USPSTF Draft Recommendation Statement Cervical Cancer : Screening

The US Preventive Services Task Force has New Draft Guidance for Cervical Cancer Screening

These recommendations do NOT apply to women with in utero exposure to diethylstilbestrol or women who have a compromised immune system (e.g., women living with HIV).

The major change from the US Preventive Services Task Force (USPSTF) 2012 recommendation is that testing for high-risk strains of human papillomavirus (hrHPV) alone is now recommended as an alternative to cytology or Papanicolaou (Pap) screening alone beginning at age 30 years; cotesting is no longer recommended.

As in the 2012 recommendation, the USPSTF continues to recommend that women aged 21 to 29 years undergo Pap screening every 3 years.

The USPSTF recommend against screening in women younger than age 21 years because there is adequate evidence that regardless of sexual history, screening younger women does not reduce cervical cancer incidence or mortality.

The USPSTF also continues to give a thumbs down to screening in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer, as well as in women who have had a hysterectomy and their cervix removed and do not have a history of a high-grade precancerous lesions or cervical cancer.

More Information

Genetic Associations with Gestational Duration and Spontaneous Preterm Birth

Massachusetts Medical Society, NEJM, 2017

Abstract

BACKGROUND
Despite evidence that genetic factors contribute to the duration of gestation and the risk of preterm birth, robust associations with genetic variants have not been identified. We used large data sets that included the gestational duration to determine possible genetic associations.

METHODS
We performed a genomewide association study in a discovery set of samples obtained from 43,568 women of European ancestry using gestational duration as a continuous trait and term or preterm (<37 weeks) birth as a dichotomous outcome. We used samples from three Nordic data sets (involving a total of 8643 women) to test for replication of genomic loci that had significant genomewide association (P<5.0×10−8) or an association with suggestive significance (P<1.0×10−6) in the discovery set.

RESULTS
In the discovery and replication data sets, four loci (EBF1, EEFSEC, AGTR2, and WNT4) were significantly associated with gestational duration. Functional analysis showed that an implicated variant in WNT4 alters the binding of the estrogen receptor. The association between variants in ADCY5 and RAP2C and gestational duration had suggestive significance in the discovery set and significant evidence of association in the replication sets; these variants also showed genomewide significance in a joint analysis. Common variants in EBF1, EEFSEC, and AGTR2 showed association with preterm birth with genomewide significance. An analysis of mother–infant dyads suggested that these variants act at the level of the maternal genome.

CONCLUSIONS
In this genomewide association study, we found that variants at the EBF1, EEFSEC, AGTR2, WNT4, ADCY5, and RAP2C loci were associated with gestational duration and variants at the EBF1, EEFSEC, and AGTR2 loci with preterm birth. Previously established roles of these genes in uterine development, maternal nutrition, and vascular control support their mechanistic involvement. (Funded by the March of Dimes and others.)

Breast feeding associated with a lower risk of endometriosis

History of breast feeding and risk of incident endometriosis: prospective cohort study

2017 Study Abstract

Objective
To investigate the association between lifetime breast feeding, exclusive breast feeding, postpartum amenorrhea, and incidence of endometriosis among parous women.

Design
Prospective cohort study.

Setting
Nurses’ Health Study II, 1989-2011.

Participants
72 394women who reported having one or more pregnancies that lasted at least six months, 3296 of whom had laparoscopically confirmed endometriosis. For each pregnancy, women reported duration of total breast feeding, exclusive breast feeding, and postpartum amenorrhea.

Main outcome measures
Incident self reported laparoscopically confirmed endometriosis (96% concordance with medical record) in parous women. Multivariable Cox proportional hazard models were used to calculate hazard ratios and 95% confidence intervals for diagnosis of endometriosis.

