The mean income for ObGyns rose by 10% in 2015 over 2014 ($277,000 compared with $249,000), according to a recent report from Medscape.¹ This jump follows a gradual increase over the last few years ($243,000 in 2013; $242,000 in 2012; $220,000 in 2011).¹⁻³ The report included responses from 19,183 physicians across 26 specialties, 5% (nearly 1,000) of whom were ObGyns.¹

The highest earners among all physician specialties were orthopedists ($443,000), cardiologists, and dermatologists. The lowest earners were pediatricians ($204,000), endocrinologists, and family physicians. The highest ObGyn earners lived in the Southwest ($307,000), the North Central region, and the West.¹

Merritt Hawkins & Associates, a national physician search and consulting firm, recently evaluated the annual starting salaries and year-over-year increases of 3,342 of its physician and advanced practitioner recruiting assignments. They found that ObGyns had the second greatest increase in starting salaries among specialties, at 16%. They also found obstetrics and gynecology to be among the top 5 specialties most in demand.⁴

The gender picture
As in past years, male ObGyns reported higher earnings than their female counterparts: full-time male ObGyns earned $304,000 while full-time female ObGyns earned $256,000.¹

According to a report published in the British Medical Journal in June 2016, there are drastic differences between the incomes of white and black male and female physicians in the United States.⁵ White male physicians had an adjusted median annual income of $253,042 (95% confidence interval [CI], $248,670−$257,413), compared with $188,230 ($170,844−$205,616) for black male physicians, $163,234 (95% CI, $159,912−$166,557) for white female physicians, and $152,784 (95% CI, $137,927−$167,641) for black female physicians.

How does employment status factor in? Of the self-employed, men earn $310,000 while women earn $285,000. Men who are employed report earning $293,000, with women reporting $244,000.⁵ (This includes full-time workers but does not control for the number of hours worked.) When Medscape evaluated full- versus part-time work (<40 hours per week), results indicated that, among primary care and most other specialties, more female physicians (25%) are part-timers than males (12%).⁶ However, among ObGyns, 13% of women report part-time employment versus 16% of men.¹

Time with patients. Medscape reports that, among all physicians, 41% of men spent 17 minutes or more with their patients, compared with 49% of women. For office-based ObGyns, 31% of men and 39% of women spent 17 minutes or more with patients.¹

Can disparity in leadership positions explain gender-related salary discrepancy?
In 2015, 48% of all medical students were female.⁷ In residency, the ratio of men to women is similar: For 2013−2014, the Association of American Medical Colleges (AAMC) reported that 46% of all residents were female.⁸ For ObGyn residency, however, the AMA’s FREIDA Online specialty training search (detailing 2014 general program information) indicates that, of the 5,018 active residents and fellows in ObGyn, 81.4% are female.⁹

Although the ObGyn field is becoming female-dominated, leadership within the specialty remains male dominated, points out Laura E. Baecher-Lind, MD, MPH, Director of the Division of General Obstetrics & Gynecology at Tufts Medical Center, Boston, Massachusetts. Dr. Baecher-Lind authored a study in 2012 in which she explored whether the proportions of ObGyn leadership positions held by women reflect the proportion of women who entered the field at the same time as current leaders.¹⁰ She found that very few academic department chair positions in ObGyn are held by women, although that number is gradually increasing.¹⁰ In addition, her study results indicated that women should hold 71 of the total of 194 ObGyn leadership positions. In actuality, 41 of the leadership positions were held by women (21.1%, P<.001) when based on the proportion of women entering residency programs. When considering only leaders who graduated during the years in which residency matching data were available, she found that women should hold 28 of 74 leadership positions, but they actually held 20 (27.0%, P = .05).¹⁰

Could the salary discrepancy disappear if more women held leadership positions? OBG <scaps>Management</scaps> posed this question to Dr. Baecher-Lind. “I suspect that the gender pay gap would persist,” she said. “Studies indicate that women hold implicit gender bias as strongly as men. This bias leads to devaluing women’s skills and accomplishments compared with men’s and is a strong contributor to the leadership and pay gaps in this country and in our specialty. We need to be mindful of this implicit bias and work against it with policies such as salary transparency and salary audits to encourage parity.”¹¹

What are ObGyns’ greatest practice concerns?
The Medicus Firm reported in its 2016 Physician Practice Preference and Relocation Survey that the top 3 major practice concerns for practicing physicians were compensation, work-life balance, and work-related burnout and stress.¹² They found that physicians in general were slightly more satisfied with their 2015 income than their 2014 income, but less optimistic about the future. Only 29% projected that their 2016 income would increase over their 2015 earnings.

With ObGyn salaries on the up in 2015, less than half (46%) of ObGyns reported to Medscape that they feel fairly compensated; these physicians made $62,000 more than those who believed their pay was unfair.¹ Fifty-four percent of employed male ObGyns and 64% of employed female ObGyns reported feeling fairly compensated, compared with 43% and 32%, respectively, who were self-employed.

ObGyns indicated in the 2016 Medscape report that the prime causes of stress were bureaucratic tasks and spending too many hours at work. More than half (52%) of ObGyns spend 30 to 45 hours per week seeing patients, and 40% spend more time than that.¹ According to employment status, 56% of those who are self-employed and 58% of those who are employed spend 10 hours or more per week on administrative tasks.¹

Lucia DiVenere, MA, Officer, Government and Political Affairs, at the American Congress of Obstetricians and Gynecologists (ACOG) in Washington, DC, offers a brief look, with an in-depth focus to come in an upcoming issue, at the growing concern of burnout among physicians and how it can affect both ObGyns and their patients. She outlines ACOG’s efforts to help ObGyns maintain work-life balance in “ObGyn burnout: ACOG takes aim.”

ObGyn burnout: ACOG takes aim

Lucia DiVenere, MA

The good news: More women have access to coverage for health care than ever before--better insurance coverage for pregnancy, contraceptives, and well-woman care.

The bad news: America faces a shortage of ObGyns to provide that care, a shortage not likely to go away soon.

One of the imperatives of this dynamic is that we need to help every practicing ObGyn perform at his or her very best: your highest level of quality care, your best productivity, and your best ability to survive and thrive in an always changing and often challenging work environment.

This imperative is undermined when ObGyns are so stressed, overworked, overworried, and undersupported that you experience the very real effects of physician burnout.

Studies show that: 

 

• ObGyns experience high rates of burnout 
• rates of burnout are increasing over time
• women, the majority gender in obstetrics and gynecology, experience higher rates of burnout than their male counterparts. 

Between 2011 and 2014, rates of physician burnout increased from 45.5% to 54.4%.¹ Fifty-one percent of ObGyns reported experiencing burnout in 2015, with women reporting 55% compared to 46% for men.²

This insert is a quick look at this important issue, which can seriously erode an ObGyn's ability to provide high-quality care and continue enjoying practice. It can take a real toll on your personal health and well-being, too. In an upcoming issue of OBG Management, I will take a deeper dive, previewing the American College of Obstetricians and Gynecologists (ACOG) and American Medical Association resources to help you avoid burnout, plus highlighting ObGyns who provide insight and inspiration. I also will interview ACOG President Tom Gellhaus, MD, who is dedicating his presidency to providing you with opportunities to experience new and meaningful aspects of the ObGyn specialty. I will discuss ACOG's programs to help you combat burnout, as well as how you can:

 

• help underserved women around the globe through medical missions
• bring your leadership and passion for women's health to your state and national capitals
• explore your artistic side.

ObGyn burnout amounts to a public health challenge in women's health care. ACOG takes your well-being seriously, so that you can continue to ensure the well-being of women.

 

---

Lucia DiVenere, MA, is Officer, Government and Political Affairs, at the American Congress of Obstetricians and Gynecologists in Washington, DC.

Ms. DiVenere reports no financial relationships relevant to this article. .

 

---

References

 

1. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clinic Proceedings. 2015;90(12):1600-1613.
2. Peckham C. Medscape Lifestyle Report 2016: Bias and Burnout. Medscape website. http://www.medscape.com/features/slideshow/lifestyle/2016/public/overview. Published January 13, 2016. Accessed June 14, 2016.

Effects of the ACA on ObGyns
As of February 2016, 12.7 million Americans selected plans through the Health Insurance Marketplace of the Affordable Care Act (ACA).¹ Physicians often have no choice in whether or not they participate in Health Insurance Exchanges; however, in 2016, 24% of ObGyns said they plan to participate in exchanges, 25% do not, and the rest are unsure.¹

It is still unclear how the ACA affects physician income.¹ When ObGyns who participated in Health Insurance Exchanges in 2015 were asked whether their income was affected, approximately 60% reported no change, 30% reported a decrease, and 9% said it increased.¹

Medicus reported that physicians’ approval of the ACA has declined since last year. In their 2016 report, 71% of respondents gave the ACA a passing grade (A, B, C, or D), compared with 83% in 2015 and 77% in 2014. Fewer than 3% of 2016 respondents gave the ACA an “A.”¹²

Medscape reported that 36% of ObGyns have seen an increase in the number of patients due to the ACA.¹ A 2015 report from the Kaiser Family Foundation and The Commonwealth Fund assessing the experiences and attitudes of primary care providers after the first year of ACA coverage found no association with lower- and higher-quality care whether or not patient load had increased.¹³ Among those in the Medscape report who said that quality of care had worsened, 21% had a greater patient load; 18% reported no increase in patient load. Seventy-eight percent of physicians whose patient load increased said that quality had stayed the same or improved; 82% of those who experienced no increase in patient load reported that quality had stayed the same or improved.¹

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

The mean income for ObGyns rose by 10% in 2015 over 2014 ($277,000 compared with $249,000), according to a recent report from Medscape.¹ This jump follows a gradual increase over the last few years ($243,000 in 2013; $242,000 in 2012; $220,000 in 2011).¹⁻³ The report included responses from 19,183 physicians across 26 specialties, 5% (nearly 1,000) of whom were ObGyns.¹

The highest earners among all physician specialties were orthopedists ($443,000), cardiologists, and dermatologists. The lowest earners were pediatricians ($204,000), endocrinologists, and family physicians. The highest ObGyn earners lived in the Southwest ($307,000), the North Central region, and the West.¹

Merritt Hawkins & Associates, a national physician search and consulting firm, recently evaluated the annual starting salaries and year-over-year increases of 3,342 of its physician and advanced practitioner recruiting assignments. They found that ObGyns had the second greatest increase in starting salaries among specialties, at 16%. They also found obstetrics and gynecology to be among the top 5 specialties most in demand.⁴

The gender picture
As in past years, male ObGyns reported higher earnings than their female counterparts: full-time male ObGyns earned $304,000 while full-time female ObGyns earned $256,000.¹

According to a report published in the British Medical Journal in June 2016, there are drastic differences between the incomes of white and black male and female physicians in the United States.⁵ White male physicians had an adjusted median annual income of $253,042 (95% confidence interval [CI], $248,670−$257,413), compared with $188,230 ($170,844−$205,616) for black male physicians, $163,234 (95% CI, $159,912−$166,557) for white female physicians, and $152,784 (95% CI, $137,927−$167,641) for black female physicians.

How does employment status factor in? Of the self-employed, men earn $310,000 while women earn $285,000. Men who are employed report earning $293,000, with women reporting $244,000.⁵ (This includes full-time workers but does not control for the number of hours worked.) When Medscape evaluated full- versus part-time work (<40 hours per week), results indicated that, among primary care and most other specialties, more female physicians (25%) are part-timers than males (12%).⁶ However, among ObGyns, 13% of women report part-time employment versus 16% of men.¹

Time with patients. Medscape reports that, among all physicians, 41% of men spent 17 minutes or more with their patients, compared with 49% of women. For office-based ObGyns, 31% of men and 39% of women spent 17 minutes or more with patients.¹

Can disparity in leadership positions explain gender-related salary discrepancy?
In 2015, 48% of all medical students were female.⁷ In residency, the ratio of men to women is similar: For 2013−2014, the Association of American Medical Colleges (AAMC) reported that 46% of all residents were female.⁸ For ObGyn residency, however, the AMA’s FREIDA Online specialty training search (detailing 2014 general program information) indicates that, of the 5,018 active residents and fellows in ObGyn, 81.4% are female.⁹

Although the ObGyn field is becoming female-dominated, leadership within the specialty remains male dominated, points out Laura E. Baecher-Lind, MD, MPH, Director of the Division of General Obstetrics & Gynecology at Tufts Medical Center, Boston, Massachusetts. Dr. Baecher-Lind authored a study in 2012 in which she explored whether the proportions of ObGyn leadership positions held by women reflect the proportion of women who entered the field at the same time as current leaders.¹⁰ She found that very few academic department chair positions in ObGyn are held by women, although that number is gradually increasing.¹⁰ In addition, her study results indicated that women should hold 71 of the total of 194 ObGyn leadership positions. In actuality, 41 of the leadership positions were held by women (21.1%, P<.001) when based on the proportion of women entering residency programs. When considering only leaders who graduated during the years in which residency matching data were available, she found that women should hold 28 of 74 leadership positions, but they actually held 20 (27.0%, P = .05).¹⁰

Could the salary discrepancy disappear if more women held leadership positions? OBG <scaps>Management</scaps> posed this question to Dr. Baecher-Lind. “I suspect that the gender pay gap would persist,” she said. “Studies indicate that women hold implicit gender bias as strongly as men. This bias leads to devaluing women’s skills and accomplishments compared with men’s and is a strong contributor to the leadership and pay gaps in this country and in our specialty. We need to be mindful of this implicit bias and work against it with policies such as salary transparency and salary audits to encourage parity.”¹¹

What are ObGyns’ greatest practice concerns?
The Medicus Firm reported in its 2016 Physician Practice Preference and Relocation Survey that the top 3 major practice concerns for practicing physicians were compensation, work-life balance, and work-related burnout and stress.¹² They found that physicians in general were slightly more satisfied with their 2015 income than their 2014 income, but less optimistic about the future. Only 29% projected that their 2016 income would increase over their 2015 earnings.

With ObGyn salaries on the up in 2015, less than half (46%) of ObGyns reported to Medscape that they feel fairly compensated; these physicians made $62,000 more than those who believed their pay was unfair.¹ Fifty-four percent of employed male ObGyns and 64% of employed female ObGyns reported feeling fairly compensated, compared with 43% and 32%, respectively, who were self-employed.

ObGyns indicated in the 2016 Medscape report that the prime causes of stress were bureaucratic tasks and spending too many hours at work. More than half (52%) of ObGyns spend 30 to 45 hours per week seeing patients, and 40% spend more time than that.¹ According to employment status, 56% of those who are self-employed and 58% of those who are employed spend 10 hours or more per week on administrative tasks.¹

Lucia DiVenere, MA, Officer, Government and Political Affairs, at the American Congress of Obstetricians and Gynecologists (ACOG) in Washington, DC, offers a brief look, with an in-depth focus to come in an upcoming issue, at the growing concern of burnout among physicians and how it can affect both ObGyns and their patients. She outlines ACOG’s efforts to help ObGyns maintain work-life balance in “ObGyn burnout: ACOG takes aim.”

ObGyn burnout: ACOG takes aim

Lucia DiVenere, MA

The good news: More women have access to coverage for health care than ever before--better insurance coverage for pregnancy, contraceptives, and well-woman care.

The bad news: America faces a shortage of ObGyns to provide that care, a shortage not likely to go away soon.

One of the imperatives of this dynamic is that we need to help every practicing ObGyn perform at his or her very best: your highest level of quality care, your best productivity, and your best ability to survive and thrive in an always changing and often challenging work environment.

This imperative is undermined when ObGyns are so stressed, overworked, overworried, and undersupported that you experience the very real effects of physician burnout.

Studies show that: 

 

• ObGyns experience high rates of burnout 
• rates of burnout are increasing over time
• women, the majority gender in obstetrics and gynecology, experience higher rates of burnout than their male counterparts. 

Between 2011 and 2014, rates of physician burnout increased from 45.5% to 54.4%.¹ Fifty-one percent of ObGyns reported experiencing burnout in 2015, with women reporting 55% compared to 46% for men.²

This insert is a quick look at this important issue, which can seriously erode an ObGyn's ability to provide high-quality care and continue enjoying practice. It can take a real toll on your personal health and well-being, too. In an upcoming issue of OBG Management, I will take a deeper dive, previewing the American College of Obstetricians and Gynecologists (ACOG) and American Medical Association resources to help you avoid burnout, plus highlighting ObGyns who provide insight and inspiration. I also will interview ACOG President Tom Gellhaus, MD, who is dedicating his presidency to providing you with opportunities to experience new and meaningful aspects of the ObGyn specialty. I will discuss ACOG's programs to help you combat burnout, as well as how you can:

 

• help underserved women around the globe through medical missions
• bring your leadership and passion for women's health to your state and national capitals
• explore your artistic side.

ObGyn burnout amounts to a public health challenge in women's health care. ACOG takes your well-being seriously, so that you can continue to ensure the well-being of women.

 

---

Lucia DiVenere, MA, is Officer, Government and Political Affairs, at the American Congress of Obstetricians and Gynecologists in Washington, DC.

