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AI-Aided Stethoscope Beats PCP in Detecting Valvular HD
, a new study shows.
The results suggest collecting relevant sounds through a stethoscope (auscultation) using AI-powered technology is an important primary care tool to detect VHD, study author Moshe A. Rancier, MD, medical director, Massachusetts General Brigham Community Physicians, Lawrence, Massachusetts, said in an interview.
“Incorporating this AI-assisted device into the primary care exam will help identify patients at risk for VHD earlier and eventually decrease costs in our healthcare system,” he said, because timely detection could avoid emergency room visits and surgeries.
The findings were presented at the annual scientific sessions of the American Heart Association.
VHD Common
Clinically significant VHD, indicating structural damage to heart valves, affects 1 in 10 adults older than 65 years. Patients may be asymptomatic or present to their PCP with an unspecific symptom like fatigue or malaise.
If VHD is undiagnosed and left untreated, patients could develop more severe symptoms, even be at risk for death, and their quality of life is significantly affected, said Dr. Rancier.
Cardiac auscultation, the current point-of-care clinical standard, has relatively low sensitivity for detecting VHD, leaving most patients undiagnosed.
The deep learning–based AI tool uses sound data to detect cardiac murmurs associated with clinically significant VHD. The device used in the study (Eko; Eko Health) is approved by the US Food and Drug Administration and is on the market.
The tool identifies background sounds that might affect the evaluation. “If there’s any noise or breath sounds, it tells me this is not a good heart sound, and asks me to record again,” said Dr. Rancier.
A doctor using the AI-assisted stethoscope carries out the auscultation exam with the sound data captured by a smartphone or tablet and sent to the AI server. “I get an answer in a second as to if there’s a murmur or not,” said Dr. Rancier.
Not only that, but the tool can determine if it’s a systolic or diastolic murmur, he added.
Real-World Population
The study enrolled a “real-world” population of 368 patients, median age 70 years, 61% female, 70% White, and 18% Hispanic without a prior VHD diagnosis or history of murmur, from three primary care clinics in Queens, New York, and Lawrence and Haverhill, Massachusetts.
About 79% of the cohort had hypertension, 68% had dyslipidemia, and 38% had diabetes, “which aligns with the population in the US,” said Dr. Rancier.
Each study participant had a regular exam carried out by Dr. Rancier using a traditional stethoscope to detect murmurs and an exam by a technician with a digital stethoscope that collected phonocardiogram (PCG) data for analysis by AI.
In addition, each patient received an echocardiogram 1-2 weeks later to confirm whether clinically significant VHD was present. An expert panel of cardiologists also reviewed the patient’s PCG recordings to confirm the presence of audible murmurs.
Dr. Rancier and the expert panel were blinded to AI and echocardiogram results.
Researchers calculated performance metrics for both PCP auscultation and the AI in detecting audible VHD.
The study showed that AI improved sensitivity to detect audible VHD by over twofold compared with PCP auscultation (94.1% vs 41.2%), with limited impact on specificity (84.5% vs 95.5%).
Dr. Rancier stressed the importance of sensitivity because clinicians tend to under-detect murmurs. “You don’t want to miss those patients because the consequences of undiagnosed VHD are dire.”
The AI tool identified 22 patients with moderate or greater VHD who were previously undiagnosed, whereas PCPs identified eight previously undiagnosed patients with VHD.
Dr. Rancier sees this tool being used beyond primary care, perhaps by emergency room personnel.
The authors plan to follow study participants and assess outcomes at for 6-12 months. They also aim to include more patients to increase the study’s power.
Expanding the Technology
They are also interested to see whether the technology can determine which valve is affected; for example, whether the issue is aortic stenosis or mitral regurgitation.
A limitation of the study was its small sample size.
Commenting on the findings, Dan Roden, MD, professor of medicine, pharmacology, and biomedical informatics, senior vice president for personalized medicine at Vanderbilt University Medical Center, Nashville, Tennessee, and chair of the American Heart Association Council on Genomic and Precision Medicine, noted that it demonstrated the AI-based stethoscope “did extraordinarily well” in predicting VHD.
“I see this as an emerging technology — using an AI-enabled stethoscope and perhaps combining it with other imaging modalities, like an AI-enabled echocardiogram built into your stethoscope,” said Dr. Roden.
“Use of these new tools to detect the presence of valvular disease, as well as the extent of valvular disease and the extent of other kinds of heart disease, will likely help to transform CVD care.”
The study was funded by Eko Health Inc. Dr. Rancier and Dr. Roden have no relevant conflicts of interest.
A version of this article appeared on Medscape.com.
, a new study shows.
The results suggest collecting relevant sounds through a stethoscope (auscultation) using AI-powered technology is an important primary care tool to detect VHD, study author Moshe A. Rancier, MD, medical director, Massachusetts General Brigham Community Physicians, Lawrence, Massachusetts, said in an interview.
“Incorporating this AI-assisted device into the primary care exam will help identify patients at risk for VHD earlier and eventually decrease costs in our healthcare system,” he said, because timely detection could avoid emergency room visits and surgeries.
The findings were presented at the annual scientific sessions of the American Heart Association.
VHD Common
Clinically significant VHD, indicating structural damage to heart valves, affects 1 in 10 adults older than 65 years. Patients may be asymptomatic or present to their PCP with an unspecific symptom like fatigue or malaise.
If VHD is undiagnosed and left untreated, patients could develop more severe symptoms, even be at risk for death, and their quality of life is significantly affected, said Dr. Rancier.
Cardiac auscultation, the current point-of-care clinical standard, has relatively low sensitivity for detecting VHD, leaving most patients undiagnosed.
The deep learning–based AI tool uses sound data to detect cardiac murmurs associated with clinically significant VHD. The device used in the study (Eko; Eko Health) is approved by the US Food and Drug Administration and is on the market.
The tool identifies background sounds that might affect the evaluation. “If there’s any noise or breath sounds, it tells me this is not a good heart sound, and asks me to record again,” said Dr. Rancier.
A doctor using the AI-assisted stethoscope carries out the auscultation exam with the sound data captured by a smartphone or tablet and sent to the AI server. “I get an answer in a second as to if there’s a murmur or not,” said Dr. Rancier.
Not only that, but the tool can determine if it’s a systolic or diastolic murmur, he added.
