Abnormal Uterine Bleeding Associated With Hormonal Contraception

Abnormal uterine bleeding is a common and bothersome symptom in people using hormonal contraception, and it can lead to discontinuation of reliable methods of contraception and unintended pregnancies. Clinicians should counsel individuals about the potential for abnormal bleeding at initiation of the contraceptive method. After considering and excluding other potential causes of abnormal uterine bleeding, clinicians can offer treatment options specific to each hormonal contraceptive method. This article includes algorithms to help clinicians treat abnormal uterine bleeding in people using levonorgestrel intrauterine devices, depo-medroxyprogesterone acetate, progestin implant, progestin-only pills, and combined hormonal contraception. For patients with levonorgestrel intrauterine devices, physicians should first ensure that the device is correctly placed within the uterus, then consider nonsteroidal anti-inflammatory drugs as a first-line treatment for abnormal uterine bleeding; estradiol can be used if nonsteroidal anti-inflammatory drugs are ineffective. For depo-medroxyprogesterone acetate or progestin implant users, combined oral contraceptives or nonsteroidal anti-inflammatory drugs may be considered. For patients using norethindrone progestin-only pills, changing to drospirenone progesterone-only pills may help reduce the bleeding. In people using combined hormonal contraception, it may be helpful to increase estrogen content from 20 mcg to 35 mcg per day, decrease the hormone-free interval (from seven to four or five days) in people using cyclic contraception, or start a trial of low-dose doxycycline. For continuous combined contraception users, adding a hormone-free interval of four or five days can help regulate bleeding patterns.

Management of Women at High Risk for Breast Cancer

BACKGROUND

Primary care clinicians screen for breast cancer risk factors and assess the risk level of their patients. Women at high risk for breast cancer (eg, 5-year risk of at least 3% or lifetime risk of ≥20%) are eligible for enhanced screening and/or chemoprophylaxis. However, many clinicians do not identify women at high risk and offer appropriate referrals, screening, or chemoprophylaxis.

METHODS

We reviewed a sample of 200 charts of women ages 35 to 50 years old with a family history of breast cancer. We identified factors that contribute to their risk for breast cancer and used the Tyrer-Cuzick Risk Assessment Calculator to determine their personal lifetime risk. We then assessed whether these patients received counseling for chemoprophylaxis, referrals, or screening. We also looked for correlations between combinations of risk factors and increased lifetime risk.

RESULTS

Out of 200 charts reviewed, 71 women were identified as high risk for breast cancer (lifetime risk of ≥20%). Of those 71 women, just 17 were referred to a high-risk clinic for enhanced screening and/or chemoprophylaxis. Three risk factors, mammographic breast density of category C or D, first degree relatives with breast cancer, and age first given birth if after 30 years old had a significant impact on lifetime risk for breast cancer.

DISCUSSION

Primary care clinicians can use these independent risk factors as cues to pursue a more formal calculation of a woman's lifetime risk for breast cancer and make appropriate referrals for enhanced screening and chemoprophylaxis counseling if indicated.

Team Science Principles Enhance Cancer Care Delivery Quality Improvement: Interdisciplinary Implementation of Breast Cancer Screening Shared Decision Making

PURPOSE

Implementing shared decision making (SDM), recommended in screening mammography by national guidelines for women age 40-49 years, faces challenges that innovations in quality improvement and team science (TS) are poised to address. We aimed to improve the effectiveness, patient-centeredness, and efficiency of SDM in primary care for breast cancer screening.

METHODS

Our interdisciplinary team included primary and specialty care, psychology, epidemiology, communication science, engineering, and stakeholders (patients and clinicians). Over a 6-year period, we executed two iterative cycles of plan-do-study-act (PDSA) to develop, revise, and implement a SDM tool using TS principles. Patient and physician surveys and retrospective analysis of tool performance informed our first PDSA cycle. Patient and physician surveys, toolkit use, and clinical outcomes in the second PDSA cycle supported SDM implementation. We gathered team member assessments on the importance of individual TS activities.

RESULTS

Our first PDSA cycle successfully generated a SDM tool called Breast Cancer Risk Estimator, deemed valuable by 87% of patients surveyed. Our second PDSA cycle increased Breast Cancer Risk Estimator utilization, from 2,000 sessions in 2017 to 4,097 sessions in 2019 while maintaining early-stage breast cancer diagnoses. Although TS activities such as culture, trust, and communication needed to be sustained throughout the project, shared goals, research/data infrastructure support, and leadership were more important earlier in the project and persisted in the later stages of the project.

CONCLUSION

Combining rigorous quality improvement and TS principles can support the complex, interdependent, and interdisciplinary activities necessary to improve cancer care delivery exemplified by our implementation of a breast cancer screening SDM tool.

How to better identify and manage women with elevated breast cancer risk

This case-based review details screening and management strategies that can maximize the care you provide to women at heightened risk.

