Recent advances in managing and understanding menstrual disorders

Chromosomal polymorphisms and susceptibility to menstrual disorders: a retrospective analysis of 24,578 women

PURPOSE

To evaluate the association between the polymorphic variants of chromosomes and menstrual disorders.

METHODS

The data from our previous retrospective, single-center cohort study were re-analyzed. Women with regular menstruation were included as controls. Women with menstrual cycle abnormalities were subgrouped according to reproductive causes. The frequency of chromosomal polymorphisms was compared between groups. Regression analysis was used to adjust for potential confounding variables.

RESULT

A total of 24,578 women composed of 8062 women with regular cycles as the control group and 16,516 women as the menstrual cycle irregularity group were included. When compared with the control group, the incidence of chromosomal polymorphisms in the total menstrual cycle irregularity group, Polycystic ovary syndrome group, and Primary ovarian insufficiency group were significantly higher (4.49% versus 5.34%, P = 0.004, 4.49% versus 5.35%, P = 0.018 and 4.49% versus 5.94%, P = 0.002, respectively). The incidences of inv(9) in the Primary ovarian insufficiency group were significantly higher than that in the control individuals (1.0% versus 1.6%, P = 0.024). Logistic regression analysis showed an effect of chromosomal polymorphisms on menstrual cycle irregularity (OR: 1.62, 95% CI: 1.234-2.187, P = 0.007; adjusted OR: 1.46, 95% CI: 1.153-1.819, P < 0.001). The result demonstrated an effect of chromosomal polymorphisms on the Primary ovarian insufficiency group (OR: 2.52, 95% CI: 1.307-5.177, P < 0.001; adjusted OR: 2.61, 95% CI: 1.371-4.605, P < 0.001).

CONCLUSION

The study suggests chromosomal polymorphisms adversely affect female menstrual cycle irregularity.

Strengthening Integrated Approaches for Family Planning and Menstrual Health

FP and menstrual health integration has the potential to improve individuals' health and well-being. The authors describe potential ways to integrate FP and menstrual health, outlining steps that stakeholders can take in designing integrated approaches.

Assessing a cut-off point for the diagnosis of abnormal uterine bleeding using the Menstrual Bleeding Questionnaire (MBQ): a validation and cultural translation study with Brazilian women

BACKGROUND

Abnormal uterine bleeding (AUB) is a common condition, and the Menstrual Bleeding Questionnaire (MBQ) is used for its assessment.

OBJECTIVES

To translate, assess the cut-off point for diagnosis, and explore psychometric properties of the MBQ for use in Brazilian Portuguese.

DESIGN AND SETTING

Prospective cohort study including 200 women (100 with and 100 without AUB) at a tertiary referral center.

METHODS

MBQ translation involved a pilot-testing phase, instrument adjustment, data collection, and back-translation. Cut-off point was obtained using receiver operating curve analysis. Menstrual patterns, impact on quality of life due to AUB, internal consistency, test-retest, responsiveness, and discriminant validity were assessed. For construct validity, the Pictorial Blood Assessment Chart (PBAC) and World Health Organization Quality of Life - abbreviated version (WHOQOL-BREF) were applied.

RESULTS

Women with AUB were older, had higher body mass indices, and had a worse quality of life during menstruation. Regarding the MBQ's psychometric variables, Cronbach's alpha coefficient was > 0.70 in all analyses, high intraclass correlation coefficient was found in both groups; no ceiling and floor effects were observed, and construct validity was demonstrated (correlation between MBQ score, PBAC score, and clinical menstrual cycle data). No difference between MBQ and PBAC scores were perceived after the test-retest. Significant differences were found between MBQ and PBAC scores before and after treatment. An MBQ score ≥ 24 was associated with a high probability of AUB; accuracy of 98%.

CONCLUSION

The MBQ is a reliable questionnaire for Brazilian women. The cut-off ≥ 24 shows high accuracy to discriminate AUB.

Impact of Dysmenorrhea on Academic Performance Among Haramaya University Undergraduate Regular Students, Eastern Ethiopia

Background:

Dysmenorrhea is the most common gynecological problem among students. The disease affects students' academic performance, although studies carried out in Ethiopia primarily focused on the prevalence aspects rather than the impacts of dysmenorrhea on academic performance and its associated factors. Therefore, this study focused on the prevalence of the impact of dysmenorrhea on academic performance and its associated factors among undergraduate female students of Haramaya University in eastern Ethiopia.

