Biomedical subjects
Publications and source records attributed to Lee P Shulman.
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Since 2000, the recommendations for women's health care have undergone considerable changes that have prompted a modification in terminology from the "annual examination" to the "periodic well-woman visit." A pelvic examination is not required before prescribing hormonal contraception, selected women 30 years or older may receive less frequent cytological testing and teaching breast self-examination is no longer recommended unless the patient requests it. Counseling will be needed to reassure women that these changes are based on sound scientific evidence. The periodic well-woman visit provides an opportunity for ongoing contraceptive counseling. The expanding array of contraceptive choices necessitates counseling that focuses on methods that are most appropriate for the individual. In addition to the changes in screening recommendations, increased utilization of ancillary staff, self-administered questionnaires and other time-saving strategies to gather information before the patient sees the health care provider can increase the time available for counseling within the time constraints of an office visit.
BACKGROUND: Drospirenone, a novel synthetic progestin, possesses characteristics more like natural progesterone than other synthetic progestins, such as medroxyprogesterone acetate and levonorgestrel. The antiandrogenic and antimineralocorticoid properties of drospirenone may, in the context of menopausal management, provide potential novel benefits in its effect on lipids and blood pressure while reducing the occurrence of water retention, acne vulgaris, and hirsutism. METHODS: This review compares safety and tolerability data from clinical trials of drospirenone, medroxyprogesterone acetate, levonorgestrel, and micronized progesterone. RESULTS: Results suggest that drospirenone possesses a generally well-accepted side effect profile and resembles comparator oral progestogens in conferring endometrial protection with no significant effect on weight. One study indicates that drospirenone may have a benign effect on lipid parameters, having been seen to significantly lower total cholesterol and lowdensity lipoprotein levels while maintaining high-density lipoprotein and triglyceride levels. Drospirenone also differs from the other progestogens in lowering blood pressure levels in hypertensive patients while having a mild blood pressure-lowering effect on nonhypertensive patients. CONCLUSIONS: Among pharmacological options for menopause management, drospirenone may provide certain advantages over other progestogens in its effect on risk factors for cardiovascular disease and, thus, constitutes a useful addition to the menopausal armamentarium.
PURPOSE: The goal of this paper is to review the imaging methods required for localizing nonpalpable Implanontrade mark. METHOD: Different localization methods for nonpalpable Implanon rods are summarized, and clinical guidance is provided as to how best to localize such implants. RESULTS: In the great majority of cases, optimal visualization of the single-rod Implanon rod is obtained with ultrasound using a high-resolution linear array transducer (10-15 MHz). An implant located just under the skin, under the fascia muscularis or one located deep in the muscle can most often be localized with ultrasound. In rare cases where ultrasound does not definitively locate the implant, magnetic resonance imaging is usually the next best choice. Measurements of serum etonogestrel levels may be necessary to confirm the presence or absence of the implant when it cannot be visualized by either of the two imaging methods. DISCUSSION: Close clinical coordination between women's health care providers and radiologists is required to minimize or prevent removal complications and to facilitate subsequent contraceptive management of the patient.
OBJECTIVE: To evaluate the association between echogenic appearing lungs on ultrasonographic examination of the fetus and aneuploidy. METHODS: Cases in which echogenic lungs were prospectively identified on ultrasonographic examination were collected. Other abnormal ultrasonographic findings were documented, as were patient data pertinent to the risk of aneuploidy, such as maternal age and results of serum screening. The chromosomal complement of each identified case is reported. RESULTS: Five fetuses were identified with diffusely echogenic lungs on ultrasound examination over a two-year period. In three of the five cases, there were other ultrasound abnormalities, although in only one of these was a major congenital abnormality detected. In all three of these cases, the fetal chromosomal complement showed trisomy 21. In 1 of the 2 cases in which the echogenic lungs were an isolated finding, the fetus also was found to have trisomy 21. CONCLUSIONS: Bilateral and diffusely echogenic lungs appear to have an association with fetal trisomy 21.
