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MacGregor B, Munro MG, Lumsden MA. Therapeutic options for the management of abnormal uterine bleeding. Int J Gynaecol Obstet 2023; 162 Suppl 2:43-57. [PMID: 37538018 DOI: 10.1002/ijgo.14947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Just as the investigation of abnormal uterine bleeding (AUB) is approached systematically using the two FIGO systems for AUB in the reproductive years, treatment options can be considered similarly. Therapeutic options fall into two categories-medical and surgical-and while medical management is typically regarded as first-line therapy, there are several exceptions defined by the presenting cause or causes, mainly when infertility is a concurrent issue. In the early 1990s, up to 60% of women underwent a hysterectomy for the symptom of heavy menstrual bleeding (HMB), but this figure has decreased. The number of women undergoing a hysterectomy for benign disorders continues to decline, along with an increase in hysterectomies performed using minimally invasive techniques. Discussions about therapeutic options are tailored to the individual patient, and we include the risks and benefits of each option, including no management, to enable the patient to make an informed choice. The different types of treatment options and the factors affecting decision-making are considered in this article.
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Affiliation(s)
| | - Malcolm G Munro
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at the University of California, Los Angeles, California, USA
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2
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Zhang Y, Zhu Y, Sun J. Analysis of Adverse Events and Medical Errors in Long-Term Hormone Treatments for Endometriosis: A Study Based on the US Food and Drug Administration Event Reporting System. Int J Womens Health 2022; 14:1237-1250. [PMID: 36097448 PMCID: PMC9464009 DOI: 10.2147/ijwh.s377418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/29/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose To investigate adverse events and medical errors, as well as their possible risk factors, of combined oral contraceptives and progestins used in patients with endometriosis. Patients and Methods Reports between January 1, 2014 and September 30, 2021 about patients with endometriosis in US Food and Drug Administration Adverse Event Reporting System were analyzed. Disproportional analysis was performed with the Gamma-Poisson Shrinker model to detect overreported drug-event pairs. Logistic regression analysis was utilized to explore potential risk factors. Results There were 823 reports on long-term hormone treatments and 6247 reports on other drugs after removing duplicates, most of which were reported by consumers and were from the United States. Procedural complications and product issues were common among long-term hormone treatment users, while some other new adverse events emerged in subgroup analysis of different dosage forms of progestin. Polytherapy was negatively associated with off label use (adjusted OR = 0.47, 95% CI 0.22–0.94) and product use in unapproved indication (adjusted OR = 0.36, 95% CI 0.15–0.76) for combined oral contraceptive users. Combined oral contraceptive users aged greater than or equal to 30 were less likely to have product use issue (adjusted OR = 0.33, 95% CI 0.12–0.82) but were at higher risk of pulmonary embolism (adjusted OR = 4.04, 95% CI 1.35–17.43). Conclusion Long-term hormone treatment products in this study are generally safe for endometriosis, while newly detected signals need to be validated by further exploration. Patients’ tolerance and fertility desire should be considered when preparing treatment plans.
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Affiliation(s)
- Yuxin Zhang
- Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, People's Republic of China
| | - Yiping Zhu
- Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, People's Republic of China
| | - Jing Sun
- Shanghai Key Laboratory of Maternal Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, 200092, People's Republic of China
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3
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de Mattos Leão T, Paula Soares RB, Capellari CA, Nisihara R. Gynecological Care for Women With Intellectual Disabilities: A Brazilian Study. JOURNAL OF INTELLECTUAL DISABILITIES : JOID 2022:17446295221123871. [PMID: 36062387 DOI: 10.1177/17446295221123871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
We aimed to identify the main challenges in the gynecological care and management of patients with intellectual disability by gynecologists. Gynecologists answered to online questionnaires about situations in which the professional reports their confidence in caring for patients with intellectual disability. Were studied 143 responses, 75% women. Among them, 53.8% felt apprehensive to conduct a routine gynecological screening, 60% were confident in advising about contraceptive services and examining the genitals. The greatest difficulty was indicating drugs to suppress menstruation and managing patients with severe intellectual disability. The female doctors were more prepared in the care of disability patients and recent certified gynecologists were more insecure. The main difficulty was time for examinations (39.2%) and the main solution was to improve medical training (64.2%). The main challenges of the gynecologist included the amount of time needed to provide clinical services, the lack of knowledge and skill; and ethical concerns.