Results
Duration of total and exclusive breast feeding was significantly associated with decreased risk of endometriosis. Among women who reported a lifetime total length of breast feeding of less than one month, there were 453 endometriosis cases/100 000 person years compared with 184 cases/100 000 person years in women who reported a lifetime total of ≥36 months of breast feeding. For every additional three months of total breast feeding per pregnancy, women experienced an 8% lower risk of endometriosis (hazard ratio 0.92, 95% confidence interval 0.90 to 0.94; P<0.001 for trend) and a 14% lower risk for every additional three months of exclusive breast feeding per pregnancy (0.86, 0.81 to 0.90; P<0.001 for trend). Women who breastfed for ≥36 months in total across their reproductive lifetime had a 40% reduced risk of endometriosis compared with women who never breast fed (0.60, 0.50 to 0.72). The protective association with breast feeding was strongest among women who gave birth within the past five years (P=0.04 for interaction). The association with total breast feeding and exclusive breast feeding on endometriosis was partially influenced by postpartum amenorrhea (% mediated was 34% (95% confidence interval 15% to 59%) for total breast feeding and 57% (27% to 82%) for exclusive breast feeding).

Conclusion
Among women who experienced at least one pregnancy that lasted at least six months, breast feeding was inversely associated with risk of incident endometriosis. This association was partially, but not fully, influenced by postpartum amenorrhea, suggesting that breast feeding could influence the risk of endometriosis both through amenorrhea and other mechanisms. Given the chronic and incurable nature of endometriosis, breast feeding should be further investigated as an important modifiable behavior to mitigate risk for pregnant women.

  • History of breast feeding and risk of incident endometriosis: prospective cohort study, BMJ 2017;358:j3778, 29 August 2017.
  • Featured image credit @bmj_latest, 2 sept. 2017.

Get Me Out

A History of Childbirth from the Garden of Eden to the Sperm Bank, by Randi Hutter

image of get me out book cover
Randi Hutter Epstein, M.D., M.P.H. is a medical writer, adjunct professor at Columbia University Graduate School of Journalism and a lecturer at Yale University.

From a witty, relentlessly inquisitive medical writer, an eye-opening history of pregnancy and birthing joys and debacles. Making and having babies—what it takes to get pregnant, stay pregnant, and deliver—has mystified women and men for the whole of human history. The birth gurus of ancient times told newlyweds that simultaneous orgasms were necessary for conception and that during pregnancy a woman should drink red wine but not too much and have sex but not too frequently. Over the last one hundred years, depending on the latest prevailing advice, women have taken morphine, practiced Lamaze, relied on ultrasound images, sampled fertility drugs, and shopped at sperm banks.

In Get Me Out, the insatiably curious Randi Hutter Epstein journeys through history, fads, and fables, and to the fringe of science, where audacious researchers have gone to extreme measures to get healthy babies out of mothers. The book has a full, good chapter on DES.

DES DiEthylStilbestrol Resources

How the egg freezing industry took advantage of the infertility fear

Adam Ruins Everything – July 2017

While “modern” fertility “advice” is based on ancient data, there is an increased risk of birth defects and miscarriage after 35. Adam Conover explains how corporate America and the egg freezing industry took advantage of the infertility fear.

Reducing maternal, newborn, and infant mortality globally : an integrated action agenda

International Journal of Gynecology & Obstetrics, Improving maternal health, 2012

Abstract

There has been increasing awareness over recent years of the persisting burden of worldwide maternal, newborn, and child mortality. The majority of maternal deaths occur during labor, delivery, and the immediate postpartum period, with obstetric hemorrhage as the primary medical cause of death. Other causes of maternal mortality include hypertensive diseases, sepsis/infections, obstructed labor, and abortion-related complications. Recent estimates indicate that in 2009 an estimated 3.3 million babies died in the first month of life and that overall, 7.3 million children under 5 die each year. Recent data also suggest that sufficient evidence- and consensus-based interventions exist to address reproductive, maternal, newborn, and child health globally, and if implemented at scale, these have the potential to reduce morbidity and mortality. There is an urgent need to put elements in place to promote integrated interventions among healthcare professionals and their associations. What is needed is the political will and partnerships to implement evidence-based interventions at scale.