Mini-Residencies to Improve Care for Women Veterans: A Decade of Re-Educating Veterans Health Administration Primary Care Providers

Background: Many primary care providers (PCPs) in the Veterans Health Administration need updated clinical training in women's health. The objective was to design, implement, and evaluate a training program to increase participants' comfort with and provision of care to women Veterans, and foster practice changes in women's health care at their local institutions. Methods: The Women's Health Mini-Residency was developed as a multi-day training program, based on principles of adult learning, wherein knowledge gleaned through didactic presentations was solidified during small-group case study discussions and further enhanced by hands-on training and creation of a facility-specific action plan to improve women Veterans' care. Pre, post, and 6-month surveys assessed attendees' comfort with and provision of care to women. The 6-month survey also queried changes in practice, promulgation of program content, and action plan progress. Results: From 2008 to 2019, 2912 PCPs attended 26 programs. A total of 2423 (83.2%) completed pretraining and 2324 (79.3%) completed post-training surveys. The 6-month survey was sent to the 645 attendees from the first 14 programs; 297 (46.1%) responded. Comparison of pre-post responses indicated significant gains in comfort managing all 19 content areas. Six-month data showed some degradation, but comfort remained significantly improved from baseline. At 6 months, participants also reported increases in providing care to women, including performing more breast and pelvic examinations, dissemination of program content to colleagues, and progress on action plans. Conclusions: This interactive program appears to have been successful in improving PCPs' comfort in providing care for women Veterans and empowering them to implement institutional change.

Adenomyosis: Diagnosis and Management

Adenomyosis is a clinical condition where endometrial glands are found in the myometrium of the uterus. One in three patients with adenomyosis is asymptomatic, but the rest may present with heavy menstrual bleeding, pelvic pain, or infertility. Heavy menstrual bleeding is the most common symptom. Adenomyosis is distinct from endometriosis (the presence of endometrial glands outside of the uterus), but the two conditions often occur simultaneously. Risk factors for developing adenomyosis include increasing age, parity, and history of uterine procedures. Most patients are diagnosed from 40 to 50 years of age, but younger patients with infertility are increasingly being diagnosed with adenomyosis as imaging modalities improve. Diagnosis of adenomyosis begins with clinical suspicion and is confirmed with transvaginal ultrasonography and pelvic magnetic resonance imaging. Treatment of adenomyosis typically starts with hormonal menstrual suppression. Levonorgestrel-releasing intrauterine systems have shown some effectiveness. Patients with adenomyosis may ultimately have a hysterectomy if symptoms are not controlled with medical therapy.

Patient and Clinician Characteristics That Predict Breast Cancer Screening Behavior in 40-49-Year-Old Women

Guidelines recommend that clinicians practice shared decision-making (SDM) with women in their 40s to discuss breast cancer screening. Traditionally, SDM includes discussion of values and preferences to help determine a decision that is congruent with what the patient desires. We analyzed 54 women's breast cancer screening decisions after a SDM conversation with their clinician. We looked at both patient and clinician characteristics that predicted whether or not a woman would get a screening mammogram. Women with a family history of breast cancer or who had a previous abnormal mammogram had higher rates of screening. Screening rates also varied widely between clinicians, raising the question of whether clinician attitudes impacted the SDM conversation.

Breast Implants: Common Questions and Answers

Breast implants are used for a wide range of cosmetic and reconstructive purposes. In addition to breast augmentation, implants can be used for postmastectomy breast reconstruction, correction of congenital breast anomalies, breast or chest wall deformities, and male-to-female top surgery. Breast implants may confer significant benefits to patients, but several factors are important to consider preoperatively, including the impact on mammography, future lactation, and potential long-term implant complications (e.g., infection, capsular contracture, rupture, and the need for revision, replacement, or removal). A fundamental understanding of implant monitoring is also paramount to implant use. Patients with silicone breast implants should undergo routine screening for implant rupture with magnetic resonance imaging or ultrasonography completed five to six years postoperatively and then every two to three years thereafter. With the exception of complications, there are no formal recommendations regarding the timing of breast implant removal or exchange. Women with unilateral breast swelling should be evaluated with ultrasonography for an effusion that might indicate breast implant-associated anaplastic large cell lymphoma. There are no specific breast cancer screening recommendations for patients with breast implants, but special mammographic views are indicated to enhance accuracy. Although these discussions are a routine component of consultation and postoperative follow-up for plastic surgeons performing these procedures, family physicians should have a working knowledge of implant indications, characteristics, and complications to better counsel their patients, to ensure appropriate screening, and to coordinate care after surgery.

