Janet Pregler

Academic Models of Clinical Care for Women: The National Centers of Excellence in Women's Health

Between 1996 and 1999, 18 academic health centers were awarded the designation of National Center of Excellence (CoE) in Womens Health by the Office on Womens Health within the Department of Health and Human Services and were provided with seed monies to develop model clinical services for women. Although the model has evolved in various forms, core characteristics that each nationally designated CoE has adopted include comprehensive, women-friendly, women-focused, women-relevant, integrated, multidisciplinary care. The permanent success of these comprehensive clinical programs resides in the ability to garner support of leaders of the academic health centers who understand both the importance of multidisciplinary programs to the clinical care they provide women and the education they offer to the future providers of womens healthcare.

Impact of participation in a community-based intimate partner violence prevention program on medical students: A multi-center study

BackgroundPhysicians are generally poorly trained to recognize, treat or refer adolescents at risk for intimate partner violence (IPV). Participation in community programs may improve medical students’ knowledge, skills, and attitudes about IPV prevention.ObjectiveTo determine whether the experience of serving as educators in a community-based adolescent IPV prevention program improves medical students’ knowledge, skills, and attitudes toward victims of IPV, beyond that of didactic training.ParticipantsOne hundred and seventeen students attending 4 medical schools.DesignStudents were randomly assigned to didactic training in adolescent IPV prevention with or without participation as educators in a community-based adolescent IPV prevention program. Students assigned to didactic training alone served as community educators after the study was completed.MeasurementKnowledge, self-assessment of skills and attitudes about intimate partner violence and future plans to pursue outreach work.ResultsThe baseline mean knowledge score of 10.25 improved to 21.64 after didactic training (p ≤ .001). Medical students in the “didactic plus outreach” group demonstrated higher levels of confidence in their ability to address issues of intimate partner violence, (mean = 41.91) than did students in the “didactic only” group (mean = 38.94) after controlling for initial levels of confidence (p ≤ .002).ConclusionsExperience as educators in a community-based program to prevent adolescent IPV improved medical students’ confidence and attitudes in recognizing and taking action in situations of adolescent IPV, whereas participation in didactic training alone significantly improved students’ knowledge.

The heart truth professional education campaign on women and heart disease: Needs assessment and evaluation results

BACKGROUND Heart disease is the leading cause of death for women in the United States. Research has identified that women are less likely than men to receive medical interventions for the prevention and treatment of heart disease. METHODS AND RESULTS As part of a campaign to educate healthcare professionals, 1245 healthcare professionals in 11 states attended a structured 1-hour continuing medical education (CME) program based on the 2004 AHA Evidence-Based Guidelines for Cardiovascular Disease Prevention in Women and completed a pretest and posttest evaluation. We identified significant knowledge deficits in the pretest: 45% of attendees would initially recommend lifestyle changes alone, rather than statin therapy, for women diagnosed with coronary artery disease (CAD); 38% identified statin therapy as less effective in women compared with men for preventing CAD events; 27% identified Asian American women at low risk (rather than high risk) for type 2 diabetes mellitus (DM); and 21% identified processed meat (rather than baked goods) as the principal dietary source of trans fatty acids. Overall, healthcare professionals answered 5.1 of 8 knowledge questions correctly in the pretest, improving to 6.8 questions in the posttest (p < 0.001). Family physicians, obstetrician/gynecologists, general internists, nurse practitioners/physician assistants, and registered nurses all statistically significantly improved knowledge and self-assessed skills and attitudes as measured by the posttest. CONCLUSIONS Significant knowledge deficits are apparent in a cross-section of healthcare providers attending a CME lecture on women and heart disease. A 1-hour presentation was successful in improving knowledge and self-assessed skills and attitudes among primary care physicians, nurse practitioners, physician assistants, and registered nurses.

Intimate partner violence in the medical school curriculum: approaches and lessons learned.