  1. Why do maternal and newborn deaths matter?
  2. Addressing determinants
  3. Defining evidence-based interventions for maternal, newborn, and child survival
  4. Delivering integrated MNCH interventions in primary care settings

Read Reducing maternal, newborn, and infant mortality globally: An integrated action agenda, International Journal of Gynecology & Obstetrics, Improving maternal health, DOI: 10.1016/j.ijgo.2012.04.001, 2012. Featured image : sti. Source: Modified from Kerber et al.

Age and body mass index v. Triclosan exposure, and diminished ovarian reserve

Urinary triclosan concentrations and diminished ovarian reserve among women undergoing treatment in a fertility clinic

2017 Study Abstract

Objective
To investigate the association between urinary triclosan concentrations and antral follicle count (AFC), a well-accepted marker of ovarian reserve, among women from a fertility center.

Design
Prospective cohort study.

Setting
Hospital fertility center.

Patient(s)
A total of 109 women.

Intervention(s)
Urinary triclosan concentrations quantified by online solid phase extraction-high performance liquid chromatography-isotope dilution tandem mass spectrometry.

Main Outcome Measure(s)
AFC through transvaginal ultrasonography on the third day of an unstimulated menstrual cycle or on the third day of a progesterone withdrawal bleed.

Result(s)
The geometric mean of the specific gravity–adjusted urinary triclosan concentrations for the 225 samples provided by the 109 women was 13.0 μg/L (95% confidence interval [CI], 8.9, 19.1). Women had median (with interquartile range) AFC of 13 (8, 18). The specific gravity–adjusted urinary triclosan concentrations were inversely associated with AFC (−4%; 95% CI, −7%, −1%). Women with triclosan concentrations above the median had lower AFC compared with those whose triclosan concentrations were equal to or below the median, with an adjusted difference of −3.2 (95% CI, −3.9, −1.6) among those with a body mass index <25 kg/m2 and −1.8 (95% CI, −3.2, −0.3) among those who were <35 years old.

Conclusion(s)
Specific gravity–adjusted urinary triclosan concentrations were inversely associated with AFC in women seeking care at a fertility center. This association was modified by age and body mass index, with the younger and leaner women showing larger decreases in AFC.

  • Urinary triclosan concentrations and diminished ovarian reserve among women undergoing treatment in a fertility clinic, American Society for Reproductive Medicine, Volume 108, Issue 2, Pages 312–319, August 2017.
  • Antibacterial Soap Triclosan image credit Mike Mozart.

The future of human uterine transplantation

Can minimally invasive techniques provide a uterus suitable for transplant?

2017 Abstract

Interest in uterine transplantation for the treatment of uterine factor infertility (UFI) has grown exponentially over the past several years. Following the first birth from this procedure in September 2014, multiple centers worldwide have announced plans to perform clinical trials of uterine transplant. A prominent consideration in creating a protocol is whether to select a living or a nonliving donor model and whether a minimally invasive technique can be successfully used to minimize living donor risk.

Although this study and others will increase optimism for the possibility of a minimally invasive uterus retrieval, no current protocols in humans or animals have yet reported a successful pregnancy using a minimally invasive approach. Although resumption of menstrual function occurred in this case report within two months of transplant, it is unknown whether a uterus drained by the utero-ovarian vessels will be able to support and sustain implantation and ongoing pregnancy in humans.

  • The future of human uterine transplantation: can minimally invasive techniques provide a uterus suitable for transplant?, American Society for Reproductive Medicine, Volume 108, Issue 2, Pages 243–244, August 2017.
  • Image of Cleveland Clinic surgeons at work performing the first uterus transplant in the US. credit vox.

The feminist appropriation of pregnancy testing in 1970s Britain

Jesse Olszynko-Gryn, Department of History and Philosophy of Science, University of Cambridge, Cambridge, UK

Abstract

This article restores pregnancy testing to its significant position in the history of the women’s liberation movement in 1970s Britain. It shows how feminists appropriated the pregnancy test kit, a medical technology which then resembled a small chemistry set, and used it as a political tool for demystifying medicine, empowering women and providing a more accessible, less judgmental alternative to the N.H.S. While the majority of testees were young women hoping for a negative result, many others were older, menopausal women as well as those anxious to conceive. By following the practice of pregnancy testing, I show that, at the grassroots level, local women’s centres were in the vanguard of not only access to contraception and abortion rights, but also awareness about infertility and menopause.