Methods

A cross-sectional study design was conducted from February to March 2020. A multistage random sampling technique was applied and a total of 356 students were included in the study. To select students, simple random sampling was used and the sample size was proportionally allocated with respect to the total number of each selected department. A semi-structured and a pre-tested self-administered questionnaire were used. The descriptive result was presented as a proportion whereas the analytic part was presented with an adjusted odds ratio.

Result

The prevalence of the impact of dysmenorrhea on academic performance was 266 [(74.7%):95%CI (70.0, 79.5%)]. Premenstrual syndrome [AOR = 4.86:95%CI (2.13, 11.06)], early menarche [AOR = 4.89:95%CI (2.03, 11.77)], moderate/severe dysmenorrhea pain intensity [AOR = 8.53:95%CI (4.45, 16.39)], and students monthly pocket money <150ETB [AOR = 3.91:95%CI (1.48, 10.29)] were significantly associated with the occurrence of the impact of dysmenorrhea on academic performance. The most common impacts were difficulty in studying followed by loss of concentration in the class.

Conclusion and Recommendation

There was a high prevalence of impact of dysmenorrhea on academic performance among undergraduate female students of the Haramaya University. Awareness should be created among Haramaya university authorities and teachers about the academic performance impact of premenstrual syndrome and dysmenorrhea pain intensity to provide psychological and academic guidance, and managing mechanisms for the affected students. Haramaya University should also establish medical care for the affected students.

Excess Heme Promotes the Migration and Infiltration of Macrophages in Endometrial Hyperplasia Complicated with Abnormal Uterine Bleeding

In patients, endometrial hyperplasia (EH) is often accompanied by abnormal uterine bleeding (AUB), which is prone to release large amounts of heme. However, the role of excess heme in the migration and infiltration of immune cells in EH complicated by AUB remains unknown. In this study, 45 patients with AUB were divided into three groups: a proliferative phase group (n = 15), a secretory phase group (n = 15) and EH (n = 15). We observed that immune cell subpopulations were significantly different among the three groups, as demonstrated by flow cytometry analysis. Of note, there was a higher infiltration of total immune cells and macrophages in the endometrium of patients with EH. Heme up-regulated the expression of heme oxygenase-1 (HO-1) and nuclear factor erythroid-2-related factor 2 (Nrf2) in endometrial epithelial cells (EECs) in vitro, as well as chemokine (e.g., CCL2, CCL3, CCL5, CXCL8) levels. Additionally, stimulation with heme led to the increased recruitment of THP-1 cells in an indirect EEC-THP-1 co-culture unit. These data suggest that sustained and excessive heme in patients with AUB may recruit macrophages by increasing the levels of several chemokines, contributing to the accumulation and infiltration of macrophages in the endometrium of EH patients, and the key molecules of heme metabolism, HO-1 and Nrf2, are also involved in this regulatory process.

Prevalence of Dysmenorrhea and Associated Factors Among Haramaya University Students, Eastern Ethiopia

Purpose

Dysmenorrhea is the most common gynecological problem among adolescents and a common cause of school absenteeism. Previously, there was no study conducted on prevalence of dysmenorrhea and associated factors among university students in Ethiopia. Therefore, the aim of this study was to assess prevalence and associated factors of dysmenorrhea among Haramaya university undergraduate regular students in Eastern Ethiopia.

Materials and Methods

An institution-based cross-sectional study design was conducted from February to March 2020. A multistage random sampling technique was applied and a total of 569 participants were included into the study. The total sample size was proportionally allocated based on the total number of students in each departments, and simple random sampling technique was employed to select participants. The data were entered to EPI‑info version 3.5.4 and then exported to Statistical Package for Social Science version 23.0 software for analysis. The associations between independent variables and outcome variable were explored using bivariate and multivariable logistic regression models. The results of these analysis were reported as odds ratios with 95% confidence intervals.

