David M. O'Sullivan

Clinical significance of atypical glandular cells on cervical cytology.

OBJECTIVE: To evaluate the prevalence and histologic outcomes of patients with atypical glandular cells of undetermined significance (AGUS), diagnosed by Pap test, and concurrent risk factors. DATA SOURCES: A PubMed/MEDLINE/Ovid HealthStar search of the English literature was conducted from January 1988 through March 2004. METHODS OF STUDY SELECTION: The search criteria included the terms “atypical glandular cells of undetermined significance,” “AGUS,” or “AGC.” All studies investigating the clinical significance of patients with an AGUS Pap test were included, except for those where consecutive Pap tests were not studied. Diagnostic outcomes were then determined. TABULATION, INTEGRATION, AND RESULTS: Of the 916 studies identified, 24 met our inclusion criteria. Of the 2,389,206 Pap tests included in these studies, 6,829 (0.29%) had AGUS. Follow-up was available for 3,890 tests. These data showed the following rates of pathology: 8.5% low-grade squamous intraepithelial lesions (LSIL), 11.1% high-grade squamous intraepithelial lesions (HSIL), 2.9% adenocarcinoma in situ, 1.4% endometrial hyperplasia, and 5.2% malignancy. The most common malignancies were endometrial adenocarcinoma (57.6%), cervical adenocarcinoma (23.6%), ovarian and fallopian tube carcinoma (6.4%), squamous cell carcinoma of the cervix (5.4%), and other (6.9%). Of the AGUS Pap tests, the remaining 71.0% corresponded to benign findings, including reactive changes, polyps, and normal histology. Patients with AGUS, which favors a neoplastic process, or with a concurrent ASCUS have a greater likelihood of disease. CONCLUSION: Histologic diagnosis showed that 29.0% of these Pap tests had findings requiring follow-up or therapeutic intervention, including a 5.2% rate of malignancy. Based on these findings, 99.6% of the diagnoses are within the region of surveillance when AGUS Pap tests are evaluated with colposcopy and directed biopsy, endocervical curettage, an endometrial biopsy in patients with risk factors for endometrial cancer, and pelvic examination.

Sexual Dysfunction, Depression, and Anxiety Among Patients of an Inner-City Menopause Clinic

OBJECTIVE The objective of this study was to identify the prevalence of female sexual dysfunction (FSD) in a sample comprising women of mostly Hispanic descent and low socioeconomic status (SES). METHODS Demographic data and symptoms related to sexuality were analyzed from 102 women who consecutively came to the Womens Life Center at Hartford Hospital (2004-2008). FSD was defined as decreased sexual desire, dyspareunia, or vaginal dryness; depression as one positive response to a validated three-question screening instrument; and anxiety as a positive response to whether the patient experiences anxiety sometimes or often. RESULTS The cohort was 52.9 ± 6.8 years of age (mean ± standard deviation [SD]) and 80.0% Hispanic, and 47.8% were unemployed. The majority (92.8%) earned <

Effects of age at first pregnancy and breast-feeding on the development of postmenopausal osteoporosis.

25,000, and most (95.8%) did not have a college degree. The prevalence of FSD was 75.6%. The prevalence of depression was 80.9% vs. 52.8% (p = 0.01) and that of anxiety was 76.6% vs. 45.7% (p = 0.01) among women with vs. without a decrease in sexual desire. The prevalence of depression was 83.3% vs. 55.9% (p = 0.03) and that of anxiety was 76.7% vs. 52.9% (p = 0.07) among women who reported dyspareunia vs. those who did not. Problems sleeping was the only variable associated with a statistically higher likelihood of FSD (odds ratio [OR] 5.57, 95% confidence interval [CI] 1.22-25.33, p = 0.03). No significant differences were seen when comparing FSD between Hispanics and non-Hispanics. CONCLUSIONS This sample of predominantly Hispanic women of low SES had a high prevalence of FSD. These data also suggest that poor sleep is significantly associated with FSD and that women of low SES with FSD may have a significantly higher prevalence of depression and anxiety.

Competition injuries in taekwondo: a literature review and suggestions for prevention and surveillance

Objective: Although pregnancy and breast-feeding require adequate calcium mobilization, it is not known if these affect the acquisition of a healthy peak bone mass (PBM) and, hence, postmenopausal osteoporosis (OPS). The objective of this study was to analyze previous pregnancies and/or breast-feeding and their association with OPS. Methods: After obtaining institutional review board approval, postmenopausal women (>49 y) presenting for a dual-energy x-ray absorptiometry bone density scan were invited to participate. Risk factors for OPS, including previous fractures, pregnancy information, and dual-energy x-ray absorptiometry results, were collected. OPS was defined as a T score of −2.5 or lower. Results: Data were obtained from 619 women. Of these, 49.8% were smokers, 27.2% used a bisphosphonate, 64.1% used hormone therapy, and 5.5% had used steroids. Based on PBM, ages at first pregnancy were dichotomized to younger than 27 years and 27 years or older. Women with a history of breast-feeding had a lower prevalence of OPS (7.6%) versus women who had never breast-fed (18.7%; P < 0.001). Women with a first pregnancy when they were 27 years or older and a history of breast-feeding had the lowest prevalence of OPS (4.6%) versus women with a first pregnancy when they were younger than 27 years and no history of breast-feeding (16.3%; P = 0.001). Conclusions: Breast-feeding seems to significantly decrease the incidence of postmenopausal OPS. Women whose first pregnancy occurs after PBM (≥27 y of age) and who have a history of breast-feeding had the lowest prevalence of OPS. Thus, an association between OPS and both breast-feeding and age of pregnancy seems to be present.