Preliminary Evaluation of a Breast Cancer Screening Shared Decision-Making Aid Utilized Within the Primary Care Clinical Encounter

Introduction:

The US Preventative Services Task Force recommends shared decision-making (SDM) between women aged 40 and 49 years and their physician regarding timing of mammography screening. This preliminary study evaluates women’s and physician’s satisfaction using Breast Cancer Risk Estimator & Decision Aid (BCARE-DA), a shared decision aid utilized during the clinical encounter, and examines SDM quality for these encounters.

Methods:

Fifty-three women and their physician utilized BCARE-DA and completed surveys measuring satisfaction with Likert-type and open-ended items and women completed the Decision Conflict Scale. Clinic visit transcripts were evaluated for SDM quality using Observer OPTION-5 and Breast Cancer Screening Decision Core Components Checklist.

Results:

Women and physicians positively evaluated BCARE-DA. Women had low decision conflict. Physicians demonstrated moderate effort toward SDM, greatest in offering options, and lowest for team talk. Physicians demonstrated 2/3 of core SDM elements in 80% to 100% of encounters.

Conclusion:

Preliminary findings suggest specific promise for such Decision Aids to facilitate SDM through understanding of personal risks for breast cancer formulated within each screening option, while some SDM elements likely require additional facilitating.

Managing a woman with BRCA mutations? Shared decision-making is key

A collaborative assessment of options and trade-offs-perhaps using visual decision aids-can help.

Beyond Birth Control: Noncontraceptive Benefits of Hormonal Methods and Their Key Role in the General Medical Care of Women

Contraceptives that contain estrogen and/or progestins are used by millions of women around the world to prevent pregnancy. Owing to their unique physiological mechanism of action, many of these medications can also be used to prevent cancer and treat multiple general medical conditions that are common in women. We performed a comprehensive literature search. This article will describe the specific mechanisms of action and summarize the available data documenting how hormonal contraceptives can prevent ovarian and uterine cancer and be used to treat women with a variety of gynecological and nongynecological conditions such as endometriosis, uterine fibroids, heavy menstrual bleeding, polycystic ovary syndrome, acne, and migraines. Contraceptive methods containing estrogen and progestin can be used for a wide variety of medical issues in women.

Transforming your daily work into scholarship: Tips for a busy clinician-scholar

This article was migrated. The article was marked as recommended. Academic faculty are pulled in multiple directions during their daily work life. Clinical issues, teaching responsibilities, and administrative duties all take up large amounts of time. At the same time, most faculty have requirements for scholarly activities for promotions. This paper discusses ways that individuals can use much of the work that they do in all of the realms of their jobs and turn it into scholarly projects. By focusing the content of their work, planning ahead, and making everything count twice, faculty can be successful in developing scholarship using their daily work.

How best to address breast pain in nonbreastfeeding women

This guide-with accompanying algorithms-will help you to streamline your approach to breast pain in a patient who isn't breastfeeding.

BRCA Mutation Carriers: Breast and Ovarian Cancer Screening Guidelines and Imaging Considerations

Patients who carry the BRCA1 and BRCA2 gene mutations have an underlying genetic predisposition for breast and ovarian cancers. These deleterious genetic mutations are the most common genes implicated in hereditary breast and ovarian cancers. This monograph summarizes the evidence behind current screening recommendations, reviews imaging protocols specific to this patient population, and illustrates some of the imaging nuances of breast and ovarian cancers in this clinical setting.

A Review of Long-Acting Reversible Contraception Methods and Barriers to Their Use

Unplanned pregnancies are a serious health concern in Wisconsin. Increasing access to contraception is a proven method to reduce unplanned pregnancies while giving patients greater agency. Long-acting reversible contraception (LARC) methods, such as subdermal implants and intrauterine devices (IUD), are among the most effective contraception methods available and have high patient satisfaction. However, relatively few Wisconsin patients use these methods. Lack of provider skill in inserting and counseling about LARCs, inability to perform same-day LARC insertion, and absent hospital protocols for immediate postpartum insertion represent barriers to LARC access. Centralized efforts are required to remove these barriers so that all patients in Wisconsin can access highly effective contraception.

Breast Cancer Screening in Primary Care: A Call for Development and Validation of Patient-Oriented Shared Decision-Making Tools

The latest recommendations on breast cancer screening in women from 40 to 49 years charge primary care providers (PCPs) with completing shared decision-making with women about screening mammography. However, there is a lack of supportive materials accompanying this directive. No easy-to-use risk assessment tool is available for PCPs to stratify women's risk. Neither is an evidence-based patient-centered way to assess values surrounding mammography available. To provide the highest quality care for women of 40-49 years, further research should clarify ways to apply risk assessment and values clarification to individual women.

Mammography Screening: Gaps in Patient's and Physician's Needs for Shared Decision-Making

As shared decision-making increasingly influences screening mammography, understanding similarities and differences between patients and physician perspectives becomes crucially important. This study compares women's and physicians' experiences of mammography shared decision-making. Results reflect the critical gaps which exist between women's expectations and physicians' confidence in shared decision-making regarding screening mammography.