The UCLA curriculum model educates students about intimate partner violence by integrating the topic into existing preclinical and clinical course work and offering elective experiences for interested students. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

Challenges in Medical Education: Training Physicians to Work Collaboratively

In an ideal setting, generalists and specialists collaborate to provide quality care to individual patients and patient populations covered by a variety of health care plans. To accomplish this, generalists and specialists must each understand the others domain and area of expertise. In many managed care settings, generalists must expand competencies. In turn, specialists must understand the extent of care generalists can provide.1 Skills required for both groups include incorporating population-based, cost-effective, and evidence-based medicine into daily practice.2–4 Specialists and generalists must be able to communicate in an efficient and timely manner to optimize consultations between physicians. The referring physician should specify the question and provide essential information to the consultant, while the consulting physician should address the question and participate in monitoring the patients care to ensure appropriate treatment.2, 3, 5–9 Generalists and specialists collaborate in the care of patients with the most complex problems. Ideally, generalists and specialists would develop consistent referral paths, and be located near one another to permit personal professional relationships. Respect, trust, and the ability to work as part of a team are the foundations for this relationship.2, 3, 9

Women's Sexual Health and Aging

Older women are often sexually active, but physicians caring for older women rarely address sexual concerns. Although womens desire for sex declines with age, a majority of older women rate sex as having importance in their lives. Women identify emotional intimacy as an important reason for engaging in sexual relationships. Women are less likely than men to have an available spousal or intimate partner and more likely to have a partner with sexual difficulties of their own. Up to half of sexually active older women report a distressing sexual problem, with low desire and problems related to genitourinary syndrome (vulvovaginal atrophy) being most common. Difficulty with orgasm in older women is often associated with a partners erectile dysfunction. Sexually transmitted infections (STIs) are increasingly prevalent in older women. A minority of older women report discussing sexual issues with a physician. Most commonly, the patient initiates discussions. Physicians should ask regularly and proactively about sexual activity and function. Important interventions include offering practical advice to common chronic medical conditions and sexual problems that confront older women; treating vulvovaginal atrophy; and providing STI screening, prevention strategies, and treatment when appropriate.

Update in Women's Health: Evidence Published in 2010

This Update summarizes studies published in 2010 that the authors consider highly relevant to the practice of womens health. Topics include osteoporosis, calcium and vitamin D, hormone therapy and...

Older Adults with Cognitive Impairment Have Sex: More Evidence Against the Medical Myth of Sexless Aging

