should recruit adequate numbers of women from racial/ethnic populations that are at disproportionate risk.
"Larger studies on aspirin use in the first or early second trimester may improve the evidence base on optimal timing of low-dose aspirin preventive medication. Other areas of research include optimal therapies that individualize the aspirin dosage and timing of administration (e.g., morning vs. bedtime)," they concluded, noting that research is also needed to explore less-well-established risk factors, and to investigate whether preeclampsia prevention with low-dose aspirin affects long-term risk for cardiovascular disease, and whether there is any benefit to continuing low-dose aspirin after delivery in those at high risk.
The use of low-dose aspirin is advisable after 12 weeks of gestation in asymptomatic pregnant women at high risk for developing preeclampsia, according to a recommendation from the U.S. Preventive Services Task Force.
The recommendation, published online Sept. 8 in the Annals of Internal Medicine, is based on a review of new evidence suggesting that the net benefit of low-dose aspirin for preventing preeclampsia is of substantial magnitude. It updates a 1996 recommendation from the USPSTF, which concluded that there was insufficient evidence at that time to recommend for or against the routine use of aspirin for the prevention of preeclampsia.
The current evidence – including 15 randomized controlled trials used to assess the health benefits of low-dose aspirin, 13 randomized controlled trials used to evaluate preeclampsia incidence, and 19 randomized controlled trials and 2 good-quality observational studies used to evaluate harms associated with low-dose aspirin use – suggests that women at risk may benefit from low-dose aspirin beginning after 12 weeks of gestation.
Preeclampsia complicates 2%-8% of pregnancies worldwide, and accounts for 15% of preterm births and 12% of maternal deaths in the United States, according to the task force.
"The USPSTF found adequate evidence of a reduction in risk for preeclampsia, preterm birth, and IUGR [intrauterine growth restriction] in women at increased risk for preeclampsia who received low-dose aspirin, thus demonstrating substantial benefit. Low-dose aspirin (range, 60-150 mg/day) reduced the risk for preeclampsia by 24% in clinical trials [pooled relative risk, 0.76] and reduced the risk for preterm birth by 14% and IUGR by 20% [pooled relative risk, 0.86 and 0.80, respectively]," the updated recommendation stated (Ann. Intern. Med. 2014 Sept. 8 [doi:10.7326/m14-1884]).
Adequate evidence also indicates that low-dose aspirin is not associated with any increase in the risk of placental abruption, postpartum hemorrhage, fetal intracranial bleeding, or perinatal mortality.
"Evidence on long-term outcomes in offspring exposed in utero to low-dose aspirin is limited, but no developmental harms were identified by age 18 months in the one study reviewed," the task force wrote, concluding – with moderate certainty – that there is a substantial net benefit of daily low-dose aspirin use to reduce the risk for preeclampsia, preterm birth, and IUGR in women at high risk.
The decision to initiate low-dose aspirin therapy in this population is typically based on medical history; there are no validated methods for identifying women at high risk based on biomarkers, clinical diagnostic tests, or medical history. However, as part of the recommendation, the USPSTF provided a pragmatic approach that may help identify those at risk.
"Women with one or more risk factors should receive low-dose aspirin. Women with several moderate risk factors may also benefit from low-dose aspirin," the task force noted, adding that the evidence for the latter approach is less certain, and that clinicians should use clinical judgment and discuss the risks and benefits with patients.
The recommendation applies to asymptomatic women at risk in whom low-dose aspirin is not contraindicated, and defines women at high risk as those with a history of preeclampsia, especially those with an adverse outcome; chronic hypertension, renal disease, type 1 or 2 diabetes, or an autoimmune disease; and those with multifetal gestation, according to the updated recommendation.
Moderate risk factors include nulliparity, obesity, a family history of preeclampsia, age greater than or equal to 35 years, African American race, low socioeconomic status, low birth rate or small for gestational age, greater than 10-year pregnancy interval, or previous adverse pregnancy outcome.
As for appropriate dosing, the most common dosage across studies was 100 mg, but the two largest trials contributing to benefit estimates used 60 mg.
An 81-mg dose was not specifically evaluated, but is commonly available in the United States in tablet form, and is a reasonable dosage for preeclampsia prophylaxis, the task force said.
The updated recommendation is generally in keeping with those of other organizations, including the American College of Obstetricians and Gynecologists, the World Health Organization, the National Institute for Health and Clinical Excellence, the American Heart Association/American Stroke Association, and the American Academy of Family Physicians. For example, ACOG recommends initiating daily low-dose aspirin during the late first trimester in those with a history of early-onset preeclampsia and preterm delivery, or with a history of preeclampsia in more than one prior pregnancy (<cf number="\"2\"">“</cf>American College of Obstetricians and Gynecologists: Hypertension in Pregnancy [Washington, D.C.: American College of Obstetricians and Gynecologists, 2013]), and WHO recommends daily low-dose aspirin as early as 12 weeks for those at high risk ("WHO Recommendations for Prevention and Treatment of Pre-Eclampsia and Eclampsia" [Geneva: World Health Organization, 2011]).
The review by the USPSTF identified several research needs. For example, additional study is needed on the effects of low-dose aspirin on the development of preeclampsia and how patient response is affected by various risk factors. Research is also needed on how to improve clinicians’ ability to identify those at risk, and particularly those who would benefit most from prophylaxis. Study is needed on risk assessment tools, and on populations at particular risk, such as African American and nulliparous women.
Future trials should recruit adequate numbers of women from racial/ethnic populations that are at disproportionate risk.
"Larger studies on aspirin use in the first or early second trimester may improve the evidence base on optimal timing of low-dose aspirin preventive medication. Other areas of research include optimal therapies that individualize the aspirin dosage and timing of administration (e.g., morning vs. bedtime)," they concluded, noting that research is also needed to explore less-well-established risk factors, and to investigate whether preeclampsia prevention with low-dose aspirin affects long-term risk for cardiovascular disease, and whether there is any benefit to continuing low-dose aspirin after delivery in those at high risk.
The use of low-dose aspirin is advisable after 12 weeks of gestation in asymptomatic pregnant women at high risk for developing preeclampsia, according to a recommendation from the U.S. Preventive Services Task Force.
The recommendation, published online Sept. 8 in the Annals of Internal Medicine, is based on a review of new evidence suggesting that the net benefit of low-dose aspirin for preventing preeclampsia is of substantial magnitude. It updates a 1996 recommendation from the USPSTF, which concluded that there was insufficient evidence at that time to recommend for or against the routine use of aspirin for the prevention of preeclampsia.
The current evidence – including 15 randomized controlled trials used to assess the health benefits of low-dose aspirin, 13 randomized controlled trials used to evaluate preeclampsia incidence, and 19 randomized controlled trials and 2 good-quality observational studies used to evaluate harms associated with low-dose aspirin use – suggests that women at risk may benefit from low-dose aspirin beginning after 12 weeks of gestation.
Preeclampsia complicates 2%-8% of pregnancies worldwide, and accounts for 15% of preterm births and 12% of maternal deaths in the United States, according to the task force.
"The USPSTF found adequate evidence of a reduction in risk for preeclampsia, preterm birth, and IUGR [intrauterine growth restriction] in women at increased risk for preeclampsia who received low-dose aspirin, thus demonstrating substantial benefit. Low-dose aspirin (range, 60-150 mg/day) reduced the risk for preeclampsia by 24% in clinical trials [pooled relative risk, 0.76] and reduced the risk for preterm birth by 14% and IUGR by 20% [pooled relative risk, 0.86 and 0.80, respectively]," the updated recommendation stated (Ann. Intern. Med. 2014 Sept. 8 [doi:10.7326/m14-1884]).
Adequate evidence also indicates that low-dose aspirin is not associated with any increase in the risk of placental abruption, postpartum hemorrhage, fetal intracranial bleeding, or perinatal mortality.
