Timothy Rowe

Canadian Consensus Conference on Menopause, 2006 Update

OBJECTIVE To provide guidelines for health care providers on the management of menopause in asymptomatic healthy women as well as in women presenting with vasomotor symptoms, urogenital, sexual, and mood and memory concerns and on specific medical considerations, and cardiovascular and cancer issues. OUTCOMES Prescription medications, complementary and alternative medicine (CAM), and lifestyle interventions are presented according to their efficacy in treating menopausal symptoms. EVIDENCE MEDLINE and the Cochrane database were searched for articles from March 2001 to April 2005 in English on subjects related to menopause, menopausal symptoms, urogenital and sexual health, mood and memory, hormone therapy, CAM, and on specific medical considerations that affect the decision of which intervention to choose. VALUES The quality of evidence is rated using the criteria described in the report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice are ranked according to the method described in this report (see Table 1). SPONSORS The development of this consensus guideline was supported by unrestricted educational grants from Berlex Canada Inc, Lilly Canada, Merck Frosst, Novartis, Novogen, Novo Nordisk, Proctor and Gamble, Schering Canada, and Wyeth Canada.

Osteoporosis in Menopause

OBJECTIVE To provide guidelines for the health care provider on the prevention, diagnosis, and clinical management of postmenopausal osteoporosis. OUTCOMES Strategies for identifying and evaluating high-risk individuals, the use of bone mineral density (BMD) and bone turnover markers in assessing diagnosis and response to management, and recommendations regarding nutrition, physical activity, and the selection of pharmacologic therapy to prevent and manage osteoporosis. EVIDENCE Published literature was retrieved through searches of PubMed and The Cochrane Library on August 30 and September 18, 2012, respectively. The strategy included the use of appropriate controlled vocabulary (e.g., oteoporosis, bone density, menopause) and key words (e.g., bone health, bone loss, BMD). Results were restricted to systematic reviews, practice guidelines, randomized and controlled clinical trials, and observational studies published in English or French. The search was limited to the publication years 2009 and following, and updates were incorporated into the guideline to March 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

SOGC CLINICAL PRACTICE GUIDELINEManaging Menopause

OBJECTIVE To provide updated guidelines for health care providers on the management of menopause in asymptomatic healthy women as well as in women presenting with vasomotor or urogenital symptoms and on considerations related to cardiovascular disease, breast cancer, urogynaecology, and sexuality. OUTCOMES Lifestyle interventions, prescription medications, and complementary and alternative therapies are presented according to their efficacy in the treatment of menopausal symptoms. Counselling and therapeutic strategies for sexuality concerns in the peri- and postmenopausal years are reviewed. Approaches to the identification and evaluation of women at high risk of osteoporosis, along with options for prevention and treatment, are presented in the companion osteoporosis guideline. EVIDENCE Published literature was retrieved through searches of PubMed and The Cochrane Library in August and September 2012 with the use of appropriate controlled vocabulary (e.g., hormone therapy, menopause, cardiovascular diseases, and sexual function) and key words (e.g., hormone therapy, perimenopause, heart disease, and sexuality). Results were restricted to clinical practice guidelines, systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Results were limited to publication dates of 2009 onwards and to material in English or French. Searches were updated on a regular basis and incorporated in the guideline until January 5, 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, national and international medical specialty societies, and clinical practice guideline collections.

Unknown intrauterine devices and infertility.

The 3 cases described illustrate instances within a 12-month span where an IUD in situ had been the cause of infertility, unknown to the women involved. In many centers, laparoscopy is performed as the primary investigation of tubal patency and normalcy, with hysterosalpingography (HSG) performed subsequently or not at all. HSG should be performed first, with laparoscopy and possible hysteroscopy carried out later as complementary procedures. Each case is reviewed briefly to determine how best to avoid failure to detect a retained IUD. The source of error in each case was the same. HSG was not performed or was not performed properly, with a preliminary plain x-ray film. In each instance the patient had been referred to a gynecologist and in case 1 to a regional tertiary referral center for infertility. There was no lack of availability of HSG, but there was not a systematic infertility investigation.

