Pelin Batur

Profile of teriparatide in the management of postmenopausal osteoporosis

One out of every 2 women within postmenopause are at risk of fracture due to osteoporosis. Fortunately, a growing arsenal of therapies is becoming available to treat this disease and prevent fracture. A new class of anabolic agents has emerged within the last decade that brought with it a new concept in osteoporosis therapy: building new stronger bone rather than simply inhibiting bone turnover. Evidence is accumulating to understand how to best utilize these new agents, and which patients benefit most. This article will review the effectiveness, risks, timing and clinical uses of teriparatide in postmenopausal osteoporosis.

Emergency contraception: A multispecialty survey of clinician knowledge and practices

OBJECTIVES To assess knowledge and provision of emergency contraception (EC), particularly the most effective methods. STUDY DESIGN A web-based survey was distributed to a cross-sectional convenience sample of healthcare providers across specialties treating reproductive-aged women. The survey was sent to 3260 practicing physicians and advanced practice clinicians in 14 academic centers between February 2013 and April 2014. We analyzed responses by provider specialty using multivariable logistic regression. RESULTS The final sample included 1684 providers (response rate=51.7%). Ninety-five percent of the respondents had heard of levonorgestrel (LNG) EC. Among reproductive health specialists, 81% provide LNG EC in their practice, although only half (52%) had heard of ulipristal acetate (UPA) and very few provide it (14%). The majority in family medicine (69%) and emergency medicine (74%) provide LNG, in contrast to 42% of internists and 55% of pediatricians. However, the more effective methods [UPA and copper intrauterine device (IUD)] were little known and rarely provided outside of reproductive health specialties; 18% of internists and 14% of emergency medicine providers had heard of UPA and 4% provide it. Only 22% of emergency providers and 32% of pediatricians had heard of the copper IUD used as EC. Among reproductive health specialists, only 36% provide copper IUD as EC in their practice. Specialty, provider type and proportion of women of reproductive age in the practice were related to knowledge and provision of some forms of EC. CONCLUSIONS Awareness and provision of the most effective EC methods, UPA and the copper IUD (which are provider dependent), are substantially lower than for LNG EC, especially among providers who do not focus on reproductive health. IMPLICATIONS In our sample of 1684 healthcare providers from diverse specialties who treat reproductive-aged women, knowledge and provision of the most effective forms of EC (UPA and the copper IUD) are far lower than for LNG EC. Women should be offered the full range of EC methods.

Risks and Effectiveness of Compounded Bioidentical Hormone Therapy: A Case Series

After the publication of the Womens Health Initiative, attitudes towards management of menopausal symptoms changed dramatically. One alternative that has received much media attention is the use of bioidentical hormone therapy (BHT). The media and celebrity endorsements have promoted a number of misconceptions about the risks and benefits associated with the various forms of BHT. This article will review the available evidence regarding the safety and efficacy of BHT in comparison to conventional hormone therapy. We will also review several cases seen in our midlife womens referral clinics, which demonstrate concerns for the safety and efficacy of BHT, including unexplained endometrial cancer in otherwise healthy BHT users. Due to the lack of sufficient data to support the efficacy or safety of BHT, we recommend the use of United States Food and Drug Administration-approved regimens in the management of menopausal symptoms.

HPV Update: Vaccination, Screening, and Associated Disease

Human papillomavirus (HPV) infection is the causative agent in cervical cancer, and is associated with numerous other genital cancers, including vulvar, vaginal, and anal cancer. Primary prevention with HPV vaccination is safe and efficacious, and a recently approved HPV vaccine will provide even more extensive protection against several oncogenic HPV strains. Screening strategies for HPV are rapidly evolving, reflecting the essential role that HPV infection plays in cervical cancer. This article highlights new evidence regarding the efficacy of the recently approved 9-valent HPV (9vHPV) vaccine and the use of primary high-risk HPV testing in cervical cancer screening. We consider the utility of urinary HPV testing in routine clinical practice and review current guidelines regarding anal HPV screening.

Emergency contraception: Separating fact from fiction

Rates of unintended pregnancy and abortion are high, yet many doctors do not feel comfortable discussing emergency contraception with patients, even in cases of sexual assault. Since the approval of ulipristal acetate (ella) for emergency contraception, there has been even more confusion and controversy. This article reviews various emergency contraceptive options, their efficacy, and special considerations for use, and will attempt to clarify myths surrounding this topic. Patients can now buy emergency contraceptives over the counter, but physicians should still take every opportunity to discuss effective contraceptive options.