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Affiliation(s)
| | | | | | - Renato Nisihara
- Post Graduate Program in Gynecology and Obstetrics, Federal University of Paraná, Curitiba, Brazil
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4
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Ebeling PR, Nguyen HH, Aleksova J, Vincent AJ, Wong P, Milat F. Secondary Osteoporosis. Endocr Rev 2022; 43:240-313. [PMID: 34476488 DOI: 10.1210/endrev/bnab028] [Citation(s) in RCA: 92] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Indexed: 02/07/2023]
Abstract
Osteoporosis is a global public health problem, with fractures contributing to significant morbidity and mortality. Although postmenopausal osteoporosis is most common, up to 30% of postmenopausal women, > 50% of premenopausal women, and between 50% and 80% of men have secondary osteoporosis. Exclusion of secondary causes is important, as treatment of such patients often commences by treating the underlying condition. These are varied but often neglected, ranging from endocrine to chronic inflammatory and genetic conditions. General screening is recommended for all patients with osteoporosis, with advanced investigations reserved for premenopausal women and men aged < 50 years, for older patients in whom classical risk factors for osteoporosis are absent, and for all patients with the lowest bone mass (Z-score ≤ -2). The response of secondary osteoporosis to conventional anti-osteoporosis therapy may be inadequate if the underlying condition is unrecognized and untreated. Bone densitometry, using dual-energy x-ray absorptiometry, may underestimate fracture risk in some chronic diseases, including glucocorticoid-induced osteoporosis, type 2 diabetes, and obesity, and may overestimate fracture risk in others (eg, Turner syndrome). FRAX and trabecular bone score may provide additional information regarding fracture risk in secondary osteoporosis, but their use is limited to adults aged ≥ 40 years and ≥ 50 years, respectively. In addition, FRAX requires adjustment in some chronic conditions, such as glucocorticoid use, type 2 diabetes, and HIV. In most conditions, evidence for antiresorptive or anabolic therapy is limited to increases in bone mass. Current osteoporosis management guidelines also neglect secondary osteoporosis and these existing evidence gaps are discussed.
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Affiliation(s)
- Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia
| | - Hanh H Nguyen
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Department of Endocrinology and Diabetes, Western Health, Victoria 3011, Australia
| | - Jasna Aleksova
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Amanda J Vincent
- Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Monash Centre for Health Research and Implementation, School of Public Health and Preventative Medicine, Monash University, Clayton, Victoria 3168, Australia
| | - Phillip Wong
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
| | - Frances Milat
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria 3168, Australia.,Department of Endocrinology, Monash Health, Clayton, Victoria 3168, Australia.,Hudson Institute of Medical Research, Clayton, Victoria 3168, Australia
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Rocca ML, Palumbo AR, Bitonti G, Brisinda C, DI Carlo C. Bone health and hormonal contraception. Minerva Obstet Gynecol 2021; 73:678-696. [PMID: 34905875 DOI: 10.23736/s2724-606x.20.04688-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Short-term and long-term steroid contraceptive systems are widely employed in adolescents and premenopausal women; they could induce variation in bone metabolism, but whether these changes increase the overall fracture risk is not yet clear. EVIDENCE ACQUISITION A systematic search of scientific publications about "hormonal contraceptives" and "bone metabolism" in reproductive age women was conducted. EVIDENCE SYNTHESIS In adolescent girl, combined oral contraceptives could have a deleterious effect on bone health when their onset is within three years after menarche and when they contain ethinyl estradiol at the dose of 20 mcg. In perimenopausal women, steroid contraceptives seem not influence bone health nor increase osteoporotic fractures risk in menopause. The oral progestogens intake is not related to negative effects on skeletal health. Depot medroxyprogesterone acetate (DMPA) induce a prolonged hypoestrogenism with secondary detrimental effect on healthy bone; the higher bone loss was observed at the DMPA dose of 150 mg intramuscular such as after long-term DMPA-users. Progestin-based implants and intrauterine devices have not negative effect on bone health. CONCLUSIONS Since sex-steroid drugs induce variations in hormonal circulating concentrations, they may negatively affect bone metabolism. Contraceptive choice should be tailored evaluating any possible effect on bone health. Clinicians should always perform a precontraceptive counselling to identify any coexisting condition that may affect bone health. Further randomized studies are needed to confirm these results.