Real-World Population
The study enrolled a “real-world” population of 368 patients, median age 70 years, 61% female, 70% White, and 18% Hispanic without a prior VHD diagnosis or history of murmur, from three primary care clinics in Queens, New York, and Lawrence and Haverhill, Massachusetts.
About 79% of the cohort had hypertension, 68% had dyslipidemia, and 38% had diabetes, “which aligns with the population in the US,” said Dr. Rancier.
Each study participant had a regular exam carried out by Dr. Rancier using a traditional stethoscope to detect murmurs and an exam by a technician with a digital stethoscope that collected phonocardiogram (PCG) data for analysis by AI.
In addition, each patient received an echocardiogram 1-2 weeks later to confirm whether clinically significant VHD was present. An expert panel of cardiologists also reviewed the patient’s PCG recordings to confirm the presence of audible murmurs.
Dr. Rancier and the expert panel were blinded to AI and echocardiogram results.
Researchers calculated performance metrics for both PCP auscultation and the AI in detecting audible VHD.
The study showed that AI improved sensitivity to detect audible VHD by over twofold compared with PCP auscultation (94.1% vs 41.2%), with limited impact on specificity (84.5% vs 95.5%).
Dr. Rancier stressed the importance of sensitivity because clinicians tend to under-detect murmurs. “You don’t want to miss those patients because the consequences of undiagnosed VHD are dire.”
The AI tool identified 22 patients with moderate or greater VHD who were previously undiagnosed, whereas PCPs identified eight previously undiagnosed patients with VHD.
Dr. Rancier sees this tool being used beyond primary care, perhaps by emergency room personnel.
The authors plan to follow study participants and assess outcomes at for 6-12 months. They also aim to include more patients to increase the study’s power.
Expanding the Technology
They are also interested to see whether the technology can determine which valve is affected; for example, whether the issue is aortic stenosis or mitral regurgitation.
A limitation of the study was its small sample size.
Commenting on the findings, Dan Roden, MD, professor of medicine, pharmacology, and biomedical informatics, senior vice president for personalized medicine at Vanderbilt University Medical Center, Nashville, Tennessee, and chair of the American Heart Association Council on Genomic and Precision Medicine, noted that it demonstrated the AI-based stethoscope “did extraordinarily well” in predicting VHD.
“I see this as an emerging technology — using an AI-enabled stethoscope and perhaps combining it with other imaging modalities, like an AI-enabled echocardiogram built into your stethoscope,” said Dr. Roden.
“Use of these new tools to detect the presence of valvular disease, as well as the extent of valvular disease and the extent of other kinds of heart disease, will likely help to transform CVD care.”
The study was funded by Eko Health Inc. Dr. Rancier and Dr. Roden have no relevant conflicts of interest.
A version of this article appeared on Medscape.com.
, a new study shows.
The results suggest collecting relevant sounds through a stethoscope (auscultation) using AI-powered technology is an important primary care tool to detect VHD, study author Moshe A. Rancier, MD, medical director, Massachusetts General Brigham Community Physicians, Lawrence, Massachusetts, said in an interview.
“Incorporating this AI-assisted device into the primary care exam will help identify patients at risk for VHD earlier and eventually decrease costs in our healthcare system,” he said, because timely detection could avoid emergency room visits and surgeries.
The findings were presented at the annual scientific sessions of the American Heart Association.
VHD Common
Clinically significant VHD, indicating structural damage to heart valves, affects 1 in 10 adults older than 65 years. Patients may be asymptomatic or present to their PCP with an unspecific symptom like fatigue or malaise.
If VHD is undiagnosed and left untreated, patients could develop more severe symptoms, even be at risk for death, and their quality of life is significantly affected, said Dr. Rancier.
Cardiac auscultation, the current point-of-care clinical standard, has relatively low sensitivity for detecting VHD, leaving most patients undiagnosed.
The deep learning–based AI tool uses sound data to detect cardiac murmurs associated with clinically significant VHD. The device used in the study (Eko; Eko Health) is approved by the US Food and Drug Administration and is on the market.
The tool identifies background sounds that might affect the evaluation. “If there’s any noise or breath sounds, it tells me this is not a good heart sound, and asks me to record again,” said Dr. Rancier.
A doctor using the AI-assisted stethoscope carries out the auscultation exam with the sound data captured by a smartphone or tablet and sent to the AI server. “I get an answer in a second as to if there’s a murmur or not,” said Dr. Rancier.
Not only that, but the tool can determine if it’s a systolic or diastolic murmur, he added.
Real-World Population
The study enrolled a “real-world” population of 368 patients, median age 70 years, 61% female, 70% White, and 18% Hispanic without a prior VHD diagnosis or history of murmur, from three primary care clinics in Queens, New York, and Lawrence and Haverhill, Massachusetts.
About 79% of the cohort had hypertension, 68% had dyslipidemia, and 38% had diabetes, “which aligns with the population in the US,” said Dr. Rancier.
Each study participant had a regular exam carried out by Dr. Rancier using a traditional stethoscope to detect murmurs and an exam by a technician with a digital stethoscope that collected phonocardiogram (PCG) data for analysis by AI.
In addition, each patient received an echocardiogram 1-2 weeks later to confirm whether clinically significant VHD was present. An expert panel of cardiologists also reviewed the patient’s PCG recordings to confirm the presence of audible murmurs.
Dr. Rancier and the expert panel were blinded to AI and echocardiogram results.
Researchers calculated performance metrics for both PCP auscultation and the AI in detecting audible VHD.
The study showed that AI improved sensitivity to detect audible VHD by over twofold compared with PCP auscultation (94.1% vs 41.2%), with limited impact on specificity (84.5% vs 95.5%).
Dr. Rancier stressed the importance of sensitivity because clinicians tend to under-detect murmurs. “You don’t want to miss those patients because the consequences of undiagnosed VHD are dire.”
The AI tool identified 22 patients with moderate or greater VHD who were previously undiagnosed, whereas PCPs identified eight previously undiagnosed patients with VHD.
Dr. Rancier sees this tool being used beyond primary care, perhaps by emergency room personnel.
The authors plan to follow study participants and assess outcomes at for 6-12 months. They also aim to include more patients to increase the study’s power.
Expanding the Technology
They are also interested to see whether the technology can determine which valve is affected; for example, whether the issue is aortic stenosis or mitral regurgitation.