"Evidence on long-term outcomes in offspring exposed in utero to low-dose aspirin is limited, but no developmental harms were identified by age 18 months in the one study reviewed," the task force wrote, concluding – with moderate certainty – that there is a substantial net benefit of daily low-dose aspirin use to reduce the risk for preeclampsia, preterm birth, and IUGR in women at high risk.
The decision to initiate low-dose aspirin therapy in this population is typically based on medical history; there are no validated methods for identifying women at high risk based on biomarkers, clinical diagnostic tests, or medical history. However, as part of the recommendation, the USPSTF provided a pragmatic approach that may help identify those at risk.
"Women with one or more risk factors should receive low-dose aspirin. Women with several moderate risk factors may also benefit from low-dose aspirin," the task force noted, adding that the evidence for the latter approach is less certain, and that clinicians should use clinical judgment and discuss the risks and benefits with patients.
The recommendation applies to asymptomatic women at risk in whom low-dose aspirin is not contraindicated, and defines women at high risk as those with a history of preeclampsia, especially those with an adverse outcome; chronic hypertension, renal disease, type 1 or 2 diabetes, or an autoimmune disease; and those with multifetal gestation, according to the updated recommendation.
Moderate risk factors include nulliparity, obesity, a family history of preeclampsia, age greater than or equal to 35 years, African American race, low socioeconomic status, low birth rate or small for gestational age, greater than 10-year pregnancy interval, or previous adverse pregnancy outcome.
As for appropriate dosing, the most common dosage across studies was 100 mg, but the two largest trials contributing to benefit estimates used 60 mg.
An 81-mg dose was not specifically evaluated, but is commonly available in the United States in tablet form, and is a reasonable dosage for preeclampsia prophylaxis, the task force said.
The updated recommendation is generally in keeping with those of other organizations, including the American College of Obstetricians and Gynecologists, the World Health Organization, the National Institute for Health and Clinical Excellence, the American Heart Association/American Stroke Association, and the American Academy of Family Physicians. For example, ACOG recommends initiating daily low-dose aspirin during the late first trimester in those with a history of early-onset preeclampsia and preterm delivery, or with a history of preeclampsia in more than one prior pregnancy (<cf number="\"2\"">“</cf>American College of Obstetricians and Gynecologists: Hypertension in Pregnancy [Washington, D.C.: American College of Obstetricians and Gynecologists, 2013]), and WHO recommends daily low-dose aspirin as early as 12 weeks for those at high risk ("WHO Recommendations for Prevention and Treatment of Pre-Eclampsia and Eclampsia" [Geneva: World Health Organization, 2011]).
The review by the USPSTF identified several research needs. For example, additional study is needed on the effects of low-dose aspirin on the development of preeclampsia and how patient response is affected by various risk factors. Research is also needed on how to improve clinicians’ ability to identify those at risk, and particularly those who would benefit most from prophylaxis. Study is needed on risk assessment tools, and on populations at particular risk, such as African American and nulliparous women.
Future trials should recruit adequate numbers of women from racial/ethnic populations that are at disproportionate risk.
"Larger studies on aspirin use in the first or early second trimester may improve the evidence base on optimal timing of low-dose aspirin preventive medication. Other areas of research include optimal therapies that individualize the aspirin dosage and timing of administration (e.g., morning vs. bedtime)," they concluded, noting that research is also needed to explore less-well-established risk factors, and to investigate whether preeclampsia prevention with low-dose aspirin affects long-term risk for cardiovascular disease, and whether there is any benefit to continuing low-dose aspirin after delivery in those at high risk.
FROM ANNALS OF INTERNAL MEDICINE
Disposable, self-administered new anal insert device effective for anal leakage
WASHINGTON – A single-use, self-administered anal insert made of soft silicone was effective and safe in reducing episodes of accidental bowel leakage, in a multi-center, prospective open-label single-arm study, Dr. Emily Lukacz reported at the scientific meetings of the American Urogynecologic Society and the International Urogynecological Association.
The device provides a nonsurgical option for managing accidental bowel leakage (ABL), as an alternative or as an adjunct to invasive therapy, said Dr. Lukacz, professor of clinical reproductive medicine at the University of California, San Diego.
The device is designed to prevent leakage of solid and liquid stool, and is expelled with each bowel movement and subsequently replaced. The manufacturer, Renew Medical, hopes to make it available by the end of 2014 and is negotiating with the Centers for Medicare & Medicaid Services for coverage, she noted.
The study enrolled 91 people with moderate to severe bowel incontinence, who experienced at least weekly leakage of solid and/or liquid stool, with a Wexner severity score of 12 or greater (ranging from 0, fully continent, to 20, full incontinence); most were female (90%) and white (91%); their mean age was almost 69 years. Seven participants withdrew because they were not satisfied with the device.
Among the 85 participants who completed at least 1 week of treatment, the frequency of ABL dropped from eight episodes per week at baseline to one-two episodes per week at 12 weeks, an 82% reduction that was statistically significant (P less than or equal to .001), Dr. Lukacz said. Of the 85 participants, 78% experienced at least a 50% reduction in ABL frequency, and 8 (9%) achieved total continence.
The mean Wexner scores improved by about 32% after treatment, from about 16 to about 11, which was also statistically significant (P less than or equal to .001). Of the 73 who completed the full 12 weeks of the study, 57 (78%) were "very or extremely satisfied with the device," Dr. Lukacz noted.
There were no serious adverse events. The three moderate adverse events were fecal urgency, soreness, and bleeding related to the use of the insert in two participants. Almost one-quarter of the patients had episodes where the device was displaced "upward into the anal canal," but was expelled with the next bowel movement, she said.
Dr. Lukacz’s disclosures included being a paid consultant to Pfizer and Renew Medical. The study was sponsored by Renew.
WASHINGTON – A single-use, self-administered anal insert made of soft silicone was effective and safe in reducing episodes of accidental bowel leakage, in a multi-center, prospective open-label single-arm study, Dr. Emily Lukacz reported at the scientific meetings of the American Urogynecologic Society and the International Urogynecological Association.
The device provides a nonsurgical option for managing accidental bowel leakage (ABL), as an alternative or as an adjunct to invasive therapy, said Dr. Lukacz, professor of clinical reproductive medicine at the University of California, San Diego.
The device is designed to prevent leakage of solid and liquid stool, and is expelled with each bowel movement and subsequently replaced. The manufacturer, Renew Medical, hopes to make it available by the end of 2014 and is negotiating with the Centers for Medicare & Medicaid Services for coverage, she noted.
The study enrolled 91 people with moderate to severe bowel incontinence, who experienced at least weekly leakage of solid and/or liquid stool, with a Wexner severity score of 12 or greater (ranging from 0, fully continent, to 20, full incontinence); most were female (90%) and white (91%); their mean age was almost 69 years. Seven participants withdrew because they were not satisfied with the device.
Among the 85 participants who completed at least 1 week of treatment, the frequency of ABL dropped from eight episodes per week at baseline to one-two episodes per week at 12 weeks, an 82% reduction that was statistically significant (P less than or equal to .001), Dr. Lukacz said. Of the 85 participants, 78% experienced at least a 50% reduction in ABL frequency, and 8 (9%) achieved total continence.
The mean Wexner scores improved by about 32% after treatment, from about 16 to about 11, which was also statistically significant (P less than or equal to .001). Of the 73 who completed the full 12 weeks of the study, 57 (78%) were "very or extremely satisfied with the device," Dr. Lukacz noted.
There were no serious adverse events. The three moderate adverse events were fecal urgency, soreness, and bleeding related to the use of the insert in two participants. Almost one-quarter of the patients had episodes where the device was displaced "upward into the anal canal," but was expelled with the next bowel movement, she said.
Dr. Lukacz’s disclosures included being a paid consultant to Pfizer and Renew Medical. The study was sponsored by Renew.
WASHINGTON – A single-use, self-administered anal insert made of soft silicone was effective and safe in reducing episodes of accidental bowel leakage, in a multi-center, prospective open-label single-arm study, Dr. Emily Lukacz reported at the scientific meetings of the American Urogynecologic Society and the International Urogynecological Association.