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Affiliation(s)
- Morena L Rocca
- Operative Unit of Obstetrics and Gynecology, Pugliese-Ciaccio Hospital, Catanzaro, Italy -
| | - Anna R Palumbo
- Department of Obstetrics and Gynecology, Magna Græcia University of Catanzaro, Catanzaro, Italy
| | - Giovanna Bitonti
- Department of Obstetrics and Gynecology, Magna Græcia University of Catanzaro, Catanzaro, Italy
| | - Caterina Brisinda
- Department of Obstetrics and Gynecology, Magna Græcia University of Catanzaro, Catanzaro, Italy
| | - Costantino DI Carlo
- Department of Obstetrics and Gynecology, Magna Græcia University of Catanzaro, Catanzaro, Italy
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Lahoti A, Yu C, Brar PC, Dalgo A, Gourgari E, Harris R, Kamboj MK, Marks S, Nandagopal R, Page L, Raman V, Reynolds DG, Sarafoglou K, Terrell C, Stanley TL. An endocrine perspective on menstrual suppression for adolescents: achieving good suppression while optimizing bone health. J Pediatr Endocrinol Metab 2021; 34:1355-1369. [PMID: 34388330 DOI: 10.1515/jpem-2020-0539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 07/19/2021] [Indexed: 11/15/2022]
Abstract
Suppression of menstruation and/or ovarian function in adolescent girls may be desired for a variety of reasons. Numerous medical options exist. The choice of the appropriate modality for an individual patient depends on several factors based on differences in the efficacy of achieving menstrual suppression as well as in their side effect profiles. Adolescence is also a period of bone mass accrual in girls, and several of these modalities may negatively influence peak bone mass. This review focuses on the efficacy of achieving menstrual suppression and the effect on bone health of the various options through an overview of the current literature and also highlights areas in need of further research.
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Affiliation(s)
- Amit Lahoti
- Pediatric Endocrine Division, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, TN, USA
| | - Christine Yu
- Section of Adult and Pediatric Endocrinology, Diabetes, & Metabolism, University of Chicago, Chicago, IL, USA
| | - Preneet Cheema Brar
- Division of Pediatric Endocrinology and Diabetes, NYU Grossman School of Medicine, New York, NY, USA
| | - Austin Dalgo
- Center for Bioethics and Health Equity, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, TN, USA
| | - Evgenia Gourgari
- Pediatric Endocrinology Division, Department of Pediatrics, Georgetown University, Washington, DC, USA
| | - Rebecca Harris
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
| | - Manmohan K Kamboj
- Section of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital at The Ohio State University, Columbus, OH, USA
| | - Seth Marks
- Section of Pediatric Endocrinology and Metabolism, Department of Pediatrics and Child Health, Children's Hospital HSC Winnipeg, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Radha Nandagopal
- Department of Medical Education and Clinical Sciences, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Laura Page
- Division of Endocrinology, Department of Pediatrics, Duke University, Durham, NC, USA
| | | | - Danielle G Reynolds
- Diabetes and Endocrinology Center, University of South Florida, Tampa, FL, USA
| | - Kyriakie Sarafoglou
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA.,Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN, USA
| | - Carrie Terrell
- Division of General Obstetrics, Gynecology, Midwifery and Family Planning at the University of Minnesota Medical School, Minneapolis, MN, USA
| | - Takara L Stanley
- Pediatric Endocrine Unit and Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Watts NB, Binkley N, Owens CD, Al-Hendy A, Puscheck EE, Shebley M, Schlaff WD, Simon JA. Bone Mineral Density Changes Associated With Pregnancy, Lactation, and Medical Treatments in Premenopausal Women and Effects Later in Life. J Womens Health (Larchmt) 2021; 30:1416-1430. [PMID: 34435897 DOI: 10.1089/jwh.2020.8989] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Bone mineral density (BMD) changes during the life span, increasing rapidly during adolescence, plateauing in the third decade of life, and subsequently entering a phase of age-related decline. In women, menopause leads to accelerated bone loss and an increase in fracture risk. Between peak bone mass attainment and menopause, BMD is generally stable and the risk of fracture is typically low. This time period is marked by life events such as pregnancy and lactation, which transiently decrease BMD, yet their long-term effects on fracture risk are less certain. BMD may also be altered by exposure to medications that affect bone metabolism (e.g., contraceptives, glucocorticoids, antidiabetic medications, antiepileptic