Daniel M. Breitkopf

Poor Knowledge Regarding the Pap Test Among Low‐Income Women Undergoing Routine Screening

CONTEXT Many women undergoing cervical cancer screening lack appropriate understanding of the Pap test. It is important to evaluate knowledge and informational needs about Pap testing among groups who may have difficulty accessing care or a relatively low likelihood of obtaining follow-up for an abnormal result, such as minority and low-income women. METHODS A sample of 338 women undergoing cervical screening at two clinics in Texas completed a questionnaire measuring their knowledge of Pap testing and asking what specific information they would like to know about the test. Group comparisons and qualitative analyses were conducted. RESULTS Women correctly answered an average of 8.7 out of 20 questions; the range was 0-17. Mean scores were higher among white women (10.2) than among blacks (8.4) and Hispanics (7.4), among women with more than a high school education than among their less educated counterparts (10.0 vs. 7.9) and among women with an annual household income of at least

Factors Associated With Completion of the Human Papillomavirus Vaccine Series

10,000 than among those with a lower income (9.3 vs. 8.4). Knowledge scores did not differ according to Pap history. Open-ended questioning identified a need for information on the purpose of the test, exam procedures, abnormal test results and prognosis. CONCLUSIONS Minority women and those of low socioeconomic status had poor understanding of Pap testing. Identifying misunderstandings in this vulnerable population and improving patient education on the most basic aspects of Pap testing may increase adherence to follow-up when abnormalities are detected.

Efficacy of second versus third generation oral contraceptives in the treatment of hirsutism.

and administration of the first dose of the vaccine between January 1, 2007, and July 1, 2007. Charts were reviewed until November 26, 2008, for a minimum 17 months of follow-up. Completion was defined as receipt of 3 HPV vaccinations. Charts were reviewed for age, race/ethnicity, type of insurance (private vs Medicaid/Child Health Insurance Program [CHIP]), and distance from home to the clinic. Sexual history variables included sexual activity status prior to initiation of the series and history within 3 years of vaccine initiation of a gynecological exam and/or Papanicolaou (Pap) test, HPV DNA test, or sexually transmitted infection. The reason for each visit was classified as nonsick visit (well child, well woman, contraception), sick visit, or vaccine only. If the patient did not complete the series, the chart was reviewed to determine if the patient had any clinic visits after she was due for her next shot. Statistical analyses were performed using SPSS, version 12.0, with an α level of <.05 determining statistical significance. Missing data did not exceed 2% for any of the predictor variables with the exception of sexual activity status for which 27% were missing. Only Caucasian, African American, or Hispanic patients were included in analyses assessing race/ ethnicity, as these 3 groups comprised >98% of the sample. Bivariate relationships between patient characteristics and vaccine series completion were conducted. Variables that were significant were entered into a logistic regression analysis using backward stepwise elimination.

Detection of benign Endometrial masses by endometrial stripe measurement in premenopausal women

OBJECTIVE To compare second versus third generation combination oral contraceptives (OCs) in the treatment of hirsutism. METHODS Women with hirsutism, as defined by a minimum Ferriman-Gallwey score of 10, were randomized in a double-blind fashion to receive an OC containing either ethinyl estradiol/desogestrel or ethinyl estradiol/levonorgestrel for 9 months of treatment. Ferriman-Gallwey scores, androgen levels and sex hormone-binding globulin were measured at baseline and every 3 months for the duration of the study. Hormones were measured in duplicate by radioimmunoassay. RESULTS Of the 47 women enrolled, 24 were randomized to ethinyl estradiol/desogestrel and 23 were randomized to ethinyl estradiol/levonorgestrel. Mean sex hormone-binding globulin increased significantly in subjects using the desogestrel-containing contraceptive compared with the levonorgestrel-containing contraceptive. Ten subjects completed the 9 months of treatment in the levonorgestrel group and 11 completed the study in the desogestrel group. Mean free testosterone and 3alpha-androstanediol glucuronide decreased significantly in the group receiving ethinyl estradiol/desogestrel but not in the ethinyl estradiol/levonorgestrel group. Mean Ferriman-Gallwey scores decreased significantly in both treatment groups. Improvement in mean Ferriman-Gallwey score was 35.7 +/- 38.1% (p < 0.001) for the ethinyl estradiol/desogestrel arm and 33.4 +/- 27.3% (p < 0.001) for the ethinyl estradiol/levonorgestrel arm. There were no statistically significant differences found in the improvement of Ferriman-Gallwey scores between the two treatment arms, although the power to detect a difference was limited by the small sample size. CONCLUSIONS Treatment of hirsute women with third generation OCs containing desogestrel results in a significant increase in sex hormone-binding globulin and decrease in free testosterone and 3alpha-androstanediol glucuronide. Both second and third generation OCs were clinically effective in treating hirsutism.