The device provides a nonsurgical option for managing accidental bowel leakage (ABL), as an alternative or as an adjunct to invasive therapy, said Dr. Lukacz, professor of clinical reproductive medicine at the University of California, San Diego.
The device is designed to prevent leakage of solid and liquid stool, and is expelled with each bowel movement and subsequently replaced. The manufacturer, Renew Medical, hopes to make it available by the end of 2014 and is negotiating with the Centers for Medicare & Medicaid Services for coverage, she noted.
The study enrolled 91 people with moderate to severe bowel incontinence, who experienced at least weekly leakage of solid and/or liquid stool, with a Wexner severity score of 12 or greater (ranging from 0, fully continent, to 20, full incontinence); most were female (90%) and white (91%); their mean age was almost 69 years. Seven participants withdrew because they were not satisfied with the device.
Among the 85 participants who completed at least 1 week of treatment, the frequency of ABL dropped from eight episodes per week at baseline to one-two episodes per week at 12 weeks, an 82% reduction that was statistically significant (P less than or equal to .001), Dr. Lukacz said. Of the 85 participants, 78% experienced at least a 50% reduction in ABL frequency, and 8 (9%) achieved total continence.
The mean Wexner scores improved by about 32% after treatment, from about 16 to about 11, which was also statistically significant (P less than or equal to .001). Of the 73 who completed the full 12 weeks of the study, 57 (78%) were "very or extremely satisfied with the device," Dr. Lukacz noted.
There were no serious adverse events. The three moderate adverse events were fecal urgency, soreness, and bleeding related to the use of the insert in two participants. Almost one-quarter of the patients had episodes where the device was displaced "upward into the anal canal," but was expelled with the next bowel movement, she said.
Dr. Lukacz’s disclosures included being a paid consultant to Pfizer and Renew Medical. The study was sponsored by Renew.
AT AUGS/IUGA 2014
Major finding: Once available, this soft silicone, self-administered anal insert could be an effective, safe alternative or adjunct to invasive treatment of accidental bowel leakage (ABL).
Key numerical finding: The frequency of ABL dropped by 82% after 12 weeks of using the anal insert, from 8 weekly episodes at baseline to 1-2 episodes per week.
Data source: A multicenter, prospective, open-label, single-arm study evaluated the effect of the device on the reduction of ABL episodes per week and severity of ABL over 12 weeks in 91 mostly female, white patients with moderate to severe anal leakage at baseline.
Disclosures: Dr. Lukacz’s disclosures included being a paid consultant to Pfizer and Renew Medical, the manufacturer of the anal insert. The study was sponsored by Renew.
Kegel exercises
The prevalence of urinary incontinence is 17%-55% among older women and 12%-42% among younger and middle-aged women. Only 45% of women with at least weekly symptoms seek medical care to address their symptoms.
For most of us, offering conservative measures is the most reasonable approach when women present. Pelvic floor muscle training, sometimes referred to as Kegel exercises, is usually one of the first things we discuss. Many women have heard this spiel before and may report having tried but not benefited from the exercises. This real or perceived lack of benefit may be related to either poor adherence or lack of efficacy.
In theory, pelvic floor muscle training builds strength and improves muscle tone, enhances conscious awareness of muscle groups, and increases perineal support by lifting pelvic viscera. But do clinical trial data support the use of pelvic muscle training for reducing urinary incontinence?
Dr. O. Celiker Tosun of Dokuz Eylül University, Izmir, Turkey, and colleagues published the results of a randomized clinical trial evaluating the effectiveness of an individually prescribed 12-week home-based pelvic floor muscle exercise program (Clin. Rehabil. 2014 Aug. 20 [doi:10.1177/0269215514546768]). Women with stress or mixed urinary incontinence were selected from a urogynecology clinic and randomized to pelvic floor muscle training (65 patients) or a control condition (65 patients).
The pelvic floor muscle training group had significant improvement in their symptoms of urinary incontinence and pelvic floor muscle strength, compared with the control group. Symptoms of urinary incontinence were significantly decreased in the training group.
This study is important because it demonstrates the utility of pelvic floor muscle training exercises under ideal circumstances.
However, the intervention provided in this study was intense and sophisticated – and it will be difficult, if not impossible, for most of us to replicate. A physiotherapist provided the training over a 12-week period, with 30-minute sessions three times a week for the first 2 weeks. Women also kept a training diary. Adherence to the protocol was 89% in the training group.
This is very different from the handout on Kegel’s we might be giving to our patients – with adherence to recommendations likely approaching 0%.
But now that we have these data, perhaps we can talk to our female patients more consistently and convincingly about the utility of this approach for reducing incontinence. If we are lucky and have a women’s health clinic with access to this type of expertise, this might be another option – at least before we refer them for higher-risk surgical procedures.
Dr. Ebbert is professor of medicine and a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. They should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.
The prevalence of urinary incontinence is 17%-55% among older women and 12%-42% among younger and middle-aged women. Only 45% of women with at least weekly symptoms seek medical care to address their symptoms.
For most of us, offering conservative measures is the most reasonable approach when women present. Pelvic floor muscle training, sometimes referred to as Kegel exercises, is usually one of the first things we discuss. Many women have heard this spiel before and may report having tried but not benefited from the exercises. This real or perceived lack of benefit may be related to either poor adherence or lack of efficacy.
In theory, pelvic floor muscle training builds strength and improves muscle tone, enhances conscious awareness of muscle groups, and increases perineal support by lifting pelvic viscera. But do clinical trial data support the use of pelvic muscle training for reducing urinary incontinence?
Dr. O. Celiker Tosun of Dokuz Eylül University, Izmir, Turkey, and colleagues published the results of a randomized clinical trial evaluating the effectiveness of an individually prescribed 12-week home-based pelvic floor muscle exercise program (Clin. Rehabil. 2014 Aug. 20 [doi:10.1177/0269215514546768]). Women with stress or mixed urinary incontinence were selected from a urogynecology clinic and randomized to pelvic floor muscle training (65 patients) or a control condition (65 patients).
The pelvic floor muscle training group had significant improvement in their symptoms of urinary incontinence and pelvic floor muscle strength, compared with the control group. Symptoms of urinary incontinence were significantly decreased in the training group.
This study is important because it demonstrates the utility of pelvic floor muscle training exercises under ideal circumstances.
However, the intervention provided in this study was intense and sophisticated – and it will be difficult, if not impossible, for most of us to replicate. A physiotherapist provided the training over a 12-week period, with 30-minute sessions three times a week for the first 2 weeks. Women also kept a training diary. Adherence to the protocol was 89% in the training group.
This is very different from the handout on Kegel’s we might be giving to our patients – with adherence to recommendations likely approaching 0%.
But now that we have these data, perhaps we can talk to our female patients more consistently and convincingly about the utility of this approach for reducing incontinence. If we are lucky and have a women’s health clinic with access to this type of expertise, this might be another option – at least before we refer them for higher-risk surgical procedures.
Dr. Ebbert is professor of medicine and a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. They should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.
The prevalence of urinary incontinence is 17%-55% among older women and 12%-42% among younger and middle-aged women. Only 45% of women with at least weekly symptoms seek medical care to address their symptoms.
For most of us, offering conservative measures is the most reasonable approach when women present. Pelvic floor muscle training, sometimes referred to as Kegel exercises, is usually one of the first things we discuss. Many women have heard this spiel before and may report having tried but not benefited from the exercises. This real or perceived lack of benefit may be related to either poor adherence or lack of efficacy.
In theory, pelvic floor muscle training builds strength and improves muscle tone, enhances conscious awareness of muscle groups, and increases perineal support by lifting pelvic viscera. But do clinical trial data support the use of pelvic muscle training for reducing urinary incontinence?
Dr. O. Celiker Tosun of Dokuz Eylül University, Izmir, Turkey, and colleagues published the results of a randomized clinical trial evaluating the effectiveness of an individually prescribed 12-week home-based pelvic floor muscle exercise program (Clin. Rehabil. 2014 Aug. 20 [doi:10.1177/0269215514546768]). Women with stress or mixed urinary incontinence were selected from a urogynecology clinic and randomized to pelvic floor muscle training (65 patients) or a control condition (65 patients).