Ms. DiVenere reports no financial relationships relevant to this article. .

 

---

References

 

1. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clinic Proceedings. 2015;90(12):1600-1613.
2. Peckham C. Medscape Lifestyle Report 2016: Bias and Burnout. Medscape website. http://www.medscape.com/features/slideshow/lifestyle/2016/public/overview. Published January 13, 2016. Accessed June 14, 2016.

Effects of the ACA on ObGyns
As of February 2016, 12.7 million Americans selected plans through the Health Insurance Marketplace of the Affordable Care Act (ACA).¹ Physicians often have no choice in whether or not they participate in Health Insurance Exchanges; however, in 2016, 24% of ObGyns said they plan to participate in exchanges, 25% do not, and the rest are unsure.¹

It is still unclear how the ACA affects physician income.¹ When ObGyns who participated in Health Insurance Exchanges in 2015 were asked whether their income was affected, approximately 60% reported no change, 30% reported a decrease, and 9% said it increased.¹

Medicus reported that physicians’ approval of the ACA has declined since last year. In their 2016 report, 71% of respondents gave the ACA a passing grade (A, B, C, or D), compared with 83% in 2015 and 77% in 2014. Fewer than 3% of 2016 respondents gave the ACA an “A.”¹²

Medscape reported that 36% of ObGyns have seen an increase in the number of patients due to the ACA.¹ A 2015 report from the Kaiser Family Foundation and The Commonwealth Fund assessing the experiences and attitudes of primary care providers after the first year of ACA coverage found no association with lower- and higher-quality care whether or not patient load had increased.¹³ Among those in the Medscape report who said that quality of care had worsened, 21% had a greater patient load; 18% reported no increase in patient load. Seventy-eight percent of physicians whose patient load increased said that quality had stayed the same or improved; 82% of those who experienced no increase in patient load reported that quality had stayed the same or improved.¹

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

The mean income for ObGyns rose by 10% in 2015 over 2014 ($277,000 compared with $249,000), according to a recent report from Medscape.¹ This jump follows a gradual increase over the last few years ($243,000 in 2013; $242,000 in 2012; $220,000 in 2011).¹⁻³ The report included responses from 19,183 physicians across 26 specialties, 5% (nearly 1,000) of whom were ObGyns.¹

The highest earners among all physician specialties were orthopedists ($443,000), cardiologists, and dermatologists. The lowest earners were pediatricians ($204,000), endocrinologists, and family physicians. The highest ObGyn earners lived in the Southwest ($307,000), the North Central region, and the West.¹

Merritt Hawkins & Associates, a national physician search and consulting firm, recently evaluated the annual starting salaries and year-over-year increases of 3,342 of its physician and advanced practitioner recruiting assignments. They found that ObGyns had the second greatest increase in starting salaries among specialties, at 16%. They also found obstetrics and gynecology to be among the top 5 specialties most in demand.⁴

The gender picture
As in past years, male ObGyns reported higher earnings than their female counterparts: full-time male ObGyns earned $304,000 while full-time female ObGyns earned $256,000.¹

According to a report published in the British Medical Journal in June 2016, there are drastic differences between the incomes of white and black male and female physicians in the United States.⁵ White male physicians had an adjusted median annual income of $253,042 (95% confidence interval [CI], $248,670−$257,413), compared with $188,230 ($170,844−$205,616) for black male physicians, $163,234 (95% CI, $159,912−$166,557) for white female physicians, and $152,784 (95% CI, $137,927−$167,641) for black female physicians.

How does employment status factor in? Of the self-employed, men earn $310,000 while women earn $285,000. Men who are employed report earning $293,000, with women reporting $244,000.⁵ (This includes full-time workers but does not control for the number of hours worked.) When Medscape evaluated full- versus part-time work (<40 hours per week), results indicated that, among primary care and most other specialties, more female physicians (25%) are part-timers than males (12%).⁶ However, among ObGyns, 13% of women report part-time employment versus 16% of men.¹

Time with patients. Medscape reports that, among all physicians, 41% of men spent 17 minutes or more with their patients, compared with 49% of women. For office-based ObGyns, 31% of men and 39% of women spent 17 minutes or more with patients.¹

Can disparity in leadership positions explain gender-related salary discrepancy?
In 2015, 48% of all medical students were female.⁷ In residency, the ratio of men to women is similar: For 2013−2014, the Association of American Medical Colleges (AAMC) reported that 46% of all residents were female.⁸ For ObGyn residency, however, the AMA’s FREIDA Online specialty training search (detailing 2014 general program information) indicates that, of the 5,018 active residents and fellows in ObGyn, 81.4% are female.⁹

Although the ObGyn field is becoming female-dominated, leadership within the specialty remains male dominated, points out Laura E. Baecher-Lind, MD, MPH, Director of the Division of General Obstetrics & Gynecology at Tufts Medical Center, Boston, Massachusetts. Dr. Baecher-Lind authored a study in 2012 in which she explored whether the proportions of ObGyn leadership positions held by women reflect the proportion of women who entered the field at the same time as current leaders.¹⁰ She found that very few academic department chair positions in ObGyn are held by women, although that number is gradually increasing.¹⁰ In addition, her study results indicated that women should hold 71 of the total of 194 ObGyn leadership positions. In actuality, 41 of the leadership positions were held by women (21.1%, P<.001) when based on the proportion of women entering residency programs. When considering only leaders who graduated during the years in which residency matching data were available, she found that women should hold 28 of 74 leadership positions, but they actually held 20 (27.0%, P = .05).¹⁰

Could the salary discrepancy disappear if more women held leadership positions? OBG <scaps>Management</scaps> posed this question to Dr. Baecher-Lind. “I suspect that the gender pay gap would persist,” she said. “Studies indicate that women hold implicit gender bias as strongly as men. This bias leads to devaluing women’s skills and accomplishments compared with men’s and is a strong contributor to the leadership and pay gaps in this country and in our specialty. We need to be mindful of this implicit bias and work against it with policies such as salary transparency and salary audits to encourage parity.”¹¹

What are ObGyns’ greatest practice concerns?
The Medicus Firm reported in its 2016 Physician Practice Preference and Relocation Survey that the top 3 major practice concerns for practicing physicians were compensation, work-life balance, and work-related burnout and stress.¹² They found that physicians in general were slightly more satisfied with their 2015 income than their 2014 income, but less optimistic about the future. Only 29% projected that their 2016 income would increase over their 2015 earnings.

With ObGyn salaries on the up in 2015, less than half (46%) of ObGyns reported to Medscape that they feel fairly compensated; these physicians made $62,000 more than those who believed their pay was unfair.¹ Fifty-four percent of employed male ObGyns and 64% of employed female ObGyns reported feeling fairly compensated, compared with 43% and 32%, respectively, who were self-employed.

ObGyns indicated in the 2016 Medscape report that the prime causes of stress were bureaucratic tasks and spending too many hours at work. More than half (52%) of ObGyns spend 30 to 45 hours per week seeing patients, and 40% spend more time than that.¹ According to employment status, 56% of those who are self-employed and 58% of those who are employed spend 10 hours or more per week on administrative tasks.¹

Lucia DiVenere, MA, Officer, Government and Political Affairs, at the American Congress of Obstetricians and Gynecologists (ACOG) in Washington, DC, offers a brief look, with an in-depth focus to come in an upcoming issue, at the growing concern of burnout among physicians and how it can affect both ObGyns and their patients. She outlines ACOG’s efforts to help ObGyns maintain work-life balance in “ObGyn burnout: ACOG takes aim.”

ObGyn burnout: ACOG takes aim

Lucia DiVenere, MA

The good news: More women have access to coverage for health care than ever before--better insurance coverage for pregnancy, contraceptives, and well-woman care.

The bad news: America faces a shortage of ObGyns to provide that care, a shortage not likely to go away soon.

One of the imperatives of this dynamic is that we need to help every practicing ObGyn perform at his or her very best: your highest level of quality care, your best productivity, and your best ability to survive and thrive in an always changing and often challenging work environment.

This imperative is undermined when ObGyns are so stressed, overworked, overworried, and undersupported that you experience the very real effects of physician burnout.

Studies show that: 

 

• ObGyns experience high rates of burnout 
• rates of burnout are increasing over time
• women, the majority gender in obstetrics and gynecology, experience higher rates of burnout than their male counterparts. 

Between 2011 and 2014, rates of physician burnout increased from 45.5% to 54.4%.¹ Fifty-one percent of ObGyns reported experiencing burnout in 2015, with women reporting 55% compared to 46% for men.²

This insert is a quick look at this important issue, which can seriously erode an ObGyn's ability to provide high-quality care and continue enjoying practice. It can take a real toll on your personal health and well-being, too. In an upcoming issue of OBG Management, I will take a deeper dive, previewing the American College of Obstetricians and Gynecologists (ACOG) and American Medical Association resources to help you avoid burnout, plus highlighting ObGyns who provide insight and inspiration. I also will interview ACOG President Tom Gellhaus, MD, who is dedicating his presidency to providing you with opportunities to experience new and meaningful aspects of the ObGyn specialty. I will discuss ACOG's programs to help you combat burnout, as well as how you can:

 

• help underserved women around the globe through medical missions
• bring your leadership and passion for women's health to your state and national capitals
• explore your artistic side.

ObGyn burnout amounts to a public health challenge in women's health care. ACOG takes your well-being seriously, so that you can continue to ensure the well-being of women.

 

---

Lucia DiVenere, MA, is Officer, Government and Political Affairs, at the American Congress of Obstetricians and Gynecologists in Washington, DC.

Ms. DiVenere reports no financial relationships relevant to this article. .

 

---

References

 

1. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clinic Proceedings. 2015;90(12):1600-1613.
2. Peckham C. Medscape Lifestyle Report 2016: Bias and Burnout. Medscape website. http://www.medscape.com/features/slideshow/lifestyle/2016/public/overview. Published January 13, 2016. Accessed June 14, 2016.

Effects of the ACA on ObGyns
As of February 2016, 12.7 million Americans selected plans through the Health Insurance Marketplace of the Affordable Care Act (ACA).¹ Physicians often have no choice in whether or not they participate in Health Insurance Exchanges; however, in 2016, 24% of ObGyns said they plan to participate in exchanges, 25% do not, and the rest are unsure.¹

It is still unclear how the ACA affects physician income.¹ When ObGyns who participated in Health Insurance Exchanges in 2015 were asked whether their income was affected, approximately 60% reported no change, 30% reported a decrease, and 9% said it increased.¹

Medicus reported that physicians’ approval of the ACA has declined since last year. In their 2016 report, 71% of respondents gave the ACA a passing grade (A, B, C, or D), compared with 83% in 2015 and 77% in 2014. Fewer than 3% of 2016 respondents gave the ACA an “A.”¹²

Medscape reported that 36% of ObGyns have seen an increase in the number of patients due to the ACA.¹ A 2015 report from the Kaiser Family Foundation and The Commonwealth Fund assessing the experiences and attitudes of primary care providers after the first year of ACA coverage found no association with lower- and higher-quality care whether or not patient load had increased.¹³ Among those in the Medscape report who said that quality of care had worsened, 21% had a greater patient load; 18% reported no increase in patient load. Seventy-eight percent of physicians whose patient load increased said that quality had stayed the same or improved; 82% of those who experienced no increase in patient load reported that quality had stayed the same or improved.¹

Share your thoughts! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

Failure to convert to laparotomy: $6.25M settlement

A 67-year-old woman with urinary incontinence underwent robot-assisted laparoscopic prolapse surgery and hysterectomy. Complications arose, including an injury to the transverse colon. Postoperatively, the patient developed sepsis and had multiple surgeries. At the time of trial, she used a colostomy bag and had a malabsorption syndrome that required frequent intravenous treatment for dehydration.

Patient's claim:

The gynecologist deviated from the standard of care by failing to convert from a laparoscopic procedure to an open procedure when complications developed.

Defendants' defense:

The procedure was properly performed.

Verdict:

A $6.25 million New Jersey settlement was reached, paid jointly by the gynecologist and the medical center.

Circumcision requires revision

A day after birth, a baby underwent circumcision performed by the mother’s ObGyn. Revision surgery was performed 2.5 years later. When the boy was age 7 years, urethral stricture developed and was treated.

Parents' claim:

Circumcision was improperly performed. Once the child was able to talk, he said that his penis constantly hurt. Pain was only relieved by revision surgery.

Physician's defense:

There was no negligence. Redundant foreskin is often left following a circumcision.

Verdict:

A Michigan defense verdict was returned.

Mother with CP has child with CP
A pregnant woman with cerebral palsy (CP) reported a prior preterm delivery at 24 weeks’ gestation to a high-risk prenatal clinic. At that time, she was offered synthetic progesterone (170HP) injections, but she declined because of the cost. She declined 170HP several times. Nine weeks after her initial visit, she declined 170HP despite ultrasonography (US) showing a shortened cervical length (25 mm) for the gestational age. In 2 weeks, when the cervical length measured 9 mm, she was hospitalized to rule out preterm labor but, before tests began, she left the hospital. Five days later, when her cervical length was 11 mm, she received the first 170HP injection. In the next month she received 4 injections, but she failed to show for the fifth injection and US. The next day, she went to the hospital with cramping. She was given steroids and medication to stop labor. US results indicated that the baby was in breech position. The mother consented to cesarean delivery, but the baby was born vaginally an hour later. The child has mild brain damage, CP, developmental delays, and learning disabilities.

Parents' claim: The mother should have been offered vaginal progesterone, which is cheaper. Given the high risk of preterm birth, steroids administered earlier would have improved fetal development. Cesarean delivery should have been performed.

Defendants' defense: Vaginal progesterone was not available at the time. Starting steroids earlier would not have improved fetal outcome. A cesarean delivery was not possible because the baby was in the birth canal.

Verdict: A $3,500,000 Michigan settlement was reached.

Fallopian tubes grow back, pregnancy

A couple decided they did not want more children and sought counseling from the woman’s ObGyn, who recommended laparoscopic tubal ligation. Several months after surgery, the patient became pregnant and gave birth to a son.

Parents' claim:

The additional child placed an economic hardship on the family, now raising 4 children. The youngest child has language delays and learning disabilities.

Physician's defense:

Regrowth of the fallopian tubes resulting in unwanted pregnancy is a known complication of tubal ligation.

Verdict:

A $397,000 Maryland verdict was returned, including funds for the cost of raising the fourth child and to cope with the child’s special needs.

Challenges in managing labor

At 37 weeks' gestation, a woman was hospitalized in labor. At 1:15 pm, she was dilated 3 cm. At 1:30 pm, she was dilated 4−5 cm with increasing contractions and a reassuring fetal heart rate (FHR). The ObGyn covering for the mother’s ObGyn ordered oxytocin augmentation, which started at 2:45 pm. Shortly thereafter, contractions became more frequent and uterine tachysystole was observed. At 4:12 pm, FHR showed multiple deep decelerations with slow recovery. The baseline dropped to a 90-bpm range and remained that way for 17 minutes. At that point, the ObGyn stopped oxytocin and administered terbutaline; the FHR returned to baseline.

After vaginal delivery, the baby’s Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. Two days later, the baby had seizures and was transferred to the neonatal intensive care unit. An electroencephalogram confirmed seizure activity. Initial imaging results were normal. However, magnetic resonance imaging performed a week after delivery showed bilateral brain damage. The child has spastic displegia, is unable to ambulate, and is blind.

Parents' claim: A suit was filed against the hospital and both ObGyns. The hospital settled before trial. The case was discontinued against the primary ObGyn. The covering ObGyn allegedly made 4 departures from accepted medical practice that caused the child’s injury: ordering and administering oxytocin, failing to closely monitor the FHR, failing to timely administer terbutaline, and failing to timely respond to and correct tachysystole.

Physician's defense: The child’s injury occurred before or after labor. The pregnancy was complicated by multiple kidney infections. A week before delivery, US revealed a blood-flow abnormality. An intranatal hypoxic event did not cause the injury, proven by the fact that, after terbutaline was administered, the FHR promptly normalized.

Verdict: A $3 million New York settlement was reached with the hospital. A $134 million verdict was returned against the covering ObGyn.

Brachial plexus injury during delivery
At 37 weeks' gestation, a mother was admitted to the hospital for induction of labor. Increasing doses of oxytocin were administered. Near midnight, FHR monitoring indicated fetal distress. The ObGyn was called and he ordered cesarean delivery. Once he arrived and examined the mother, he found no fetal concerns and decided to proceed with the original birth plan. At 3:30 am, the patient was fully dilated and in active labor. The ObGyn used a vacuum extractor. Upon delivery of the baby’s head, the ObGyn encountered shoulder dystocia and called for assistance. The child was born with a near-total brachial plexus injury: avulsions of all 5 brachial plexus nerves with trauma to the cervical nerve roots at C5−C8 and T1. The child has undergone multiple nerve grafts and orthopedic operations.

Parents' claim: Fetal distress should have prompted the ObGyn to perform cesarean delivery. There was no reason to use vacuum extraction. Based on the severity of the outcome, the ObGyn must have applied excessive force and inappropriate traction during delivery maneuvers.