Contraceptive Implant Migration and Removal by Interventional Radiology

As the reversible contraceptive arm implants grow more popular, there is an increasing need to recognize the complications resulting from implant migration and removal. This review summarizes the findings of imaging and removal methods. When an implant is lost, the axillary region should be investigated first. If the implant still cannot be found, visualization though different methods have been employed for non-radiopaque implants. Real-time fluoroscopic-guided localization and removal can be accomplished for radiopaque Nexplanon. Once the implant has been located, standard removal method and other modified techniques can be used to safely remove the implant depending on the implants location.

Migraine Throughout the Female Reproductive Life Cycle

Abstract By the end of their reproductive life cycle, roughly 40% of women have experienced migraine. Women have certain times of vulnerability for migraine that relate to abrupt declines in estrogen levels. Specifically, the prevalence of migraine is higher after menarche, during menstruation, during the postpartum period, and during perimenopause, but it is commonly lower during the second and third trimesters of pregnancy and the postmenopausal years. Therapeutic strategies for migraine management include hormonal manipulation aimed at eliminating or minimizing the decreases in estrogen that trigger the especially severe menstrual‐related attacks. This article reviews special considerations for triptan use in pregnant and lactating women and in women with high risk for cardiovascular disease. Health care professionals caring for women throughout their life span should be aware of these important sex‐based differences in migraine and migraine management.

Contraception Update: Extended Use of Long Acting Methods, Hormonal Contraception Risks, and Over the Counter Access

The clinical update serves as a brief review of recently published, high-impact, and potentially practice changing journal articles summarized for our readers. Topics include menopause, sexual dysfunction, breast health, contraception, osteoporosis, and cardiovascular disease. For this clinical update, we reviewed both reproductive and general medical journals for clinically relevant publications related to the use of contraceptive methods. We have chosen to highlight articles examining the extended use of highly effective (long-acting) methods, complications of implants, risks associated with oral combined hormonal contraceptives, and the availability of over the counter contraception.

Contraceptive Implant Removals with the Use of IR

care. She received lipid emulsion 20% as a bolus of 75.15 mL for empiric treatment of LAST. A decision was made to forego infusion because the patient was in hemodynamically stable condition and had no further seizures. The patient regained consciousness in approximately 30 minutes and responded to verbal commands. An electroencephalogram showed no epileptiform activity and no evidence of encephalopathy. She was extubated after 3 hours and exhibited a good recovery. She remained in the hospital for observation overnight and was discharged the following day without further complications. An SNHB requires the use of high doses of local anesthetic agent, which increases the risk of toxicity. Bupivacaine is a well-established regional anesthetic agent, but has been associated with an increased risk of cardiac toxicity that can be refractory to traditional Advanced Cardiac Life Support. Ropivacaine is a newer local anesthetic agent that is the pure S-enantiomer of bupivacaine, resulting in similar onset, quality, and duration of sensory block, but with some distinct differences. Ropivacaine is less lipophilic than bupivacaine and is therefore less likely to penetrate large myelinated motor fibers, which decreases the potential for central nervous system toxicity and cardiac toxicity (3). Following identification of LAST, airway support, seizure suppression, and Advanced Cardiac Life Support protocol should be initiated. Lipid emulsion (20%) therapy should be started as a 1.5-mL/kg bolus, followed by a 0.25-mL/kg/min infusion. This infusion should be continued for at least 10 minutes or until circulatory stability has been achieved (4). SNHB is gaining popularity and can be performed by using a reproducible technical protocol with a less toxic local anesthetic agent (ropivacaine) as detailed here. However, as the present case exemplifies, LAST is still possible, and any interventional radiologist who performs SNHB should be aware of LAST and recognize the steps needed to reverse it.

Drospirenone Litigation: Does the Punishment Fit the Crime?

There has been much controversy in the scientific literature and lay press about the potential for increased relative risks (RRs) of venous thromboembolism associated with certain contraceptives over others. This commentary reviews the conflicting data on drospirenones relative venous and arterial risks and summarizes the details of over two billion dollars in litigation surrounding the use of these products. The current legal environment supports litigation focused on small potential RRs, associated with even smaller absolute risks. The absolute risks of venous and arterial thrombotic events in drospirenone users are low and comparable to that of other combined hormonal contraceptives. Women should have access to a wide array of contraceptive choices, including those containing drospirenone.