The pelvic floor muscle training group had significant improvement in their symptoms of urinary incontinence and pelvic floor muscle strength, compared with the control group. Symptoms of urinary incontinence were significantly decreased in the training group.
This study is important because it demonstrates the utility of pelvic floor muscle training exercises under ideal circumstances.
However, the intervention provided in this study was intense and sophisticated – and it will be difficult, if not impossible, for most of us to replicate. A physiotherapist provided the training over a 12-week period, with 30-minute sessions three times a week for the first 2 weeks. Women also kept a training diary. Adherence to the protocol was 89% in the training group.
This is very different from the handout on Kegel’s we might be giving to our patients – with adherence to recommendations likely approaching 0%.
But now that we have these data, perhaps we can talk to our female patients more consistently and convincingly about the utility of this approach for reducing incontinence. If we are lucky and have a women’s health clinic with access to this type of expertise, this might be another option – at least before we refer them for higher-risk surgical procedures.
Dr. Ebbert is professor of medicine and a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author. They should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician.
Successful bariatric surgery also may improve urinary incontinence
WASHINGTON – The majority of obese women who had urinary incontinence before bariatric surgery had complete or near-complete resolution of symptoms for up to 3 years after surgery in a study of more than 1,500 women, Dr. Leslee Subak reported at the scientific meetings of the American Urogynecologic Society and the International Urogynecological Association.
These results indicate that "improvement in incontinence may be another long-term benefit of weight loss, in this case surgical weight loss," said Dr. Subak, professor of obstetrics and gynecology and reproductive sciences, epidemiology and biostatistics, and urology at the University of California, San Francisco.
The study evaluated the effect of surgery on urinary incontinence in 1,565 severely obese women who were part of the multicenter Longitudinal Cohort Study of Bariatric Surgery-2 and had completed self-administered questionnaires about urinary incontinence episodes before surgery and at one or more annual follow-up assessments within 3 years of surgery.
The results were based on outcomes of the 772 women who reported experiencing episodes of incontinence at least weekly, with an average of about 11 incontinence episodes per week. Their median age was 46 years and most were white; about 7% had undergone previous incontinence surgery and about 8% had received or were receiving behavioral treatment or medication for incontinence.
Most of the patients underwent a Roux-en-Y gastric bypass (71%) or laparoscopic adjustable gastric banding (25%). After the first year, they had lost a median of about 30% of their baseline weight, which was maintained through the third year.
At all follow-up times after surgery, there were significantly fewer incontinence episodes, compared with baseline, with a remission rate of 60%-65%, Dr. Subak said.
Urinary incontinence episodes dropped from an average of about 11 episodes per week before surgery to an average of almost 3 episodes per week at 1 year and 4 episodes per week at 2 and 3 years, she noted. Episodes of stress incontinence also decreased from an average of about 5 episodes per week at baseline to about 1 episode per week at 1 year and almost 2 episodes per week at 2 and 3 years.
The remission rate – defined as less than 1 weekly urinary incontinence episode over the past 3 months – was 70% at 1 year, dropping to and stabilizing at about 61%-62% at 2 and 3 years. Moreover, 25% of the women had a complete remission (no episodes of incontinence during the past 3 months) at 3 years, a slight increase from almost 27% at 1 year, Dr. Subak said.
"The magnitude of weight loss was the strongest predictor of improvement in incontinence over time," she noted. "Incontinence and BMI [body mass index] seemed to track together, as [whenever] there’s a reduction in BMI ... there’s a reduction in urinary incontinence episode frequency."
A younger age also was significantly associated with a reduction in the frequency or a remission of urinary incontinence, while being pregnant in the previous year and having had a hysterectomy were associated with a lower likelihood of having a remission.
Dr. Subak noted that limitations of the study included the observational design and the lack of a control group, as well as the fact that data were based on self-reports.
She referred to urinary incontinence and obesity as "twin epidemics," with about a fourfold increased risk of urinary incontinence associated with obesity. About one-third of women in the United States are obese and about 70% of women with incontinence are obese, she pointed out.
The Longitudinal Cohort Study of Bariatric Surgery-2 is funded by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Subak received additional funding from the NIDDK; she had no other disclosures.
WASHINGTON – The majority of obese women who had urinary incontinence before bariatric surgery had complete or near-complete resolution of symptoms for up to 3 years after surgery in a study of more than 1,500 women, Dr. Leslee Subak reported at the scientific meetings of the American Urogynecologic Society and the International Urogynecological Association.
These results indicate that "improvement in incontinence may be another long-term benefit of weight loss, in this case surgical weight loss," said Dr. Subak, professor of obstetrics and gynecology and reproductive sciences, epidemiology and biostatistics, and urology at the University of California, San Francisco.
The study evaluated the effect of surgery on urinary incontinence in 1,565 severely obese women who were part of the multicenter Longitudinal Cohort Study of Bariatric Surgery-2 and had completed self-administered questionnaires about urinary incontinence episodes before surgery and at one or more annual follow-up assessments within 3 years of surgery.
The results were based on outcomes of the 772 women who reported experiencing episodes of incontinence at least weekly, with an average of about 11 incontinence episodes per week. Their median age was 46 years and most were white; about 7% had undergone previous incontinence surgery and about 8% had received or were receiving behavioral treatment or medication for incontinence.
Most of the patients underwent a Roux-en-Y gastric bypass (71%) or laparoscopic adjustable gastric banding (25%). After the first year, they had lost a median of about 30% of their baseline weight, which was maintained through the third year.
At all follow-up times after surgery, there were significantly fewer incontinence episodes, compared with baseline, with a remission rate of 60%-65%, Dr. Subak said.
Urinary incontinence episodes dropped from an average of about 11 episodes per week before surgery to an average of almost 3 episodes per week at 1 year and 4 episodes per week at 2 and 3 years, she noted. Episodes of stress incontinence also decreased from an average of about 5 episodes per week at baseline to about 1 episode per week at 1 year and almost 2 episodes per week at 2 and 3 years.
The remission rate – defined as less than 1 weekly urinary incontinence episode over the past 3 months – was 70% at 1 year, dropping to and stabilizing at about 61%-62% at 2 and 3 years. Moreover, 25% of the women had a complete remission (no episodes of incontinence during the past 3 months) at 3 years, a slight increase from almost 27% at 1 year, Dr. Subak said.
"The magnitude of weight loss was the strongest predictor of improvement in incontinence over time," she noted. "Incontinence and BMI [body mass index] seemed to track together, as [whenever] there’s a reduction in BMI ... there’s a reduction in urinary incontinence episode frequency."
A younger age also was significantly associated with a reduction in the frequency or a remission of urinary incontinence, while being pregnant in the previous year and having had a hysterectomy were associated with a lower likelihood of having a remission.
Dr. Subak noted that limitations of the study included the observational design and the lack of a control group, as well as the fact that data were based on self-reports.
She referred to urinary incontinence and obesity as "twin epidemics," with about a fourfold increased risk of urinary incontinence associated with obesity. About one-third of women in the United States are obese and about 70% of women with incontinence are obese, she pointed out.
The Longitudinal Cohort Study of Bariatric Surgery-2 is funded by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Subak received additional funding from the NIDDK; she had no other disclosures.
WASHINGTON – The majority of obese women who had urinary incontinence before bariatric surgery had complete or near-complete resolution of symptoms for up to 3 years after surgery in a study of more than 1,500 women, Dr. Leslee Subak reported at the scientific meetings of the American Urogynecologic Society and the International Urogynecological Association.
These results indicate that "improvement in incontinence may be another long-term benefit of weight loss, in this case surgical weight loss," said Dr. Subak, professor of obstetrics and gynecology and reproductive sciences, epidemiology and biostatistics, and urology at the University of California, San Francisco.