Results

The prevalence of dysmenorrhea in this study was 356 (64.7%) 95% CI [60.7%, 68.7%]. Premenstrual syndrome (AOR = 5.20:95% CI [2.82, 9.61]), early menarche (AOR = 4.67:95% CI [2.33, 9.37]), history of anxiety (AOR = 4.08:95% CI [2.31, 7.19]), taking of ≥4 glass of tea per day (AOR = 5.69:95% CI [1.49, 21.77]), usually eating fat and oil (AOR = 2.03:95% CI [1.15, 3.59]) and usual use of meat food (AOR = 3.61:95% CI [2.03, 6.39]) were positively and independently associated with the occurrence of dysmenorrhea.

Conclusion

Dysmenorrhea was a common problem among Haramaya University female students. History of anxiety, early menarche, premenstrual syndrome, tea consumption, usual use of fat and oil containing food and usual use of meat food were significantly associated to dysmenorrhea. We recommend Haramaya University to provide accessible and appropriate medical treatment and counseling service for dysmenorrhea affected students.

The Menstrual Disturbances in Endocrine Disorders: A Narrative Review

CONTEXT

Menstrual cycle is considered the fifth vital sign among women. This study aimed to summarize the menstrual disturbances in different endocrine disorders.

EVIDENCE ACQUISITION

In this narrative review, relevant studies (up to December 2019) were searched based on the MeSH keywords diabetes, polycystic ovary syndrome, Cushing's syndrome, thyroid dysfunction, hyperprolactinemia, menstrual cycle, uterine bleeding, and menstruation. Databases used for searching articles included Google Scholar, Scopus, PubMed, and Web of science for observational, experimental, and review studies.

RESULTS

Endocrine disorders trigger the onset of menstrual disturbance across the reproductive lifespan of women. Endocrine glands (pituitary, thyroid, pancreas, adrenal, and ovaries) have a functional role in endocrine regulation of the menstrual cycle. According to available evidence, oligomenorrhea (cycles longer than 35 days) is the most common menstrual disturbance among endocrine disorders (thyrotoxicosis, hypothyroidism, polycystic ovary syndrome, Cushing's syndrome, and diabetes). Complex endocrine pathways play an essential role in a women's menstrual calendar.

CONCLUSIONS

The menstrual cycle length and amount of bleeding can be indicative of endocrine disorders. Further studies are needed to identify the unknowns about the association between endocrine disorders and the menstrual cycle.

Prevalence and knowledge of heavy menstrual bleeding among gynecology outpatients by scanning a WeChat QR Code

The aim of this study was to assess menstrual blood loss (MBL) and knowledge of heavy menstrual bleeding (HMB) among the gynecology outpatients at Peking University People’s Hospital, by scanning a WeChat (a social media application software developed by Tencent) QR Code using a mobile phone or tablet. This survey was conducted among outpatients who were treated at the Gynecology Department of Peking University People’s Hospital between September 2016 and November 2016. All participants filled up the questionnaires and scales through WeChat: general information questionnaire, Pictorial Blood Loss Assessment Chart (PBAC), Menorrhagia Multi-Attribute Quality-of-Life Scale (MMAS), and HMB knowledge questionnaire. Menstrual blood volume was assessed by the PBAC and self-assessment. Among the 1152 patients who filled out the survey, 77.4% (892/1152) had normal menstrual cycle (assessed by the patients), 15.6% (180/1152) patients described themselves as HMB, whereas the results from PBAC showed that 58.0% (668/1152) had HMB (PBAC ≥100). Among patients with PBAC ≥100, only 26.8% (179/668) patients reported HMB through self-assessment. Regarding its impact on daily life, the MMAS scores of HMB patients (PBAC ≥100) were significantly lower compared to those with normal blood loss (P<0.001). Regarding the awareness to HMB, 63.2% (728/1152) of the patients were not familiar with HMB. HMB is a common abnormal uterine bleeding and is frequently found among Chinese gynecology outpatients. HMB has major impacts on a woman’s quality of life, affecting both physical and emotional health domains. Since women generally have low levels of awareness and understanding of HMB, they could assess their blood loss using the PBAC, which they can forward to their health care provider using a mobile phone or tablet and the WeChat platform. This tool may be effortlessly used by the health care providers and patients to easily share HMB-related data.

Bleeding changes after levonorgestrel 52-mg intrauterine system insertion for contraception in women with self-reported heavy menstrual bleeding

BACKGROUND

The levonorgestrel 52-mg intrauterine system has proven efficacy for heavy menstrual bleeding treatment in clinical trials, but few data exist to demonstrate how rapidly the effects occur and the effects in women with self-reported heavy bleeding, as seen commonly in clinical practice.

