Robert H. Lea

Prevalence of Primary Dysmenorrhea in Canada

OBJECTIVE The aim of this study was to describe the prevalence, clinical effect, characteristics, and underlying risk factors of primary dysmenorrhea (PD) in Canada. METHODS A stratified, random sample of 2721 women 18 years and older was identified, and the women were interviewed by telephone. Data about menstrual symptoms and patterns and socio-demographic factors were obtained. The frequency, severity, and effect of menstrual pain were quantified. Logistic regression analysis was performed in order to identify independent risk factors for PD. RESULTS In the sample, 1546 women were having menstrual periods; of these, 934 (60%) met the criteria for PD. Sixty percent of the women with PD described their pain as moderate or severe. Fifty-one percent reported that their activities had been limited, and 17% reported missing school or work because of PD. The prevalence of PD decreased with increasing age (P < 0.001) and increased with smoking (P = 0.002). Users of oral contraceptives (OCs) tended to have less pain than non-users (P = 0.005). Socio-economic status, nulliparity, and earlier age at menarche were not independently associated with PD. However, nulliparous women, smokers, and women not using OCs were more likely to report disabling symptoms. CONCLUSIONS The majority of Canadian women will suffer from dysmenorrhea at some time during their reproductive years. Available prescription treatments are underused. Young age, smoking, and non-use of OCs are independent risk factors for PD.

Consensus Guidelines for the Management of Chronic Pelvic Pain

OBJECTIVE To improve the understanding of chronic pelvic pain (CPP) and to provide evidence-based guidelines of value to primary care health professionals, general obstetricians and gynaecologists, and those who specialize in chronic pain. BURDEN OF SUFFERING: CPP is a common, debilitating condition affecting women. It accounts for substantial personal suffering and health care expenditure for interventions, including multiple consultations and medical and surgical therapies. Because the underlying pathophysiology of this complex condition is poorly understood, these treatments have met with variable success rates. OUTCOMES Effectiveness of diagnostic and therapeutic options, including assessment of myofascial dysfunction, multidisciplinary care, a rehabilitation model that emphasizes achieving higher function with some pain rather than a cure, and appropriate use of opiates for the chronic pain state. EVIDENCE Medline and the Cochrane Database from 1982 to 2004 were searched for articles in English on subjects related to CPP, including acute care management, myofascial dysfunction, and medical and surgical therapeutic options. The committee reviewed the literature and available data from a needs assessment of subjects with CPP, using a consensus approach to develop recommendations. VALUES The quality of the evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice were ranked according to the method described in that report (Table 1). RECOMMENDATIONS The recommendations are directed to the following areas: (a) an understanding of the needs of women with CPP; (b) general clinical assessment; (c) practical assessment of pain levels; (d) myofascial pain; (e) medications and surgical procedures; (f) principles of opiate management; (g) increased use of magnetic resonance imaging (MRI); (h) documentation of the surgically observed extent of disease; (i) alternative therapies; (j) access to multidisciplinary care models that have components of physical therapy (such as exercise and posture) and psychology (such as cognitive-behavioural therapy), along with other medical isciplines, such as gynaecology and anesthesia; (k) increased attention to CPP in the training of health care professionals; and (l) increased attention to CPP in formal, high-calibre research. The committee recommends that provincial ministries of health pursue the creation of multidisciplinary teams to manage the condition. CHAPTER 7: MYOFASCIAL DYSFUNCTION: 1. Health care providers should become more aware of myofascial dysfunction as a cause of chronic pelvic pain (CPP) and the available treatment options (IB). 2. Patients should participate in the management of CPP due to myofascial dysfunction by actively using a home stretching and exercise program (ll-2B). CHAPTER 8: MEDICAL THERAPY--EVIDENCE ON EFFECTIVENESS: 1. Opioid therapy can be considered for pain control under adequate supervision (II-3B). 2. Hormonal treatment of chronic pelvic pain of gynaecologic origin, including oral contraceptives, progestins, danazol, and gonadotropin-releasing hormone agonists, has been studied extensively and should be considered as the first line for many women, especially those with endometriosis (I and II-1A). 3. Adjuvant medications, such as antidepressants and antibiotics, can be of supporting help in specific situations (II-3B). CHAPTER 9: SURGERY-EVIDENCE ON EFFECTIVENESS: 1. The lack of robust clinical trials of the surgical management of chronic pelvic pain should be addressed. The use of alternative epidemiologic models, including case-controlled and cohort-controlled trials, should be considered (III-A). 2. Further delineation of the role of appendectomy and of presacral neurectomy appears warranted in the management of endometriosis-related pain (III-A). CHAPTER 11: MULTIDISCIPLINARY CHRONIC PAIN MANAGEMENT: 1. Multidisciplinary chronic pain management should be available for women with chronic pelvic pain within the publicly funded health care system in each province and territory of Canada (III-B). CHAPTER 14: FUTURE DIRECTIONS 1. The curriculum for professional development should be expanded to include theory and techniques in the management of myofascial dysfunction (A). 2. Research into CPP should be encouraged, particularly in the areas of the impact of CPP on the use of health services, the pathophysiology of myofascial dysfunction, and gene therapy. Because randomized trials for qualitative outcomes are exceedingly difficult, alternative robust models, such as case-controlled or cohort-controlled trials, should be pursued (A). 3. Methods of improving interaction with patients should be explored. They might include formal contractual approaches to managing pain with opiates and efforts to better appreciate the patients perceived needs (A).