The study evaluated the effect of surgery on urinary incontinence in 1,565 severely obese women who were part of the multicenter Longitudinal Cohort Study of Bariatric Surgery-2 and had completed self-administered questionnaires about urinary incontinence episodes before surgery and at one or more annual follow-up assessments within 3 years of surgery.
The results were based on outcomes of the 772 women who reported experiencing episodes of incontinence at least weekly, with an average of about 11 incontinence episodes per week. Their median age was 46 years and most were white; about 7% had undergone previous incontinence surgery and about 8% had received or were receiving behavioral treatment or medication for incontinence.
Most of the patients underwent a Roux-en-Y gastric bypass (71%) or laparoscopic adjustable gastric banding (25%). After the first year, they had lost a median of about 30% of their baseline weight, which was maintained through the third year.
At all follow-up times after surgery, there were significantly fewer incontinence episodes, compared with baseline, with a remission rate of 60%-65%, Dr. Subak said.
Urinary incontinence episodes dropped from an average of about 11 episodes per week before surgery to an average of almost 3 episodes per week at 1 year and 4 episodes per week at 2 and 3 years, she noted. Episodes of stress incontinence also decreased from an average of about 5 episodes per week at baseline to about 1 episode per week at 1 year and almost 2 episodes per week at 2 and 3 years.
The remission rate – defined as less than 1 weekly urinary incontinence episode over the past 3 months – was 70% at 1 year, dropping to and stabilizing at about 61%-62% at 2 and 3 years. Moreover, 25% of the women had a complete remission (no episodes of incontinence during the past 3 months) at 3 years, a slight increase from almost 27% at 1 year, Dr. Subak said.
"The magnitude of weight loss was the strongest predictor of improvement in incontinence over time," she noted. "Incontinence and BMI [body mass index] seemed to track together, as [whenever] there’s a reduction in BMI ... there’s a reduction in urinary incontinence episode frequency."
A younger age also was significantly associated with a reduction in the frequency or a remission of urinary incontinence, while being pregnant in the previous year and having had a hysterectomy were associated with a lower likelihood of having a remission.
Dr. Subak noted that limitations of the study included the observational design and the lack of a control group, as well as the fact that data were based on self-reports.
She referred to urinary incontinence and obesity as "twin epidemics," with about a fourfold increased risk of urinary incontinence associated with obesity. About one-third of women in the United States are obese and about 70% of women with incontinence are obese, she pointed out.
The Longitudinal Cohort Study of Bariatric Surgery-2 is funded by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Subak received additional funding from the NIDDK; she had no other disclosures.
AT AUGS/IUGA 2014
Key clinical point: Obese women who report urinary incontinence may experience improvement or even resolution of symptoms after bariatric surgery.
Major finding: About one-quarter of the 772 severely obese women who reported having urinary incontinence before undergoing bariatric surgery had complete remission of urinary incontinence 3 years after surgery.
Data source: The frequency of urinary incontinence symptoms at baseline and for up to 3 years after bariatric surgery was evaluated in a substudy of 1,565 severely obese women who were enrolled in a multicenter, longitudinal cohort study based on self-administered questionnaires.
Disclosures: The Longitudinal Cohort Study of Bariatric Surgery-2 is funded by the National Institute of Diabetes and Digestive and Kidney Diseases. Dr. Subak received additional funding from the NIDDK; she had no other disclosures.
Two possible biomarkers identified for interstitial cystitis
ORLANDO – Two potential biomarkers for interstitial cystitis have been identified, according to Jayoung Kim, Ph.D.
The metabolites tyramine and 2-oxoglutarate appeared to discriminate 45 interstitial cystitis patients from 19 age- and gender-matched controls. The findings set the stage for prospective clinical trials of these potential biomarkers, Dr. Kim of Cedars-Sinai Medical Center, Los Angeles, reported at the annual meeting of the American Urological Association.
Dr. Kim and her colleagues performed a nuclear magnetic resonance analysis of urine samples and identified 140 peaks that differed significantly between the two groups. Fifteen NMR peaks were identified as having the strongest signature for interstitial cystitis, she said.
Three of the peaks were annotated as the pain-related neuromodulator tyramine and two were 2-oxoglutarate. The findings suggest that levels of these two metabolites might be significantly upregulated in urine specimens from patients who have interstitial cystitis.
Patients with interstitial cystitis or painful bladder syndrome report variable symptoms, such as pelvic or perineal pain, discomfort, urinary frequency, and urinary urgency. A poor understanding of the mechanism of interstitial cystitis and the lack of convenient biomarkers have posed challenges to improving diagnosis and treatment. The findings elucidate clinically relevant disease indicators that could be important in the development of new treatments, Dr. Kim said.
This study was supported by grants from the National Institutes of Health, an ICA Pilot grant, the Fishbein Family IC Research Foundation/Interstitial Cystitis Association, the New York Academy of Medicine, and Children’s Hospital Boston Faculty Development.
ORLANDO – Two potential biomarkers for interstitial cystitis have been identified, according to Jayoung Kim, Ph.D.
The metabolites tyramine and 2-oxoglutarate appeared to discriminate 45 interstitial cystitis patients from 19 age- and gender-matched controls. The findings set the stage for prospective clinical trials of these potential biomarkers, Dr. Kim of Cedars-Sinai Medical Center, Los Angeles, reported at the annual meeting of the American Urological Association.
Dr. Kim and her colleagues performed a nuclear magnetic resonance analysis of urine samples and identified 140 peaks that differed significantly between the two groups. Fifteen NMR peaks were identified as having the strongest signature for interstitial cystitis, she said.
Three of the peaks were annotated as the pain-related neuromodulator tyramine and two were 2-oxoglutarate. The findings suggest that levels of these two metabolites might be significantly upregulated in urine specimens from patients who have interstitial cystitis.
Patients with interstitial cystitis or painful bladder syndrome report variable symptoms, such as pelvic or perineal pain, discomfort, urinary frequency, and urinary urgency. A poor understanding of the mechanism of interstitial cystitis and the lack of convenient biomarkers have posed challenges to improving diagnosis and treatment. The findings elucidate clinically relevant disease indicators that could be important in the development of new treatments, Dr. Kim said.
This study was supported by grants from the National Institutes of Health, an ICA Pilot grant, the Fishbein Family IC Research Foundation/Interstitial Cystitis Association, the New York Academy of Medicine, and Children’s Hospital Boston Faculty Development.
ORLANDO – Two potential biomarkers for interstitial cystitis have been identified, according to Jayoung Kim, Ph.D.
The metabolites tyramine and 2-oxoglutarate appeared to discriminate 45 interstitial cystitis patients from 19 age- and gender-matched controls. The findings set the stage for prospective clinical trials of these potential biomarkers, Dr. Kim of Cedars-Sinai Medical Center, Los Angeles, reported at the annual meeting of the American Urological Association.
Dr. Kim and her colleagues performed a nuclear magnetic resonance analysis of urine samples and identified 140 peaks that differed significantly between the two groups. Fifteen NMR peaks were identified as having the strongest signature for interstitial cystitis, she said.
Three of the peaks were annotated as the pain-related neuromodulator tyramine and two were 2-oxoglutarate. The findings suggest that levels of these two metabolites might be significantly upregulated in urine specimens from patients who have interstitial cystitis.
Patients with interstitial cystitis or painful bladder syndrome report variable symptoms, such as pelvic or perineal pain, discomfort, urinary frequency, and urinary urgency. A poor understanding of the mechanism of interstitial cystitis and the lack of convenient biomarkers have posed challenges to improving diagnosis and treatment. The findings elucidate clinically relevant disease indicators that could be important in the development of new treatments, Dr. Kim said.
This study was supported by grants from the National Institutes of Health, an ICA Pilot grant, the Fishbein Family IC Research Foundation/Interstitial Cystitis Association, the New York Academy of Medicine, and Children’s Hospital Boston Faculty Development.
AT THE AUA ANNUAL MEETING
Key clinical point: Biomarkers unique to urine samples from interstitial cystitis may guide research for new treatments.
Major finding: Tyramine and 2-oxoglutarate were upregulated in urine specimens from patients with interstitial cystitis.