A limitation of the study was its small sample size.
Commenting on the findings, Dan Roden, MD, professor of medicine, pharmacology, and biomedical informatics, senior vice president for personalized medicine at Vanderbilt University Medical Center, Nashville, Tennessee, and chair of the American Heart Association Council on Genomic and Precision Medicine, noted that it demonstrated the AI-based stethoscope “did extraordinarily well” in predicting VHD.
“I see this as an emerging technology — using an AI-enabled stethoscope and perhaps combining it with other imaging modalities, like an AI-enabled echocardiogram built into your stethoscope,” said Dr. Roden.
“Use of these new tools to detect the presence of valvular disease, as well as the extent of valvular disease and the extent of other kinds of heart disease, will likely help to transform CVD care.”
The study was funded by Eko Health Inc. Dr. Rancier and Dr. Roden have no relevant conflicts of interest.
A version of this article appeared on Medscape.com.
FROM AHA 2023
Patients with HR-positive breast cancer can safely use ART
SAN ANTONIO — who pause endocrine therapy to conceive, according to new data from the POSITIVE trial.
“We believe these data are of vital importance for the oncofertility counseling of young breast cancer patients,” Hatem A. Azim Jr., MD, PhD, adjunct professor, School of Medicine and Breast Cancer Center, Monterrey Institute of Technology, Mexico, said in a presentation at the San Antonio Breast Cancer Symposium.
As reported previously by this news organization, the primary results of the POSITIVE trial showed that interrupting endocrine therapy to allow pregnancy does not increase the risk of recurrence at 41 months follow-up.
Yet, there is concern that use of fertility preservation or assisted reproductive technology methods — especially those that entail the use of hormones — could have harmful effects on patients with HR-positive breast cancers, Dr. Azim explained.
To investigate, Dr. Azim and colleagues did a secondary analysis of outcomes from the POSITIVE trial, focusing on resumption of menstruation and use of fertility preservation and assisted reproductive technologies.
Among 516 women evaluated for the menstruation analysis, two thirds were aged 35 and older and a little more than half (53%) reported amenorrhea at enrollment, “which is not surprising,” Dr. Azim said.
“What is encouraging,” he said, is that 85% of women recovered menses within 6 months and 94% within 12 months of pausing endocrine therapy.
Among 497 evaluable participants who paused endocrine therapy to attempt pregnancy, 368 (74%) became pregnant.
Looking at time to pregnancy, there was a clear association between younger age at enrollment and shorter time to pregnancy. The cumulative incidence of pregnancy at 12 months was 64% in women younger than age 35 years, 54% in those aged 35-39, and 38% in those age 40-42. In a multivariable model, age < 35 was the only factor independently associated with a shorter time to pregnancy.
No Harmful Impact on Breast Cancer Outcomes
Turning to fertility preservation and use of assisted reproductive technologies, roughly half of the women (51%) underwent some form of fertility preservation at breast cancer diagnosis and before trial enrollment, most commonly ovarian stimulation for embryo or oocyte cryopreservation.
After enrollment, 43% of women underwent some form of assisted reproductive technology to attempt pregnancy, most commonly ovarian stimulation for in vitro fertilization (IVF) and cryopreserved embryo transfer.
In the multivariable model, cryopreserved embryo transfer was the only assisted reproductive technology significantly associated with a greater chance of becoming pregnant, more than doubling patients’ odds (odds ratio, 2.4).
“This means that at breast cancer diagnosis, we should consider cryopreservation of embryos for future use if desired,” Dr. Azim said.
Again, age mattered. Women younger than 35 undergoing assisted reproductive technologies had a 50% higher chance of becoming pregnant compared with peers aged 35-39, and an 84% higher chance than women aged 40-42.
Importantly, there was no apparent short-term detrimental impact of fertility preservation and/or assisted reproductive technologies on breast cancer outcomes, Dr. Azim reported. At 3 years, the breast cancer-free interval was almost identical between women who underwent ovarian stimulation for cryopreservation and those who did not (9.7% vs 8.7%).
“POSITIVE showed positive results that emphasize the importance of active oncofertility counseling with the patient starting at diagnosis,” said Hee Jeong Kim, MD, PhD, professor, Division of Breast Surgery, Asan Medical Center, Seoul, Republic of Korea, and discussant for the study.
“These data are reassuring for our young patients with a diagnosis of breast cancer and shows that assisted reproductive technology is an option and is probably safe to do with the caveat that it needs longer follow-up,” added SABCS codirector Carlos Arteaga, MD, director, Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas.
Dr. Azim has no relevant disclosures. Dr. Arteaga is a scientific adviser to Novartis, Lilly, Merck, AstraZeneca, Daiichi Sankyo, OrigiMed, Immunomedics, PUMA Biotechnology, TAIHO Oncology, Sanofi, and the Susan G. Komen Foundation. He has received grant support from Pfizer, Lilly, and Takeda. Dr. Kim reports no relevant financial relationships.
A version of this article appeared on Medscape.com.
SAN ANTONIO — who pause endocrine therapy to conceive, according to new data from the POSITIVE trial.
“We believe these data are of vital importance for the oncofertility counseling of young breast cancer patients,” Hatem A. Azim Jr., MD, PhD, adjunct professor, School of Medicine and Breast Cancer Center, Monterrey Institute of Technology, Mexico, said in a presentation at the San Antonio Breast Cancer Symposium.
As reported previously by this news organization, the primary results of the POSITIVE trial showed that interrupting endocrine therapy to allow pregnancy does not increase the risk of recurrence at 41 months follow-up.
Yet, there is concern that use of fertility preservation or assisted reproductive technology methods — especially those that entail the use of hormones — could have harmful effects on patients with HR-positive breast cancers, Dr. Azim explained.
To investigate, Dr. Azim and colleagues did a secondary analysis of outcomes from the POSITIVE trial, focusing on resumption of menstruation and use of fertility preservation and assisted reproductive technologies.
Among 516 women evaluated for the menstruation analysis, two thirds were aged 35 and older and a little more than half (53%) reported amenorrhea at enrollment, “which is not surprising,” Dr. Azim said.
“What is encouraging,” he said, is that 85% of women recovered menses within 6 months and 94% within 12 months of pausing endocrine therapy.