OBJECTIVE

Evaluate changes in bleeding patterns in women with self-reported heavy menstrual bleeding before levonorgestrel 52-mg intrauterine system insertion.

STUDY DESIGN

A total of 1714 women aged 16-45 years old received a levonorgestrel 52-mg intrauterine system in a multicenter trial evaluating contraceptive efficacy and safety for up to 10 years. At screening, participants described their baseline menstrual bleeding patterns for the previous 3 months. Participants completed daily diaries with subjective evaluation of bleeding information for the first 2 years. For this analysis, we included women with at least 1 complete 28-day cycle of intrauterine system use and excluded women using a hormonal or copper intrauterine contraception in the month prior to study enrollment. We evaluated changes in menstrual bleeding and discontinuation for bleeding complaints per 28-day cycle over 26 cycles (2 years) in women who self-reported their baseline pattern as heavy. We also compared rates of amenorrhea, defined as no bleeding or spotting, within the entire study population in women with subjective heavy menstrual bleeding at baseline compared with those who did not complain of heavy menstrual bleeding.

RESULTS

Of the 1513 women in this analysis, 150 (9.9%) reported baseline heavy menstrual bleeding. The majority of women reported no longer experiencing heavy menstrual bleeding by the end of cycle 1 (112/150, 74.7%) with even greater rates by cycle 2 (124/148, 83.8%). At the end of cycles 6, 13, and 26, 129 of 140 (92.1%; 95% confidence interval, 87.7%-96.6%), 114 of 123 (92.7%; 95% confidence interval, 88.1%-97.3%), and 100 of 103 (97.1%; 95% confidence interval, 93.8%-100%) women reported no heavy menstrual bleeding, respectively. After cycles 13 and 26, 63 of 123 (51.2%; 95% confidence interval, 42.4%-60.1%) and 66 of 103 (64.1%; 95% confidence interval, 54.8%-73.3%), respectively, reported their bleeding as amenorrhea or spotting only. A lower proportion of women with baseline self-reported heavy menstrual bleeding reported amenorrhea as compared with women in the overall study cohort without heavy menstrual bleeding at the end of 6 cycles (319 [25.5%] vs 21 [15.0%], P=.005) and 13 cycles (382 [34.4%] vs 26 [21.1%], P=.003); differences were not significant after 19 cycles (367 [37.2%] vs 36 [31.0%], P=.022) and 26 cycles (383 [43.5%] vs 38 [36.9%], P=.21). Only 4 (2.7%) women with baseline heavy menstrual bleeding discontinued for bleeding complaints (2 for heavy menstrual bleeding and 2 for irregular bleeding), all within the first year.

CONCLUSION

Most women who self-report heavy menstrual bleeding experience significant improvement quickly after levonorgestrel 52-mg intrauterine system insertion. Discontinuation for bleeding complaints among women with baseline heavy menstrual bleeding is very low.

A Clinicopathological Correlation of International Federation of Gynecology and Obstetrics's PALM-COEIN Classification of Abnormal Uterine Bleeding: Indian Scenario

Background

Abnormal uterine bleeding (AUB) is a common problem affecting the women of reproductive age group and may also have a significant impact on their physical, social, and emotional aspects directly affecting their quality of life. The International Federation of Gynecology and Obstetrics (FIGO) devised a universally acceptable system of nomenclature and classification, namely PALM-COEIN classification of AUB in the year 2011. The objective of the present study was to analyze the structural (PALM) and functional (COEIN) component of FIGO system in the Indian scenario.

Materials and Methods

Three hundred patients with complaints of AUB were taken. A clinical diagnosis according to PALM-COEIN system was made after thorough history and clinical examination. Additional investigations if required were done, and endometrial sampling or hysterectomy was done whichever indicated. A histological diagnosis was made, and each case was allocated a category according to PALM-COEIN classification. A clinicopathological correlation was done in the hysterectomy cases for structural causes (PALM).

Results

Leiomyoma (30%) was the most common cause of AUB closely followed by adenomyosis (29.66%) overall. The clinicopathological correlation in hysterectomy cases was good with concordance rate of 85.03%. The concordance between clinical and pathological diagnoses for AUB-L, AUB-A, AUB-M, and AUB-A, L was statistically significant with P < 05 in positive cases. However, additional finding of adenomyosis was diagnosed in 48.2% of the cases apart from primary clinical diagnosis.