Physician's defense: The standard of care did not require a cesarean delivery. The vacuum extractor did not cause shoulder dystocia. The ObGyn did not apply excessive force or traction to complete the delivery. The extent of the outcome was partially due to a fetal anomaly and hypotonia.

Verdict: An Illinois defense verdict was returned.

HPV-positive pap tests results never reported
A single mother of 4 children underwent Papanicolaou (Pap) tests in 2004, 2005, and 2007 at a federally funded clinic. Each time, she tested positive for oncogenic human papillomaviruses. In 2011, the patient died of cervical cancer.

Estate's claim: The patient was never notified that the results of the 3 Pap tests were abnormal because all correspondence was sent to an outdated address although she had been treated at the same clinic for other issues during that period of time. Cervical dysplasia identified in 2004 progressed to cancer and metastasized, leading to her death 7 years later.

Defendants' defense: The case was settled during trial.

Verdict: A $4,950,000 Illinois settlement was reached.

Failure to convert to laparotomy: $6.25M settlement

A 67-year-old woman with urinary incontinence underwent robot-assisted laparoscopic prolapse surgery and hysterectomy. Complications arose, including an injury to the transverse colon. Postoperatively, the patient developed sepsis and had multiple surgeries. At the time of trial, she used a colostomy bag and had a malabsorption syndrome that required frequent intravenous treatment for dehydration.

Patient's claim:

The gynecologist deviated from the standard of care by failing to convert from a laparoscopic procedure to an open procedure when complications developed.

Defendants' defense:

The procedure was properly performed.

Verdict:

A $6.25 million New Jersey settlement was reached, paid jointly by the gynecologist and the medical center.

Circumcision requires revision

A day after birth, a baby underwent circumcision performed by the mother’s ObGyn. Revision surgery was performed 2.5 years later. When the boy was age 7 years, urethral stricture developed and was treated.

Parents' claim:

Circumcision was improperly performed. Once the child was able to talk, he said that his penis constantly hurt. Pain was only relieved by revision surgery.

Physician's defense:

There was no negligence. Redundant foreskin is often left following a circumcision.

Verdict:

A Michigan defense verdict was returned.

Mother with CP has child with CP
A pregnant woman with cerebral palsy (CP) reported a prior preterm delivery at 24 weeks’ gestation to a high-risk prenatal clinic. At that time, she was offered synthetic progesterone (170HP) injections, but she declined because of the cost. She declined 170HP several times. Nine weeks after her initial visit, she declined 170HP despite ultrasonography (US) showing a shortened cervical length (25 mm) for the gestational age. In 2 weeks, when the cervical length measured 9 mm, she was hospitalized to rule out preterm labor but, before tests began, she left the hospital. Five days later, when her cervical length was 11 mm, she received the first 170HP injection. In the next month she received 4 injections, but she failed to show for the fifth injection and US. The next day, she went to the hospital with cramping. She was given steroids and medication to stop labor. US results indicated that the baby was in breech position. The mother consented to cesarean delivery, but the baby was born vaginally an hour later. The child has mild brain damage, CP, developmental delays, and learning disabilities.

Parents' claim: The mother should have been offered vaginal progesterone, which is cheaper. Given the high risk of preterm birth, steroids administered earlier would have improved fetal development. Cesarean delivery should have been performed.

Defendants' defense: Vaginal progesterone was not available at the time. Starting steroids earlier would not have improved fetal outcome. A cesarean delivery was not possible because the baby was in the birth canal.

Verdict: A $3,500,000 Michigan settlement was reached.

Fallopian tubes grow back, pregnancy

A couple decided they did not want more children and sought counseling from the woman’s ObGyn, who recommended laparoscopic tubal ligation. Several months after surgery, the patient became pregnant and gave birth to a son.

Parents' claim:

The additional child placed an economic hardship on the family, now raising 4 children. The youngest child has language delays and learning disabilities.

Physician's defense:

Regrowth of the fallopian tubes resulting in unwanted pregnancy is a known complication of tubal ligation.

Verdict:

A $397,000 Maryland verdict was returned, including funds for the cost of raising the fourth child and to cope with the child’s special needs.

Challenges in managing labor

At 37 weeks' gestation, a woman was hospitalized in labor. At 1:15 pm, she was dilated 3 cm. At 1:30 pm, she was dilated 4−5 cm with increasing contractions and a reassuring fetal heart rate (FHR). The ObGyn covering for the mother’s ObGyn ordered oxytocin augmentation, which started at 2:45 pm. Shortly thereafter, contractions became more frequent and uterine tachysystole was observed. At 4:12 pm, FHR showed multiple deep decelerations with slow recovery. The baseline dropped to a 90-bpm range and remained that way for 17 minutes. At that point, the ObGyn stopped oxytocin and administered terbutaline; the FHR returned to baseline.

After vaginal delivery, the baby’s Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. Two days later, the baby had seizures and was transferred to the neonatal intensive care unit. An electroencephalogram confirmed seizure activity. Initial imaging results were normal. However, magnetic resonance imaging performed a week after delivery showed bilateral brain damage. The child has spastic displegia, is unable to ambulate, and is blind.

Parents' claim: A suit was filed against the hospital and both ObGyns. The hospital settled before trial. The case was discontinued against the primary ObGyn. The covering ObGyn allegedly made 4 departures from accepted medical practice that caused the child’s injury: ordering and administering oxytocin, failing to closely monitor the FHR, failing to timely administer terbutaline, and failing to timely respond to and correct tachysystole.

Physician's defense: The child’s injury occurred before or after labor. The pregnancy was complicated by multiple kidney infections. A week before delivery, US revealed a blood-flow abnormality. An intranatal hypoxic event did not cause the injury, proven by the fact that, after terbutaline was administered, the FHR promptly normalized.

Verdict: A $3 million New York settlement was reached with the hospital. A $134 million verdict was returned against the covering ObGyn.

Brachial plexus injury during delivery
At 37 weeks' gestation, a mother was admitted to the hospital for induction of labor. Increasing doses of oxytocin were administered. Near midnight, FHR monitoring indicated fetal distress. The ObGyn was called and he ordered cesarean delivery. Once he arrived and examined the mother, he found no fetal concerns and decided to proceed with the original birth plan. At 3:30 am, the patient was fully dilated and in active labor. The ObGyn used a vacuum extractor. Upon delivery of the baby’s head, the ObGyn encountered shoulder dystocia and called for assistance. The child was born with a near-total brachial plexus injury: avulsions of all 5 brachial plexus nerves with trauma to the cervical nerve roots at C5−C8 and T1. The child has undergone multiple nerve grafts and orthopedic operations.

Parents' claim: Fetal distress should have prompted the ObGyn to perform cesarean delivery. There was no reason to use vacuum extraction. Based on the severity of the outcome, the ObGyn must have applied excessive force and inappropriate traction during delivery maneuvers.

Physician's defense: The standard of care did not require a cesarean delivery. The vacuum extractor did not cause shoulder dystocia. The ObGyn did not apply excessive force or traction to complete the delivery. The extent of the outcome was partially due to a fetal anomaly and hypotonia.

Verdict: An Illinois defense verdict was returned.

HPV-positive pap tests results never reported
A single mother of 4 children underwent Papanicolaou (Pap) tests in 2004, 2005, and 2007 at a federally funded clinic. Each time, she tested positive for oncogenic human papillomaviruses. In 2011, the patient died of cervical cancer.

Estate's claim: The patient was never notified that the results of the 3 Pap tests were abnormal because all correspondence was sent to an outdated address although she had been treated at the same clinic for other issues during that period of time. Cervical dysplasia identified in 2004 progressed to cancer and metastasized, leading to her death 7 years later.

Defendants' defense: The case was settled during trial.

Verdict: A $4,950,000 Illinois settlement was reached.

Failure to convert to laparotomy: $6.25M settlement

A 67-year-old woman with urinary incontinence underwent robot-assisted laparoscopic prolapse surgery and hysterectomy. Complications arose, including an injury to the transverse colon. Postoperatively, the patient developed sepsis and had multiple surgeries. At the time of trial, she used a colostomy bag and had a malabsorption syndrome that required frequent intravenous treatment for dehydration.

Patient's claim:

The gynecologist deviated from the standard of care by failing to convert from a laparoscopic procedure to an open procedure when complications developed.

Defendants' defense:

The procedure was properly performed.

Verdict:

A $6.25 million New Jersey settlement was reached, paid jointly by the gynecologist and the medical center.

Circumcision requires revision

A day after birth, a baby underwent circumcision performed by the mother’s ObGyn. Revision surgery was performed 2.5 years later. When the boy was age 7 years, urethral stricture developed and was treated.

Parents' claim:

Circumcision was improperly performed. Once the child was able to talk, he said that his penis constantly hurt. Pain was only relieved by revision surgery.

Physician's defense:

There was no negligence. Redundant foreskin is often left following a circumcision.

Verdict:

A Michigan defense verdict was returned.

Mother with CP has child with CP
A pregnant woman with cerebral palsy (CP) reported a prior preterm delivery at 24 weeks’ gestation to a high-risk prenatal clinic. At that time, she was offered synthetic progesterone (170HP) injections, but she declined because of the cost. She declined 170HP several times. Nine weeks after her initial visit, she declined 170HP despite ultrasonography (US) showing a shortened cervical length (25 mm) for the gestational age. In 2 weeks, when the cervical length measured 9 mm, she was hospitalized to rule out preterm labor but, before tests began, she left the hospital. Five days later, when her cervical length was 11 mm, she received the first 170HP injection. In the next month she received 4 injections, but she failed to show for the fifth injection and US. The next day, she went to the hospital with cramping. She was given steroids and medication to stop labor. US results indicated that the baby was in breech position. The mother consented to cesarean delivery, but the baby was born vaginally an hour later. The child has mild brain damage, CP, developmental delays, and learning disabilities.

Parents' claim: The mother should have been offered vaginal progesterone, which is cheaper. Given the high risk of preterm birth, steroids administered earlier would have improved fetal development. Cesarean delivery should have been performed.

Defendants' defense: Vaginal progesterone was not available at the time. Starting steroids earlier would not have improved fetal outcome. A cesarean delivery was not possible because the baby was in the birth canal.

Verdict: A $3,500,000 Michigan settlement was reached.

Fallopian tubes grow back, pregnancy

A couple decided they did not want more children and sought counseling from the woman’s ObGyn, who recommended laparoscopic tubal ligation. Several months after surgery, the patient became pregnant and gave birth to a son.

Parents' claim:

The additional child placed an economic hardship on the family, now raising 4 children. The youngest child has language delays and learning disabilities.

Physician's defense:

Regrowth of the fallopian tubes resulting in unwanted pregnancy is a known complication of tubal ligation.

Verdict:

A $397,000 Maryland verdict was returned, including funds for the cost of raising the fourth child and to cope with the child’s special needs.

Challenges in managing labor

At 37 weeks' gestation, a woman was hospitalized in labor. At 1:15 pm, she was dilated 3 cm. At 1:30 pm, she was dilated 4−5 cm with increasing contractions and a reassuring fetal heart rate (FHR). The ObGyn covering for the mother’s ObGyn ordered oxytocin augmentation, which started at 2:45 pm. Shortly thereafter, contractions became more frequent and uterine tachysystole was observed. At 4:12 pm, FHR showed multiple deep decelerations with slow recovery. The baseline dropped to a 90-bpm range and remained that way for 17 minutes. At that point, the ObGyn stopped oxytocin and administered terbutaline; the FHR returned to baseline.

After vaginal delivery, the baby’s Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. Two days later, the baby had seizures and was transferred to the neonatal intensive care unit. An electroencephalogram confirmed seizure activity. Initial imaging results were normal. However, magnetic resonance imaging performed a week after delivery showed bilateral brain damage. The child has spastic displegia, is unable to ambulate, and is blind.

Parents' claim: A suit was filed against the hospital and both ObGyns. The hospital settled before trial. The case was discontinued against the primary ObGyn. The covering ObGyn allegedly made 4 departures from accepted medical practice that caused the child’s injury: ordering and administering oxytocin, failing to closely monitor the FHR, failing to timely administer terbutaline, and failing to timely respond to and correct tachysystole.

Physician's defense: The child’s injury occurred before or after labor. The pregnancy was complicated by multiple kidney infections. A week before delivery, US revealed a blood-flow abnormality. An intranatal hypoxic event did not cause the injury, proven by the fact that, after terbutaline was administered, the FHR promptly normalized.

Verdict: A $3 million New York settlement was reached with the hospital. A $134 million verdict was returned against the covering ObGyn.

Brachial plexus injury during delivery
At 37 weeks' gestation, a mother was admitted to the hospital for induction of labor. Increasing doses of oxytocin were administered. Near midnight, FHR monitoring indicated fetal distress. The ObGyn was called and he ordered cesarean delivery. Once he arrived and examined the mother, he found no fetal concerns and decided to proceed with the original birth plan. At 3:30 am, the patient was fully dilated and in active labor. The ObGyn used a vacuum extractor. Upon delivery of the baby’s head, the ObGyn encountered shoulder dystocia and called for assistance. The child was born with a near-total brachial plexus injury: avulsions of all 5 brachial plexus nerves with trauma to the cervical nerve roots at C5−C8 and T1. The child has undergone multiple nerve grafts and orthopedic operations.

Parents' claim: Fetal distress should have prompted the ObGyn to perform cesarean delivery. There was no reason to use vacuum extraction. Based on the severity of the outcome, the ObGyn must have applied excessive force and inappropriate traction during delivery maneuvers.

Physician's defense: The standard of care did not require a cesarean delivery. The vacuum extractor did not cause shoulder dystocia. The ObGyn did not apply excessive force or traction to complete the delivery. The extent of the outcome was partially due to a fetal anomaly and hypotonia.

Verdict: An Illinois defense verdict was returned.

HPV-positive pap tests results never reported
A single mother of 4 children underwent Papanicolaou (Pap) tests in 2004, 2005, and 2007 at a federally funded clinic. Each time, she tested positive for oncogenic human papillomaviruses. In 2011, the patient died of cervical cancer.

Estate's claim: The patient was never notified that the results of the 3 Pap tests were abnormal because all correspondence was sent to an outdated address although she had been treated at the same clinic for other issues during that period of time. Cervical dysplasia identified in 2004 progressed to cancer and metastasized, leading to her death 7 years later.

Defendants' defense: The case was settled during trial.

Verdict: A $4,950,000 Illinois settlement was reached.

“10 TIPS FOR OVERCOMING COMMON CHALLENGES OF INTRAPARTUM FETAL MONITORING”
M. SEAN ESPLIN, MD, AND ALEXANDRA G. ELLER, MD, MPH (MAY 2016)

Determining fetal demise
I appreciate and thank Drs. Esplin and Eller for their discussion of fetal monitoring pitfalls. I agree with their sentiment that this is an inexact science. After 40 years of looking at these strips, I am convinced there must be a better way. I look forward to some innovative approach to better determine fetal well-being in labor. This article raises a question I have asked, and sought the answer to, for years.

On occasion, I have diagnosed intrauterine fetal demise by detecting the maternal heart rate with an internal fetal scalp electrode. On one particular occasion, somewhere between the time of admission, spontaneous rupture of membranes, and applying the fetal scalp electrode, the fetus died. This case was similar to the one you describe in which early efforts with the external Doppler were unsatisfactory and fetal status was suspect. My question: “What is the time interval from the moment of fetal death and loss of fetal electrical activity until the fetus becomes an effective conduit for the conduction of the maternal cardiac signal? Is it minutes, hours, days? Clearly, this would be difficult to evaluate other than on animal models, but I have yet to find an answer.

Edward Hall, MD
Edgewood, Kentucky

Drs. Esplin and Eller respond
We are grateful for your interest in our article. Unfortunately the answer to your question about the timing between fetal demise and the appearance of maternal electrocardiac activity detected by a fetal scalp electrode after transmission through the fetal body is not clear. We are not aware of any data that would conclusively prove the time required for this to occur. It is likely that this type of information would require an animal model to elucidate. However, we are aware of at least 2 clinical cases in which fetal cardiac activity was convincingly documented at admission and for several hours intrapartum with subsequent episodic loss of signal and then delivery of a dead fetus wherein retrospective review confirmed that for a period of time the maternal heart rate was recorded and interpreted to be the fetal heart rate. From these experiences we conclude that this is possible shortly after the fetal demise, likely within minutes to hours.

Despite this uncertainty, we are confident that the information in our article will help clinicians identify and correct those instances when the maternal heart rate is being recorded instead of the fetal heart rate. Fortunately, this rarely involves a situation in which there has been an undiagnosed intrauterine fetal demise.

“SERMs IN MENOPAUSE: MATCHING AGENTS TO PATIENTS’ SYMPTOMS AND ATTRIBUTES”
JAMES H. LIU, MD, AND GRETCHEN COLLINS, MD (MAY 2016 Special issue)

“SERMs” definition inaccurate
I disagree with Drs. Liu and Collins’ description of selective estrogen receptor modulators (SERMs) on page S18, in which they state, “Estrogens and SERMs are lipid-soluble steroid hormones that bind to 2 specific hormone receptors, estrogen receptor α and estrogen receptor β…” SERMs are not hormones, and they are defined improperly as such.