Data source: Nuclear magnetic resonance analysis of urine samples from 45 patients and 19 controls.
Disclosures: This study was supported by grants from the National Institutes of Health, an ICA Pilot grant, the Fishbein Family IC Research Foundation/Interstitial Cystitis Association, the New York Academy of Medicine, and Children’s Hospital Boston Faculty Development.
USPSTF: Offer behavioral counseling to prevent cardiovascular disease
Overweight or obese adults at risk for cardiovascular disease should receive intensive behavioral counseling interventions, according to a recommendation statement by the U. S. Preventive Services Task Force.
After a comprehensive review of the current literature, the USPSTF concluded "with moderate certainty" that interventions promoting a healthful diet and increased physical activity have a moderate net benefit in this patient population, said Dr. Michael L. LeFevre, chair of the task force at the time the recommendation was finalized, and professor of family medicine at the University of Missouri, Columbia.
The recommendation statement issued Aug. 25 is "an update and refinement" of the 2003 USPSTF recommendation on dietary counseling for at-risk adults, this time targeting overweight or obese patients who have additional CVD risk factors such as hypertension, dyslipidemia, impaired fasting glucose, or metabolic syndrome.
The group reviewed 74 trials assessing the effectiveness of behavioral counseling interventions of various intensities. Only 16 reported on direct health outcomes such as CVD events, mortality, or quality of life, the task force noted, so there is inadequate evidence about intensive behavioral counseling’s effect on such outcomes.
A total of 71 trials involving more than 32,000 participants focused on intermediate health outcomes such as lipid levels, blood pressure, glucose levels, weight, and medication use. Overall, intensive counseling interventions made "small but important changes" in these outcomes, with total cholesterol levels decreasing approximately 3-6 mg/dL, LDL cholesterol decreasing by 1.5-5.0 mg/dL, systolic blood pressure decreasing by 1-3 mm Hg, diastolic blood pressure decreasing by 1-2 mm Hg, and fasting glucose levels decreasing by 1-3 mg/dL.
In addition, weight decreased by a mean of approximately 3 kg, and the proportion of patients who participated in moderate-intensity exercise for 150 minutes per week rose from 10% to 25%. However, few of these studies followed patients for more than 1-2 years, so the evidence was inadequate to assess longer-term benefits.
Because very few and mostly minor adverse events were associated with these interventions, they yielded a moderate net benefit.
Most of the intensive behavioral counseling interventions that were assessed averaged 5-16 individual or group sessions during a period of 9-12 months. All included didactic education; in most programs, specially trained professionals (dietitians, nutritionists, physiotherapists, exercise professionals, health educators, and psychologists) provided monitoring and feedback for the participants, devised individualized care plans, and taught problem-solving skills. Many types and combinations of interventions were effective, and almost all were delivered outside the primary care setting.
The recommendation statement is in line with others published by the American Heart Association, the American College of Sports Medicine, and the American Academy of Family Physicians. The AAFP is updating its recommendations regarding behavioral counseling to prevent CVD, Dr. LeFevre and his associates noted.
The USPSTF, funded by but independent of the federal government, makes recommendations about the effectiveness of specific preventive-care services based on evidence of benefits and harms, without considering costs.
Do you refer overweight or obese patients with cardiovascular risk factors for intensive behavioral counseling? Take our Quick Poll on the Family Practice News homepage.
Overweight or obese adults at risk for cardiovascular disease should receive intensive behavioral counseling interventions, according to a recommendation statement by the U. S. Preventive Services Task Force.
After a comprehensive review of the current literature, the USPSTF concluded "with moderate certainty" that interventions promoting a healthful diet and increased physical activity have a moderate net benefit in this patient population, said Dr. Michael L. LeFevre, chair of the task force at the time the recommendation was finalized, and professor of family medicine at the University of Missouri, Columbia.
The recommendation statement issued Aug. 25 is "an update and refinement" of the 2003 USPSTF recommendation on dietary counseling for at-risk adults, this time targeting overweight or obese patients who have additional CVD risk factors such as hypertension, dyslipidemia, impaired fasting glucose, or metabolic syndrome.
The group reviewed 74 trials assessing the effectiveness of behavioral counseling interventions of various intensities. Only 16 reported on direct health outcomes such as CVD events, mortality, or quality of life, the task force noted, so there is inadequate evidence about intensive behavioral counseling’s effect on such outcomes.
A total of 71 trials involving more than 32,000 participants focused on intermediate health outcomes such as lipid levels, blood pressure, glucose levels, weight, and medication use. Overall, intensive counseling interventions made "small but important changes" in these outcomes, with total cholesterol levels decreasing approximately 3-6 mg/dL, LDL cholesterol decreasing by 1.5-5.0 mg/dL, systolic blood pressure decreasing by 1-3 mm Hg, diastolic blood pressure decreasing by 1-2 mm Hg, and fasting glucose levels decreasing by 1-3 mg/dL.
In addition, weight decreased by a mean of approximately 3 kg, and the proportion of patients who participated in moderate-intensity exercise for 150 minutes per week rose from 10% to 25%. However, few of these studies followed patients for more than 1-2 years, so the evidence was inadequate to assess longer-term benefits.
Because very few and mostly minor adverse events were associated with these interventions, they yielded a moderate net benefit.
Most of the intensive behavioral counseling interventions that were assessed averaged 5-16 individual or group sessions during a period of 9-12 months. All included didactic education; in most programs, specially trained professionals (dietitians, nutritionists, physiotherapists, exercise professionals, health educators, and psychologists) provided monitoring and feedback for the participants, devised individualized care plans, and taught problem-solving skills. Many types and combinations of interventions were effective, and almost all were delivered outside the primary care setting.
The recommendation statement is in line with others published by the American Heart Association, the American College of Sports Medicine, and the American Academy of Family Physicians. The AAFP is updating its recommendations regarding behavioral counseling to prevent CVD, Dr. LeFevre and his associates noted.
The USPSTF, funded by but independent of the federal government, makes recommendations about the effectiveness of specific preventive-care services based on evidence of benefits and harms, without considering costs.
Do you refer overweight or obese patients with cardiovascular risk factors for intensive behavioral counseling? Take our Quick Poll on the Family Practice News homepage.
Overweight or obese adults at risk for cardiovascular disease should receive intensive behavioral counseling interventions, according to a recommendation statement by the U. S. Preventive Services Task Force.
After a comprehensive review of the current literature, the USPSTF concluded "with moderate certainty" that interventions promoting a healthful diet and increased physical activity have a moderate net benefit in this patient population, said Dr. Michael L. LeFevre, chair of the task force at the time the recommendation was finalized, and professor of family medicine at the University of Missouri, Columbia.
The recommendation statement issued Aug. 25 is "an update and refinement" of the 2003 USPSTF recommendation on dietary counseling for at-risk adults, this time targeting overweight or obese patients who have additional CVD risk factors such as hypertension, dyslipidemia, impaired fasting glucose, or metabolic syndrome.
The group reviewed 74 trials assessing the effectiveness of behavioral counseling interventions of various intensities. Only 16 reported on direct health outcomes such as CVD events, mortality, or quality of life, the task force noted, so there is inadequate evidence about intensive behavioral counseling’s effect on such outcomes.
A total of 71 trials involving more than 32,000 participants focused on intermediate health outcomes such as lipid levels, blood pressure, glucose levels, weight, and medication use. Overall, intensive counseling interventions made "small but important changes" in these outcomes, with total cholesterol levels decreasing approximately 3-6 mg/dL, LDL cholesterol decreasing by 1.5-5.0 mg/dL, systolic blood pressure decreasing by 1-3 mm Hg, diastolic blood pressure decreasing by 1-2 mm Hg, and fasting glucose levels decreasing by 1-3 mg/dL.
In addition, weight decreased by a mean of approximately 3 kg, and the proportion of patients who participated in moderate-intensity exercise for 150 minutes per week rose from 10% to 25%. However, few of these studies followed patients for more than 1-2 years, so the evidence was inadequate to assess longer-term benefits.