Among 497 evaluable participants who paused endocrine therapy to attempt pregnancy, 368 (74%) became pregnant.
Looking at time to pregnancy, there was a clear association between younger age at enrollment and shorter time to pregnancy. The cumulative incidence of pregnancy at 12 months was 64% in women younger than age 35 years, 54% in those aged 35-39, and 38% in those age 40-42. In a multivariable model, age < 35 was the only factor independently associated with a shorter time to pregnancy.
No Harmful Impact on Breast Cancer Outcomes
Turning to fertility preservation and use of assisted reproductive technologies, roughly half of the women (51%) underwent some form of fertility preservation at breast cancer diagnosis and before trial enrollment, most commonly ovarian stimulation for embryo or oocyte cryopreservation.
After enrollment, 43% of women underwent some form of assisted reproductive technology to attempt pregnancy, most commonly ovarian stimulation for in vitro fertilization (IVF) and cryopreserved embryo transfer.
In the multivariable model, cryopreserved embryo transfer was the only assisted reproductive technology significantly associated with a greater chance of becoming pregnant, more than doubling patients’ odds (odds ratio, 2.4).
“This means that at breast cancer diagnosis, we should consider cryopreservation of embryos for future use if desired,” Dr. Azim said.
Again, age mattered. Women younger than 35 undergoing assisted reproductive technologies had a 50% higher chance of becoming pregnant compared with peers aged 35-39, and an 84% higher chance than women aged 40-42.
Importantly, there was no apparent short-term detrimental impact of fertility preservation and/or assisted reproductive technologies on breast cancer outcomes, Dr. Azim reported. At 3 years, the breast cancer-free interval was almost identical between women who underwent ovarian stimulation for cryopreservation and those who did not (9.7% vs 8.7%).
“POSITIVE showed positive results that emphasize the importance of active oncofertility counseling with the patient starting at diagnosis,” said Hee Jeong Kim, MD, PhD, professor, Division of Breast Surgery, Asan Medical Center, Seoul, Republic of Korea, and discussant for the study.
“These data are reassuring for our young patients with a diagnosis of breast cancer and shows that assisted reproductive technology is an option and is probably safe to do with the caveat that it needs longer follow-up,” added SABCS codirector Carlos Arteaga, MD, director, Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas.
Dr. Azim has no relevant disclosures. Dr. Arteaga is a scientific adviser to Novartis, Lilly, Merck, AstraZeneca, Daiichi Sankyo, OrigiMed, Immunomedics, PUMA Biotechnology, TAIHO Oncology, Sanofi, and the Susan G. Komen Foundation. He has received grant support from Pfizer, Lilly, and Takeda. Dr. Kim reports no relevant financial relationships.
A version of this article appeared on Medscape.com.
SAN ANTONIO — who pause endocrine therapy to conceive, according to new data from the POSITIVE trial.
“We believe these data are of vital importance for the oncofertility counseling of young breast cancer patients,” Hatem A. Azim Jr., MD, PhD, adjunct professor, School of Medicine and Breast Cancer Center, Monterrey Institute of Technology, Mexico, said in a presentation at the San Antonio Breast Cancer Symposium.
As reported previously by this news organization, the primary results of the POSITIVE trial showed that interrupting endocrine therapy to allow pregnancy does not increase the risk of recurrence at 41 months follow-up.
Yet, there is concern that use of fertility preservation or assisted reproductive technology methods — especially those that entail the use of hormones — could have harmful effects on patients with HR-positive breast cancers, Dr. Azim explained.
To investigate, Dr. Azim and colleagues did a secondary analysis of outcomes from the POSITIVE trial, focusing on resumption of menstruation and use of fertility preservation and assisted reproductive technologies.
Among 516 women evaluated for the menstruation analysis, two thirds were aged 35 and older and a little more than half (53%) reported amenorrhea at enrollment, “which is not surprising,” Dr. Azim said.
“What is encouraging,” he said, is that 85% of women recovered menses within 6 months and 94% within 12 months of pausing endocrine therapy.
Among 497 evaluable participants who paused endocrine therapy to attempt pregnancy, 368 (74%) became pregnant.
Looking at time to pregnancy, there was a clear association between younger age at enrollment and shorter time to pregnancy. The cumulative incidence of pregnancy at 12 months was 64% in women younger than age 35 years, 54% in those aged 35-39, and 38% in those age 40-42. In a multivariable model, age < 35 was the only factor independently associated with a shorter time to pregnancy.
No Harmful Impact on Breast Cancer Outcomes
Turning to fertility preservation and use of assisted reproductive technologies, roughly half of the women (51%) underwent some form of fertility preservation at breast cancer diagnosis and before trial enrollment, most commonly ovarian stimulation for embryo or oocyte cryopreservation.
After enrollment, 43% of women underwent some form of assisted reproductive technology to attempt pregnancy, most commonly ovarian stimulation for in vitro fertilization (IVF) and cryopreserved embryo transfer.
In the multivariable model, cryopreserved embryo transfer was the only assisted reproductive technology significantly associated with a greater chance of becoming pregnant, more than doubling patients’ odds (odds ratio, 2.4).
“This means that at breast cancer diagnosis, we should consider cryopreservation of embryos for future use if desired,” Dr. Azim said.
Again, age mattered. Women younger than 35 undergoing assisted reproductive technologies had a 50% higher chance of becoming pregnant compared with peers aged 35-39, and an 84% higher chance than women aged 40-42.
Importantly, there was no apparent short-term detrimental impact of fertility preservation and/or assisted reproductive technologies on breast cancer outcomes, Dr. Azim reported. At 3 years, the breast cancer-free interval was almost identical between women who underwent ovarian stimulation for cryopreservation and those who did not (9.7% vs 8.7%).
“POSITIVE showed positive results that emphasize the importance of active oncofertility counseling with the patient starting at diagnosis,” said Hee Jeong Kim, MD, PhD, professor, Division of Breast Surgery, Asan Medical Center, Seoul, Republic of Korea, and discussant for the study.
“These data are reassuring for our young patients with a diagnosis of breast cancer and shows that assisted reproductive technology is an option and is probably safe to do with the caveat that it needs longer follow-up,” added SABCS codirector Carlos Arteaga, MD, director, Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas.