Conclusion

A good clinicopathological correlation was seen in the cases when classified according to PALM-COEIN classification. The system also provides for consideration of multiple etiologies contributing toward AUB both clinically and histopathologically. However, histopathology remains the cornerstone in establishing the accurate diagnosis as the cases without specific symptoms can be missed clinically.

The effect of plantain syrup on heavy menstrual bleeding: A randomized triple blind clinical trial

Given the importance of heavy menstrual bleeding (HMB), we investigated the effect of plantain syrup on HMB. This randomized clinical trial was performed on 68 women with HMB who were referred to the traditional medicine clinics of Mashhad University of Medical Sciences. The intervention group received placebo capsule and plantain syrup, whereas the control group received mefenamic acid capsule and placebo syrup in the first 5 days of menstruation for three menstruation cycles. Patients were asked to complete pictorial blood assessment chart one cycle before the intervention and three intervention cycles. Hemoglobin was measured at the beginning and at the end of the study. The results showed that the bleeding duration and severity diminished in both groups. No significant difference was observed between two groups in severity of bleeding after intervention (Cohen's d = .24), but duration of bleeding in mefenamic acid group was reduced significantly in comparison with plantain group (Cohen's d = .57). Although mean hemoglobin alterations in mefenamic acid group had a significant difference before and after the intervention, there was no significant difference between the two groups in mean hemoglobin alterations postintervention. Plantain syrup could be suggested as a complementary treatment for HMB, but further studies are required.

Critical evaluation of the PALM-COEIN classification system among women with abnormal uterine bleeding in low-resource settings

OBJECTIVE

To assess the feasibility of the PALM-COEIN system for the classification of abnormal uterine bleeding (AUB) in low-resource settings and to suggest modifications.

METHODS

A prospective study was conducted among women with AUB who were admitted to the gynecology ward of a tertiary care hospital and research center in central India between November 2014 and October 2016. All patients were managed as per department protocols. The causes of AUB were classified before treatment using the PALM-COEIN system (classification I) and on the basis of the histopathology reports of the hysterectomy specimens (classification II); the results were compared using classification II as the gold standard.

RESULTS

The study included 200 women with AUB; hysterectomy was performed in 174 women. Preoperative classification of AUB per the PALM-COEIN system was correct in 130 (65.0%) women. Adenomyosis (evaluated by transvaginal ultrasonography) and endometrial hyperplasia (evaluated by endometrial curettage) were underdiagnosed.

CONCLUSION

The PALM-COEIN classification system helps in deciding the best treatment modality for women with AUB on a case-by-case basis. The incorporation of suggested modifications will further strengthen its utility as a pretreatment classification system in low-resource settings.

Efficacy of Foley's Catheter and the Effect of Histopathology, Age and Endometrial Thickness Relative to the Measured Outcomes in Menorrhagia

INTRODUCTION

Menorrhagia adversely affects the quality of life. Hysterectomy is the definitive treatment for menorrhagia however, a number of conservative alternatives are available.

AIM

Hysterectomy is the definitive treatment for menorrhagia however, a number of conservative alternatives are available. A thermal balloon is an effective but costly option. We used a Foley's catheter as an alternative to commercially available thermal balloons. If effective, it will provide a cheap alternative to the thermal balloon.

MATERIALS AND METHODS

A Foley's catheter was placed in the uterine cavity for 10 minutes using 0.9% saline. The measured outcomes were amenorrhea, eumenorrhea, oligomenorrhea or failure of the therapy. Endometrial thickness, age and endometrial biopsy results were also measured to determine if these variables had any effects on the outcome.

RESULTS

Out of the total 42 participants, nearly half had amenorrhea (42.9%, n=18). Furthermore, 28.6% had oligomenorrhea (n=12) and 26.2% experienced eumenorrhea (n=11). Only one participant failed to respond (2.4%, n=1). There were no differences in outcomes between the different forms of histopathology. This means that thermal balloon therapy is effective in causing amenorrhea. No significant relationships existed between participants' measured outcomes and a model containing predictor variables (age and endometrial thickness), R=0.313, R2=0.098, p=0.141.