Gideon G. Panter, MD
New York, New York

Drs. Liu and Collins respond
Thank you for your interest in our article. SERMs are typically synthetic organic compounds that can activate estrogen receptors or modify activity of the estrogen receptor and, thus, can be considered hormones.

“START OFFERING ASPIRIN TO PREGNANT WOMEN AT HIGH RISK FOR PREECLAMPSIA”
ROBERT L. BARBIERI, MD (EDITORIAL; MAY 2016)

Stop aspirin in pregnancy?
Like many colleagues, I had been stopping low-dose aspirin prior to planned or expected delivery. Evidence suggests a bigger risk of rebound hypercoagulability than bleeding after stopping low-dose aspirin, according to an article on aspirin use in the perioperative period.¹ Because of lack of benefit and increased risks of stopping aspirin, it may be time to change our practice and continue aspirin to minimize peridelivery thromboembolic risk.

Mark Jacobs, MD
Mill Valley, CA

Reference

Dr. Barbieri responds
I thank Dr. Jacobs for his advice to continue low-dose aspirin throughout pregnancy in women taking aspirin for prevention of preeclampsia. The review he references is focused on elderly patients taking aspirin for existing heart disease, which is a very different population than pregnant women. There are no high-quality data from clinical trials on whether to continue or stop low-dose aspirin in pregnant women as they approach their due date. I think obstetricians can use their best judgment in making the decision of whether to stop low-dose aspirin at 36 or 37 weeks or continue aspirin throughout the pregnancy.

“CESAREAN SCAR DEFECT:WHAT IS IT AND HOW SHOULD IT BE TREATED?”
CAMRAN NEZHAT, MD; LINDSEY GRACE, MD;ROSE SOLIEMANNJAD, BS;GITY MESHKAT RAZAVI, MD; AND AZADEH NEZHAT, MD (APRIL 2016)

Technique for preventing cesarean scar defect
I read with interest the proposed treatment options that Dr. Nezhat and colleagues suggested for cesarean scar defect. However, nowhere did I see mention of preventing this defect.

For 30 years I have been closing the hysterotomy in a fashion that I believe leaves no presence of an isthmocele and is a superior closure. I overlap the upper flap with the lower flap and, most importantly, close with chromic catgut. A cesarean scar “niche” occurs with involution of the uterus causing the suture line to bunch up. Chromic catgut has a shorter half-life and will “give;” a suture made of polypropylene will not stretch. I use a running interlocking line with sutures about 0.5 inches apart.

Donald M. Werner, MD
Binghamton, New York

Dr. Nezhat and colleagues respond
We thank Dr. Werner for his inquiry regarding the prevention of cesarean scar defects; as we all agree, the best treatment is prevention. As mentioned in our article, there are no definitive results from the studies published to date that show superiority of one surgical technique over another in regard to hysterotomy closure and prevention of cesarean scar defects. Possible risk factors for developing cesarean scar defects include low (cervical) hysterotomy, single-layer uterine wall closure, use of locking sutures, closure of hysterotomy with endometrial-sparing technique, and multiple cesarean deliveries. Although these factors may be associated with increased risk of cesarean scar defects, additional randomized controlled trials need to be performed prior to being able to offer a recommendation on a conclusive preventative measure. For additional information, I would direct you to references 3 and 4 in our article. We thank you for sharing your positive experience and eagerly await additional studies on the topic.

Share your thoughts! Send your Letter to the Editor to [email protected]

“10 TIPS FOR OVERCOMING COMMON CHALLENGES OF INTRAPARTUM FETAL MONITORING”
M. SEAN ESPLIN, MD, AND ALEXANDRA G. ELLER, MD, MPH (MAY 2016)

Determining fetal demise
I appreciate and thank Drs. Esplin and Eller for their discussion of fetal monitoring pitfalls. I agree with their sentiment that this is an inexact science. After 40 years of looking at these strips, I am convinced there must be a better way. I look forward to some innovative approach to better determine fetal well-being in labor. This article raises a question I have asked, and sought the answer to, for years.

On occasion, I have diagnosed intrauterine fetal demise by detecting the maternal heart rate with an internal fetal scalp electrode. On one particular occasion, somewhere between the time of admission, spontaneous rupture of membranes, and applying the fetal scalp electrode, the fetus died. This case was similar to the one you describe in which early efforts with the external Doppler were unsatisfactory and fetal status was suspect. My question: “What is the time interval from the moment of fetal death and loss of fetal electrical activity until the fetus becomes an effective conduit for the conduction of the maternal cardiac signal? Is it minutes, hours, days? Clearly, this would be difficult to evaluate other than on animal models, but I have yet to find an answer.

Edward Hall, MD
Edgewood, Kentucky

Drs. Esplin and Eller respond
We are grateful for your interest in our article. Unfortunately the answer to your question about the timing between fetal demise and the appearance of maternal electrocardiac activity detected by a fetal scalp electrode after transmission through the fetal body is not clear. We are not aware of any data that would conclusively prove the time required for this to occur. It is likely that this type of information would require an animal model to elucidate. However, we are aware of at least 2 clinical cases in which fetal cardiac activity was convincingly documented at admission and for several hours intrapartum with subsequent episodic loss of signal and then delivery of a dead fetus wherein retrospective review confirmed that for a period of time the maternal heart rate was recorded and interpreted to be the fetal heart rate. From these experiences we conclude that this is possible shortly after the fetal demise, likely within minutes to hours.

Despite this uncertainty, we are confident that the information in our article will help clinicians identify and correct those instances when the maternal heart rate is being recorded instead of the fetal heart rate. Fortunately, this rarely involves a situation in which there has been an undiagnosed intrauterine fetal demise.

“SERMs IN MENOPAUSE: MATCHING AGENTS TO PATIENTS’ SYMPTOMS AND ATTRIBUTES”
JAMES H. LIU, MD, AND GRETCHEN COLLINS, MD (MAY 2016 Special issue)

“SERMs” definition inaccurate
I disagree with Drs. Liu and Collins’ description of selective estrogen receptor modulators (SERMs) on page S18, in which they state, “Estrogens and SERMs are lipid-soluble steroid hormones that bind to 2 specific hormone receptors, estrogen receptor α and estrogen receptor β…” SERMs are not hormones, and they are defined improperly as such.

Gideon G. Panter, MD
New York, New York

Drs. Liu and Collins respond
Thank you for your interest in our article. SERMs are typically synthetic organic compounds that can activate estrogen receptors or modify activity of the estrogen receptor and, thus, can be considered hormones.

“START OFFERING ASPIRIN TO PREGNANT WOMEN AT HIGH RISK FOR PREECLAMPSIA”
ROBERT L. BARBIERI, MD (EDITORIAL; MAY 2016)

Stop aspirin in pregnancy?
Like many colleagues, I had been stopping low-dose aspirin prior to planned or expected delivery. Evidence suggests a bigger risk of rebound hypercoagulability than bleeding after stopping low-dose aspirin, according to an article on aspirin use in the perioperative period.¹ Because of lack of benefit and increased risks of stopping aspirin, it may be time to change our practice and continue aspirin to minimize peridelivery thromboembolic risk.

Mark Jacobs, MD
Mill Valley, CA

Reference

Dr. Barbieri responds
I thank Dr. Jacobs for his advice to continue low-dose aspirin throughout pregnancy in women taking aspirin for prevention of preeclampsia. The review he references is focused on elderly patients taking aspirin for existing heart disease, which is a very different population than pregnant women. There are no high-quality data from clinical trials on whether to continue or stop low-dose aspirin in pregnant women as they approach their due date. I think obstetricians can use their best judgment in making the decision of whether to stop low-dose aspirin at 36 or 37 weeks or continue aspirin throughout the pregnancy.

“CESAREAN SCAR DEFECT:WHAT IS IT AND HOW SHOULD IT BE TREATED?”
CAMRAN NEZHAT, MD; LINDSEY GRACE, MD;ROSE SOLIEMANNJAD, BS;GITY MESHKAT RAZAVI, MD; AND AZADEH NEZHAT, MD (APRIL 2016)

Technique for preventing cesarean scar defect
I read with interest the proposed treatment options that Dr. Nezhat and colleagues suggested for cesarean scar defect. However, nowhere did I see mention of preventing this defect.

For 30 years I have been closing the hysterotomy in a fashion that I believe leaves no presence of an isthmocele and is a superior closure. I overlap the upper flap with the lower flap and, most importantly, close with chromic catgut. A cesarean scar “niche” occurs with involution of the uterus causing the suture line to bunch up. Chromic catgut has a shorter half-life and will “give;” a suture made of polypropylene will not stretch. I use a running interlocking line with sutures about 0.5 inches apart.

Donald M. Werner, MD
Binghamton, New York

Dr. Nezhat and colleagues respond
We thank Dr. Werner for his inquiry regarding the prevention of cesarean scar defects; as we all agree, the best treatment is prevention. As mentioned in our article, there are no definitive results from the studies published to date that show superiority of one surgical technique over another in regard to hysterotomy closure and prevention of cesarean scar defects. Possible risk factors for developing cesarean scar defects include low (cervical) hysterotomy, single-layer uterine wall closure, use of locking sutures, closure of hysterotomy with endometrial-sparing technique, and multiple cesarean deliveries. Although these factors may be associated with increased risk of cesarean scar defects, additional randomized controlled trials need to be performed prior to being able to offer a recommendation on a conclusive preventative measure. For additional information, I would direct you to references 3 and 4 in our article. We thank you for sharing your positive experience and eagerly await additional studies on the topic.

Share your thoughts! Send your Letter to the Editor to [email protected]

“10 TIPS FOR OVERCOMING COMMON CHALLENGES OF INTRAPARTUM FETAL MONITORING”
M. SEAN ESPLIN, MD, AND ALEXANDRA G. ELLER, MD, MPH (MAY 2016)

Determining fetal demise
I appreciate and thank Drs. Esplin and Eller for their discussion of fetal monitoring pitfalls. I agree with their sentiment that this is an inexact science. After 40 years of looking at these strips, I am convinced there must be a better way. I look forward to some innovative approach to better determine fetal well-being in labor. This article raises a question I have asked, and sought the answer to, for years.

On occasion, I have diagnosed intrauterine fetal demise by detecting the maternal heart rate with an internal fetal scalp electrode. On one particular occasion, somewhere between the time of admission, spontaneous rupture of membranes, and applying the fetal scalp electrode, the fetus died. This case was similar to the one you describe in which early efforts with the external Doppler were unsatisfactory and fetal status was suspect. My question: “What is the time interval from the moment of fetal death and loss of fetal electrical activity until the fetus becomes an effective conduit for the conduction of the maternal cardiac signal? Is it minutes, hours, days? Clearly, this would be difficult to evaluate other than on animal models, but I have yet to find an answer.

Edward Hall, MD
Edgewood, Kentucky

Drs. Esplin and Eller respond
We are grateful for your interest in our article. Unfortunately the answer to your question about the timing between fetal demise and the appearance of maternal electrocardiac activity detected by a fetal scalp electrode after transmission through the fetal body is not clear. We are not aware of any data that would conclusively prove the time required for this to occur. It is likely that this type of information would require an animal model to elucidate. However, we are aware of at least 2 clinical cases in which fetal cardiac activity was convincingly documented at admission and for several hours intrapartum with subsequent episodic loss of signal and then delivery of a dead fetus wherein retrospective review confirmed that for a period of time the maternal heart rate was recorded and interpreted to be the fetal heart rate. From these experiences we conclude that this is possible shortly after the fetal demise, likely within minutes to hours.

Despite this uncertainty, we are confident that the information in our article will help clinicians identify and correct those instances when the maternal heart rate is being recorded instead of the fetal heart rate. Fortunately, this rarely involves a situation in which there has been an undiagnosed intrauterine fetal demise.

“SERMs IN MENOPAUSE: MATCHING AGENTS TO PATIENTS’ SYMPTOMS AND ATTRIBUTES”
JAMES H. LIU, MD, AND GRETCHEN COLLINS, MD (MAY 2016 Special issue)

“SERMs” definition inaccurate
I disagree with Drs. Liu and Collins’ description of selective estrogen receptor modulators (SERMs) on page S18, in which they state, “Estrogens and SERMs are lipid-soluble steroid hormones that bind to 2 specific hormone receptors, estrogen receptor α and estrogen receptor β…” SERMs are not hormones, and they are defined improperly as such.

Gideon G. Panter, MD
New York, New York

Drs. Liu and Collins respond
Thank you for your interest in our article. SERMs are typically synthetic organic compounds that can activate estrogen receptors or modify activity of the estrogen receptor and, thus, can be considered hormones.

“START OFFERING ASPIRIN TO PREGNANT WOMEN AT HIGH RISK FOR PREECLAMPSIA”
ROBERT L. BARBIERI, MD (EDITORIAL; MAY 2016)

Stop aspirin in pregnancy?
Like many colleagues, I had been stopping low-dose aspirin prior to planned or expected delivery. Evidence suggests a bigger risk of rebound hypercoagulability than bleeding after stopping low-dose aspirin, according to an article on aspirin use in the perioperative period.¹ Because of lack of benefit and increased risks of stopping aspirin, it may be time to change our practice and continue aspirin to minimize peridelivery thromboembolic risk.

Mark Jacobs, MD
Mill Valley, CA

Reference

Dr. Barbieri responds
I thank Dr. Jacobs for his advice to continue low-dose aspirin throughout pregnancy in women taking aspirin for prevention of preeclampsia. The review he references is focused on elderly patients taking aspirin for existing heart disease, which is a very different population than pregnant women. There are no high-quality data from clinical trials on whether to continue or stop low-dose aspirin in pregnant women as they approach their due date. I think obstetricians can use their best judgment in making the decision of whether to stop low-dose aspirin at 36 or 37 weeks or continue aspirin throughout the pregnancy.

“CESAREAN SCAR DEFECT:WHAT IS IT AND HOW SHOULD IT BE TREATED?”
CAMRAN NEZHAT, MD; LINDSEY GRACE, MD;ROSE SOLIEMANNJAD, BS;GITY MESHKAT RAZAVI, MD; AND AZADEH NEZHAT, MD (APRIL 2016)

Technique for preventing cesarean scar defect
I read with interest the proposed treatment options that Dr. Nezhat and colleagues suggested for cesarean scar defect. However, nowhere did I see mention of preventing this defect.

For 30 years I have been closing the hysterotomy in a fashion that I believe leaves no presence of an isthmocele and is a superior closure. I overlap the upper flap with the lower flap and, most importantly, close with chromic catgut. A cesarean scar “niche” occurs with involution of the uterus causing the suture line to bunch up. Chromic catgut has a shorter half-life and will “give;” a suture made of polypropylene will not stretch. I use a running interlocking line with sutures about 0.5 inches apart.

Donald M. Werner, MD
Binghamton, New York

Dr. Nezhat and colleagues respond
We thank Dr. Werner for his inquiry regarding the prevention of cesarean scar defects; as we all agree, the best treatment is prevention. As mentioned in our article, there are no definitive results from the studies published to date that show superiority of one surgical technique over another in regard to hysterotomy closure and prevention of cesarean scar defects. Possible risk factors for developing cesarean scar defects include low (cervical) hysterotomy, single-layer uterine wall closure, use of locking sutures, closure of hysterotomy with endometrial-sparing technique, and multiple cesarean deliveries. Although these factors may be associated with increased risk of cesarean scar defects, additional randomized controlled trials need to be performed prior to being able to offer a recommendation on a conclusive preventative measure. For additional information, I would direct you to references 3 and 4 in our article. We thank you for sharing your positive experience and eagerly await additional studies on the topic.

Share your thoughts! Send your Letter to the Editor to [email protected]

ACCESS TO HARD-TO-REACH UTERINE CAVITY

Hologic has added the MyoSure REACH device to its tissue removal system to maximize access for resection of fibroids up to 3 cm in size. The MyoSure REACH is designed to access hard-to-reach areas, including the upper third of the uterine cavity. Hologic says that the MyoSure REACH features a shortened distance from the distal tip to the cutting window of less than 1 millimeter to allow for easier access to polyps and fibroids. When compared with the predecessor device, the new design has been shown to get 3 times closer to the uterine wall and removes 25% more tissue in a simulated bench top model. The MyoSure REACH has an outer diameter of 3 mm and working length of 32 cm, with scope compatibility with MyoSure and MyoSure XL. The blade is made of coated stainless steel with ultra-hardness and high-wear resistance.

FOR MORE INFORMATION, VISIT: www.myosure.com/hcp/myosure-reach

DNA TESTING AND GENETIC COUNSELING SERVICE

Counsyl, a DNA testing and genetic counseling service, announced expansion into the oncology market with a focus on advancing cancer risk screening and cancer prevention.

Counsyl’s Inherited Cancer Screen is a prescription-based genetic screening test available for patients to take at the physician’s office or receive via mail. Tests include on-demand genetic counseling that is in-network with most insurance providers. Inherited Cancer Screen helps physicians identify patients who may benefit from more aggressive screening procedures, changes in lifestyle or medication regimens, or preventive actions such as surgery. Inherited Cancer Screen is designed to test for up to 36 genes associated with increased risk of cancers of the breast, ovaries, pancreas, colon, prostate, and skin, with results typically delivered within 2 weeks. To help inform these decisions, Counsyl provides physicians and patients access to a team of more than 40 board-certified genetic counselors.