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OBJECTIVE: The objective of this study was to describe the characteristics of and outcomes and side effects in patients using triphasic oral contraceptives (OCs) in a continuous use regimen. METHODS: A retrospective review of patient charts from four community-based physician practices was conducted. All patients had been using triphasic OCs in a continuous regimen (i.e., to prevent withdrawal bleeding) for a planned duration of at least three 28-day cycles. Data collected through retrospective chart abstraction included demographic and clinical indicators, duration of and reason for continuous triphasic OC use, prior OC history and side effect incidence and treatment. RESULTS: Forty-three patients meeting the inclusion criteria had data of sufficient quality to be included in all analyses. These patients represented 603 total cycles. Nearly half of the patients (49%) indicated that their primary reason for continuous OC use was personal preference rather than medical reasons. More than half of the patients (56%) had previously used triphasic OCs in a noncontinuous regimen; 24% had no prior OC experience. The median duration of continuous use was 237 days (including right-censored patients; range, 55-994). Of the 39% of patients who terminated continuous use, the most common reason given was the desire to become pregnant (35%). Sixty-one percent of the patients reported no side effects from continuous use. The most common side effect occurring beyond Day 21 of continuous use was breakthrough bleeding (reported in four patients). Survival analysis indicated that time on continuous triphasic use was positively related to parity >0 (p<.05) and the absence of side effects (p<.1). CONCLUSION: The data suggest that successful continuous use is feasible with triphasic OCs, with few adverse side effects.
STUDY OBJECTIVE: We sought to evaluate the prenatal decision-making of pregnant adolescents identified at increased risk for identifiable fetal genetic abnormalities. DESIGN: A retrospective review of records of gravid women 19 years old or younger undergoing genetic counseling from 2001-2003 (inclusive) was undertaken. SETTING: Hospital-based academic center. PARTICIPANTS: Thirty-seven women were identified; four cases did not meet inclusion criteria. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Decision to undergo or forgo invasive prenatal testing. RESULTS: Of the 33 women included in this study, the average age was 17.6 years (range: 15-19). Eighteen were Latinas, eight were African-Americans, and seven were Caucasians. Sixteen women had positive maternal serum screening outcomes; nine women sought counseling because of personal/family histories of genetic abnormalities, seven sought counseling after fetal structural anomalies were detected by ultrasound, and one woman sought counseling because she and her partner were positive for Mendelian disorder screening (sickle cell disease). Sixteen of the women (48.5%) chose to undergo invasive testing (15 amniocenteses, one chorionic villus sampling) whereas 17 (51.5%) chose to forgo invasive testing. CONCLUSIONS: Adolescents offered invasive prenatal diagnosis will chose to undergo or forgo such testing based on diagnostic and personal criteria as do adult women. Nonetheless, unique adolescent issues may make the process by which information is obtained and communicated during counseling to be different from counseling provided to adults. The development of new genetic screening and diagnostic protocols has and will increase the number of pregnant adolescent women who will be offered genetic counseling during their pregnancies. Such an increase in numbers will place considerably more pressure on an already taxed genetic counseling system; accordingly, new counseling paradigms will need to be developed to provide service to an expanded patient population seeking information for an increasing number of genetic issues.
Women who want safe, effective contraception have many more options than they did only a few years ago. Each option must be weighed carefully according to the needs and lifestyle of each particular woman. One method that provides long-term convenience with a side-effect profile that is comparable to that of oral contraceptives is the once-a-month injectable contraceptive containing 25 mg medroxyprogesterone acetate and 5 mg estradiol cypionate. Another option is the levonorgestrel-releasing intrauterine contraceptive system that offers pregnancy prevention for 5 years. Finally, hormonal implants that release low doses of progestins have been used for more than 30 years by a total of 10 million women, and easier-to-use implants will soon be available.
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Recent publications of the initial outcomes from the Women's Health Initiative (WHI) study of menopausal management have raised concerns over the safety of hormone therapy [1,2]. Every study, no matter how large or well conducted, has biases and limitations that preclude the ability to apply the outcomes to a larger group of individuals not specifically evaluated in the analysis. In particular, the hormonal arms of the WHI evaluated only a single dose of a daily oral regimen of conjugated equine oestrogen 0.625 mg [1,2], combined with medroxyprogesterone acetate 2.5 mg if the subject had a uterus [1]. The failure to evaluate non-oral regimens prevented the evaluation of hormone delivery systems that have been shown to provide similar symptom relief to oral regimens, but with a considerably different physiological impact. The once-weekly transdermal patch (Climara Pro releasing 17beta-estradiol 0.045 mg/day and levonorgestrel 0.015 mg/day has been shown to be highly effective in rapidly reducing the frequency and intensity of vasomotor symptoms and to significantly improve all categories in the quality of life Women's Health Questionnaire [3]. In addition, this transdermal combination system was not associated with any cases of endometrial hyperplasia, adverse impacts on cholesterol or lipid values and was associated with an increasing rate of amenorrhoea over time [3]. The 17beta-estradiol/levonorgestrel transdermal system is approved in the US for the treatment of moderate-to-severe vasomotor symptoms and the prevention and treatment of urogenital atrophy.