CONCLUSION

A Foley's catheter is effective with reasonable measured outcomes in cases of menorrhagia.

Knowledge of Latin American Obstetricians and Gynecologists regarding Heavy Menstrual Bleeding

Background. Heavy menstrual bleeding (HMB) is a common gynecological complaint affecting quality of life. Objectives. To assess knowledge on diagnosis and treatments of HMB of Latin American (LA) obstetricians and gynecologists (OBGYNs). Methods. A survey was conducted during a scientific meeting, organized to provide updated information on topics of reproductive medicine to OBGYNs from 12 LA countries who were invited to respond to a multiple-choice questionnaire. Results. Of the 210 OBGYNs participating in the survey, from 169 (80.4%) to 203 (96.7%) answered the questions. Most respondents (80%) gave accurate answers regarding the amount of blood loss which defines HMB, underreported the proportion of women who consulted due to HMB, and were aware that the use of combined oral contraceptives (COCs) with ethynyl estradiol is not an adequate treatment in women with HMB. Female OBGYNs and those who worked in the private sector were more prone to report a higher possibility of improvement of HMB with a COC that contained estradiol valerate and dienogest or with a levonorgestrel-releasing intrauterine system. Conclusions. In general, the respondents were aware of the importance of HMB in gynecological practice and of the new medical treatments and underreported the proportion of women who consulted due to HMB.

Effectiveness and safety of dydrogesterone in regularization of menstrual cycle: a post-marketing study

Oral administration of dydrogesterone during second half of menstrual cycle has been shown to reduce menstrual irregularities. This prospective, observational study aimed to determine continued effectiveness of dydrogesterone (prescribed between 1 and 6 cycles or longer) in menstrual cycle regularization in Indian women aged ≥18 years with irregular menstrual cycle for at least 3 months. Those achieving regular cycles (21 to 35 days, inclusive) during treatment were followed up for 6 months after cessation of dydrogesterone treatment. Of the 910 women completing dydrogesterone treatment, 880 (96.7%) achieved cycle regularization (p<0.0001 for 90% success rate) at end of treatment (EOT). Of the 788 subjects available for follow up at 6 months, 747 (94.8%) reported cycle regularity (p<0.0001 for 90% success rate). At EOT, the mean cycle duration reduced by 16.14 (±24.04) days and mean amount of menstrual bleeding decreased by 0.45 (±1.20) pads/day. While five subjects reported worst pain at baseline, none experienced it at EOT. One serious adverse event (appendicitis) and three non-serious adverse events were reported. Dydrogesterone regularizes and improves the duration of the menstrual cycle, reduces the amount of bleeding, relieves menstrual pain and prevents relapse of irregular cycles at six months after discontinuation of treatment.

Comparison of classic terminology with the FIGO PALM-COEIN system for classification of the underlying causes of abnormal uterine bleeding

OBJECTIVE

To compare classic terminology and the PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory disorders, endometrium, iatrogenic, and not classified) classification system among women who underwent surgery for abnormal uterine bleeding (AUB), and to subclassify the components of the PALM group for future studies.

METHODS

In a retrospective study, data were obtained for nonpregnant women aged 18-55years who underwent hysterectomy, myomectomy, or polypectomy for AUB at a center in Turkey in 2014. The patients were retrospectively classified according to the PALM-COEIN system, and the two terminologies were compared.

RESULTS

A total of 471 women were included. The term "hypermenorrhea" covered 15 different pathology combinations, "menorrhagia" nine, "metrorrhagia" 14, and "menometrorrhagia" 18. Of 92 patients with polyp, 5 (5.4%) had two polyps and 1 (1.1%) had three. Of 146 patients with adenomyosis, 131 (89.7%) had diffuse adenomyosis and 12 (8.2%) had adenomyoma. Of 309 patients with myoma uteri, 108 (34.9%) had submucous myoma and 201 (65.1%) had other types of myoma.

CONCLUSION

Classic terminology for AUB is insufficient and confusing with respect to etiologic pathologies among nonpregnant women of reproductive age. Widespread adoption of the PALM-COEIN system for AUB classification will facilitate more meaningful communication among both clinicians and investigators, and clarify the populations that should be evaluated in clinical trials, thereby enhancing communication with patients.