Calcium/vitamin D supplementation, serum 25-hydroxyvitamin D concentrations, and cholesterol profiles in the Women's Health Initiative calcium/vitamin D randomized trial.

Objective To review competition injuries in taekwondo and use this information to develop recommendations to reduce the number and severity of injuries in taekwondo competition. Methods The available literature was searched for prospective studies on taekwondo injuries in adult athletes. An injury was defined as any circumstance for which the athlete sought the assistance of the on-site medical personnel. Injury rates were expressed per athlete-exposures (A–E) and 95% CIs calculated. Results Total injury rates for elite men varied from 20.6/1000 A–E (95% CI 11.8 to 29.3) to 139.5/1000 A–E (95% CI 94.0 to 185.1). For elite women, the rates varied from 25.3/1000 A–E (95% CI 3.1 to 47.4) to 105.5/1000 A–E (95% CI 89.8 to 121.1). About one-third of all injuries (29.6%) in the men were to the head and neck region, while almost half of the injuries (44.5%) were to the lower extremities. In women, 15.2% of injuries were to the head and neck and 53.1% to the lower extremities. The vast majority of all injuries were contusions (42.7% in the men and 62.7% in the women). Point estimates of rates of head injuries and concussions were found to be higher in taekwondo than in other contact sports such as football (soccer) and American gridiron football. Time-loss injury rates in the men varied from 6.9/1000 A–E (95% CI 1.8 to 11.9) to 33.6/1000 A–E (95% CI 18.9 to 48.3). In the women, they varied from 2.4/1000 A–E (95% CI 2.3 to 7.2) to 23.0/1000 A–E (95% CI 15.7 to 30.4). The turning kick was most often involved in causing injury: 56.9% of all injuries in the men and 49.8% in the women. Lack of blocking skills was identified as one of the main injury mechanisms. Conclusions Rule changes should be considered and it is recommended that governing bodies employ qualified medical personnel. Establishing an ongoing injury surveillance system in taekwondo should be the first priority.

The association of breast arterial calcification and coronary heart disease.

ObjectiveThe objective of this study was to evaluate whether increased serum 25-hydroxyvitamin D3 (25OHD3) concentrations, in response to calcium/vitamin D (CaD) supplementation, are associated with improved lipids in postmenopausal women. MethodsThe parent trial was a double-blind, randomized, placebo-controlled, parallel-group trial designed to test the effects of CaD supplementation (1,000 mg of elemental calcium + 400 IU of vitamin D3 daily) versus placebo in postmenopausal women. Women from the general community, including multiple sites in the United States, were enrolled between 1993 and 1998. This cohort included 300 white, 200 African-American, and 100 Hispanic participants who were randomly selected from the Women’s Health Initiative CaD trial. Serum 25OHD3 and lipid (fasting plasma triglycerides [TG], high-density lipoprotein cholesterol [HDL-C], and calculated low-density lipoprotein cholesterol [LDL-C]) levels were assessed before and after CaD randomization. ResultsThere was a 38% increase in mean serum 25OHD3 concentrations after 2 years (95% CI, 1.29-1.47, P < 0.001) for women randomized to CaD (24.3 ng/mL postrandomization mean) compared with placebo (18.2 ng/mL). Women randomized to CaD had a 4.46–mg/dL mean decrease in LDL-C (P = 0.03). Higher concentrations of 25OHD3 were associated with higher HDL-C levels (P = 0.003), along with lower LDL-C and TG levels (P = 0.02 and P < 0.001, respectively). ConclusionsSupplemental CaD significantly increases 25OHD3 concentrations and decreases LDL-C. Women with higher 25OHD3 concentrations have more favorable lipid profiles, including increased HDL-C, lower LDL-C, and lower TG. These results support the hypothesis that higher concentrations of 25OHD3, in response to CaD supplementation, are associated with improved LDL-C.