Because very few and mostly minor adverse events were associated with these interventions, they yielded a moderate net benefit.
Most of the intensive behavioral counseling interventions that were assessed averaged 5-16 individual or group sessions during a period of 9-12 months. All included didactic education; in most programs, specially trained professionals (dietitians, nutritionists, physiotherapists, exercise professionals, health educators, and psychologists) provided monitoring and feedback for the participants, devised individualized care plans, and taught problem-solving skills. Many types and combinations of interventions were effective, and almost all were delivered outside the primary care setting.
The recommendation statement is in line with others published by the American Heart Association, the American College of Sports Medicine, and the American Academy of Family Physicians. The AAFP is updating its recommendations regarding behavioral counseling to prevent CVD, Dr. LeFevre and his associates noted.
The USPSTF, funded by but independent of the federal government, makes recommendations about the effectiveness of specific preventive-care services based on evidence of benefits and harms, without considering costs.
Do you refer overweight or obese patients with cardiovascular risk factors for intensive behavioral counseling? Take our Quick Poll on the Family Practice News homepage.
FROM ANNALS OF INTERNAL MEDICINE
Key clinical point: Refer overweight or obese patients at risk of cardiovascular disease for intensive behavioral counseling.
Major Finding: Intensive behavioral counseling interventions made small but important changes in several intermediate health outcomes, with total cholesterol levels decreasing by about 3-6 mg/dL, LDL cholesterol decreasing by 1.5-5.0 mg/dL, systolic blood pressure decreasing by 1-3 mm Hg, diastolic blood pressure decreasing by 1-2 mm Hg, fasting glucose levels decreasing by 1-3 mg/dL, and weight decreasing by a mean of 3 kg.
Data Source: An update and refinement of a 2003 USPSTF recommendation on dietary counseling for overweight/obese adults who have additional risk factors for CVD, based on a comprehensive review of the literature.
Disclosures: The USPSTF, funded by but independent of the federal government, makes recommendations about the effectiveness of specific preventive-care services based on evidence of benefits and harms, without considering costs.
Estrogen-containing OCs cloud measurement of ovarian reserve
MUNICH – Oral contraceptives do more than prevent unwanted pregnancy. They also make it hard to gauge a woman’s ovarian reserve, based on data from 833 women aged 19-46 years seen at a single Danish fertility clinic.
Study findings suggested that an accurate measure of a woman’s ovarian reserve can occur only after she has been off an estrogen-containing OC, probably for at least 3 months, Dr. Kathrine Birch Petersen reported at the annual meeting of the European Society of Human Reproduction and Embryology.
The impact of estrogen-containing OC use on reducing ovarian volume was especially pronounced in women under age 30, the reduction increased with longer durations of OC use, and the ability of OCs to mask a woman’s actual ovarian reserve was strong enough to potentially conceal a true case of premature ovarian insufficiency, said Dr. Birch Petersen, an ob.gyn. at the Fertility Assessment and Counseling Clinic at Rigshospitalet in Copenhagen.
"When we see a woman on an OC with impaired ovarian reserve, we would presume [based on these new findings] that her real ovarian reserve was about 30% higher than what we measure. We would advise her to be retested after she was off her OC for about 3 months," Dr. Birch Petersen said during a press conference before her presentation at the meeting.
The study included the first women seen at the clinic since it opened in 2011, excluding those who were pregnant or failed to supply adequate information. The cross-sectional cohort included 240 women on an estrogen-containing OC and 593 women with natural cycles.
The analysis focused on three parameters: blood level of anti-Müllerian hormone (AMH), antral follicle count (AFC), and ovarian volume. The multivariate, linear regression analysis adjusted for age, body mass index, smoking, age of maternal menopause, maternal smoking during pregnancy, preterm birth, and duration of OC use.
The analysis showed that compared with the women with natural cycles, those on an OC had a 19% relative reduction in their average blood level of AMH, a 16% relative reduction in average AFC, and a 47% relative reduction in average ovarian volume. The women on an OC also had smaller antral follicles. All three differences were statistically significant.
Seeing an effect from an estrogen-containing OC on all three measures makes sense because of their interrelatedness. The antral follicles produce AMH, and a reduction in antral follicle number as well as size would shrink the ovarian contents and result in reduced volume. These effects would not occur in women on a progestin-only OC, she said.
Dr. Birch Petersen had no disclosures.
On Twitter @mitchelzoler
MUNICH – Oral contraceptives do more than prevent unwanted pregnancy. They also make it hard to gauge a woman’s ovarian reserve, based on data from 833 women aged 19-46 years seen at a single Danish fertility clinic.
Study findings suggested that an accurate measure of a woman’s ovarian reserve can occur only after she has been off an estrogen-containing OC, probably for at least 3 months, Dr. Kathrine Birch Petersen reported at the annual meeting of the European Society of Human Reproduction and Embryology.
The impact of estrogen-containing OC use on reducing ovarian volume was especially pronounced in women under age 30, the reduction increased with longer durations of OC use, and the ability of OCs to mask a woman’s actual ovarian reserve was strong enough to potentially conceal a true case of premature ovarian insufficiency, said Dr. Birch Petersen, an ob.gyn. at the Fertility Assessment and Counseling Clinic at Rigshospitalet in Copenhagen.
"When we see a woman on an OC with impaired ovarian reserve, we would presume [based on these new findings] that her real ovarian reserve was about 30% higher than what we measure. We would advise her to be retested after she was off her OC for about 3 months," Dr. Birch Petersen said during a press conference before her presentation at the meeting.
The study included the first women seen at the clinic since it opened in 2011, excluding those who were pregnant or failed to supply adequate information. The cross-sectional cohort included 240 women on an estrogen-containing OC and 593 women with natural cycles.
The analysis focused on three parameters: blood level of anti-Müllerian hormone (AMH), antral follicle count (AFC), and ovarian volume. The multivariate, linear regression analysis adjusted for age, body mass index, smoking, age of maternal menopause, maternal smoking during pregnancy, preterm birth, and duration of OC use.
The analysis showed that compared with the women with natural cycles, those on an OC had a 19% relative reduction in their average blood level of AMH, a 16% relative reduction in average AFC, and a 47% relative reduction in average ovarian volume. The women on an OC also had smaller antral follicles. All three differences were statistically significant.
Seeing an effect from an estrogen-containing OC on all three measures makes sense because of their interrelatedness. The antral follicles produce AMH, and a reduction in antral follicle number as well as size would shrink the ovarian contents and result in reduced volume. These effects would not occur in women on a progestin-only OC, she said.
Dr. Birch Petersen had no disclosures.
On Twitter @mitchelzoler
MUNICH – Oral contraceptives do more than prevent unwanted pregnancy. They also make it hard to gauge a woman’s ovarian reserve, based on data from 833 women aged 19-46 years seen at a single Danish fertility clinic.
Study findings suggested that an accurate measure of a woman’s ovarian reserve can occur only after she has been off an estrogen-containing OC, probably for at least 3 months, Dr. Kathrine Birch Petersen reported at the annual meeting of the European Society of Human Reproduction and Embryology.
The impact of estrogen-containing OC use on reducing ovarian volume was especially pronounced in women under age 30, the reduction increased with longer durations of OC use, and the ability of OCs to mask a woman’s actual ovarian reserve was strong enough to potentially conceal a true case of premature ovarian insufficiency, said Dr. Birch Petersen, an ob.gyn. at the Fertility Assessment and Counseling Clinic at Rigshospitalet in Copenhagen.
"When we see a woman on an OC with impaired ovarian reserve, we would presume [based on these new findings] that her real ovarian reserve was about 30% higher than what we measure. We would advise her to be retested after she was off her OC for about 3 months," Dr. Birch Petersen said during a press conference before her presentation at the meeting.
The study included the first women seen at the clinic since it opened in 2011, excluding those who were pregnant or failed to supply adequate information. The cross-sectional cohort included 240 women on an estrogen-containing OC and 593 women with natural cycles.