FirstCare is a web and mobile-friendly software tool to help physicians determine patient eligibility for genetic screening, based on factors such as family history.

Counsyl also provides prepregnancy and prenatal genetic testing. The fee for each test includes a consultation with a genetic counselor.

FOR MORE INFORMATION, VISIT: www.counsyl.com

PERSONAL LUBRICANTS AND WASH

Good Clean Love offers vaginal lubricants and a moisturizing personal wash formulated, according to the manufacturer, to match the ideal pH, salt balance, and type of lactic acid produced by healthy bacteria levels in the vagina.

Good Clean Love’s Personal Lubricants have been developed to mimic the body’s natural mucous production using certified 95% organic and natural ingredients, including aloe and agar, without chemical additives. The 2 choices are Almost Naked Organic Personal Lubricant, lightly scented with lemon and vanilla, and Cinnamon Vanilla Organic Personal Lubricant.

Bio-Match™ Restore™ Moisturizing Personal Lubricant mimics the body’s natural lubricating response, is fertility-friendly, 100% vegan, petroleum-, glycerin-, and paraben-free, and is safe for use with latex condoms and toys.

Bio-Match™ Balance™ Moisturizing Personal Wash is a moisturizing vaginal cleanser made from botanical extracts that Good Clean Love says returns genital pH and salinity to a naturally healthy balance. It is 100% vegan, and petroleum- and paraben-free.

FOR MORE INFORMATION, VISIT: http://goodcleanlove.com

PRENATAL VITAMINS WITH EGG-BASED DHA

OB Complete^® Gold are prescription prenatal vitamin supple-ments from Vertical Pharmaceuticals indicated for use in improving the nutritional status of women prior to conception, throughout pregnancy, and in the postnatal period for both lactating and nonlactating women. The supplement delivers gluten-free, sugar-free, and lactose-free multivitamins and minerals in a small softgel taken once a day.

OB Complete Gold prenatal vitamin supplements contain OmEGGa DHA™ (docosahexaenoic acid), an egg-based Omega 3 fatty acid that is believed to play an important role in the development of the brain, retina, and central nervous system of the fetus. According to Vertical Pharmaceuticals, this form of DHA, found naturally in the body and breast milk, is more easily absorbed, digested, and distributed to the body’s tissues than the triglyceride form of DHA developed from marine sources such as fish or algae, which can produce unwanted side effects such as bad breath, a fishy taste, and burping.

FOR MORE INFORMATION, VISIT: www.obcompletegold.com

ACCESS TO HARD-TO-REACH UTERINE CAVITY

Hologic has added the MyoSure REACH device to its tissue removal system to maximize access for resection of fibroids up to 3 cm in size. The MyoSure REACH is designed to access hard-to-reach areas, including the upper third of the uterine cavity. Hologic says that the MyoSure REACH features a shortened distance from the distal tip to the cutting window of less than 1 millimeter to allow for easier access to polyps and fibroids. When compared with the predecessor device, the new design has been shown to get 3 times closer to the uterine wall and removes 25% more tissue in a simulated bench top model. The MyoSure REACH has an outer diameter of 3 mm and working length of 32 cm, with scope compatibility with MyoSure and MyoSure XL. The blade is made of coated stainless steel with ultra-hardness and high-wear resistance.

FOR MORE INFORMATION, VISIT: www.myosure.com/hcp/myosure-reach

DNA TESTING AND GENETIC COUNSELING SERVICE

Counsyl, a DNA testing and genetic counseling service, announced expansion into the oncology market with a focus on advancing cancer risk screening and cancer prevention.

Counsyl’s Inherited Cancer Screen is a prescription-based genetic screening test available for patients to take at the physician’s office or receive via mail. Tests include on-demand genetic counseling that is in-network with most insurance providers. Inherited Cancer Screen helps physicians identify patients who may benefit from more aggressive screening procedures, changes in lifestyle or medication regimens, or preventive actions such as surgery. Inherited Cancer Screen is designed to test for up to 36 genes associated with increased risk of cancers of the breast, ovaries, pancreas, colon, prostate, and skin, with results typically delivered within 2 weeks. To help inform these decisions, Counsyl provides physicians and patients access to a team of more than 40 board-certified genetic counselors.

FirstCare is a web and mobile-friendly software tool to help physicians determine patient eligibility for genetic screening, based on factors such as family history.

Counsyl also provides prepregnancy and prenatal genetic testing. The fee for each test includes a consultation with a genetic counselor.

FOR MORE INFORMATION, VISIT: www.counsyl.com

PERSONAL LUBRICANTS AND WASH

Good Clean Love offers vaginal lubricants and a moisturizing personal wash formulated, according to the manufacturer, to match the ideal pH, salt balance, and type of lactic acid produced by healthy bacteria levels in the vagina.

Good Clean Love’s Personal Lubricants have been developed to mimic the body’s natural mucous production using certified 95% organic and natural ingredients, including aloe and agar, without chemical additives. The 2 choices are Almost Naked Organic Personal Lubricant, lightly scented with lemon and vanilla, and Cinnamon Vanilla Organic Personal Lubricant.

Bio-Match™ Restore™ Moisturizing Personal Lubricant mimics the body’s natural lubricating response, is fertility-friendly, 100% vegan, petroleum-, glycerin-, and paraben-free, and is safe for use with latex condoms and toys.

Bio-Match™ Balance™ Moisturizing Personal Wash is a moisturizing vaginal cleanser made from botanical extracts that Good Clean Love says returns genital pH and salinity to a naturally healthy balance. It is 100% vegan, and petroleum- and paraben-free.

FOR MORE INFORMATION, VISIT: http://goodcleanlove.com

PRENATAL VITAMINS WITH EGG-BASED DHA

OB Complete^® Gold are prescription prenatal vitamin supple-ments from Vertical Pharmaceuticals indicated for use in improving the nutritional status of women prior to conception, throughout pregnancy, and in the postnatal period for both lactating and nonlactating women. The supplement delivers gluten-free, sugar-free, and lactose-free multivitamins and minerals in a small softgel taken once a day.

OB Complete Gold prenatal vitamin supplements contain OmEGGa DHA™ (docosahexaenoic acid), an egg-based Omega 3 fatty acid that is believed to play an important role in the development of the brain, retina, and central nervous system of the fetus. According to Vertical Pharmaceuticals, this form of DHA, found naturally in the body and breast milk, is more easily absorbed, digested, and distributed to the body’s tissues than the triglyceride form of DHA developed from marine sources such as fish or algae, which can produce unwanted side effects such as bad breath, a fishy taste, and burping.

FOR MORE INFORMATION, VISIT: www.obcompletegold.com

ACCESS TO HARD-TO-REACH UTERINE CAVITY

Hologic has added the MyoSure REACH device to its tissue removal system to maximize access for resection of fibroids up to 3 cm in size. The MyoSure REACH is designed to access hard-to-reach areas, including the upper third of the uterine cavity. Hologic says that the MyoSure REACH features a shortened distance from the distal tip to the cutting window of less than 1 millimeter to allow for easier access to polyps and fibroids. When compared with the predecessor device, the new design has been shown to get 3 times closer to the uterine wall and removes 25% more tissue in a simulated bench top model. The MyoSure REACH has an outer diameter of 3 mm and working length of 32 cm, with scope compatibility with MyoSure and MyoSure XL. The blade is made of coated stainless steel with ultra-hardness and high-wear resistance.

FOR MORE INFORMATION, VISIT: www.myosure.com/hcp/myosure-reach

DNA TESTING AND GENETIC COUNSELING SERVICE

Counsyl, a DNA testing and genetic counseling service, announced expansion into the oncology market with a focus on advancing cancer risk screening and cancer prevention.

Counsyl’s Inherited Cancer Screen is a prescription-based genetic screening test available for patients to take at the physician’s office or receive via mail. Tests include on-demand genetic counseling that is in-network with most insurance providers. Inherited Cancer Screen helps physicians identify patients who may benefit from more aggressive screening procedures, changes in lifestyle or medication regimens, or preventive actions such as surgery. Inherited Cancer Screen is designed to test for up to 36 genes associated with increased risk of cancers of the breast, ovaries, pancreas, colon, prostate, and skin, with results typically delivered within 2 weeks. To help inform these decisions, Counsyl provides physicians and patients access to a team of more than 40 board-certified genetic counselors.

FirstCare is a web and mobile-friendly software tool to help physicians determine patient eligibility for genetic screening, based on factors such as family history.

Counsyl also provides prepregnancy and prenatal genetic testing. The fee for each test includes a consultation with a genetic counselor.

FOR MORE INFORMATION, VISIT: www.counsyl.com

PERSONAL LUBRICANTS AND WASH

Good Clean Love offers vaginal lubricants and a moisturizing personal wash formulated, according to the manufacturer, to match the ideal pH, salt balance, and type of lactic acid produced by healthy bacteria levels in the vagina.

Good Clean Love’s Personal Lubricants have been developed to mimic the body’s natural mucous production using certified 95% organic and natural ingredients, including aloe and agar, without chemical additives. The 2 choices are Almost Naked Organic Personal Lubricant, lightly scented with lemon and vanilla, and Cinnamon Vanilla Organic Personal Lubricant.

Bio-Match™ Restore™ Moisturizing Personal Lubricant mimics the body’s natural lubricating response, is fertility-friendly, 100% vegan, petroleum-, glycerin-, and paraben-free, and is safe for use with latex condoms and toys.

Bio-Match™ Balance™ Moisturizing Personal Wash is a moisturizing vaginal cleanser made from botanical extracts that Good Clean Love says returns genital pH and salinity to a naturally healthy balance. It is 100% vegan, and petroleum- and paraben-free.

FOR MORE INFORMATION, VISIT: http://goodcleanlove.com

PRENATAL VITAMINS WITH EGG-BASED DHA

OB Complete^® Gold are prescription prenatal vitamin supple-ments from Vertical Pharmaceuticals indicated for use in improving the nutritional status of women prior to conception, throughout pregnancy, and in the postnatal period for both lactating and nonlactating women. The supplement delivers gluten-free, sugar-free, and lactose-free multivitamins and minerals in a small softgel taken once a day.

OB Complete Gold prenatal vitamin supplements contain OmEGGa DHA™ (docosahexaenoic acid), an egg-based Omega 3 fatty acid that is believed to play an important role in the development of the brain, retina, and central nervous system of the fetus. According to Vertical Pharmaceuticals, this form of DHA, found naturally in the body and breast milk, is more easily absorbed, digested, and distributed to the body’s tissues than the triglyceride form of DHA developed from marine sources such as fish or algae, which can produce unwanted side effects such as bad breath, a fishy taste, and burping.

FOR MORE INFORMATION, VISIT: www.obcompletegold.com

SCOTTSDALE, ARIZ. – Children and adolescents receiving methotrexate for psoriasis were significantly less likely to experience gastrointestinal side effects when they took a folate supplement every day instead of once weekly or 6 days a week, in a retrospective study of more than 400 pediatric psoriasis patients.

Laboratory abnormalities were significantly more common among children who received a folate supplement 6 days per week rather than daily, noted Inge Bronckers of the department of dermatology, Radboud University, Nijmegen, the Netherlands. “These results support the use of daily folate” in this group of patients,” she said in a poster presentation at the annual meeting of the Society for Investigative Dermatology.

thinkstockphotos.com

Few studies have examined patterns of use or adverse effects of pediatric psoriasis therapies. Although methotrexate is a folate antagonist with related toxicities, whether folate supplementation counteracts the efficacy of methotrexate is also unclear. Because of these uncertainties, some clinicians recommend a supplement 6 days per week, avoiding the day methotrexate is given, while others recommend it daily or once weekly.

To better understand the effects of these regimens, Ms. Inge and her coinvestigators studied 446 children and adolescents who received phototherapy or systemic treatments for moderate to severe psoriasis at 20 centers in the United States, Canada, and Europe between 1990 and 2014. The patients’ average age was 8 years (standard deviation, 4 years); 238 were female and 208 were male.

Among the 390 patients receiving systemic medications, almost 70% were receiving methotrexate, while 27% were being treated with etanercept or another biologic, 15% were using retinoids, 8% were using cyclosporine, and 5% were using fumaric acid. About 19% of patients were receiving more than one of these medications. Methotrexate most often led to nausea (affecting 18% of patients), elevated hepatic transaminases (13%), dyspepsia (7%), and infections (4%), usually of the skin and upper airways. In contrast, biologics most often caused injection-site reactions (19%) and upper airways infections (10%).

Most (253) of the 270 patients on methotrexate had been prescribed folic acid, typically at a dose of about 8 mg/wk, and nearly always in the form of pure folic acid, rather than a multivitamin. Of the patients taking folic acid, about 34% took it 6 days per week, 34% received it daily and 30% – including most patients in Europe – received it once weekly.

Notably, the odds of gastrointestinal side effects were 75% lower for patients who received folic acid daily or 6 days per week, compared with those who received folic acid once a week (odds ratio, 0.25, in both cases; P less than .001), the investigators found. However, laboratory abnormalities were significantly more likely when folic acid was given 6 days a week, compared with daily (OR, 2.31; P = .03) or weekly (OR, 3.9; P = .002). Patients in Europe, who usually received folic acid weekly, were significantly more likely to have methotrexate-related gastrointestinal side effects than were patients in North America (OR, 3.4; P less than .001), and were less likely to have laboratory abnormalities (OR, 0.32; P = .004).

Patients on biologic therapy were less likely to develop laboratory abnormalities or stop treatment because of side effects than were those on other systemic therapies, Ms. Inge and her associates found. Because methotrexate was associated with elevated liver enzymes, it also was dose adjusted more often than other therapies. No patient on any therapy was diagnosed with tuberculosis or malignancy, but three patients on methotrexate had severe adverse effects, including liver disease, methotrexate hypersensitivity pneumonitis, and severe personality changes. In contrast, fumarate was associated with one case each of pericarditis and bone marrow suppression, while one patient on the biologic adalimumab developed appendicitis.

The study underscores the need to monitor the long-term risks of pediatric psoriasis treatments, the researchers concluded. Data and lessons from the study are being used to develop a prospective pediatric psoriasis registry. “If industry joins forces to use this prospective international registry to capture prospective pediatric data, we will ensure early detection of safety signals and facilitate comparative analyses of efficacy and safety,” Ms. Inge said in the poster.

The International Psoriasis Council funded the study. The investigators did not list disclosures.

SCOTTSDALE, ARIZ. – Children and adolescents receiving methotrexate for psoriasis were significantly less likely to experience gastrointestinal side effects when they took a folate supplement every day instead of once weekly or 6 days a week, in a retrospective study of more than 400 pediatric psoriasis patients.

Laboratory abnormalities were significantly more common among children who received a folate supplement 6 days per week rather than daily, noted Inge Bronckers of the department of dermatology, Radboud University, Nijmegen, the Netherlands. “These results support the use of daily folate” in this group of patients,” she said in a poster presentation at the annual meeting of the Society for Investigative Dermatology.

thinkstockphotos.com

Few studies have examined patterns of use or adverse effects of pediatric psoriasis therapies. Although methotrexate is a folate antagonist with related toxicities, whether folate supplementation counteracts the efficacy of methotrexate is also unclear. Because of these uncertainties, some clinicians recommend a supplement 6 days per week, avoiding the day methotrexate is given, while others recommend it daily or once weekly.

To better understand the effects of these regimens, Ms. Inge and her coinvestigators studied 446 children and adolescents who received phototherapy or systemic treatments for moderate to severe psoriasis at 20 centers in the United States, Canada, and Europe between 1990 and 2014. The patients’ average age was 8 years (standard deviation, 4 years); 238 were female and 208 were male.

Among the 390 patients receiving systemic medications, almost 70% were receiving methotrexate, while 27% were being treated with etanercept or another biologic, 15% were using retinoids, 8% were using cyclosporine, and 5% were using fumaric acid. About 19% of patients were receiving more than one of these medications. Methotrexate most often led to nausea (affecting 18% of patients), elevated hepatic transaminases (13%), dyspepsia (7%), and infections (4%), usually of the skin and upper airways. In contrast, biologics most often caused injection-site reactions (19%) and upper airways infections (10%).

Most (253) of the 270 patients on methotrexate had been prescribed folic acid, typically at a dose of about 8 mg/wk, and nearly always in the form of pure folic acid, rather than a multivitamin. Of the patients taking folic acid, about 34% took it 6 days per week, 34% received it daily and 30% – including most patients in Europe – received it once weekly.

Notably, the odds of gastrointestinal side effects were 75% lower for patients who received folic acid daily or 6 days per week, compared with those who received folic acid once a week (odds ratio, 0.25, in both cases; P less than .001), the investigators found. However, laboratory abnormalities were significantly more likely when folic acid was given 6 days a week, compared with daily (OR, 2.31; P = .03) or weekly (OR, 3.9; P = .002). Patients in Europe, who usually received folic acid weekly, were significantly more likely to have methotrexate-related gastrointestinal side effects than were patients in North America (OR, 3.4; P less than .001), and were less likely to have laboratory abnormalities (OR, 0.32; P = .004).