In this edition of the Journal of the American Geriatrics Society, Lindau and colleagues have published important, novel work describing the relationship between sexual function and cognition in approximately 3,200 homedwelling adults aged 62 to 91; 83% of men and 57% of women reported that they were partnered. Although the likelihood of partnership was lower in those with lower cognitive scores, nearly half of men and one-fifth of women with dementia were reported to be sexually active, and 60% of partnered men and 51% of partnered women reported engaging in sexual activity. More than 40% of partnered men and women with dementia aged 80 and older reported being sexually active . There are many reasons that older adults should discuss sexual activity with their physician or other healthcare provider. Most do not. Evidence suggests that a major reason is that healthcare providers do not initiate such conversations, despite evidence that people are open to such discussions . Lack of communication results in missed opportunities to improve quality of life and preventive care. There are effective medical treatments for common causes of sexual dysfunction in men and women, including erectile dysfunction and dyspareunia from vulvovaginal atrophy. Screening for sexually transmitted infection (STIs) is recommended for high-risk older adults. The highest rates of increase in STIs in recent years in the United States have been in people aged 45 and older 3,4 . Lindau and colleagues found that men were more likely than women to discuss sex with a partner or a doctor . This is probably because of multiple factors. One reason may be that men become more likely to see a specialist in men’s sexuality (urologist) as they age and develop prostate and bladder problems. In contrast, women are less likely to attend routine visits with a specialist in women’s sexuality (gynecologist) as they “age out” of cervical cancer screening, which is no longer routinely recommended after the age of 65 or after hysterectomy . Attitudes that sexuality should be natural and spontaneous, not requiring skills or communication, or that sexuality is “something dirty” that should not be discussed may also affect women more . Sex steroid levels decline in aging men and women, but most healthy partnered home-dwelling older adults remain sexually active into their eighth decade . The influence of sex steroids on dementia and cognitive function in older men and women is complex. Low sex steroid levels have been suggested as a risk factor for dementia, as well as a consequence . Despite the association between low sex steroid levels and cognitive dysfunction and dementia, treatment with sex steroids is not associated with improvement in cognitive function in men or women . Lindau and colleagues found that a majority of older men and women across cognitive groups felt that sex was an important part of life and were satisfied with the quality of their sex life. There were interesting sex differences, in that men with dementia were less likely than other men to be satisfied with their sex life and that men with dementia were many times as likely to report having sex primarily out of obligation or duty as other men. These findings were not present in women . Men with dementia have lower testosterone levels, which has been associated with lower sexual desire and higher rates of sexual dysfunction concomitant with cognitive decline . Lindau and colleagues report that erectile dysfunction was less commonly seen in men with worse cognitive function. Low testosterone levels in older men are most strongly linked to decrease in sexual desire , and lack of libido is the symptom most likely to improve in response to testosterone treatment . Erectile dysfunction also responds to testosterone treatment but is etiologically more complex, with multiple contributing factors; dementia and dementia treatment may influence it. Studies have not shown a consistent association between lower testosterone levels and sexual dysfunction in women . Sexual abuse is of concern across the lifespan. Lindau and colleagues’ work found that people with dementia had obligatory sex and sex without feeling aroused more frequently than those who were more cognitively intact. Subjects were not asked directly about sexual assault and rape . More research is needed on effective ways to identify sexual abuse in cognitively impaired adults. There is much work to do to build consensus around what constitutes consent for sexual activity in this population. Experts advocate supporting autonomy and preventing exploitation and abuse a balance which may be difficult to achieve in clinical practice. Only 2 of more than 3000 older adults reported being in a same-sex relationship. The authors attributed this to a focus on marital dyads. It is also likely that subjects in same-sex relationships chose not to participate in the study or did not disclose same-sex relationships when they did. Physicians and other healthcare providers, while respecting people’s decisions and autonomy, should remain open to the possibility that same-sex persons identified as This editorial comments on the article by Lindau et al.