drugs). Although oral contraceptives are often believed to be neutral with regard to bone health, depot medroxyprogesterone acetate (DMPA) and gonadotropin-releasing hormone (GnRH) agonists have been associated with decreases in BMD. Development of newer medical therapies, principally GnRH antagonists (e.g., ASP1707, elagolix, linzagolix, relugolix), for treatment of endometriosis-associated pelvic pain and heavy menstrual bleeding due to uterine fibroids has renewed interest in the short- and long-term impacts of changes in BMD experienced by premenopausal women. It is important to understand how these drugs influence BMD and put the findings into context with regard to measurement variability and naturally occurring factors that influence bone health. This review summarizes what is known about the effects on bone health pregnancy, lactation, and use of DMPA, GnRH agonists, and GnRH antagonists in premenopausal women and potential consequences later in life. ClinicalTrials.gov identifier: NCT03213457.
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Affiliation(s)
- Nelson B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, Ohio, USA
| | - Neil Binkley
- Department of Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | | | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, The University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Elizabeth E Puscheck
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan, USA.,InVia Fertility, Hoffman Estates, Illinois, USA
| | | | - William D Schlaff
- Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - James A Simon
- IntimMedicine Specialists, Washington, District of Columbia, USA
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8
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Golden NH. Bones and Birth Control in Adolescent Girls. J Pediatr Adolesc Gynecol 2020; 33:249-254. [PMID: 31972296 DOI: 10.1016/j.jpag.2020.01.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/07/2020] [Accepted: 01/11/2020] [Indexed: 12/24/2022]
Abstract
Peak bone mass acquisition during adolescence is an important determinant of adult bone health. Knowledge about the effects of different contraceptives on peak bone mass acquisition could influence choice of method recommended. This review summarizes normal bone acquisition during adolescence, discusses methods of assessing bone health in this age group, and reviews the effects of different contraceptive options on bone health, both in adults and in adolescents. Based on the evidence, long-acting reversible contraceptives do not appear to affect peak bone mass acquisition or future fracture risk and remain the first-line contraceptive choice for adolescents. Oral contraceptives with doses of ethinyl estradiol greater than 30 μg should be used in preference to lower-dose preparations, and the adverse effects of depo medroxyprogesterone acetate (DMPA) on bone health are reversible on discontinuation of the medication. Concerns about bone health should not prevent use of DMPA in an adolescent who prefers this method.
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Affiliation(s)
- Neville H Golden
- Lucile Packard Children's Hospital, Stanford, Stanford University School of Medicine, Palo Alto, California.
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Bachrach LK. Hormonal Contraception and Bone Health in Adolescents. Front Endocrinol (Lausanne) 2020; 11:603. [PMID: 32973688 PMCID: PMC7472551 DOI: 10.3389/fendo.2020.00603] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 07/24/2020] [Indexed: 11/16/2022] Open
Abstract
Hormonal contraception is prescribed commonly to adolescents for myriad indications from pregnancy prevention to treatment for acne, hirsutism or dysmenorrhea. Although use of these hormones generally has no effect or benefits bone health in mature premenopausal women, the same may not be true for adolescents. The teen years are a critical period for acquiring peak bone strength. Sex hormones, growth hormone, and insulin-like growth factors (IGFs) interact to modulate the changes in bone size, geometry, mineral content, and microarchitecture that determine skeletal strength. Combined oral contraceptives (COCs) and intramuscular depo medroxyprogesterone (DMPA) can compromise the expected gains in adolescence by altering estrogen and IGF concentrations. Use of these medications has been associated with slower accrual of bone mineral density (BMD) and increased fracture risk in some studies. Far less is known about the skeletal effects of the newer long acting reversible contraceptives (LARCs). This review takes a critical look at the gaps in current knowledge of the skeletal effects of COCs, DMPA, and LARCs and underscores the need for additional research.
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