Consensus Guidelines for the Management of Chronic Pelvic Pain. This guideline was developed by the Chronic Pelvic Pain Working Group and approved by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada

OBJECTIVE To improve the understanding of chronic pelvic pain (CPP) and to provide evidence-based guidelines of value to primary care health professionals, general obstetricians and gynaecologists, and those who specialize in chronic pain. BURDEN OF SUFFERING: CPP is a common, debilitating condition affecting women. It accounts for substantial personal suffering and health care expenditure for interventions, including multiple consultations and medical and surgical therapies. Because the underlying pathophysiology of this complex condition is poorly understood, these treatments have met with variable success rates. OUTCOMES Effectiveness of diagnostic and therapeutic options, including assessment of myofascial dysfunction, multidisciplinary care, a rehabilitation model that emphasizes achieving higher function with some pain rather than a cure, and appropriate use of opiates for the chronic pain state. EVIDENCE Medline and the Cochrane Database from 1982 to 2004 were searched for articles in English on subjects related to CPP, including acute care management, myofascial dysfunction, and medical and surgical therapeutic options. The committee reviewed the literature and available data from a needs assessment of subjects with CPP, using a consensus approach to develop recommendations. VALUES The quality of the evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice were ranked according to the method described in that report (Table 1). RECOMMENDATIONS The recommendations are directed to the following areas: (a) an understanding of the needs of women with CPP; (b) general clinical assessment; (c) practical assessment of pain levels; (d) myofascial pain; (e) medications and surgical procedures; (d) principles of opiate management; (f) increased use of magnetic resonance imaging (MRI); (g) documentation of the surgically observed extent of disease; (h) alternative therapies; (i) access to multidisciplinary care models that have components of physical therapy (such as exercise and posture) and psychology (such as cognitive-behavioural therapy), along with other medical disciplines, such as gynaecology and anesthesia; (j) increased attention to CPP in the training of health care professionals; and (k) increased attention to CPP in formal, high-calibre research. The committee recommends that provincial ministries of health pursue the creation of multidisciplinary teams to manage the condition.

Breast self-examination.

OBJECTIVE To examine the value of teaching regular breast self-examination (BSE). OUTCOME Reduction of benign biopsy rates. BENEFITS To provide better advice for women about the risks and benefits of BSE, and to ensure that women who choose to practise BSE are taught to perform it proficiently. SUMMARY STATEMENT Routine teaching of BSE does not reduce mortality and likely increases benign biopsy rates. (I) RECOMMENDATIONS: 1. Breast self-examination should not be routinely taught to women. (ID) 2. A full discussion of breast self-examination, including risks, should be provided for the woman who requests it. (IIIA) 3. If a woman makes an informed decision to practise BSE, care providers should ensure she is taught the skills and that she performs self-examination proficiently. (IIIA) VALIDATION: This committee opinion was developed by the Breast Disease Committee of the Society of Obstetricians and Gynaecologists of Canada. It was approved by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada. SPONSOR The Society of Obstetricians and Gynaecologists of Canada.