Dr. Azim has no relevant disclosures. Dr. Arteaga is a scientific adviser to Novartis, Lilly, Merck, AstraZeneca, Daiichi Sankyo, OrigiMed, Immunomedics, PUMA Biotechnology, TAIHO Oncology, Sanofi, and the Susan G. Komen Foundation. He has received grant support from Pfizer, Lilly, and Takeda. Dr. Kim reports no relevant financial relationships.
A version of this article appeared on Medscape.com.
FROM SABCS 2023
Living in a Food Swamp Tied to High Breast Cancer Mortality
SAN ANTONIO — a novel ecological study has found.
“Food deserts and food swamps are both bad, but it’s worse in food swamps,” Malcolm Bevel, PhD, MSPH, with Augusta University in Georgia, said in an interview.
He presented his research at the San Antonio Breast Cancer Symposium.
Breast cancer is the fourth leading cause of cancer death in the United States and is one of 13 obesity-related cancers. Healthy food consumption is a protective factor shown to decrease obesity risk and postmenopausal breast cancer mortality.
However, residing in food deserts or food swamps reduces access to healthy foods and has been severely understudied regarding postmenopausal breast cancer mortality, Dr. Bevel explained.
To investigate, Dr. Bevel and colleagues did a cross-sectional, ecological analysis where they merged 2010 to 2020 postmenopausal breast cancer mortality data from the Centers for Disease Control and Prevention (CDC) with aggregated 2012 to 2020 data from the US Department of Agriculture Food Environment Atlas.
A food swamp score was calculated as the ratio of fast-food and convenience stores to grocery stores and farmer’s markets.
A food desert score was calculated as the proportion of residents living more than 1 mile (urban) or 10 miles (rural) from a grocery store and household income ≤ 200% of the federal poverty threshold.
The researchers categorized food deserts and food swamps as low, moderate, or high, with higher scores denoting counties with fewer resources for healthy food.
Counties with high postmenopausal breast cancer mortality rates had a higher percentage of non-Hispanic Black population (5.8% vs. 2.1%), poverty rates (17.2% vs 14.2%), and adult obesity (32.5% vs 32%) and diabetes rates (11.8% vs 10.5%), compared with counties with low postmenopausal breast cancer mortality rates, Dr. Bevel reported.
The age-adjusted odds of counties having high postmenopausal breast cancer mortality was 53% higher in counties with high food desert scores (adjusted odds ratio [aOR] 1.53; 95% CI, 1.26 - 1.88), and over twofold higher in those with high food swamp scores (aOR, 2.09; 95% CI: 1.69 - 2.58).
In fully adjusted models, the likelihood of counties having moderate postmenopausal breast cancer mortality rates was 32% higher in those with moderate food swamp scores (aOR, 1.32; 95% CI, 1.03 - 1.70).
Growing Epidemic Requires System Change
These findings are in line with another study by Dr. Bevel and his colleagues published earlier this year in JAMA Oncology.
In that study, communities with easy access to fast food were 77% more likely to have high levels of obesity-related cancer mortality, as reported by this news organization.
There is a “growing epidemic” of food deserts and food swamps in the US, which could be due to systemic issues such as gentrification/redlining and lack of investment with chain grocery stores that provide healthy food options, said Dr. Bevel.
Local policymakers and community stakeholders could implement culturally tailored, sustainable interventions for obesity and obesity-related cancer prevention, including postmenopausal breast cancer. These could include creating more walkable neighborhoods and community vegetable gardens, he suggested.
“This is an important study demonstrating how the environment impacts outcomes in postmenopausal women diagnosed with breast cancer,” said Lia Scott, PhD, MPH, discussant for the study.
“Most of the literature is primarily focused on food deserts to characterize the food environment. However, these authors looked at both food deserts and food swamps. And even after adjusting for various factors and age, counties with high food swamp scores at greater odds of having higher postmenopausal breast cancer mortality rates,” said Dr. Scott, who is from Georgia State University School of Public Health in Atlanta.
“There is a clear need for systems change. With ecological studies like this one, we could potentially drive policy by providing actionable data,” she added.
The study had no specific funding. Dr. Bevel and Dr. Scott report no relevant financial relationships.
A version of this article appeared on Medscape.com.
SAN ANTONIO — a novel ecological study has found.
“Food deserts and food swamps are both bad, but it’s worse in food swamps,” Malcolm Bevel, PhD, MSPH, with Augusta University in Georgia, said in an interview.
He presented his research at the San Antonio Breast Cancer Symposium.
Breast cancer is the fourth leading cause of cancer death in the United States and is one of 13 obesity-related cancers. Healthy food consumption is a protective factor shown to decrease obesity risk and postmenopausal breast cancer mortality.
However, residing in food deserts or food swamps reduces access to healthy foods and has been severely understudied regarding postmenopausal breast cancer mortality, Dr. Bevel explained.
To investigate, Dr. Bevel and colleagues did a cross-sectional, ecological analysis where they merged 2010 to 2020 postmenopausal breast cancer mortality data from the Centers for Disease Control and Prevention (CDC) with aggregated 2012 to 2020 data from the US Department of Agriculture Food Environment Atlas.
A food swamp score was calculated as the ratio of fast-food and convenience stores to grocery stores and farmer’s markets.
A food desert score was calculated as the proportion of residents living more than 1 mile (urban) or 10 miles (rural) from a grocery store and household income ≤ 200% of the federal poverty threshold.
The researchers categorized food deserts and food swamps as low, moderate, or high, with higher scores denoting counties with fewer resources for healthy food.
Counties with high postmenopausal breast cancer mortality rates had a higher percentage of non-Hispanic Black population (5.8% vs. 2.1%), poverty rates (17.2% vs 14.2%), and adult obesity (32.5% vs 32%) and diabetes rates (11.8% vs 10.5%), compared with counties with low postmenopausal breast cancer mortality rates, Dr. Bevel reported.
The age-adjusted odds of counties having high postmenopausal breast cancer mortality was 53% higher in counties with high food desert scores (adjusted odds ratio [aOR] 1.53; 95% CI, 1.26 - 1.88), and over twofold higher in those with high food swamp scores (aOR, 2.09; 95% CI: 1.69 - 2.58).
In fully adjusted models, the likelihood of counties having moderate postmenopausal breast cancer mortality rates was 32% higher in those with moderate food swamp scores (aOR, 1.32; 95% CI, 1.03 - 1.70).
