Margaret E. Long

Bleeding related to etonogestrel subdermal implant in a US population

BACKGROUND The etonogestrel subdermal implant received US Food and Drug Administration approval in 2006. Menstrual changes represent a common reason why recipients of this implant request early implant removal. STUDY DESIGN Retrospective review of medical records of 155 patients with placement of this implant at Mayo Clinic in Rochester, Minnesota, and medical literature review. RESULTS In 151 patients (97.4%), this implant was placed for contraception. Sixty-four patients (41.3%) contacted a health care provider about implant-related issues after insertion, including 39 (25.2%) for abnormal bleeding. Mean body mass index (BMI) was 28.5, higher than prior studies of implant-related bleeding. Implant removal rate was 25.2% (mean interval, 9.8 months), with 14.8% requesting removal for bleeding changes. No insertion or postinsertion complications or contraceptive failures were found. CONCLUSIONS Age, race, BMI, parity, prior contraception method, and postpartum and breastfeeding status did not predict bleeding or removal for bleeding risk. Removal rates were higher for amenorrhea, occasional spotting or bleeding, and regular menses than for prolonged or continuous bleeding.

Abnormal Cervical Appearance: What to Do, When to Worry?

Many clinicians encounter cervical lesions that may or may not be associated with cytologic abnormalities. Such abnormalities as ectropion, Nabothian cysts, and small cervical polyps are quite benign and need not generate concern for patient or clinician, whereas others, including those associated with a history of exposure to diethylstilbestrol, cervical inflammation, abnormal cervical cytology, and postcoital bleeding, should prompt additional evaluation. Further, in some patients, the cervix may be difficult to visualize. Several useful clinical suggestions for the optimal examination of the cervix are presented.

Association of body mass index with removal of etonogestrel subdermal implant

BACKGROUND Bleeding irregularities represent the most common etonogestrel subdermal implant (ESI) removal indication. STUDY DESIGN ESI placements (n=304) from June 2007 to April 2011 were grouped by removal indications. Group characteristics were compared using one-way analysis of variance, Kruskal-Wallis and χ(2) test. RESULTS Of 304 insertions, 30.6% reported irregular bleeding. Removal indications included bleeding (Group 1, n=50), side effects (Group 2, n=17) and desired pregnancy/no need (Group 3, n=25). Group 4 kept (n=198) or reinserted (n=14) ESI. Median body mass index was lower for Group 1 compared to other groups (p=.012). Group 3 was older than Group 1 or 4 (p=.021), and more likely parous (p<.001) and postpartum (p=.001) than other groups. Lactational placement was more common in Group 3 than 4 (p<.001). Obese women were 2.6 times less likely to remove ESI for bleeding vs. normal-weight or overweight women (95% confidence interval, 1.2-5.7; p=.014). CONCLUSIONS After adjusting for age and parity, obese women were less likely to have ESI removal for bleeding.

Caring for the breast cancer survivor's health and well-being.

The breast cancer care continuum entails detection, diagnosis, treatment, and survivorship. During this time, focus on the whole woman and medical concerns beyond the breast cancer diagnosis itself is essential. In this comprehensive review, we critically review and evaluate recent evidence regarding several topics pertinent to and specific for the woman living with a prior history of breast cancer. More specifically, we discuss the most recent recommendations for contraceptive options including long-acting reversible contraception and emergency contraception, fertility and pregnancy considerations during and after breast cancer treatment, management of menopausal vasomotors symptoms and vulvovaginal atrophy which often occurs even in young women during treatment for breast cancer. The need to directly query the patient about these concerns is emphasized. Our focus is on non-systemic hormones and non-hormonal options. Our holistic approach to the care of the breast cancer survivor includes such preventive health issues as sexual and bone health,which are important in optimizing quality of life. We also discuss strategies for breast cancer recurrence surveillance in the setting of a prior breast cancer diagnosis. This review is intended for primary care practitioners as well as specialists caring for female breast cancer survivors and includes key points for evidence-based best practice recommendations.

Current issues in contraception

Contraceptive management in women should take into account patient lifestyle and coexisting medical issues as well as method safety, efficacy, and noncontraceptive benefits. This review focuses on common and timely issues related to contraception encountered in clinical practice, including migraine headaches and associated risk of ischemic stroke, the use of combined hormonal contraception along with citalopram and escitalopram, contraceptive efficacy and safety in the setting of obesity, contraceptives for treatment of menorrhagia, the association of intrauterine contraception and decreased risk of cervical cancer, and the association of venous thromboembolism and combined hormonal contraception. Recent trends supporting the use of long-acting reversible contraception are also reviewed.

Contraception and Hormonal Management in the Perimenopause

This literature review focuses on contraception in perimenopausal women. As women age, their fecundity decreases but does not disappear until menopause. After age 40, 75% of pregnancies are unplanned and may result in profound physical and emotional impact. Clinical evaluation must be relied on to diagnose menopause, since hormonal levels fluctuate widely. Until menopause is confirmed, some potential for pregnancy remains; at age 45, womens sterility rate is 55%. Older gravidas experience higher rates of diabetes, hypertension, and death. Many safe and effective contraceptive options are available to perimenopausal women. In addition to preventing an unplanned and higher-risk pregnancy, perimenopausal contraception may improve abnormal uterine bleeding, hot flashes, and menstrual migraines. Long-acting reversible contraceptives, including the levonorgestrel intrauterine system (LNG-IUS), the etonogestrel subdermal implant (ESI), and the copper intrauterine device (Cu-IUD), provide high efficacy without estrogen. LNG-IUS markedly decreases menorrhagia commonly seen in perimenopause. Both ESI and LNG-IUS provide endometrial protection for women using estrogen for vasomotor symptoms. Women without cardiovascular risk factors can safely use combined hormonal contraception. The CDCs Medical Eligibility Criteria for Contraceptive Use informs choices for women with comorbidities. No medical contraindications exist for levonorgestrel emergency-contraceptive pills, though obesity does decrease efficacy. In contrast, the Cu-IUD provides reliable emergency and ongoing contraception regardless of body mass index (BMI).