… Many G.P.s also prescribed, on the N.H.S., Schering’s ‘Primodos,’ a ‘hormonal pregnancy test’ in tablet form that was less expensive and faster than ordering a urine test. The drug, which worked by inducing menstruation in non-pregnant women (a ‘negative’ result), was taken off the market in 1978 amidst concerns that it caused a variety of birth defects. Primodos Was a Revolutionary Oral Pregnancy Test: But Was It Safe?

  • … continue reading Jesse Olszynko-Gryn‘s full paper The feminist appropriation of pregnancy testing in 1970s Britain on tandfonline and/or download the PDF.
  • Featured image of the Pregnosticon Planotest credit tandfonline.

Care of girls and women with Turner syndrome

Beyond growth and hormones, 2017
A Guideline of the Turner Syndrome Study Group, 2009

Beyond growth and hormones

2017 Study Abstract

Turner syndrome (TS), although considered a rare disease, is the most common sex chromosome abnormality in women, with an incident of 1 in 2500 female births. TS is characterized by distinctive physical features such as short stature, ovarian dysgenesis, an increased risk for heart and renal defects as well as a specific cognitive and psychosocial phenotype. Given the complexity of the condition, patients face manifold difficulties which increase over the lifespan. Furthermore, failures during the transitional phase to adult care result in moderate health outcomes and decreased quality of life. Guidelines on the optimal screening procedures and medical treatment are easy to find. However, recommendations for the treatment of the incriminating psychosocial aspects in TS are scarce. In this work, we first reviewed the literature on the cognitive and psychosocial development of girls with TS compared with normal development, from disclosure to young adulthood, and then introduce a psychosocial approach to counseling and treating patients with TS, including recommendations for age-appropriate psychological diagnostics. With this work, we aim to facilitate the integration of emphasized psychosocial care in state-of-the-art treatment for girls and women with TS.

A Guideline of the Turner Syndrome Study Group

2009 Study Abstract

Objectives
The objective of this work is to provide updated guidelines for the evaluation and treatment of girls and women with Turner syndrome (TS).

Participants
The Turner Syndrome Consensus Study Group is a multidisciplinary panel of experts with relevant clinical and research experience with TS that met in Bethesda, Maryland, April 2006. The meeting was supported by the National Institute of Child Health and unrestricted educational grants from pharmaceutical companies.

Evidence
The study group used peer-reviewed published information to form its principal recommendations. Expert opinion was used where good evidence was lacking.

Consensus
The study group met for 3 d to discuss key issues. Breakout groups focused on genetic, cardiological, auxological, psychological, gynecological, and general medical concerns and drafted recommendations for presentation to the whole group. Draft reports were available for additional comment on the meeting web site. Synthesis of the section reports and final revisions were reviewed by e-mail and approved by whole-group consensus.

Conclusions
We suggest that parents receiving a prenatal diagnosis of TS be advised of the broad phenotypic spectrum and the good quality of life observed in TS in recent years. We recommend that magnetic resonance angiography be used in addition to echocardiography to evaluate the cardiovascular system and suggest that patients with defined cardiovascular defects be cautioned in regard to pregnancy and certain types of exercise. We recommend that puberty should not be delayed to promote statural growth. We suggest a comprehensive educational evaluation in early childhood to identify potential attention-deficit or nonverbal learning disorders. We suggest that caregivers address the prospect of premature ovarian failure in an open and sensitive manner and emphasize the critical importance of estrogen treatment for feminization and for bone health during the adult years. All individuals with TS require continued monitoring of hearing and thyroid function throughout the lifespan. We suggest that adults with TS be monitored for aortic enlargement, hypertension, diabetes, and dyslipidemia.

Sources

  • Care of girls and women with Turner syndrome: beyond growth and hormones, endocrine connections, 23 March 2017.
  • Care of Girls and Women with Turner Syndrome: A Guideline of the Turner Syndrome Study Group, press endocrine, January 14, 2009.
  • Image credit healthdarts.