Breast Cancer and Abortion

In a collaborative reanalysis of data from 53 epidemiologic studies that included 83 000 women with breast cancer from 16 countries, the overall relative risk (RR) of breast cancer for women having one or more pregnancies that ended as a spontaneous abortion versus women with no such record was 0.98 (95% confidence interval [CI] 0.92–1.04, P = 0.5). The corresponding RR for induced abortion was 0.93 (95% CI 0.89–0.96, P = 0.0002). Among women with a prospectively documented spontaneous or induced abortion, the risk of breast cancer did not differ significantly according to the number or timing for either type of abortion.1 Two studies,2,3 published too late for inclusion in the above collaborative reanalysis, confirmed that neither induced nor spontaneous abortion was associated with increased risk of breast cancer. Paoletti and Clavel-Chapelon2 found no association between a history of induced abortion and breast cancer risk either in the whole population (RR 0.91; 95% CI 0.82–0.99) or in subgroups defined by parity or by menopausal status. Overall, there was no significant association between spontaneous abortion and breast cancer (RR 1.05; 95% CI 0.95–1.15). However, with increased number of spontaneous abortions (3 or more), the risk of breast cancer decreased in premenopausal women (RR 0.55; 95% CI 0.26–1.14) and increased in postmenopausal women (RR 1.50; 95% CI 1.10–2.05), based on 7 and 42 incident breast cancer cases of a total 3022. Erlandsson et al.3 reported a significantly reduced risk of breast cancer in women with a history of at least 1 compared with no abortions (adjusted odds ratio [OR] 0.84; 95% CI 0.72–0.99). The adjusted OR decreases step-wise with number of abortions to 0.59 (95% CI 0.34–1.03) for 3 or more abortions, compared with no abortions. The patterns are similar for induced and spontaneous abortions.

Availability of hormone replacement therapy products in Canada.

OBJECTIVES To determine the availability in Canada of different types of hormone replacement therapy (HRT) products, and to compare the availability of HRT products in Canada to their availability in other countries. METHODS A systematic review was conducted of the availability of products indicated for treatment of menopausal symptoms in Canada, the United States (US), the United Kingdom (UK), Sweden, and Australia. Products indicated for the treatment of menopausal symptoms were determined for each country by using on-line drug product databases. Products administered by injection and androgen products, unless combined with estrogens, were excluded from the analysis. RESULTS There were 111 different brands identified in the 5 countries examined, with Canada having the lowest number of brands and active ingredients (28 and 22, respectively) compared to the other countries (Sweden and UK at 67 and 47 brands and 39 and 40 active ingredients, respectively). Not available in Canada are 34 active ingredients (either alone or in combination products) and 5 different types of formulations of HRT. There was a significant difference between the number of combination brand products available in Canada and in the UK (5 versus 29, P <.001, respectively). CONCLUSIONS Canadian women have comparatively few options available to them for the management of menopausal symptoms. The wide range of HRT products available in other developed countries provides alternatives for managing side

The Benefits of Awareness Study: An Evaluation of Targetted, User-Friendly Education among Oral Contraceptive Users

Abstract Despite widespread availability of patient package inserts and information booklets, myths regarding oral contraceptive (OC) usage are perceived as facts by many women. The purpose of this large clinical trial, conducted in collaboration with the SOGC, was to determine if targetted, user-friendly information could dispel the myths associated with the OC. Data were collected from 6,224 women, over a series of up to four automated telephone interviews. Questions regarding common myths about OCs were posed to women randomized to intervention and control groups, before and after an educational intervention. The educational intervention consisted of two SOGC-endorsed brochures which addressed these myths. One brochure was targeted for a younger patient (22 years old or younger), the other for a more mature woman (23 years or older). Both intervention and control groups showed numerous statistically and clinically significant changes in responses to questions posed about myths associated with OCs, over several interviews. In addition, significantly (p This study demonstrated that these targetted educational materials effectively can dispel myths associated with OCs. Significant response changes in the control group suggest that evaluating patient knowledge regarding OCs may encourage patients to discover the facts.