Update in Women's Health: Evidence Published in 2013Update in Women's Health

This update summarizes 10 important studies published in 2013 that can change clinical practice. The authors reviewed articles relevant to sex- and gender-based differences in the care of women, defined as research on diseases and conditions more common in women or unique to women and on diseases and conditions in which the approach to care may be different for women. A major theme of research results is the importance of individualizing counseling, screening, and treatment strategies on the basis of patient characteristics. Breast Cancer Continuing Adjuvant Tamoxifen Treatment for 10 Years Reduced Recurrence and Increased Survival in Women With Estrogen ReceptorPositive Breast Cancer Davies C Pan H Godwin J et al Adjuvant Tamoxifen: Longer Against Shorter (ATLAS) Collaborative Group Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial. Lancet 2013 381 805 16 23219286 Background: Breast cancer recurrence and death frequently occur more than 5 years after diagnosis. Previous studies of continuing adjuvant treatment with tamoxifen beyond 5 years did not show benefit, but these studies were criticized because of small size and limited follow-up. According to current guidelines from the American Society of Clinical Oncology, adjuvant treatment with tamoxifen is recommended for premenopausal women with estrogen receptorpositive tumors and for postmenopausal women with estrogen receptorpositive tumors who are unable to tolerate aromatase inhibitors (1). Findings: In an international trial recruiting patients from Europe, North and South America, Australia and New Zealand, Asia, Africa, and the Middle East between 1996 and 2005, a total of 12894 women with stage I, II, and III breast cancer who had completed 5 years of tamoxifen treatment were randomly assigned to continue tamoxifen for a total of 10 years or to stop. Among these, 6846 women with estrogen receptorpositive tumors supplied data regarding breast cancer outcomes and adverse effects. The remainder of the women, for whom estrogen receptor status was negative or unknown, had initial analysis for adverse effects only. Average follow-up was 12.6 years after diagnosis. Women with estrogen receptorpositive disease randomly assigned to 10 years of tamoxifen had a reduced risk for breast cancer recurrence (617 vs. 711 patients; P= 0.002), breast cancer mortality (331 vs. 397 patients; P= 0.01), and overall mortality (639 vs. 722 patients; P= 0.01). The absolute reduction in mortality for women within 5 and 14 years of diagnosis who continued tamoxifen treatment was 2.8 percentage points, with most of the benefit occurring in the period beyond 10 years. Mortality in women without breast cancer recurrence did not differ between the 2 groups (691 vs. 679 patients; relative risk [RR], 0.99; P= 0.84). Pulmonary embolism (RR, 1.87 [95% CI, 1.13 to 3.07]) and endometrial cancer (RR, 1.74 [CI, 1.30 to 2.34]) were more common among women randomly assigned to continuation of tamoxifen treatment. Cautions: Many women initially randomly assigned had undetermined estrogen receptor status and were excluded from analysis of breast cancer outcomes. Implications: An additional large trial reported in 2013 also showed benefit from continuing tamoxifen treatment for 10 years (2). Continuing tamoxifen therapy should be considered for women who have completed 5 years of therapy. Clinicians should be alert for signs and symptoms of endometrial cancer (such as vaginal bleeding) and venous thromboembolism in women taking tamoxifen. Aromatase inhibitors, with or without sequential tamoxifen, remain the preferred adjuvant endocrine therapy for postmenopausal women (1). Compared With Biennial Mammography, Annual Mammography Was Associated With Lower Risk for Advanced Cancer and Large Tumors in Women Aged 40 to 49 Years With Extremely Dense Breasts Kerlikowske K Zhu W Hubbard RA et al Breast Cancer Surveillance Consortium Outcomes of screening mammography by frequency, breast density, and postmenopausal hormone therapy. JAMA Intern Med 2013 173 807 16 23552817 Background: High breast density is associated with increased risk for breast cancer. The optimal approach to screening women with high breast density is unknown. In the United States, federal law requires that women receive written notification of mammography results. As of September 2013, only 13 U.S. states required that notification include breast density results (3). Breast density is reported using Breast Imaging-Reporting and Data System breast density categories: 1=almost entirely fat, 2=scattered fibroglandular densities, 3=heterogeneously dense, and 4=extremely dense. In 2009, the U.S. Preventive Services Task Force (USPSTF) found convincing evidence that mammography in women aged 40 to 49 years reduced death from breast cancer. However, the overall benefit was deemed to be small, resulting in the recommendation that the