Growing Epidemic Requires System Change
These findings are in line with another study by Dr. Bevel and his colleagues published earlier this year in JAMA Oncology.
In that study, communities with easy access to fast food were 77% more likely to have high levels of obesity-related cancer mortality, as reported by this news organization.
There is a “growing epidemic” of food deserts and food swamps in the US, which could be due to systemic issues such as gentrification/redlining and lack of investment with chain grocery stores that provide healthy food options, said Dr. Bevel.
Local policymakers and community stakeholders could implement culturally tailored, sustainable interventions for obesity and obesity-related cancer prevention, including postmenopausal breast cancer. These could include creating more walkable neighborhoods and community vegetable gardens, he suggested.
“This is an important study demonstrating how the environment impacts outcomes in postmenopausal women diagnosed with breast cancer,” said Lia Scott, PhD, MPH, discussant for the study.
“Most of the literature is primarily focused on food deserts to characterize the food environment. However, these authors looked at both food deserts and food swamps. And even after adjusting for various factors and age, counties with high food swamp scores at greater odds of having higher postmenopausal breast cancer mortality rates,” said Dr. Scott, who is from Georgia State University School of Public Health in Atlanta.
“There is a clear need for systems change. With ecological studies like this one, we could potentially drive policy by providing actionable data,” she added.
The study had no specific funding. Dr. Bevel and Dr. Scott report no relevant financial relationships.
A version of this article appeared on Medscape.com.
SAN ANTONIO — a novel ecological study has found.
“Food deserts and food swamps are both bad, but it’s worse in food swamps,” Malcolm Bevel, PhD, MSPH, with Augusta University in Georgia, said in an interview.
He presented his research at the San Antonio Breast Cancer Symposium.
Breast cancer is the fourth leading cause of cancer death in the United States and is one of 13 obesity-related cancers. Healthy food consumption is a protective factor shown to decrease obesity risk and postmenopausal breast cancer mortality.
However, residing in food deserts or food swamps reduces access to healthy foods and has been severely understudied regarding postmenopausal breast cancer mortality, Dr. Bevel explained.
To investigate, Dr. Bevel and colleagues did a cross-sectional, ecological analysis where they merged 2010 to 2020 postmenopausal breast cancer mortality data from the Centers for Disease Control and Prevention (CDC) with aggregated 2012 to 2020 data from the US Department of Agriculture Food Environment Atlas.
A food swamp score was calculated as the ratio of fast-food and convenience stores to grocery stores and farmer’s markets.
A food desert score was calculated as the proportion of residents living more than 1 mile (urban) or 10 miles (rural) from a grocery store and household income ≤ 200% of the federal poverty threshold.
The researchers categorized food deserts and food swamps as low, moderate, or high, with higher scores denoting counties with fewer resources for healthy food.
Counties with high postmenopausal breast cancer mortality rates had a higher percentage of non-Hispanic Black population (5.8% vs. 2.1%), poverty rates (17.2% vs 14.2%), and adult obesity (32.5% vs 32%) and diabetes rates (11.8% vs 10.5%), compared with counties with low postmenopausal breast cancer mortality rates, Dr. Bevel reported.
The age-adjusted odds of counties having high postmenopausal breast cancer mortality was 53% higher in counties with high food desert scores (adjusted odds ratio [aOR] 1.53; 95% CI, 1.26 - 1.88), and over twofold higher in those with high food swamp scores (aOR, 2.09; 95% CI: 1.69 - 2.58).
In fully adjusted models, the likelihood of counties having moderate postmenopausal breast cancer mortality rates was 32% higher in those with moderate food swamp scores (aOR, 1.32; 95% CI, 1.03 - 1.70).
Growing Epidemic Requires System Change
These findings are in line with another study by Dr. Bevel and his colleagues published earlier this year in JAMA Oncology.
In that study, communities with easy access to fast food were 77% more likely to have high levels of obesity-related cancer mortality, as reported by this news organization.
There is a “growing epidemic” of food deserts and food swamps in the US, which could be due to systemic issues such as gentrification/redlining and lack of investment with chain grocery stores that provide healthy food options, said Dr. Bevel.
Local policymakers and community stakeholders could implement culturally tailored, sustainable interventions for obesity and obesity-related cancer prevention, including postmenopausal breast cancer. These could include creating more walkable neighborhoods and community vegetable gardens, he suggested.
“This is an important study demonstrating how the environment impacts outcomes in postmenopausal women diagnosed with breast cancer,” said Lia Scott, PhD, MPH, discussant for the study.
“Most of the literature is primarily focused on food deserts to characterize the food environment. However, these authors looked at both food deserts and food swamps. And even after adjusting for various factors and age, counties with high food swamp scores at greater odds of having higher postmenopausal breast cancer mortality rates,” said Dr. Scott, who is from Georgia State University School of Public Health in Atlanta.
“There is a clear need for systems change. With ecological studies like this one, we could potentially drive policy by providing actionable data,” she added.
The study had no specific funding. Dr. Bevel and Dr. Scott report no relevant financial relationships.
A version of this article appeared on Medscape.com.
FROM SABCS 2023
Why Are Prion Diseases on the Rise?
This transcript has been edited for clarity.
In 1986, in Britain, cattle started dying.
The condition, quickly nicknamed “mad cow disease,” was clearly infectious, but the particular pathogen was difficult to identify. By 1993, 120,000 cattle in Britain were identified as being infected. As yet, no human cases had occurred and the UK government insisted that cattle were a dead-end host for the pathogen. By the mid-1990s, however, multiple human cases, attributable to ingestion of meat and organs from infected cattle, were discovered. In humans, variant Creutzfeldt-Jakob disease (CJD) was a media sensation — a nearly uniformly fatal, untreatable condition with a rapid onset of dementia, mobility issues characterized by jerky movements, and autopsy reports finding that the brain itself had turned into a spongy mess.
The United States banned UK beef imports in 1996 and only lifted the ban in 2020.
The disease was made all the more mysterious because the pathogen involved was not a bacterium, parasite, or virus, but a protein — or a proteinaceous infectious particle, shortened to “prion.”