Patients on biologic therapy were less likely to develop laboratory abnormalities or stop treatment because of side effects than were those on other systemic therapies, Ms. Inge and her associates found. Because methotrexate was associated with elevated liver enzymes, it also was dose adjusted more often than other therapies. No patient on any therapy was diagnosed with tuberculosis or malignancy, but three patients on methotrexate had severe adverse effects, including liver disease, methotrexate hypersensitivity pneumonitis, and severe personality changes. In contrast, fumarate was associated with one case each of pericarditis and bone marrow suppression, while one patient on the biologic adalimumab developed appendicitis.

The study underscores the need to monitor the long-term risks of pediatric psoriasis treatments, the researchers concluded. Data and lessons from the study are being used to develop a prospective pediatric psoriasis registry. “If industry joins forces to use this prospective international registry to capture prospective pediatric data, we will ensure early detection of safety signals and facilitate comparative analyses of efficacy and safety,” Ms. Inge said in the poster.

The International Psoriasis Council funded the study. The investigators did not list disclosures.

SCOTTSDALE, ARIZ. – Children and adolescents receiving methotrexate for psoriasis were significantly less likely to experience gastrointestinal side effects when they took a folate supplement every day instead of once weekly or 6 days a week, in a retrospective study of more than 400 pediatric psoriasis patients.

Laboratory abnormalities were significantly more common among children who received a folate supplement 6 days per week rather than daily, noted Inge Bronckers of the department of dermatology, Radboud University, Nijmegen, the Netherlands. “These results support the use of daily folate” in this group of patients,” she said in a poster presentation at the annual meeting of the Society for Investigative Dermatology.

thinkstockphotos.com

Few studies have examined patterns of use or adverse effects of pediatric psoriasis therapies. Although methotrexate is a folate antagonist with related toxicities, whether folate supplementation counteracts the efficacy of methotrexate is also unclear. Because of these uncertainties, some clinicians recommend a supplement 6 days per week, avoiding the day methotrexate is given, while others recommend it daily or once weekly.

To better understand the effects of these regimens, Ms. Inge and her coinvestigators studied 446 children and adolescents who received phototherapy or systemic treatments for moderate to severe psoriasis at 20 centers in the United States, Canada, and Europe between 1990 and 2014. The patients’ average age was 8 years (standard deviation, 4 years); 238 were female and 208 were male.

Among the 390 patients receiving systemic medications, almost 70% were receiving methotrexate, while 27% were being treated with etanercept or another biologic, 15% were using retinoids, 8% were using cyclosporine, and 5% were using fumaric acid. About 19% of patients were receiving more than one of these medications. Methotrexate most often led to nausea (affecting 18% of patients), elevated hepatic transaminases (13%), dyspepsia (7%), and infections (4%), usually of the skin and upper airways. In contrast, biologics most often caused injection-site reactions (19%) and upper airways infections (10%).

Most (253) of the 270 patients on methotrexate had been prescribed folic acid, typically at a dose of about 8 mg/wk, and nearly always in the form of pure folic acid, rather than a multivitamin. Of the patients taking folic acid, about 34% took it 6 days per week, 34% received it daily and 30% – including most patients in Europe – received it once weekly.

Notably, the odds of gastrointestinal side effects were 75% lower for patients who received folic acid daily or 6 days per week, compared with those who received folic acid once a week (odds ratio, 0.25, in both cases; P less than .001), the investigators found. However, laboratory abnormalities were significantly more likely when folic acid was given 6 days a week, compared with daily (OR, 2.31; P = .03) or weekly (OR, 3.9; P = .002). Patients in Europe, who usually received folic acid weekly, were significantly more likely to have methotrexate-related gastrointestinal side effects than were patients in North America (OR, 3.4; P less than .001), and were less likely to have laboratory abnormalities (OR, 0.32; P = .004).

Patients on biologic therapy were less likely to develop laboratory abnormalities or stop treatment because of side effects than were those on other systemic therapies, Ms. Inge and her associates found. Because methotrexate was associated with elevated liver enzymes, it also was dose adjusted more often than other therapies. No patient on any therapy was diagnosed with tuberculosis or malignancy, but three patients on methotrexate had severe adverse effects, including liver disease, methotrexate hypersensitivity pneumonitis, and severe personality changes. In contrast, fumarate was associated with one case each of pericarditis and bone marrow suppression, while one patient on the biologic adalimumab developed appendicitis.

The study underscores the need to monitor the long-term risks of pediatric psoriasis treatments, the researchers concluded. Data and lessons from the study are being used to develop a prospective pediatric psoriasis registry. “If industry joins forces to use this prospective international registry to capture prospective pediatric data, we will ensure early detection of safety signals and facilitate comparative analyses of efficacy and safety,” Ms. Inge said in the poster.

The International Psoriasis Council funded the study. The investigators did not list disclosures.

SCOTTSDALE, ARIZ. – Children and adolescents receiving methotrexate for psoriasis were significantly less likely to experience gastrointestinal side effects when they took a folate supplement every day instead of once weekly or 6 days a week, in a retrospective study of more than 400 pediatric psoriasis patients.

Laboratory abnormalities were significantly more common among children who received a folate supplement 6 days per week rather than daily, noted Inge Bronckers of the department of dermatology, Radboud University, Nijmegen, the Netherlands. “These results support the use of daily folate” in this group of patients,” she said in a poster presentation at the annual meeting of the Society for Investigative Dermatology.

thinkstockphotos.com

Few studies have examined patterns of use or adverse effects of pediatric psoriasis therapies. Although methotrexate is a folate antagonist with related toxicities, whether folate supplementation counteracts the efficacy of methotrexate is also unclear. Because of these uncertainties, some clinicians recommend a supplement 6 days per week, avoiding the day methotrexate is given, while others recommend it daily or once weekly.

To better understand the effects of these regimens, Ms. Inge and her coinvestigators studied 446 children and adolescents who received phototherapy or systemic treatments for moderate to severe psoriasis at 20 centers in the United States, Canada, and Europe between 1990 and 2014. The patients’ average age was 8 years (standard deviation, 4 years); 238 were female and 208 were male.

Among the 390 patients receiving systemic medications, almost 70% were receiving methotrexate, while 27% were being treated with etanercept or another biologic, 15% were using retinoids, 8% were using cyclosporine, and 5% were using fumaric acid. About 19% of patients were receiving more than one of these medications. Methotrexate most often led to nausea (affecting 18% of patients), elevated hepatic transaminases (13%), dyspepsia (7%), and infections (4%), usually of the skin and upper airways. In contrast, biologics most often caused injection-site reactions (19%) and upper airways infections (10%).

Most (253) of the 270 patients on methotrexate had been prescribed folic acid, typically at a dose of about 8 mg/wk, and nearly always in the form of pure folic acid, rather than a multivitamin. Of the patients taking folic acid, about 34% took it 6 days per week, 34% received it daily and 30% – including most patients in Europe – received it once weekly.

Notably, the odds of gastrointestinal side effects were 75% lower for patients who received folic acid daily or 6 days per week, compared with those who received folic acid once a week (odds ratio, 0.25, in both cases; P less than .001), the investigators found. However, laboratory abnormalities were significantly more likely when folic acid was given 6 days a week, compared with daily (OR, 2.31; P = .03) or weekly (OR, 3.9; P = .002). Patients in Europe, who usually received folic acid weekly, were significantly more likely to have methotrexate-related gastrointestinal side effects than were patients in North America (OR, 3.4; P less than .001), and were less likely to have laboratory abnormalities (OR, 0.32; P = .004).

Patients on biologic therapy were less likely to develop laboratory abnormalities or stop treatment because of side effects than were those on other systemic therapies, Ms. Inge and her associates found. Because methotrexate was associated with elevated liver enzymes, it also was dose adjusted more often than other therapies. No patient on any therapy was diagnosed with tuberculosis or malignancy, but three patients on methotrexate had severe adverse effects, including liver disease, methotrexate hypersensitivity pneumonitis, and severe personality changes. In contrast, fumarate was associated with one case each of pericarditis and bone marrow suppression, while one patient on the biologic adalimumab developed appendicitis.

The study underscores the need to monitor the long-term risks of pediatric psoriasis treatments, the researchers concluded. Data and lessons from the study are being used to develop a prospective pediatric psoriasis registry. “If industry joins forces to use this prospective international registry to capture prospective pediatric data, we will ensure early detection of safety signals and facilitate comparative analyses of efficacy and safety,” Ms. Inge said in the poster.

The International Psoriasis Council funded the study. The investigators did not list disclosures.

SCOTTSDALE, ARIZ. – Children and adolescents receiving methotrexate for psoriasis were significantly less likely to experience gastrointestinal side effects when they took a folate supplement every day instead of once weekly or 6 days a week, in a retrospective study of more than 400 pediatric psoriasis patients.

Laboratory abnormalities were significantly more common among children who received a folate supplement 6 days per week rather than daily, noted Inge Bronckers of the department of dermatology, Radboud University, Nijmegen, the Netherlands. “These results support the use of daily folate” in this group of patients,” she said in a poster presentation at the annual meeting of the Society for Investigative Dermatology.

thinkstockphotos.com

Few studies have examined patterns of use or adverse effects of pediatric psoriasis therapies. Although methotrexate is a folate antagonist with related toxicities, whether folate supplementation counteracts the efficacy of methotrexate is also unclear. Because of these uncertainties, some clinicians recommend a supplement 6 days per week, avoiding the day methotrexate is given, while others recommend it daily or once weekly.

To better understand the effects of these regimens, Ms. Inge and her coinvestigators studied 446 children and adolescents who received phototherapy or systemic treatments for moderate to severe psoriasis at 20 centers in the United States, Canada, and Europe between 1990 and 2014. The patients’ average age was 8 years (standard deviation, 4 years); 238 were female and 208 were male.

Among the 390 patients receiving systemic medications, almost 70% were receiving methotrexate, while 27% were being treated with etanercept or another biologic, 15% were using retinoids, 8% were using cyclosporine, and 5% were using fumaric acid. About 19% of patients were receiving more than one of these medications. Methotrexate most often led to nausea (affecting 18% of patients), elevated hepatic transaminases (13%), dyspepsia (7%), and infections (4%), usually of the skin and upper airways. In contrast, biologics most often caused injection-site reactions (19%) and upper airways infections (10%).

Most (253) of the 270 patients on methotrexate had been prescribed folic acid, typically at a dose of about 8 mg/wk, and nearly always in the form of pure folic acid, rather than a multivitamin. Of the patients taking folic acid, about 34% took it 6 days per week, 34% received it daily and 30% – including most patients in Europe – received it once weekly.

Notably, the odds of gastrointestinal side effects were 75% lower for patients who received folic acid daily or 6 days per week, compared with those who received folic acid once a week (odds ratio, 0.25, in both cases; P less than .001), the investigators found. However, laboratory abnormalities were significantly more likely when folic acid was given 6 days a week, compared with daily (OR, 2.31; P = .03) or weekly (OR, 3.9; P = .002). Patients in Europe, who usually received folic acid weekly, were significantly more likely to have methotrexate-related gastrointestinal side effects than were patients in North America (OR, 3.4; P less than .001), and were less likely to have laboratory abnormalities (OR, 0.32; P = .004).

Patients on biologic therapy were less likely to develop laboratory abnormalities or stop treatment because of side effects than were those on other systemic therapies, Ms. Inge and her associates found. Because methotrexate was associated with elevated liver enzymes, it also was dose adjusted more often than other therapies. No patient on any therapy was diagnosed with tuberculosis or malignancy, but three patients on methotrexate had severe adverse effects, including liver disease, methotrexate hypersensitivity pneumonitis, and severe personality changes. In contrast, fumarate was associated with one case each of pericarditis and bone marrow suppression, while one patient on the biologic adalimumab developed appendicitis.

The study underscores the need to monitor the long-term risks of pediatric psoriasis treatments, the researchers concluded. Data and lessons from the study are being used to develop a prospective pediatric psoriasis registry. “If industry joins forces to use this prospective international registry to capture prospective pediatric data, we will ensure early detection of safety signals and facilitate comparative analyses of efficacy and safety,” Ms. Inge said in the poster.

The International Psoriasis Council funded the study. The investigators did not list disclosures.

SCOTTSDALE, ARIZ. – Children and adolescents receiving methotrexate for psoriasis were significantly less likely to experience gastrointestinal side effects when they took a folate supplement every day instead of once weekly or 6 days a week, in a retrospective study of more than 400 pediatric psoriasis patients.

Laboratory abnormalities were significantly more common among children who received a folate supplement 6 days per week rather than daily, noted Inge Bronckers of the department of dermatology, Radboud University, Nijmegen, the Netherlands. “These results support the use of daily folate” in this group of patients,” she said in a poster presentation at the annual meeting of the Society for Investigative Dermatology.

thinkstockphotos.com

Few studies have examined patterns of use or adverse effects of pediatric psoriasis therapies. Although methotrexate is a folate antagonist with related toxicities, whether folate supplementation counteracts the efficacy of methotrexate is also unclear. Because of these uncertainties, some clinicians recommend a supplement 6 days per week, avoiding the day methotrexate is given, while others recommend it daily or once weekly.

To better understand the effects of these regimens, Ms. Inge and her coinvestigators studied 446 children and adolescents who received phototherapy or systemic treatments for moderate to severe psoriasis at 20 centers in the United States, Canada, and Europe between 1990 and 2014. The patients’ average age was 8 years (standard deviation, 4 years); 238 were female and 208 were male.

Among the 390 patients receiving systemic medications, almost 70% were receiving methotrexate, while 27% were being treated with etanercept or another biologic, 15% were using retinoids, 8% were using cyclosporine, and 5% were using fumaric acid. About 19% of patients were receiving more than one of these medications. Methotrexate most often led to nausea (affecting 18% of patients), elevated hepatic transaminases (13%), dyspepsia (7%), and infections (4%), usually of the skin and upper airways. In contrast, biologics most often caused injection-site reactions (19%) and upper airways infections (10%).

Most (253) of the 270 patients on methotrexate had been prescribed folic acid, typically at a dose of about 8 mg/wk, and nearly always in the form of pure folic acid, rather than a multivitamin. Of the patients taking folic acid, about 34% took it 6 days per week, 34% received it daily and 30% – including most patients in Europe – received it once weekly.

Notably, the odds of gastrointestinal side effects were 75% lower for patients who received folic acid daily or 6 days per week, compared with those who received folic acid once a week (odds ratio, 0.25, in both cases; P less than .001), the investigators found. However, laboratory abnormalities were significantly more likely when folic acid was given 6 days a week, compared with daily (OR, 2.31; P = .03) or weekly (OR, 3.9; P = .002). Patients in Europe, who usually received folic acid weekly, were significantly more likely to have methotrexate-related gastrointestinal side effects than were patients in North America (OR, 3.4; P less than .001), and were less likely to have laboratory abnormalities (OR, 0.32; P = .004).

Patients on biologic therapy were less likely to develop laboratory abnormalities or stop treatment because of side effects than were those on other systemic therapies, Ms. Inge and her associates found. Because methotrexate was associated with elevated liver enzymes, it also was dose adjusted more often than other therapies. No patient on any therapy was diagnosed with tuberculosis or malignancy, but three patients on methotrexate had severe adverse effects, including liver disease, methotrexate hypersensitivity pneumonitis, and severe personality changes. In contrast, fumarate was associated with one case each of pericarditis and bone marrow suppression, while one patient on the biologic adalimumab developed appendicitis.

The study underscores the need to monitor the long-term risks of pediatric psoriasis treatments, the researchers concluded. Data and lessons from the study are being used to develop a prospective pediatric psoriasis registry. “If industry joins forces to use this prospective international registry to capture prospective pediatric data, we will ensure early detection of safety signals and facilitate comparative analyses of efficacy and safety,” Ms. Inge said in the poster.

The International Psoriasis Council funded the study. The investigators did not list disclosures.

To the Editor: I read with great interest the article by Thomas et al, “Interpreting SPRINT: How low should you go?”¹

Hypertension is the most prevalent modifiable risk factor, affecting almost one in every three people in the United States.² Moreover, only half of people with hypertension have their blood pressure under control to the current standard of lower than 140/90 mm Hg.² The Systolic Blood Pressure Intervention Trial (SPRINT) tested a lower goal systolic pressure, ie, less than 120 mm Hg, and found it more beneficial than the standard goal of less than 140 mm Hg.³

A drawback of SPRINT that Thomas et al did not address in their interpretation of the trial is that the two study groups were not homogeneous in terms of the antihypertensive drugs used. Antihypertensive drugs do not only lower blood pressure—some of them have additional pleiotropic effects, making their use more advantageous in special situations. For example, renin-angiotensin-aldosterone system (RAAS) blockers—ie, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and mineralocorticoid receptor antagonists—are disease-modfying drugs in heart failure, as are certain beta-blockers.⁴ The cardiovascular benefit seen in the intensive-treatment group in SPRINT compared with the standard-therapy group was primarily due to a reduction in heart failure (a 38% relative risk reduction, P = .0002),³ for which RAAS blockers and beta-adrenergic blocking drugs have been shown consistently to be beneficial. But the intensive- and standard-therapy groups were not homogeneous in terms of the use of RAAS blockers and beta-blockers.