decision to start screening mammography before age 50 years should be an individual one and should take patient context into account, including the patients values regarding specific benefits and harms. Biennial screening was recommended on the basis of evidence of benefit similar to that of annual screening and decreased false-positive results (4, 5). Findings: In a prospective cohort study, data were collected from 11474 women with breast cancer and 922624 women without breast cancer who underwent mammography from radiology facilities in the United States between 1994 and 2008. Compared with annual mammography, biennial mammography for women aged 50 to 74 years was not associated with an increased risk for advanced stage or large tumors, regardless of breast density or menopausal hormone use. Compared with annual mammography, biennial mammography for women aged 40 to 49 years with extremely dense breasts was associated with an increased risk for advanced-stage cancer (odds ratio [OR], 1.89 [CI, 1.06 to 3.39]) and large tumors, defined as tumors greater than 20 mm in diameter (OR, 2.39 [CI, 1.37 to 4.18]). False-positive results were high among women with extremely dense breasts aged 40 to 49 years undergoing annual mammography (65.5% cumulative 10-year risk) and among women with extremely dense breasts who were receiving estrogen plus progestin therapy undergoing annual mammography (65.8% cumulative 10-year risk). The rate of false-positive results was lower among women with fatty breasts aged 50 to 74 years who underwent biennial mammography (17.4% cumulative 10-year risk). Cautions: Participants were not randomly assigned. The study was not designed to determine the effects of screening on breast cancer mortality and overall mortality. Implications: This study suggests that women aged 40 to 49 years who choose to undergo mammography and are found to have extremely dense breasts may benefit from annual mammography to reduce diagnoses of advanced disease, at the risk of increased false-positive results. Like all women, women with extremely dense breasts should undergo breast cancer risk evaluation, with genetic testing for women with a family history suggestive of presence of a BRCA1/2 mutation, and consideration of screening magnetic resonance imaging for women found to have greater than 20% lifetime risk for cancer (6, 7). Disparities in Survival Between White and Black Medicare Beneficiaries With Breast Cancer Were Mainly Attributable to Differences in Presentation and Comorbid Conditions Silber JH Rosenbaum PR Clark AS et al Characteristics associated with differences in survival among black and white women with breast cancer. JAMA 2013 310 389 97 23917289 Background: In the United States before 1980, after adjustment for higher incidence among white persons, there were minimal differences in breast cancer mortality between white and black women. Since that time, a significant survival disparity has emerged. The causes of this disparity are not completely understood (8). Findings: By using the U.S. Surveillance, Epidemiology, and End Results (SEER)Medicare database, 7375 black women aged 65 years or older diagnosed with breast cancer between 1991 and 2005 were matched with white controls. After adjustment for demographic factors, the 5-year survival rate was 68.8% for white women and 55.9% for black women (difference, 12.9 percentage points [CI, 11.5 to 14.5 percentage points]; P< 0.001). Median duration of survival was nearly 3 years shorter for black women. This difference did not significantly change between 1991 and 2005. After adjustment for socioeconomic status, the hazard ratio for breast cancer mortality was no longer significant (1.02 [CI, 0.97 to 1.09]; P= 0.41). Most of the difference in 5-year survival was explained by differences in cancer presentation and comorbid conditions. After adjustment for these factors, the difference in median survival was less than 1 year. Black women received diagnoses of more advanced disease with more adverse biological features. They also had more comorbid conditions and poorer health. Black women waited longer for treatment (29.2 days vs. 22.5 days; P< 0.001), were statistically significantly more likely to have a delay of 3 months or more from diagnosis to treatment (5.8% vs. 2.5%; P< 0.001), and were less likely to receive anthracycline and taxane chemotherapy (3.7% vs. 5.0%; P< 0.001). They were more likely to receive no treatment except breast-conserving surgery (8.2% vs. 7.3%; P= 0.04) or no treatment (12.6% vs. 8.2%; P< 0.001). After matching for demographic characteristics, black women were less likely than white women to have had mammography within the past 6 to 18 months (23.5% vs. 35.7%; P< 0.001) and less likely to have evidence of at least 1 primary care visit during the preceding 6 to 18 months (80.5% vs. 88.5%; P< 0.001). Cautions: Endocrine therapies could not be tracked in SEER. Data from SEER could not identify tripl