Prions are misfolded proteins that aggregate in cells — in this case, in nerve cells. But what makes prions different from other misfolded proteins is that the misfolded protein catalyzes the conversion of its non-misfolded counterpart into the misfolded configuration. It creates a chain reaction, leading to rapid accumulation of misfolded proteins and cell death.
And, like a time bomb, we all have prion protein inside us. In its normally folded state, the function of prion protein remains unclear — knockout mice do okay without it — but it is also highly conserved across mammalian species, so it probably does something worthwhile, perhaps protecting nerve fibers.
Far more common than humans contracting mad cow disease is the condition known as sporadic CJD, responsible for 85% of all cases of prion-induced brain disease. The cause of sporadic CJD is unknown.
But one thing is known: Cases are increasing.
I don’t want you to freak out; we are not in the midst of a CJD epidemic. But it’s been a while since I’ve seen people discussing the condition — which remains as horrible as it was in the 1990s — and a new research letter appearing in JAMA Neurology brought it back to the top of my mind.
Researchers, led by Matthew Crane at Hopkins, used the CDC’s WONDER cause-of-death database, which pulls diagnoses from death certificates. Normally, I’m not a fan of using death certificates for cause-of-death analyses, but in this case I’ll give it a pass. Assuming that the diagnosis of CJD is made, it would be really unlikely for it not to appear on a death certificate.
The main findings are seen here. 
Note that we can’t tell whether these are sporadic CJD cases or variant CJD cases or even familial CJD cases; however, unless there has been a dramatic change in epidemiology, the vast majority of these will be sporadic.
The question is, why are there more cases?
Whenever this type of question comes up with any disease, there are basically three possibilities:
First, there may be an increase in the susceptible, or at-risk, population. In this case, we know that older people are at higher risk of developing sporadic CJD, and over time, the population has aged. To be fair, the authors adjusted for this and still saw an increase, though it was attenuated.
Second, we might be better at diagnosing the condition. A lot has happened since the mid-1990s, when the diagnosis was based more or less on symptoms. The advent of more sophisticated MRI protocols as well as a new diagnostic test called “real-time quaking-induced conversion testing” may mean we are just better at detecting people with this disease.
Third (and most concerning), a new exposure has occurred. What that exposure might be, where it might come from, is anyone’s guess. It’s hard to do broad-scale epidemiology on very rare diseases.
But given these findings, it seems that a bit more surveillance for this rare but devastating condition is well merited.
F. Perry Wilson, MD, MSCE, is an associate professor of medicine and public health and director of Yale’s Clinical and Translational Research Accelerator. His science communication work can be found in the Huffington Post, on NPR, and here on Medscape. He tweets @fperrywilson and his new book, How Medicine Works and When It Doesn’t, is available now.
F. Perry Wilson, MD, MSCE, has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
In 1986, in Britain, cattle started dying.
The condition, quickly nicknamed “mad cow disease,” was clearly infectious, but the particular pathogen was difficult to identify. By 1993, 120,000 cattle in Britain were identified as being infected. As yet, no human cases had occurred and the UK government insisted that cattle were a dead-end host for the pathogen. By the mid-1990s, however, multiple human cases, attributable to ingestion of meat and organs from infected cattle, were discovered. In humans, variant Creutzfeldt-Jakob disease (CJD) was a media sensation — a nearly uniformly fatal, untreatable condition with a rapid onset of dementia, mobility issues characterized by jerky movements, and autopsy reports finding that the brain itself had turned into a spongy mess.
The United States banned UK beef imports in 1996 and only lifted the ban in 2020.
The disease was made all the more mysterious because the pathogen involved was not a bacterium, parasite, or virus, but a protein — or a proteinaceous infectious particle, shortened to “prion.”
Prions are misfolded proteins that aggregate in cells — in this case, in nerve cells. But what makes prions different from other misfolded proteins is that the misfolded protein catalyzes the conversion of its non-misfolded counterpart into the misfolded configuration. It creates a chain reaction, leading to rapid accumulation of misfolded proteins and cell death.
And, like a time bomb, we all have prion protein inside us. In its normally folded state, the function of prion protein remains unclear — knockout mice do okay without it — but it is also highly conserved across mammalian species, so it probably does something worthwhile, perhaps protecting nerve fibers.
Far more common than humans contracting mad cow disease is the condition known as sporadic CJD, responsible for 85% of all cases of prion-induced brain disease. The cause of sporadic CJD is unknown.
But one thing is known: Cases are increasing.
I don’t want you to freak out; we are not in the midst of a CJD epidemic. But it’s been a while since I’ve seen people discussing the condition — which remains as horrible as it was in the 1990s — and a new research letter appearing in JAMA Neurology brought it back to the top of my mind.
Researchers, led by Matthew Crane at Hopkins, used the CDC’s WONDER cause-of-death database, which pulls diagnoses from death certificates. Normally, I’m not a fan of using death certificates for cause-of-death analyses, but in this case I’ll give it a pass. Assuming that the diagnosis of CJD is made, it would be really unlikely for it not to appear on a death certificate.
The main findings are seen here.
Note that we can’t tell whether these are sporadic CJD cases or variant CJD cases or even familial CJD cases; however, unless there has been a dramatic change in epidemiology, the vast majority of these will be sporadic.
The question is, why are there more cases?
Whenever this type of question comes up with any disease, there are basically three possibilities:
First, there may be an increase in the susceptible, or at-risk, population. In this case, we know that older people are at higher risk of developing sporadic CJD, and over time, the population has aged. To be fair, the authors adjusted for this and still saw an increase, though it was attenuated.
Second, we might be better at diagnosing the condition. A lot has happened since the mid-1990s, when the diagnosis was based more or less on symptoms. The advent of more sophisticated MRI protocols as well as a new diagnostic test called “real-time quaking-induced conversion testing” may mean we are just better at detecting people with this disease.
Third (and most concerning), a new exposure has occurred. What that exposure might be, where it might come from, is anyone’s guess. It’s hard to do broad-scale epidemiology on very rare diseases.
But given these findings, it seems that a bit more surveillance for this rare but devastating condition is well merited.
F. Perry Wilson, MD, MSCE, is an associate professor of medicine and public health and director of Yale’s Clinical and Translational Research Accelerator. His science communication work can be found in the Huffington Post, on NPR, and here on Medscape. He tweets @fperrywilson and his new book, How Medicine Works and When It Doesn’t, is available now.