The analysis focused on three parameters: blood level of anti-Müllerian hormone (AMH), antral follicle count (AFC), and ovarian volume. The multivariate, linear regression analysis adjusted for age, body mass index, smoking, age of maternal menopause, maternal smoking during pregnancy, preterm birth, and duration of OC use.
The analysis showed that compared with the women with natural cycles, those on an OC had a 19% relative reduction in their average blood level of AMH, a 16% relative reduction in average AFC, and a 47% relative reduction in average ovarian volume. The women on an OC also had smaller antral follicles. All three differences were statistically significant.
Seeing an effect from an estrogen-containing OC on all three measures makes sense because of their interrelatedness. The antral follicles produce AMH, and a reduction in antral follicle number as well as size would shrink the ovarian contents and result in reduced volume. These effects would not occur in women on a progestin-only OC, she said.
Dr. Birch Petersen had no disclosures.
On Twitter @mitchelzoler
AT ESHRE 2014
Key clinical point: Estrogen-containing oral contraceptive use is linked with significantly reduced levels of ovarian volume, antral follicle count, and anti-Müllerian hormone.
Major finding: Users of estrogen-containing OCs had an average 47% reduced ovarian volume, compared with similar women not taking an OC.
Data source: Review of 833 women aged 19-46 years seen at a Danish fertility clinic during 2011-2014.
Disclosures: Dr. Birch Petersen had no disclosures.
AHA wants e-cigarettes regulated but notes they help some smokers quit
The American Heart Association has released its recommendations regarding the sale and usage of e-cigarettes, cautioning that the devices should be regulated to avoid enticing children to smoke while also saying that e-cigarettes could be used as a way to help some current smokers quit.
The guidelines, published online Aug. 24 in Circulation, state that clinicians "should not discourage" their patients from resorting to e-cigarettes if other approved forms of smoking cessation, such as the nicotine patch, have been exhausted. The AHA warned, however, that further studies are needed to fully understand the effects of e-cigarette usage, stressing that e-cigarettes have not been approved by the Food and Drug Administration as an acceptable smoking cessation device and could contain low amounts of toxic chemicals that would prove more harmful than helpful to patients in the long run.
"E-cigarettes have caused a major shift in the tobacco-control landscape," Aruni Bhatnagar, Ph.D., lead author of the guidelines and chair of cardiovascular medicine at the University of Louisville, Ky., said in a statement. "It’s critical that we rigorously examine the long-term impact of this new technology on public health, cardiovascular disease, and stroke, and pay careful attention to the effect of e-cigarettes on adolescents."
For now, the AHA says that clinicians should tell their patients who use e-cigarettes to set a firm quit date, warning that any device that delivers nicotine into the body is harmful and likely lethal.
"Nicotine is a dangerous and highly addictive chemical no matter what form it takes – conventional cigarettes or some other tobacco product," Dr. Elliott Antman, AHA president, said in the statement. "Every life that has been lost to tobacco addiction" could have been saved, he noted.
To that end, the AHA also called for strong regulations regarding the potential marketability of e-cigarettes to youngsters. The group recommended a federal ban on the sale of e-cigarettes to minors, warning that the devices could become a gateway to actual cigarettes for young people who see e-cigarettes as "high-tech, accessible, and convenient," according to a JAMA Pediatrics study of 40,000 middle and high school students. The AHA also recommended that all existing rules and regulations in place for tobacco-related products should apply to e-cigarettes.
"We must protect future generations from any potential smokescreens in the tobacco product landscape that will cause us to lose precious ground in the fight to make our nation 100% tobacco-free," Dr. Antman said.
According to the AHA, 20 million Americans have lost their lives to tobacco over the last 50 years.
The American Heart Association has released its recommendations regarding the sale and usage of e-cigarettes, cautioning that the devices should be regulated to avoid enticing children to smoke while also saying that e-cigarettes could be used as a way to help some current smokers quit.
The guidelines, published online Aug. 24 in Circulation, state that clinicians "should not discourage" their patients from resorting to e-cigarettes if other approved forms of smoking cessation, such as the nicotine patch, have been exhausted. The AHA warned, however, that further studies are needed to fully understand the effects of e-cigarette usage, stressing that e-cigarettes have not been approved by the Food and Drug Administration as an acceptable smoking cessation device and could contain low amounts of toxic chemicals that would prove more harmful than helpful to patients in the long run.
"E-cigarettes have caused a major shift in the tobacco-control landscape," Aruni Bhatnagar, Ph.D., lead author of the guidelines and chair of cardiovascular medicine at the University of Louisville, Ky., said in a statement. "It’s critical that we rigorously examine the long-term impact of this new technology on public health, cardiovascular disease, and stroke, and pay careful attention to the effect of e-cigarettes on adolescents."
For now, the AHA says that clinicians should tell their patients who use e-cigarettes to set a firm quit date, warning that any device that delivers nicotine into the body is harmful and likely lethal.
"Nicotine is a dangerous and highly addictive chemical no matter what form it takes – conventional cigarettes or some other tobacco product," Dr. Elliott Antman, AHA president, said in the statement. "Every life that has been lost to tobacco addiction" could have been saved, he noted.
To that end, the AHA also called for strong regulations regarding the potential marketability of e-cigarettes to youngsters. The group recommended a federal ban on the sale of e-cigarettes to minors, warning that the devices could become a gateway to actual cigarettes for young people who see e-cigarettes as "high-tech, accessible, and convenient," according to a JAMA Pediatrics study of 40,000 middle and high school students. The AHA also recommended that all existing rules and regulations in place for tobacco-related products should apply to e-cigarettes.
"We must protect future generations from any potential smokescreens in the tobacco product landscape that will cause us to lose precious ground in the fight to make our nation 100% tobacco-free," Dr. Antman said.
According to the AHA, 20 million Americans have lost their lives to tobacco over the last 50 years.
The American Heart Association has released its recommendations regarding the sale and usage of e-cigarettes, cautioning that the devices should be regulated to avoid enticing children to smoke while also saying that e-cigarettes could be used as a way to help some current smokers quit.
The guidelines, published online Aug. 24 in Circulation, state that clinicians "should not discourage" their patients from resorting to e-cigarettes if other approved forms of smoking cessation, such as the nicotine patch, have been exhausted. The AHA warned, however, that further studies are needed to fully understand the effects of e-cigarette usage, stressing that e-cigarettes have not been approved by the Food and Drug Administration as an acceptable smoking cessation device and could contain low amounts of toxic chemicals that would prove more harmful than helpful to patients in the long run.
"E-cigarettes have caused a major shift in the tobacco-control landscape," Aruni Bhatnagar, Ph.D., lead author of the guidelines and chair of cardiovascular medicine at the University of Louisville, Ky., said in a statement. "It’s critical that we rigorously examine the long-term impact of this new technology on public health, cardiovascular disease, and stroke, and pay careful attention to the effect of e-cigarettes on adolescents."
For now, the AHA says that clinicians should tell their patients who use e-cigarettes to set a firm quit date, warning that any device that delivers nicotine into the body is harmful and likely lethal.
"Nicotine is a dangerous and highly addictive chemical no matter what form it takes – conventional cigarettes or some other tobacco product," Dr. Elliott Antman, AHA president, said in the statement. "Every life that has been lost to tobacco addiction" could have been saved, he noted.
To that end, the AHA also called for strong regulations regarding the potential marketability of e-cigarettes to youngsters. The group recommended a federal ban on the sale of e-cigarettes to minors, warning that the devices could become a gateway to actual cigarettes for young people who see e-cigarettes as "high-tech, accessible, and convenient," according to a JAMA Pediatrics study of 40,000 middle and high school students. The AHA also recommended that all existing rules and regulations in place for tobacco-related products should apply to e-cigarettes.
"We must protect future generations from any potential smokescreens in the tobacco product landscape that will cause us to lose precious ground in the fight to make our nation 100% tobacco-free," Dr. Antman said.
According to the AHA, 20 million Americans have lost their lives to tobacco over the last 50 years.
FROM CIRCULATION