Adult Women's Attitudes Toward the HPV Vaccine

OBJECTIVE: Our objective was to estimate whether a transvaginal endometrial stripe of less than 5 mm in premenopausal women would exclude endometrial polyps and intracavitary leiomyomata, thereby eliminating the need for sonohysterography. METHODS: Data from 206 consecutive sonohysterograms performed in premenopausal women with abnormal uterine bleeding between August 1998 and October 2001 were collected retrospectively. Endometrial stripe measurements were obtained in the sagittal plane before sonohysterography. Baseline endometrial stripe images were reviewed by one of the authors, who was blinded to sonohysterography and pathology results, to evaluate for gross endometrial abnormalities on transvaginal ultrasonography. RESULTS: Endometrial stripe measurements were obtained before sonohysterography in 200 of the 206 consecutive exams in premenopausal subjects. Of the 80 subjects with an endometrial stripe measurement less than 5 mm, 11 had endometrial polyps and 5 had submucosal fibroids on sonohysterography. With an endometrial stripe thickness of less than 5 mm, the sensitivity was 74% (95% confidence interval 62–84), the specificity was 46% (95% confidence interval 38–54), the positive predictive value was 37%, and the negative predictive value was 80%. The detection of pathology was not improved by excluding cases with an abnormal-appearing endometrial stripe on the baseline transvaginal images. The use of other endometrial stripe cutoff values did not improve the diagnostic accuracy. CONCLUSION: Using an endometrial stripe cutoff of 5 mm in premenopausal women would miss significant intracavitary pathology. The sonographic evaluation of abnormal uterine bleeding in premenopausal women should include sonohysterography or equivalently accurate testing regardless of endometrial stripe thickness. LEVEL OF EVIDENCE: II-3

Combined endometrial ablation and levonorgestrel intrauterine system use in women with dysmenorrhea and heavy menstrual bleeding: Novel approach for challenging cases

AIMS Two human papillomavirus (HPV) vaccines have demonstrated efficacy in preventing HPV infection and are currently being administered to adolescent girls in several countries. Although the most efficient HPV prevention strategy is immunizing adolescents before there is any risk of exposure, adult women also may benefit from vaccination. This study aimed to explore the attitudes of women aged 27-55 years toward the HPV vaccine. METHODS Thirty-eight women were recruited from a university-based gynecological practice, completed a demographic questionnaire, and then were interviewed. RESULTS Most participants had heard about the vaccine and were positive about the HPV vaccine for adult women. Women advocated universal access to this vaccine, indicating that all women should have the option. They assessed their risk level in several ways, including level of monogamy, relationship status, previous sexual risk behaviors, history of an abnormal Pap smear, and family history. All but 2 woman described barriers to vaccination, including cost, side effects, and hassle factors. Most women did not believe the vaccine would change risk behaviors. CONCLUSIONS The women from this convenience sample knew the HPV vaccine existed and in general found it acceptable. If an HPV vaccine becomes available to adult women, healthcare professionals will be faced with the challenge of providing accurate information, being sensitive and willing to help each individual woman make a decision, and being creative when developing new ways to eliminate barriers to getting the vaccine.

Asymptomatic Thickened Endometrium in Postmenopausal Women: Malignancy Risk

STUDY OBJECTIVE To evaluate the feasibility and impact of levonorgestrel intrauterine system (LNG-IUS) on treatment failure after endometrial ablation (EA) in women with heavy menstrual bleeding (HMB) and dysmenorrhea at 4 years. DESIGN Cohort study (Canadian Task Force II-2). SETTING An academic institution in the upper Midwest. PATIENTS All women with HMB and dysmenorrhea who underwent EA with combined placement of LNG-IUS (EA/LNG-IUS cohort, 23 women) after 2005 and an historic reference group from women who had EA alone (EA cohort, 65 women) from 1998 through the end of 2005. INTERVENTION Radiofrequency EA, thermal balloon ablation, and LNG-IUS. MEASUREMENTS AND MAIN RESULTS The primary outcome was treatment failure defined as persistent pain, bleeding, and hysterectomy after EA at 4 years. The combined treatment failure outcome was documented in 2 patients (8.7%) in the EA/LNG-IUS group and 19 patients (29.2%) in the EA group with an unadjusted OR of .23 (95% CI, .05-1.08). After adjusting for known risk factors of failure, the adjusted OR was .19 (95% CI, .26-.88). None of the women who underwent EA/LNG-IUS had hysterectomy for treatment failure compared with 16 (24%) in the EA group (p = .009); postablation pelvic pain was documented in 1 woman (4.3%) in the EA/LNG-IUS group compared with 8 women (12.3%) in the EA group (p = .24). One woman in the EA/LNG-IUS group (4.3%) presented with persistent bleeding compared with 15 (23.1%) in the EA group (p = .059). Office removal of the intrauterine device was performed in 4 women with no complications. CONCLUSION LNG-IUS insertion at the time of EA is feasible and can provide added benefit after EA in women with dysmenorrhea and HMB.

Intervention to improve follow-up for abnormal Papanicolaou tests: a randomized clinical trial.