So, was the cardiovascular benefit attained in the intensive-treatment group in SPRINT due to the benefit of lower blood pressure or to the drugs used?

To the Editor: I read with great interest the article by Thomas et al, “Interpreting SPRINT: How low should you go?”¹

Hypertension is the most prevalent modifiable risk factor, affecting almost one in every three people in the United States.² Moreover, only half of people with hypertension have their blood pressure under control to the current standard of lower than 140/90 mm Hg.² The Systolic Blood Pressure Intervention Trial (SPRINT) tested a lower goal systolic pressure, ie, less than 120 mm Hg, and found it more beneficial than the standard goal of less than 140 mm Hg.³

A drawback of SPRINT that Thomas et al did not address in their interpretation of the trial is that the two study groups were not homogeneous in terms of the antihypertensive drugs used. Antihypertensive drugs do not only lower blood pressure—some of them have additional pleiotropic effects, making their use more advantageous in special situations. For example, renin-angiotensin-aldosterone system (RAAS) blockers—ie, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and mineralocorticoid receptor antagonists—are disease-modfying drugs in heart failure, as are certain beta-blockers.⁴ The cardiovascular benefit seen in the intensive-treatment group in SPRINT compared with the standard-therapy group was primarily due to a reduction in heart failure (a 38% relative risk reduction, P = .0002),³ for which RAAS blockers and beta-adrenergic blocking drugs have been shown consistently to be beneficial. But the intensive- and standard-therapy groups were not homogeneous in terms of the use of RAAS blockers and beta-blockers.

So, was the cardiovascular benefit attained in the intensive-treatment group in SPRINT due to the benefit of lower blood pressure or to the drugs used?

To the Editor: I read with great interest the article by Thomas et al, “Interpreting SPRINT: How low should you go?”¹

Hypertension is the most prevalent modifiable risk factor, affecting almost one in every three people in the United States.² Moreover, only half of people with hypertension have their blood pressure under control to the current standard of lower than 140/90 mm Hg.² The Systolic Blood Pressure Intervention Trial (SPRINT) tested a lower goal systolic pressure, ie, less than 120 mm Hg, and found it more beneficial than the standard goal of less than 140 mm Hg.³

A drawback of SPRINT that Thomas et al did not address in their interpretation of the trial is that the two study groups were not homogeneous in terms of the antihypertensive drugs used. Antihypertensive drugs do not only lower blood pressure—some of them have additional pleiotropic effects, making their use more advantageous in special situations. For example, renin-angiotensin-aldosterone system (RAAS) blockers—ie, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and mineralocorticoid receptor antagonists—are disease-modfying drugs in heart failure, as are certain beta-blockers.⁴ The cardiovascular benefit seen in the intensive-treatment group in SPRINT compared with the standard-therapy group was primarily due to a reduction in heart failure (a 38% relative risk reduction, P = .0002),³ for which RAAS blockers and beta-adrenergic blocking drugs have been shown consistently to be beneficial. But the intensive- and standard-therapy groups were not homogeneous in terms of the use of RAAS blockers and beta-blockers.

So, was the cardiovascular benefit attained in the intensive-treatment group in SPRINT due to the benefit of lower blood pressure or to the drugs used?

A day in the psychiatry clinic? No—just scenes from that high-stakes festival of intense human competitiveness gone awry: the current presidential election. Alas, we have no FDA-approved treatments for any of these unusual political behaviors.

More stunning is how blind some loyal voters are to the flaws of their candidate of choice. They seem to be joyfully intoxicated by sharing the unusual beliefs of the candidate, in a cultish folie en masse of epidemic proportion.

Other (rational) voters are stunned and jarred by what they see and hear; they appear to be in need of Rx: an intellectual antiemetic.

The rise of uber-narcissism
A certain amount of narcissism is, understandably, necessary to run for the nation’s highest office and to believe, against all odds, that winning is certain despite microscopic favorability in the polls. In this election cycle, the cup of narcissism has run over; yet, to adoring fans, narcissism only adds a wondrous halo to their candidate.

The history of the United States is rife with similar behavior by elected officials, including our revered Founding Fathers.¹ But today’s psychiatrists, witnessing this national charade, are perplexed and question the rationality of the national psyche. Established rules for seeking the Presidency have been demolished and the show goes on as if heightened narcissism is the new normal in human behavior.

Giving voice to my colleagues’ consternation
Here are a few thoughts that might cross the mind of psychiatrists as they watch, with a frown and pursed lips, this unconventional election cycle:

From a psychoanalytic perspective, the id has left the ego in its dust, and the super-ego went home to hide.

When boorishness trumps civility, hillaryous consequences ensue.

The gullibility of voters deserves serious scientific study. Jeste and Harris² reviewed the evidence for a neurobiology of wisdom; The National Institutes of Health should fund research into how some voters believe the candidate of their choice will provide them with everything they wish. The chicken in every pot expands to 100 in every pot, and money grows on trees (at least on 1% of the forest!).

From an evolutionary standpoint, survival of the fittest has become survival of the most bombastic.

The zeitgeist reflects an electorate that oscillates agonizingly from surprise to anger to cynicism to disgust.

The traditional internal conflict (studied by political scientists) of choosing between 2 reasonably meritorious candidates has been transformed into a conflict over whether to vote at all.

This is the least nuanced presidential campaign—ever.

All decision-making in politics is unconscious, political scientist Jon A. Krosnick proposed. In this election, however, candidates’ enunciations are so overt that it’s hard to believe there’s anything left in the unconscious. Freud spoke of the “primary process” arising from the unconscious; he definitely was not referring to the primary process we experienced during this election cycle.

From a neuropsychiatric perspective, the limbic system has kicked the cortex in the metaphorical derrière in this election campaign.

Unabashed display of character flaws, personal shortcomings, and biases prove that anyone can run for president in a democracy, and that some voters will display a flight of reason and vote for a flawed candidate.

Even an inept demagogue can be misperceived as a savior by followers. Some voters could use a few sessions of insight-oriented therapy or cognitive-behavioral therapy for their unrealistic expectations.

It is dizzying, mentally, to watch candidates’ verbal acrobatics as they try to pass several litmus tests to satisfy disparate demands of sundry constituencies and mendaciously flip-flop on many issues—ignoring the fact that everything they have said was recorded or videotaped. Intellectual transvestism is a political sin, and sinners abound.

Oh, for a Jenner, Pasteur, or Sabin to discover vaccines for the intellect
Writing this editorial has been therapeutic. It feels good to ventilate about this bizarre election process that has the nation in its grip. I would feel much better if neuroscientists would develop and license vaccines that would broadly inoculate candidates against demagoguery, dishonesty, and pandering and voters against mind-boggling gullibility.

That would make elections so boring. But also so on-label….

A day in the psychiatry clinic? No—just scenes from that high-stakes festival of intense human competitiveness gone awry: the current presidential election. Alas, we have no FDA-approved treatments for any of these unusual political behaviors.

More stunning is how blind some loyal voters are to the flaws of their candidate of choice. They seem to be joyfully intoxicated by sharing the unusual beliefs of the candidate, in a cultish folie en masse of epidemic proportion.

Other (rational) voters are stunned and jarred by what they see and hear; they appear to be in need of Rx: an intellectual antiemetic.

The rise of uber-narcissism
A certain amount of narcissism is, understandably, necessary to run for the nation’s highest office and to believe, against all odds, that winning is certain despite microscopic favorability in the polls. In this election cycle, the cup of narcissism has run over; yet, to adoring fans, narcissism only adds a wondrous halo to their candidate.

The history of the United States is rife with similar behavior by elected officials, including our revered Founding Fathers.¹ But today’s psychiatrists, witnessing this national charade, are perplexed and question the rationality of the national psyche. Established rules for seeking the Presidency have been demolished and the show goes on as if heightened narcissism is the new normal in human behavior.

Giving voice to my colleagues’ consternation
Here are a few thoughts that might cross the mind of psychiatrists as they watch, with a frown and pursed lips, this unconventional election cycle:

From a psychoanalytic perspective, the id has left the ego in its dust, and the super-ego went home to hide.

When boorishness trumps civility, hillaryous consequences ensue.

The gullibility of voters deserves serious scientific study. Jeste and Harris² reviewed the evidence for a neurobiology of wisdom; The National Institutes of Health should fund research into how some voters believe the candidate of their choice will provide them with everything they wish. The chicken in every pot expands to 100 in every pot, and money grows on trees (at least on 1% of the forest!).

From an evolutionary standpoint, survival of the fittest has become survival of the most bombastic.

The zeitgeist reflects an electorate that oscillates agonizingly from surprise to anger to cynicism to disgust.

The traditional internal conflict (studied by political scientists) of choosing between 2 reasonably meritorious candidates has been transformed into a conflict over whether to vote at all.

This is the least nuanced presidential campaign—ever.

All decision-making in politics is unconscious, political scientist Jon A. Krosnick proposed. In this election, however, candidates’ enunciations are so overt that it’s hard to believe there’s anything left in the unconscious. Freud spoke of the “primary process” arising from the unconscious; he definitely was not referring to the primary process we experienced during this election cycle.

From a neuropsychiatric perspective, the limbic system has kicked the cortex in the metaphorical derrière in this election campaign.

Unabashed display of character flaws, personal shortcomings, and biases prove that anyone can run for president in a democracy, and that some voters will display a flight of reason and vote for a flawed candidate.

Even an inept demagogue can be misperceived as a savior by followers. Some voters could use a few sessions of insight-oriented therapy or cognitive-behavioral therapy for their unrealistic expectations.

It is dizzying, mentally, to watch candidates’ verbal acrobatics as they try to pass several litmus tests to satisfy disparate demands of sundry constituencies and mendaciously flip-flop on many issues—ignoring the fact that everything they have said was recorded or videotaped. Intellectual transvestism is a political sin, and sinners abound.

Oh, for a Jenner, Pasteur, or Sabin to discover vaccines for the intellect
Writing this editorial has been therapeutic. It feels good to ventilate about this bizarre election process that has the nation in its grip. I would feel much better if neuroscientists would develop and license vaccines that would broadly inoculate candidates against demagoguery, dishonesty, and pandering and voters against mind-boggling gullibility.

That would make elections so boring. But also so on-label….

A day in the psychiatry clinic? No—just scenes from that high-stakes festival of intense human competitiveness gone awry: the current presidential election. Alas, we have no FDA-approved treatments for any of these unusual political behaviors.

More stunning is how blind some loyal voters are to the flaws of their candidate of choice. They seem to be joyfully intoxicated by sharing the unusual beliefs of the candidate, in a cultish folie en masse of epidemic proportion.

Other (rational) voters are stunned and jarred by what they see and hear; they appear to be in need of Rx: an intellectual antiemetic.

The rise of uber-narcissism
A certain amount of narcissism is, understandably, necessary to run for the nation’s highest office and to believe, against all odds, that winning is certain despite microscopic favorability in the polls. In this election cycle, the cup of narcissism has run over; yet, to adoring fans, narcissism only adds a wondrous halo to their candidate.

The history of the United States is rife with similar behavior by elected officials, including our revered Founding Fathers.¹ But today’s psychiatrists, witnessing this national charade, are perplexed and question the rationality of the national psyche. Established rules for seeking the Presidency have been demolished and the show goes on as if heightened narcissism is the new normal in human behavior.

Giving voice to my colleagues’ consternation
Here are a few thoughts that might cross the mind of psychiatrists as they watch, with a frown and pursed lips, this unconventional election cycle:

From a psychoanalytic perspective, the id has left the ego in its dust, and the super-ego went home to hide.

When boorishness trumps civility, hillaryous consequences ensue.

The gullibility of voters deserves serious scientific study. Jeste and Harris² reviewed the evidence for a neurobiology of wisdom; The National Institutes of Health should fund research into how some voters believe the candidate of their choice will provide them with everything they wish. The chicken in every pot expands to 100 in every pot, and money grows on trees (at least on 1% of the forest!).

From an evolutionary standpoint, survival of the fittest has become survival of the most bombastic.

The zeitgeist reflects an electorate that oscillates agonizingly from surprise to anger to cynicism to disgust.

The traditional internal conflict (studied by political scientists) of choosing between 2 reasonably meritorious candidates has been transformed into a conflict over whether to vote at all.

This is the least nuanced presidential campaign—ever.

All decision-making in politics is unconscious, political scientist Jon A. Krosnick proposed. In this election, however, candidates’ enunciations are so overt that it’s hard to believe there’s anything left in the unconscious. Freud spoke of the “primary process” arising from the unconscious; he definitely was not referring to the primary process we experienced during this election cycle.

From a neuropsychiatric perspective, the limbic system has kicked the cortex in the metaphorical derrière in this election campaign.

Unabashed display of character flaws, personal shortcomings, and biases prove that anyone can run for president in a democracy, and that some voters will display a flight of reason and vote for a flawed candidate.

Even an inept demagogue can be misperceived as a savior by followers. Some voters could use a few sessions of insight-oriented therapy or cognitive-behavioral therapy for their unrealistic expectations.

It is dizzying, mentally, to watch candidates’ verbal acrobatics as they try to pass several litmus tests to satisfy disparate demands of sundry constituencies and mendaciously flip-flop on many issues—ignoring the fact that everything they have said was recorded or videotaped. Intellectual transvestism is a political sin, and sinners abound.

Oh, for a Jenner, Pasteur, or Sabin to discover vaccines for the intellect
Writing this editorial has been therapeutic. It feels good to ventilate about this bizarre election process that has the nation in its grip. I would feel much better if neuroscientists would develop and license vaccines that would broadly inoculate candidates against demagoguery, dishonesty, and pandering and voters against mind-boggling gullibility.

That would make elections so boring. But also so on-label….

Granulosa cell tumors arise from ovarian sex cords and make up an estimated 1% of all ovarian cancer cases but comprise more than 70% of all sex cord stromal tumors.

Granulosa cell tumors (GCTs) can be divided into adult and juvenile types. Adult GCTs are much more common, representing 95% of all GCTs. Women diagnosed with adult GCTs are typically younger as compared with those with epithelial ovarian cancer. The average age of diagnosis for adult GCTs is 50 years, and for women with juvenile GCTs, the average age at diagnosis is 20 years.

Granulosa cell tumors have been shown to be more common in nonwhite women, those with a high body mass index, and a family history of breast or ovarian cancer.¹

Adult GCTs can be associated with Peutz-Jeghers and Potter syndromes. Juvenile GCTs are exceedingly rare but can also be associated with mesodermal dysplastic syndromes characterized by the presence of enchondromatosis and hemangioma formation, such as Ollier disease or Maffucci syndrome.

Adult granulosa cell tumors are large, hormonally active tumors; typically secreting estrogen and associated with symptoms of hyperestrogenism. In one study, 55% of women with GCTs were reported to have hyperestrogenic findings such as breast tenderness, virulism, abnormal or postmenopausal bleeding, and hyperplasia, and those with juvenile GCTs may present with precocious puberty.^2,3

In pregnancy, hormonal symptoms are temporized, thus the most common presentation is acute rupture. Initial evaluation of women with adult GCTs will reveal a palpable unilateral pelvic mass typically larger than 10cm. Juvenile and adult GCTs are unilateral in 95% of cases.⁴

In women presenting with a large adnexal mass, the appropriate initial clinical evaluation includes radiographic and laboratory studies. Endovaginal ultrasound typically reveals a large adnexal mass with heterogeneous solid and cystic components, areas of hemorrhage or necrosis and increased vascularity on Doppler. Juvenile GCTs have a more distinct appearance of solid growth with focal areas of follicular formation.

Laboratory findings suggestive of GCT include elevated inhibin-A, inhibin-B, anti-Mullerian hormone (AMH), and CA-125. Inhibin-B is the most commonly used tumor marker for the clinical monitoring of adult GCTs, but AMH may be the most specific.⁵ Lastly, an endometrial biopsy should be considered in all patients with abnormal uterine bleeding and in all postmenopausal women with an adnexal mass and an endometrial stripe greater than 5mm.⁶

Surgical staging for adult GCTs is the standard of care. For women who do not desire fertility, this includes total hysterectomy, bilateral salpingo-oophorectomy and removal of all gross disease. Comprehensive nodal dissection is not indicated except when necessary for complete cytoreduction. In contrast to epithelial ovarian cancer, approximately 80% of women with adult GCTs are diagnosed with stage I disease. For stage IA disease, treatment with surgery alone is sufficient, yet in women with stage II-IV disease or with tumors that are ruptured intraoperatively, platinum-based chemotherapy is recommended. The most common regimen is bleomycin, etoposide, and cisplatin, though there is increasing experience with an outpatient regimen of paclitaxel and carboplatin.