Civility in Debate

The Presidential campaign in the United States brought the political and social polarization of that country’s population into clear view, and by virtue of its position in the world we all paid attention—and tended to take sides ourselves. Since health professionals are, by nature and training, supportive and non-judgemental, and because in Canada we see first-hand the undeniable benefits of a universal system of care, most of my colleagues who expressed an opinion favoured the left-hand side. But not all did, and it led to some interesting discussions. Nevertheless, perhaps because the outcome of the campaign did not affect them directly, the protagonists remained friends. And that is a valuable outcome in civilized debate.

The Male Medical Student Problem

Amajor part of an undergraduate’s training in obstetrics and gynaecology is learning to conduct pelvic examinations under supervision. Most Canadian curricula provide initial training with the use of plastic or inert pelvic models, and the luckier undergraduates also receive instruction from professional teaching associates who allow the students to examine them and provide subjective feedback. 1 The students then graduate to performing pelvic examinations in clinical settings under supervision. Clinicians negotiate consent with patients to permit medical students to carry out pelvic examinations with “hands on” supervision. 2 Given that pelvic examinations performed by students are of necessity more time-consuming than those performed by the clinician alone, the problem for organizers of undergraduate education used to be persuading clinicians to accept medical students into their offices. Now it’s not so much trying to place medical students, but to place male medical students. Clinicians have consciously or unconsciously come to recognize that less negotiation for consent to involve a student will be needed if the student is female. The lone male medical student standing uncomfortably outside the examining room while his gynaecology mentor attends to the patient within is one of the saddest sights in medical education. In this issue, Jennifer Racz and colleagues report their findings from a survey of the attitudes of clinic patients and high-school students to having medical students of either gender involved in conducting breast or pelvic examinations. The observation that young women with minimal experience of undergoing these examinations were less accepting of having male students involved than were older women with more experience is perhaps what we might expect, but it is discouraging for educators and male students nonetheless. What is not known is whether the reluctance of younger women to have male students involved in their examinations can be modified at all. As Dr Racz and colleagues point out, the potential consequences for male students of this reluctance are that they gain less experience in performing intimate examinations and develop an aversion to pursuing careers that involve performing these examinations, particularly obstetrics and gynaecology. Carried to extremes, the potential consequences include the perceptions inside and outside the profession that these examinations should be performed only by female clinicians and that obstetrics and gynaecology is a specialty for female practitioners only. The pool of candidates for residency training in obstetrics and gynaecology is shallow enough already; shrinking it to female candidates only would make it a puddle rather than a pool.

Exercise and Reproduction

J Obstet Gynaecol Can 2013;35(7):593–594 T idea of women exercising to the elite level is relatively new, although from today’s perspective this may seem quaint. Some kinds of athletic activity were for many years deemed inappropriate for women, and exercise during pregnancy was frowned upon. Even distance running was considered inappropriate until comparatively recently; a 1500 metre race for women was not included in the Olympic Games until 1972, and the women’s marathon was not included until 1984. Imagine that.

Medical education 2.0.

J Obstet Gynaecol Can 2012;34(11):1019–1020 I usually not long after beginning clinical practice that we run into a problem for which we are not prepared. Human nature being what it is, such an encounter usually leads to our reflecting on our training, and how (as we start to heat up) we seemed to spend so much scheduled time on clinical problems that aren’t particularly important— despite what the objectives say. And we start to reflect on how much better (now we’re really starting to feel aggrieved) the program could have been designed, and what on earth was the Resident Education Committee thinking, anyway? It is clear that those people (now our blood pressure is rising) are out of touch, and a snippy email to the Program Director would be entirely appropriate.

A Word About Bioidenticals

http://dx.doi.org/10.1016/j.jogc.2016.04.092 After publication of the findings in the Women’s Health Initiative (WHI) combined estrogen-progestin trial, the public mood turned against the use of this pharmaceutical combination in postmenopausal women. Into the therapeutic void that followed leapt the protagonists who supported (and wished to market) compounded preparations of estrogens and progesterone. It was a once-in-ageneration opportunity. To assist in promoting the use of these preparations, their supporters coined the term “bioidentical.” It was a stroke of marketing genius because the word sounded both scientific and natural.

Thank You, and Good Night.

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