Update in Women's Health

This Update in Womens Health reviews the past years research publications that have the most relevance to the practice of internal medicine. We have included a summary of new guideline recommendations for the prevention of heart disease in women. Our selection process was guided by advice from our colleagues in general internal medicine, geriatrics, obstetrics and gynecology, cardiology, and oncology. Breast Cancer Magnetic Resonance Imaging Was More Sensitive than Ultrasound, Mammography, or Clinical Breast Examination for Detecting Breast Cancer in BRCA1 and BRCA2 Mutation Carriers Warner E, Plewes DB, Hill KA, et al. Surveillance of BRCA1 and BRCA2 mutation carriers with magnetic resonance imaging, ultrasound, mammography, and clinical breast examination. JAMA. 2004;292:1317-25. [PMID: 15367553] Women with mutations of the BRCA1 and BRCA2 genes have a lifetime breast cancer risk of 50% to 85%. Routine mammography detects approximately 50% of tumors in women with the mutation versus 75% of tumors in women who do not have the mutation (1). Decreased sensitivity of mammography in BRCA1 and BRCA2 mutation carriers is the result of several factors. BRCA1 and BRCA2 mutation carriers are more likely to develop breast cancer at younger ages, when dense breast tissue makes tumors more difficult to detect. In addition, breast cancer in patients with BRCA1 is less likely to be associated with microcalcifications and more likely to have round margins, making it more difficult to identify by mammography. This study compared the sensitivity and specificity of mammography, magnetic resonance imaging (MRI), ultrasonography, and clinical breast examination in 263 Canadian women with BRCA1 or BRCA2 mutations. The women, who ranged in age from 25 to 65 years, underwent 1 to 3 annual examinations with 3 modalities: mammography, MRI, and ultrasonography. Clinical breast examination was also performed on the day of screening and at 6-month intervals. Of 22 detected tumors (16 invasive and 6 ductal carcinoma in situ), 17 (77%) were detected by MRI, 8 (36%) by mammography, 7 (33%) by ultrasonography, and 2 (9%) by clinical breast examination. After initial screening with MRI, 26% of the study participants were recalled for further diagnostic evaluation, consisting of immediate diagnostic MRI or close follow-up with a 6-month interval MRI. Seven tumors were detected by MRI but missed by all other modalities. Two tumors were detected by ultrasonography alone, and 2 tumors were detected by mammography alone. One interval case of cancer (detected between study evaluations) was identified with all modalities at the time of diagnosis; retrospective analysis revealed that the tumor had also been visible on previous MRI and mammography. On the basis of biopsy rates, the sensitivity and specificity for the detection of breast cancer were 77% and 95.4% for MRI, 36% and 99.8% for mammography, 33% and 96% for ultrasonography, and 9.1% and 99.3% for clinical breast examination. In conclusion, MRI was more sensitive than ultrasonography, mammography, or clinical breast examination alone in this group of women with BRCA1 and BRCA2 mutations. No modality detected all of the tumors. The use of all 4 modalities had greater sensitivity than the traditionally recommended combination of mammography and clinical breast examination, but one fourth of patients who underwent MRI required additional testing after the first evaluation to better discriminate suspicious lesions. Including ultrasonography in the protocol decreased specificity because of additional biopsies; however, eliminating ultrasonography decreased sensitivity from 95% to 86%. Whether surveillance regimens that include MRI and ultrasonography reduce mortality from breast cancer in high-risk women is unknown. This study added to a growing body of literature that suggests MRI and ultrasonography improve cancer detection in women with BRCA mutations. The American Cancer Society recommends that women with BRCA mutations talk with their physicians about the benefits and limitations of undergoing mammography when they are younger, having additional tests (such as breast ultrasonography or MRI), or having more frequent clinical breast examinations (2). Some insurance carriers already offer coverage for enhanced screening of women at high genetic risk for breast cancer. Ideally, women with BRCA1 and BRCA2 mutations should be enrolled in clinical trials of screening protocols. The value of enhanced screening remains debatable for women who do not have BRCA mutations. Until more studies are done, most experts would not recommend MRI or ultrasonography in women with lesser degrees of breast cancer risk (3, 4). The false-positive rate of MRI is unacceptably high in women at average risk for breast cancer. Screening ultrasonography is not recommended for women who are not at increased risk for breast cancer (2, 5). Exemestane Therapy after 2 to 3 Years of Tamoxifen Therapy Improved