The gross appearance of both adult and juvenile GCTs are of a large, tan-yellow tumor with cystic, solid, and hemorrhagic components. Microscopically, juvenile GCTs are more distinct than that of adult GCTs. Whereas adult GCTs comprise diffuse cords or trabeculae and small follicles termed Call-Exner bodies of rounded cells with scant cytoplasm and pale “coffee-bean” nuclei, juvenile GCTs have nuclei that are rounded, hyperchromatic with moderate to abundant eosinophilic or vacuolated cytoplasm.

The prognosis of GCTs is largely dependent on the stage at diagnosis and presence of residual disease after debulking. Negative prognostic factors for recurrence include tumor size, rupture, atypia and increased mitotic activity.

There are distinct clinical, radiographic, and laboratory characteristics that may raise the suspicion of the practicing gynecologist for a GCT. In such cases, expedient referral for surgical exploration to a gynecologic oncologist is warranted. If the tumor is encountered inadvertently, intraoperative consultation from a gynecologic oncologist should be requested. If a gynecologic oncologist is not available, it is paramount to optimize surgical exposure to clearly document any abnormal pelvic or intra-abdominal findings, take care to prevent surgical spillage, and preserve fertility if indicated.

If referred appropriately and completely resected, the 5-year overall survival of stage IA disease can be upward of 90%. Recurrences are stage dependent with an average time to recurrence of just under 5 years. When recurrences occur, they tend to happen in the pelvis. All women with a history of GCT will require surveillance and monitoring.

References

1. Gynecol Oncol. 2005 May;97(2):519-23.

2. “Rare and Uncommon Gynecological Cancers: A Clinical Guide” (Heidelberg: Springer, 2011): Reed N.

3. Obstet Gynecol. 1980 Feb;55(2):231-8.

4. “Principles and Practice of Gynecologic Oncology” (Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2013): Barakat R.

5. Indian J Surg Oncol. 2013 Mar;4(1):37-47.

6. “Uncommon Gynecologic Cancers” (Indianapolis: Wiley-Blackwell, 2014): Del Carmen M.

Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Castellano is a resident physician in the obstetrics and gynecology program at the university. They reported having no relevant financial disclosures. To comment, email them at [email protected].

Granulosa cell tumors arise from ovarian sex cords and make up an estimated 1% of all ovarian cancer cases but comprise more than 70% of all sex cord stromal tumors.

Granulosa cell tumors (GCTs) can be divided into adult and juvenile types. Adult GCTs are much more common, representing 95% of all GCTs. Women diagnosed with adult GCTs are typically younger as compared with those with epithelial ovarian cancer. The average age of diagnosis for adult GCTs is 50 years, and for women with juvenile GCTs, the average age at diagnosis is 20 years.

Granulosa cell tumors have been shown to be more common in nonwhite women, those with a high body mass index, and a family history of breast or ovarian cancer.¹

Adult GCTs can be associated with Peutz-Jeghers and Potter syndromes. Juvenile GCTs are exceedingly rare but can also be associated with mesodermal dysplastic syndromes characterized by the presence of enchondromatosis and hemangioma formation, such as Ollier disease or Maffucci syndrome.

Adult granulosa cell tumors are large, hormonally active tumors; typically secreting estrogen and associated with symptoms of hyperestrogenism. In one study, 55% of women with GCTs were reported to have hyperestrogenic findings such as breast tenderness, virulism, abnormal or postmenopausal bleeding, and hyperplasia, and those with juvenile GCTs may present with precocious puberty.^2,3

In pregnancy, hormonal symptoms are temporized, thus the most common presentation is acute rupture. Initial evaluation of women with adult GCTs will reveal a palpable unilateral pelvic mass typically larger than 10cm. Juvenile and adult GCTs are unilateral in 95% of cases.⁴

In women presenting with a large adnexal mass, the appropriate initial clinical evaluation includes radiographic and laboratory studies. Endovaginal ultrasound typically reveals a large adnexal mass with heterogeneous solid and cystic components, areas of hemorrhage or necrosis and increased vascularity on Doppler. Juvenile GCTs have a more distinct appearance of solid growth with focal areas of follicular formation.

Laboratory findings suggestive of GCT include elevated inhibin-A, inhibin-B, anti-Mullerian hormone (AMH), and CA-125. Inhibin-B is the most commonly used tumor marker for the clinical monitoring of adult GCTs, but AMH may be the most specific.⁵ Lastly, an endometrial biopsy should be considered in all patients with abnormal uterine bleeding and in all postmenopausal women with an adnexal mass and an endometrial stripe greater than 5mm.⁶

Surgical staging for adult GCTs is the standard of care. For women who do not desire fertility, this includes total hysterectomy, bilateral salpingo-oophorectomy and removal of all gross disease. Comprehensive nodal dissection is not indicated except when necessary for complete cytoreduction. In contrast to epithelial ovarian cancer, approximately 80% of women with adult GCTs are diagnosed with stage I disease. For stage IA disease, treatment with surgery alone is sufficient, yet in women with stage II-IV disease or with tumors that are ruptured intraoperatively, platinum-based chemotherapy is recommended. The most common regimen is bleomycin, etoposide, and cisplatin, though there is increasing experience with an outpatient regimen of paclitaxel and carboplatin.

The gross appearance of both adult and juvenile GCTs are of a large, tan-yellow tumor with cystic, solid, and hemorrhagic components. Microscopically, juvenile GCTs are more distinct than that of adult GCTs. Whereas adult GCTs comprise diffuse cords or trabeculae and small follicles termed Call-Exner bodies of rounded cells with scant cytoplasm and pale “coffee-bean” nuclei, juvenile GCTs have nuclei that are rounded, hyperchromatic with moderate to abundant eosinophilic or vacuolated cytoplasm.

The prognosis of GCTs is largely dependent on the stage at diagnosis and presence of residual disease after debulking. Negative prognostic factors for recurrence include tumor size, rupture, atypia and increased mitotic activity.

There are distinct clinical, radiographic, and laboratory characteristics that may raise the suspicion of the practicing gynecologist for a GCT. In such cases, expedient referral for surgical exploration to a gynecologic oncologist is warranted. If the tumor is encountered inadvertently, intraoperative consultation from a gynecologic oncologist should be requested. If a gynecologic oncologist is not available, it is paramount to optimize surgical exposure to clearly document any abnormal pelvic or intra-abdominal findings, take care to prevent surgical spillage, and preserve fertility if indicated.

If referred appropriately and completely resected, the 5-year overall survival of stage IA disease can be upward of 90%. Recurrences are stage dependent with an average time to recurrence of just under 5 years. When recurrences occur, they tend to happen in the pelvis. All women with a history of GCT will require surveillance and monitoring.

References

1. Gynecol Oncol. 2005 May;97(2):519-23.

2. “Rare and Uncommon Gynecological Cancers: A Clinical Guide” (Heidelberg: Springer, 2011): Reed N.

3. Obstet Gynecol. 1980 Feb;55(2):231-8.

4. “Principles and Practice of Gynecologic Oncology” (Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2013): Barakat R.

5. Indian J Surg Oncol. 2013 Mar;4(1):37-47.

6. “Uncommon Gynecologic Cancers” (Indianapolis: Wiley-Blackwell, 2014): Del Carmen M.

Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Castellano is a resident physician in the obstetrics and gynecology program at the university. They reported having no relevant financial disclosures. To comment, email them at [email protected].

Granulosa cell tumors arise from ovarian sex cords and make up an estimated 1% of all ovarian cancer cases but comprise more than 70% of all sex cord stromal tumors.

Granulosa cell tumors (GCTs) can be divided into adult and juvenile types. Adult GCTs are much more common, representing 95% of all GCTs. Women diagnosed with adult GCTs are typically younger as compared with those with epithelial ovarian cancer. The average age of diagnosis for adult GCTs is 50 years, and for women with juvenile GCTs, the average age at diagnosis is 20 years.

Granulosa cell tumors have been shown to be more common in nonwhite women, those with a high body mass index, and a family history of breast or ovarian cancer.¹

Adult GCTs can be associated with Peutz-Jeghers and Potter syndromes. Juvenile GCTs are exceedingly rare but can also be associated with mesodermal dysplastic syndromes characterized by the presence of enchondromatosis and hemangioma formation, such as Ollier disease or Maffucci syndrome.

Adult granulosa cell tumors are large, hormonally active tumors; typically secreting estrogen and associated with symptoms of hyperestrogenism. In one study, 55% of women with GCTs were reported to have hyperestrogenic findings such as breast tenderness, virulism, abnormal or postmenopausal bleeding, and hyperplasia, and those with juvenile GCTs may present with precocious puberty.^2,3

In pregnancy, hormonal symptoms are temporized, thus the most common presentation is acute rupture. Initial evaluation of women with adult GCTs will reveal a palpable unilateral pelvic mass typically larger than 10cm. Juvenile and adult GCTs are unilateral in 95% of cases.⁴

In women presenting with a large adnexal mass, the appropriate initial clinical evaluation includes radiographic and laboratory studies. Endovaginal ultrasound typically reveals a large adnexal mass with heterogeneous solid and cystic components, areas of hemorrhage or necrosis and increased vascularity on Doppler. Juvenile GCTs have a more distinct appearance of solid growth with focal areas of follicular formation.

Laboratory findings suggestive of GCT include elevated inhibin-A, inhibin-B, anti-Mullerian hormone (AMH), and CA-125. Inhibin-B is the most commonly used tumor marker for the clinical monitoring of adult GCTs, but AMH may be the most specific.⁵ Lastly, an endometrial biopsy should be considered in all patients with abnormal uterine bleeding and in all postmenopausal women with an adnexal mass and an endometrial stripe greater than 5mm.⁶

Surgical staging for adult GCTs is the standard of care. For women who do not desire fertility, this includes total hysterectomy, bilateral salpingo-oophorectomy and removal of all gross disease. Comprehensive nodal dissection is not indicated except when necessary for complete cytoreduction. In contrast to epithelial ovarian cancer, approximately 80% of women with adult GCTs are diagnosed with stage I disease. For stage IA disease, treatment with surgery alone is sufficient, yet in women with stage II-IV disease or with tumors that are ruptured intraoperatively, platinum-based chemotherapy is recommended. The most common regimen is bleomycin, etoposide, and cisplatin, though there is increasing experience with an outpatient regimen of paclitaxel and carboplatin.

The gross appearance of both adult and juvenile GCTs are of a large, tan-yellow tumor with cystic, solid, and hemorrhagic components. Microscopically, juvenile GCTs are more distinct than that of adult GCTs. Whereas adult GCTs comprise diffuse cords or trabeculae and small follicles termed Call-Exner bodies of rounded cells with scant cytoplasm and pale “coffee-bean” nuclei, juvenile GCTs have nuclei that are rounded, hyperchromatic with moderate to abundant eosinophilic or vacuolated cytoplasm.

The prognosis of GCTs is largely dependent on the stage at diagnosis and presence of residual disease after debulking. Negative prognostic factors for recurrence include tumor size, rupture, atypia and increased mitotic activity.

There are distinct clinical, radiographic, and laboratory characteristics that may raise the suspicion of the practicing gynecologist for a GCT. In such cases, expedient referral for surgical exploration to a gynecologic oncologist is warranted. If the tumor is encountered inadvertently, intraoperative consultation from a gynecologic oncologist should be requested. If a gynecologic oncologist is not available, it is paramount to optimize surgical exposure to clearly document any abnormal pelvic or intra-abdominal findings, take care to prevent surgical spillage, and preserve fertility if indicated.

If referred appropriately and completely resected, the 5-year overall survival of stage IA disease can be upward of 90%. Recurrences are stage dependent with an average time to recurrence of just under 5 years. When recurrences occur, they tend to happen in the pelvis. All women with a history of GCT will require surveillance and monitoring.

References

1. Gynecol Oncol. 2005 May;97(2):519-23.

2. “Rare and Uncommon Gynecological Cancers: A Clinical Guide” (Heidelberg: Springer, 2011): Reed N.

3. Obstet Gynecol. 1980 Feb;55(2):231-8.

4. “Principles and Practice of Gynecologic Oncology” (Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2013): Barakat R.

5. Indian J Surg Oncol. 2013 Mar;4(1):37-47.

6. “Uncommon Gynecologic Cancers” (Indianapolis: Wiley-Blackwell, 2014): Del Carmen M.

Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Castellano is a resident physician in the obstetrics and gynecology program at the university. They reported having no relevant financial disclosures. To comment, email them at [email protected].

To the Editor: In their review,¹ Thomas et al noted that the benefits of intensive blood pressure lowering seen in the SPRINT study² were not observed in the Action to Control Cardiovascular Risk in Diabetes-Blood pressure (ACCORD BP) trial³ or in the Secondary Prevention of Small Subcortical Strokes (SPS3) trial.⁴ In addition to the reasons discussed in their review, the discrepancy may be due to the surprisingly low rate of statin use in the patients enrolled in SPRINT. Even though 61% of the patients in SPRINT had a 10-year Framingham risk score greater than 15%, only 44% of the patients were on statin therapy. In comparison, rates of statin use in ACCORD BP and SPS3 were 65% and 83%, respectively.

A possible interaction between statin use and intensive blood pressure lowering is consistent with previous data on angiotensin-converting enzyme (ACE) inhibitor use in high-risk populations.

The Heart Outcomes Prevention Evaluation (HOPE) trial,⁵ in which only 29% of patients received lipid-lowering therapy, found that ACE inhibitor use was associated with a significant reduction in a composite cardiovascular outcome, whereas the Prevention of Events With Angiotensin-Converting Enzyme Inhibitor Therapy (PEACE) trial,⁶ in which 70% of patients were on lipid-lowering therapy, did not show a benefit for ACE inhibitor therapy. In addition, there are many drug interactions between statins and calcium channel blockers, potentially limiting options for simultaneous aggressive treatment of lipid levels and blood pressure.

In summary, aggressive use of statins may confer sufficient cardiovascular protection when aggressive antihypertensive therapy provides little or no incremental benefit. Hopefully, further analyses of these trials will shed light on this important question.

To the Editor: In their review,¹ Thomas et al noted that the benefits of intensive blood pressure lowering seen in the SPRINT study² were not observed in the Action to Control Cardiovascular Risk in Diabetes-Blood pressure (ACCORD BP) trial³ or in the Secondary Prevention of Small Subcortical Strokes (SPS3) trial.⁴ In addition to the reasons discussed in their review, the discrepancy may be due to the surprisingly low rate of statin use in the patients enrolled in SPRINT. Even though 61% of the patients in SPRINT had a 10-year Framingham risk score greater than 15%, only 44% of the patients were on statin therapy. In comparison, rates of statin use in ACCORD BP and SPS3 were 65% and 83%, respectively.

A possible interaction between statin use and intensive blood pressure lowering is consistent with previous data on angiotensin-converting enzyme (ACE) inhibitor use in high-risk populations.

The Heart Outcomes Prevention Evaluation (HOPE) trial,⁵ in which only 29% of patients received lipid-lowering therapy, found that ACE inhibitor use was associated with a significant reduction in a composite cardiovascular outcome, whereas the Prevention of Events With Angiotensin-Converting Enzyme Inhibitor Therapy (PEACE) trial,⁶ in which 70% of patients were on lipid-lowering therapy, did not show a benefit for ACE inhibitor therapy. In addition, there are many drug interactions between statins and calcium channel blockers, potentially limiting options for simultaneous aggressive treatment of lipid levels and blood pressure.

In summary, aggressive use of statins may confer sufficient cardiovascular protection when aggressive antihypertensive therapy provides little or no incremental benefit. Hopefully, further analyses of these trials will shed light on this important question.

To the Editor: In their review,¹ Thomas et al noted that the benefits of intensive blood pressure lowering seen in the SPRINT study² were not observed in the Action to Control Cardiovascular Risk in Diabetes-Blood pressure (ACCORD BP) trial³ or in the Secondary Prevention of Small Subcortical Strokes (SPS3) trial.⁴ In addition to the reasons discussed in their review, the discrepancy may be due to the surprisingly low rate of statin use in the patients enrolled in SPRINT. Even though 61% of the patients in SPRINT had a 10-year Framingham risk score greater than 15%, only 44% of the patients were on statin therapy. In comparison, rates of statin use in ACCORD BP and SPS3 were 65% and 83%, respectively.

A possible interaction between statin use and intensive blood pressure lowering is consistent with previous data on angiotensin-converting enzyme (ACE) inhibitor use in high-risk populations.

The Heart Outcomes Prevention Evaluation (HOPE) trial,⁵ in which only 29% of patients received lipid-lowering therapy, found that ACE inhibitor use was associated with a significant reduction in a composite cardiovascular outcome, whereas the Prevention of Events With Angiotensin-Converting Enzyme Inhibitor Therapy (PEACE) trial,⁶ in which 70% of patients were on lipid-lowering therapy, did not show a benefit for ACE inhibitor therapy. In addition, there are many drug interactions between statins and calcium channel blockers, potentially limiting options for simultaneous aggressive treatment of lipid levels and blood pressure.

In summary, aggressive use of statins may confer sufficient cardiovascular protection when aggressive antihypertensive therapy provides little or no incremental benefit. Hopefully, further analyses of these trials will shed light on this important question.