STUDY OBJECTIVE To assess the diagnostic findings and determine the frequency of malignancy in postmenopausal women evaluated by office hysteroscopy for a thickened endometrium without bleeding. DESIGN Retrospective cohort (Canadian Task Force classification II-B). SETTING Academic medical center in the Midwestern United States. PATIENTS Over 3600 women underwent an office hysteroscopy between January 1, 2007, and October 20, 2011, for abnormal uterine bleeding or an abnormal ultrasound. Of these, 154 postmenopausal women had a thickened endometrium (>4 mm) and no bleeding. INTERVENTIONS Flexible office hysteroscopy using a 3.1-mm scope with saline as the distending media was performed for clinical reasons, and results were captured within a research database. MEASUREMENTS AND MAIN RESULTS For the 154 women, the range of endometrial measurements was 4.2 to 28 mm (mean = 10.0 mm). Hysteroscopy diagnoses included 93 patients with polyps, 19 with myomas or uterine synechiae, and 34 with benign-appearing endometrium. Nine hysteroscopies were inadequate because of poor visualization (n = 1), cervical stenosis (n = 6), or patient discomfort (n = 2). Endometrial biopsies (EMBs) were performed in 109 patients, and none were found to have cancer or an atypical endometrium. Six had simple hyperplasia without atypia, and their endometrial measurements were within the range of the patients in our study who had a benign endometrium (5-15 mm, mean = 10.3). Of the women with a polyp, 73 (78.4%) subsequently underwent polypectomy. On final pathology, 1 had cancer (endometrial measurement = 24 mm), and 1 had complex hyperplasia with atypia (endometrial measurement = 17 mm). EMBs performed in the office for these 2 patients showed an insufficient endometrium and inactive endometrium, respectively. CONCLUSION Cancer and atypia can occur in asymptomatic women. Endometrial thickness was 17 mm or greater in 2 cases, and EMBs performed in the office were inconsistent with the final diagnosis. Hysteroscopy is important when ultrasound and EMB do not agree. Polypectomy may be indicated even in asymptomatic women, but further studies regarding an endometrial measurement threshold or polyp size are warranted.

Perceived risk of cervical cancer among low-income women

OBJECTIVE To evaluate the effect of a theory-based, culturally targeted intervention on adherence to follow-up among low-income and minority women who experience an abnormal Pap test. METHOD 5,049 women were enrolled and underwent Pap testing. Of these, 378 had an abnormal result and 341 (90%) were randomized to one of three groups to receive their results: Intervention (I): culturally targeted behavioral and normative beliefs + knowledge/skills + salience + environmental constraints/barriers counseling; Active Control (AC): nontargeted behavioral and normative beliefs + knowledge/skills + salience + environmental constraints/barriers counseling; or Standard Care Only (SCO). The primary outcome was attendance at the initial follow-up appointment. Secondary outcomes included delay in care, completion of care at 18 months, state anxiety (STAI Y-6), depressive symptoms (CES-D), and distress (CDDQ). Anxiety was assessed at enrollment, notification of results, and 7-14 days later with the CDDQ and CES-D. RESULTS 299 women were included in intent-to-treat analyses. Adherence rates were 60% (I), 54% (AC), and 58% (SCO), p = .73. Completion rates were 39% (I) and 35% in the AC and SCO groups, p = .77. Delay in care (in days) was (M ± SD): 58 ± 75 (I), 69 ± 72 (AC), and 54 ± 75 (SCO), p = .75. Adherence was associated with higher anxiety at notification, p < .01 and delay < 90 days (vs. 90+) was associated with greater perceived personal responsibility, p < .05. Women not completing their care (vs. those who did) had higher CES-D scores at enrollment, p < .05. CONCLUSIONS A theory-based, culturally targeted message was not more effective than a nontargeted message or standard care in improving behavior.

Correlation of Behavioral Interviewing Performance With Obstetrics and Gynecology Residency Applicant Characteristics.

Background Risk perception is an important predictor of cancer prevention behaviors. We examined the perceived risk of cervical cancer among an ethnically diverse population of women of lower socioeconomic status. Materials and Methods Females attending a women’s health clinic were recruited for a study addressing cervical cancer prevention. Survey questions evaluated lifetime perceived risk of cervical cancer (0%–100%), beliefs about the accuracy of the Pap test, and estimated incidence of abnormal Pap test results. Risk estimates for oneself were followed with an item seeking a brief, qualitative explanation of the risk estimate. Results Surveys were completed by 338 women. The mean (SD) age of respondents was 29.9 (8.6) years. Women self-identified as Hispanic/Latina (32%, n = 107), White (34%, n = 116), and African American (34%, n = 115). Estimated perceived lifetime risk of getting cervical cancer ranged from 0% to 100% (59.2 [29.5]). Risk estimates were associated with perceived prevalence of abnormal results (r = 0.24, p< .001) and perceptions regarding the accuracy of the Pap test (r = 0.13, p < .05). On average, women estimated that nearly half of all women have ever had an abnormal result (49.2 [26.9]; n = 335; range, 0%–100%), with African American women estimating a higher percentage compared to Hispanic/Latina and White women. Women who themselves experienced an abnormal Pap test result reported higher proportions of other women experiencing an abnormal result (t333 = −3.67, p < .01). Conclusions This study advances our understanding of misperception of risk and how women qualitatively view their risk of cervical cancer. The findings underscore areas for practitioners to enhance patient education efforts.