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PURPOSE OF REVIEW: Unintended pregnancy continues to exact a considerable economic, social and personal cost in industrialized nations despite the ready availability of safe, reliable and highly effective methods of contraception. Adolescents still demonstrate some of the highest rates of unintended pregnancy and thus may benefit from considering new contraceptive options that provide unique side effect profiles or delivery systems that could facilitate and improve compliance of contraceptive methods. RECENT FINDINGS: The recent launch of several new combination oral contraceptive pills with novel side effect profiles has expanded the choices for teenagers who choose to use a daily oral contraceptive. Of potentially greater interest is the recent availability of several nondaily contraceptives, as compliance remains a critical issue with successful contraceptive use in adolescents. SUMMARY: New contraceptive methods bring unique side effect profiles and delivery systems that may improve overall contraceptive compliance, especially among teenagers who are more prone to misuse from a wide array of side effect and compliance issues. Even the most accepted method, however, will not provide effective contraception if the process by which contraception is provided fails to address the unique concerns and lifestyle issues of each individual adolescent.
Despite the wide variety of reversible contraceptives, unintended pregnancy rates in developed nations are still considered markedly elevated by most epidemiologists and clinicians. Indeed, the US has one of the highest unintended pregnancy rates among the industrialized nations of the world. Although many factors appear to influence this problem, what may play an important role in this apparent paradox is the process by which a woman obtains contraception. Although most nonbarrier methods have similar efficacy, the ability to use that method consistently and correctly will determine whether it provides maximal contraception. Oral contraceptives are the most popular method in the US; accordingly, the process by which US women obtain their contraception may not take into account the desire of many women to use nondaily methods. The recent introduction of nondaily methods in the US and elsewhere has provided more choice so that a successful contraceptive decision can be made in the first instance rather than after an adverse clinical outcome or unintended pregnancy with a method not as well suited to that woman's lifestyle. These new methods are not characterized by improved safety or efficacy; rather, they have novel components or delivery systems that may provide important options to women who may not be able to or willing to use existing methods of contraception. The transdermal patch, vaginal ring, and monthly injectable are combination estrogen/progestogen methods characterized by novel delivery systems and compliance regimens. The single rod implant is a facile and well accepted method that has not yet been approved for use in the US but has been an increasingly popular choice elsewhere. The levonorgestrel intrauterine system has been used in Europe for over 10 years and has recently been introduced in the US. This intrauterine contraceptive provides high efficacy and reliability, and may have considerable noncontraceptive benefit with regard to the nonsurgical treatment of uterine bleeding problems and endometrial protection for menopausal hormone therapy. The increasing popularity of these methods can be considered a testament to the desire of women to consider nondaily contraceptives as first-line, mainstream options. It is hoped that increasing use of these methods will lead to a considerable decrease in the rate of unintended pregnancy.
Fetal cells in maternal blood represent the future of prenatal screening and diagnosis. The possibility of analyzing fetal cells recovered from maternal blood could provide screening and diagnostic protocols characterized by high sensitivity and specificity with no direct risk to the developing fetus. Years of investigation have thus far not led to the development of reliable and consistent protocols; nonetheless, fetal cell recovery promises to be an attractive addition to noninvasive prenatal diagnosis.
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In the last decade, the contribution of the progestin component of oral contraceptives (OCs) to the risk of venous thromboembolism (VTE) has come under scrutiny. The publication of 4 papers in late 1995 and early 1996 led to many women discontinuing OCs containing desogestrel and gastodene, the so-called third-generation OCs. This "pill scare" was the result of study findings that the third-generation OCs were associated with a higher risk of VTE than were OCs containing older progestins, primarily levonorgestrel. Subsequent studies and reanalysis of the original studies have not provided a definitive answer to this continuing debate. More recently, a question was raised about a possible increase in the risk of VTE associated with the use of an OC containing the novel progestin drospirenone. However, the information to date does not support any increase in the risk of VTE with use of the drospirenone-containing OC as compared with any other combination OC.