Impact of pessary use on prolapse symptoms, quality of life, and body image

OBJECTIVE: To estimate whether mammography can be an early, valid tool for predicting the development of coronary heart disease (CHD) in women. METHODS: Women presenting for routine mammograms between June and August 2004 were recruited for the study. Baseline data collected included risk factors and family history of heart disease, as well as any cardiac events experienced by the patient. Similar follow-up data were collected during subsequent years, and these patient-completed surveys were correlated with the baseline mammograms screened for breast arterial calcifications. RESULTS: Throughout the 5-year follow-up, CHD was present in 20.8% of women who screened positive for breast arterial calcification and in 5.4% of who screened negative for breast arterial calcification (P<.001). Among women who did not have CHD at baseline, breast arterial calcification-positive women were more likely to develop CHD or a stroke than those who were breast arterial calcification-negative (6.3% compared with 2.3%, P=.003; and 58.3% compared with 13.3%, P<.001), respectively. These results remained significant even when controlling for age. CONCLUSION: The presence of breast arterial calcifications on mammograms indicates a significantly increased risk of developing CHD or a stroke. These results suggest that breast arterial calcifications should be routinely reported on mammograms and viewed as a marker for the development of CHD. LEVEL OF EVIDENCE: II

Assessment of Postmenopausal Women and Significant Risk Factors for Osteoporosis

OBJECTIVE We sought to evaluate whether use of a vaginal pessary would change body image, bother symptoms, and quality of life in women with pelvic organ prolapse. STUDY DESIGN Women presenting for pessary insertion completed the short forms of Pelvic Floor Distress Inventory-20, Pelvic Floor Impact Questionnaire, and Body Image Scale. After successful pessary insertion and use for at least 3 months, subjects completed the surveys again. Scores were compared with a paired t test. RESULTS A total of 75 subjects were enrolled and follow-up responses were available for 54 subjects for analysis. Body Image Scale scores showed a significant decrease (6.1-3.4; P<.001), indicating an improvement in these womens perception of themselves, as did Pelvic Floor Distress Inventory-20 scores (81.34-45.83; P<.001) and Pelvic Floor Impact Questionnaire scores (50.32-17.98; P=.003). CONCLUSION The use of a pessary for 3 months reduces bother symptoms and improves both quality of life and perception of body image in women.

Menopausal symptoms in Hispanic women and the role of socioeconomic factors.

The assessment of osteoporosis risk factors can help guide early intervention. The objective of this study was to analyze numerous potential risk factors to see which were associated with postmenopausal osteoporosis. Women aged 49 or greater presenting for dual-energy x-ray absorptiometry bone scans were recruited from radiology sites in the Hartford, Connecticut, area between January 2007 and March 2009, inclusive. Information was collected regarding primary and secondary risk factors for osteoporosis development, as well as family history and history of pregnancy and breast-feeding. Survey results were subsequently correlated with each womans dual-energy x-ray absorptiometry scan results. In a sample of 619 women, history of fracture (odds ratio [OR], 12.49), weight less than 127 pounds (OR, 3.50), and use of anticoagulants (OR, 5.40) increased the chance of developing osteoporosis. In contrast, multiparity (OR, 0.45) and history of breast-feeding (OR, 0.38) decreased the development of osteoporosis in postmenopausal women. In women aged 49 to 54, breast-feeding was significantly protective, while low body mass index was most indicative of osteoporosis in women ages 55 to 64. Both previous fracture and low body mass index were associated with osteoporosis in women over age 64. The current results are consistent with other studies suggesting that previous fracture, low body weight, and use of anticoagulants increase the risk of osteoporosis. Our results also suggest that a history of pregnancy and breast-feeding protects against the development of postmenopausal osteoporosis, especially in women aged 49 to 54. Target Audience: Obstetricians & Gynecologists. Learning Objectives: After completing this CME activity, readers should be better able to evaluate the impact of osteoporosis in postmenopausal women; assess the risk factors associated with postmenopausal osteoporotic fractures; counsel women on what steps they can take to lower their risk of developing the condition in the future; and demonstrate that the risk factors associated with postmenopausal osteoporosis change based on age.

Pilot study of menopause symptoms in a clinic population

The objective of this study was to assess differences in menopausal symptoms between postmenopausal (PM) Hispanic (H) and PM Caucasian (C) women. This was a prospective survey. Data from a convenience sample of 404 PM women (50% H, 50% C) were evaluated. Comparing H with C women, statistically significant differences (P < 0.05) in symptoms were noted with mood changes (76% H, 54% C), a decrease in energy (56% H, 36% C), palpitations (54% H, 26% C), breast tenderness (39% H, 28% C), memory loss (34% H, 22% C), and vaginal dryness (34% H, 44% C). When controlling for education and income, there were differences in mood changes, a decrease in energy and palpitations between the groups. Consistent with previous data, hot flashes (80% H, 75% C) and night sweats (67% H, 64% C) were the most common symptoms in the PM C women, and there were no significant differences compared with PM H women. Symptoms reported by PM C women in this sample are consistent with rates in the literature, but PM H women reported several symptoms at a higher rate. These differences remain when socioeconomic factors are considered, suggesting ethnicity may be an independent variable in menopausal symptomatology. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to state that the symptoms of menopause affect all women independently of race/ethnicity, recall that Hispanic and Caucasian women did differ in the frequency of some common symptoms, and explain that when socioeconomic factors were considered the differences remained suggesting that ethnicity may be an independent variable in menopausal symptomatology.