Survival Compared with 5 Years of Tamoxifen Therapy Alone Coombes RC, Hall E, Gibson LJ, et al. A randomized trial of exemestane after two to three years of tamoxifen therapy in postmenopausal women with primary breast cancer. N Engl J Med. 2004;350:1081-92. [PMID: 15014181] For many years, experts agreed that most postmenopausal women with early-stage, estrogen receptorpositive tumors should receive tamoxifen (a selective estrogen-receptor modulator) as adjuvant therapy for 5 years. On the basis of recent studies, however, the American Society of Clinical Oncology has changed this recommendation. New guidelines now state that optimal adjuvant hormonal therapy for a postmenopausal woman with breast cancer includes an aromatase inhibitor as initial therapy or after treatment with tamoxifen (6). Aromatase inhibitors, which inhibit or inactivate an enzyme that catalyzes the conversion of androgens to estrogens, profoundly reduce systemic estrogen levels in postmenopausal women. In this trial, Coombes and associates wanted to determine if, after 2 to 3 years of tamoxifen therapy, switching patients to an aromatase inhibitor (exemestane) was more effective than continuing tamoxifen for the remaining 5 years of treatment. In a randomized, double-blind trial, 4742 patients were initially treated with tamoxifen. After a median duration of 2.4 years of tamoxifen therapy, 2362 women were randomly assigned to switch to exemestane while 2380 women continued to receive tamoxifen. The primary end point was disease-free survival. After a median follow-up of 30.6 months, the unadjusted hazard ratio for local or metastatic recurrence, contralateral breast cancer, or death was 0.68 for the exemestane group (95% CI, 0.56 to 0.82). Three years after randomization, the absolute benefit of exemestane on disease-free survival was 4.7% (CI, 2.6% to 6.8%). Exemestane use was associated with a higher incidence of arthralgia and diarrhea. Tamoxifen use was associated with a higher incidence of thromboembolic events, gynecologic symptoms (including vaginal bleeding), and muscle cramps. In addition to the adverse effects reported in this paper, studies of aromatase inhibitors have consistently shown that the risk for osteoporosis and fracture is increased compared with placebo or tamoxifen (7-9). According to American Society of Clinical Oncology guidelines, women should undergo a baseline bone mineral density evaluation before beginning treatment with aromatase inhibitors. Bisphosphonate therapy should be prescribed for breast cancer patients with osteoporosis. Women taking aromatase inhibitors who are not being treated for osteoporosis should undergo annual bone mineral density screening (10). With the availability of another choice of adjuvant therapy, medical oncologists and patients must work together to determine which drugs are most appropriate on the basis of individual patient characteristics. Breast cancer survivors who are taking tamoxifen (or who have recently completed tamoxifen therapy) and are being followed by general internists may need to be re-referred to oncologists for consideration of additional therapy. Ovarian Cancer Ovarian Cancer Should Be Considered in Women with Increased Abdominal Size, Bloating, Urinary Urgency, and Pelvic Pain Goff BA, Mandel LS, Melancon CH, et al. Frequency of symptoms of ovarian cancer in women presenting to primary care clinics. JAMA. 2004;291:2705-12. [PMID: 15187051] Ovarian cancer is the fifth leading cause of cancer deaths among women in the United States. The usefulness of serial pelvic ultrasonography and serum CA-125 tumor marker testing has been investigated, but the American College of Physicians, the American College of Obstetricians and Gynecologists (ACOG), and the U.S. Preventive Services Task Force all recommend against routine screening of the general population because of lack of effectiveness and high rates of false-positive results (11-13). Women with symptoms of ovarian cancer often present first to physicians other than gynecologists, particularly general internists. In a recent retrospective study of 1725 women in the United States and Canada, 45% of ovarian cancer patients who were surveyed reported that cancer was diagnosed more than 3 months after an initial consultation with a health care provider for associated symptoms (14). Diagnosis at an earlier stage is highly correlated with better survival (15), and recent studies suggest that many women with earlier stage disease are symptomatic (14, 16-18). This prospective, casecontrol study compared the frequency, severity, and duration of symptoms of 1709 women who visited a primary care clinic with those of 128 women known to have pelvic masses. All participants completed an anonymous survey of symptoms experienced during the previous 12 months; the latter group was surveyed before surgery to determine if the mass was benign (n= 84) or malignant (n= 44). Compared with clinic controls, women with malignant pelvic masses (ovaria