Surveillance and Care of the Gynecologic Cancer Survivor

Abstract Background: Care of the gynecologic cancer survivor extends beyond cancer treatment to encompass promotion of sexual, cardiovascular, bone, and brain health; management of fertility, contraception, and vasomotor symptoms; and genetic counseling. Methods: This is a narrative review of the data and guidelines regarding care and surveillance of the gynecologic cancer survivor. We searched databases including PubMed, Cochrane, and Scopus using the search terms gynecologic cancer, cancer surveillance, and cancer survivor and reached a consensus for articles chosen for inclusion in the review based on availability in the English language and publication since 2001, as well as key older articles, consensus statements, and practice guidelines from professional societies. However, we did not undertake an extensive systematic search of the literature to identify all potentially relevant studies, nor did we utilize statistical methods to summarize data. We offer clinical recommendations for the management of gynecologic cancer survivors based on review of evidence and our collective clinical experience. Results: Key messages include the limitations of laboratory studies, including CA-125, and imaging in the setting of gynecologic cancer surveillance, hormonal and non-hormonal management of treatment-related vasomotor symptoms and genitourinary syndrome of menopause, as well as recommendations for general health screening, fertility preservation, and contraception. Conclusions: A holistic approach to care extending beyond cancer treatment alone benefits gynecologic cancer survivors. In addition to surveillance for cancer recurrence and late treatment side effects, survivors benefit from guidance on hormonal, contraceptive, and fertility management and promotion of cardiovascular, bone, brain, and sexual health.

Transient neonatal acquired von Willebrand syndrome due to transplacental transfer of maternal monoclonal antibodies

Although typically a disorder of adults, acquired von Willebrand syndrome (AVWS) is increasingly being recognized in the pediatric population in association with congenital cardiac diseases, certain neoplasia, and hypothyroidism. Transplacental transfer of maternal immunoglobulin G (IgG) antibodies as a cause of neonatal disorders in infants born to mothers with autoimmune conditions has been reported. We describe the diagnosis and peripartum clinical management of AVWS due to monoclonal gammopathy of undetermined significance (MGUS) and the first reported case of transient neonatal AVWS due to transplacental transfer of maternal IgG antibodies. Pediatr Blood Cancer 2009;53:655–657.

Comparison of dysplastic and benign endocervical polyps

Objective This study aimed to estimate dysplasia rate in histologically evaluated endocervical polyps and to compare histological and clinical characteristics of dysplastic (D) polyps with those displaying representative benign changes. Materials and Methods Endocervical polyps removed at Mayo Clinic from January 1994 to December 2010 were categorized as polyp without other descriptors, benign polyp variants, adenomatous or reactive atypical (AR) polyps, and D polyps. Clinical characteristics, cervical cytological result, and polyp histological result of patients in the latter 2 categories were compared. Results Among the 4,328 patients with endocervical polyps, 3,656 were classified as polyp without other descriptors, 628 as benign polyp variants, 34 as AR polyps, and 9 as D polyps. Dysplasia was mild in 4 polyps, moderate in 1 polyp, and severe in 4 polyps. Overall risk of dysplasia was 0.2%. Patients with D polyps were younger (mean = 40.3 vs. 49.8 years, p = .009) and more likely to have abnormal cervical cytological result before polyp removal (67% vs. 21%, p = .014) as compared with those with AR. Patients with D polyps tended to have a polyp greater than 20 mm (44% vs. 15%, p = .074) compared with those with AR polyps. Associated endometrial pathological diagnosis was limited to a prolapsed endometrial polyp in 1 patient and submucosal endometriosis in 1 patient. Conclusions Patients with D polyps were younger and had a greater likelihood of abnormal cytological result before polyp removal. No polyp size threshold below which dysplasia could be excluded was identified. No primary cervical cancer, endometrial hyperplasia, or cancer was identified.

Female Sexual Function Improves After Endometrial Ablation

BACKGROUND Many women have heavy menstrual bleeding during perimenopause that may interfere with overall quality of life and contribute to sexual dysfunction. We aimed to determine whether sexual function in women improves after endometrial ablation for heavy menstrual periods. METHODS Validated surveys (Female Sexual Function Index [FSFI], Female Sexual Distress Scale [FSDS], and Short-Form Health Survey [SF-12]) were administered to 136 women before and after endometrial ablation from August 2008 through June 2013. Scores at baseline and 6 months after surgery were compared using the paired t test. RESULTS A total of 97 women completed the FSFI and FSDS surveys at baseline and 6 months after ablation. Mean full-scale FSFI score increased from 26.5 to 28.8 (p < .001), with improvement in 5 of 6 FSFI domains. Mean FSDS score decreased from 13.6 to 9.7 (p < .001), showing decreased personal distress regarding sexual function. In assessing quality of life, SF-12 scores improved for global physical function (p < .001) and mental function (p = .002). CONCLUSIONS Female sexual function improved and personal distress associated with sexual function decreased after endometrial ablation for heavy menstrual cycles.