F. Perry Wilson, MD, MSCE, has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
In 1986, in Britain, cattle started dying.
The condition, quickly nicknamed “mad cow disease,” was clearly infectious, but the particular pathogen was difficult to identify. By 1993, 120,000 cattle in Britain were identified as being infected. As yet, no human cases had occurred and the UK government insisted that cattle were a dead-end host for the pathogen. By the mid-1990s, however, multiple human cases, attributable to ingestion of meat and organs from infected cattle, were discovered. In humans, variant Creutzfeldt-Jakob disease (CJD) was a media sensation — a nearly uniformly fatal, untreatable condition with a rapid onset of dementia, mobility issues characterized by jerky movements, and autopsy reports finding that the brain itself had turned into a spongy mess.
The United States banned UK beef imports in 1996 and only lifted the ban in 2020.
The disease was made all the more mysterious because the pathogen involved was not a bacterium, parasite, or virus, but a protein — or a proteinaceous infectious particle, shortened to “prion.”
Prions are misfolded proteins that aggregate in cells — in this case, in nerve cells. But what makes prions different from other misfolded proteins is that the misfolded protein catalyzes the conversion of its non-misfolded counterpart into the misfolded configuration. It creates a chain reaction, leading to rapid accumulation of misfolded proteins and cell death.
And, like a time bomb, we all have prion protein inside us. In its normally folded state, the function of prion protein remains unclear — knockout mice do okay without it — but it is also highly conserved across mammalian species, so it probably does something worthwhile, perhaps protecting nerve fibers.
Far more common than humans contracting mad cow disease is the condition known as sporadic CJD, responsible for 85% of all cases of prion-induced brain disease. The cause of sporadic CJD is unknown.
But one thing is known: Cases are increasing.
I don’t want you to freak out; we are not in the midst of a CJD epidemic. But it’s been a while since I’ve seen people discussing the condition — which remains as horrible as it was in the 1990s — and a new research letter appearing in JAMA Neurology brought it back to the top of my mind.
Researchers, led by Matthew Crane at Hopkins, used the CDC’s WONDER cause-of-death database, which pulls diagnoses from death certificates. Normally, I’m not a fan of using death certificates for cause-of-death analyses, but in this case I’ll give it a pass. Assuming that the diagnosis of CJD is made, it would be really unlikely for it not to appear on a death certificate.
The main findings are seen here.
Note that we can’t tell whether these are sporadic CJD cases or variant CJD cases or even familial CJD cases; however, unless there has been a dramatic change in epidemiology, the vast majority of these will be sporadic.
The question is, why are there more cases?
Whenever this type of question comes up with any disease, there are basically three possibilities:
First, there may be an increase in the susceptible, or at-risk, population. In this case, we know that older people are at higher risk of developing sporadic CJD, and over time, the population has aged. To be fair, the authors adjusted for this and still saw an increase, though it was attenuated.
Second, we might be better at diagnosing the condition. A lot has happened since the mid-1990s, when the diagnosis was based more or less on symptoms. The advent of more sophisticated MRI protocols as well as a new diagnostic test called “real-time quaking-induced conversion testing” may mean we are just better at detecting people with this disease.
Third (and most concerning), a new exposure has occurred. What that exposure might be, where it might come from, is anyone’s guess. It’s hard to do broad-scale epidemiology on very rare diseases.
But given these findings, it seems that a bit more surveillance for this rare but devastating condition is well merited.
F. Perry Wilson, MD, MSCE, is an associate professor of medicine and public health and director of Yale’s Clinical and Translational Research Accelerator. His science communication work can be found in the Huffington Post, on NPR, and here on Medscape. He tweets @fperrywilson and his new book, How Medicine Works and When It Doesn’t, is available now.
F. Perry Wilson, MD, MSCE, has disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
Is migraine really a female disorder?
BARCELONA, SPAIN — Migraine is widely considered a predominantly female disorder. Its frequency, duration, and severity tend to be higher in women, and women are also more likely than men to receive a migraine diagnosis. However, gender expectations, differences in the likelihood of self-reporting, and problems with how migraine is classified make it difficult to estimate its true prevalence in men and women.
Different Symptoms
Headache disorders are estimated to affect 50% of the general population ; tension-type headache and migraine are the two most common. According to epidemiologic studies, migraine is more prevalent in women, with a female-to-male ratio of 3:1. There are numerous studies of why this might be, most of which focus largely on female-related factors, such as hormones and the menstrual cycle.
“Despite many years of research, there isn’t one clear factor explaining this substantial difference between women and men,” said Tobias Kurth of Charité – Universitätsmedizin Berlin, Germany. “So the question is: Are we missing something else?”
One factor in these perceived sex differences in migraine is that women seem to report their migraines differently from men, and they also have different symptoms. For example, women are more likely than men to report severe pain, and their migraine attacks are more often accompanied by photophobia, phonophobia, and nausea, whereas men’s migraines are more often accompanied by aura.
“By favoring female symptoms, the classification system may not be picking up male symptoms because they’re not being classified in the right way,” Dr. Kurth said, with one consequence being that migraine is underdiagnosed in men. “Before trying to understand the biological and behavioral reasons for these sex differences, we first need to consider these methodological challenges that we all apply knowingly or unknowingly.”
Christian Lampl, professor of neurology at Konventhospital der Barmherzigen Brüder Linz, Austria, and president of the European Headache Federation, said in an interview, “I’m convinced that this 3:1 ratio which has been stated for decades is wrong, but we still don’t have the data. The criteria we have [for classifying migraine] are useful for clinical trials, but they are useless for determining the male-to-female ratio.
“We need a new definition of migraine,” he added. “Migraine is an episode, not an attack. Attacks have a sudden onset, and migraine onset is not sudden — it is an episode with a headache attack.”
Inadequate Menopause Services
Professor Anne MacGregor of St. Bartholomew’s Hospital in London, United Kingdom, specializes in migraine and women’s health. She presented data showing that migraine is underdiagnosed in women; one reason being that the disorder receives inadequate attention from healthcare professionals at specialist menopause services.
Menopause is associated with an increased prevalence of migraine, but women do not discuss headache symptoms at specialist menopause services, Dr. MacGregor said.
She then described unpublished results from a survey of 117 women attending the specialist menopause service at St. Bartholomew’s Hospital. Among the respondents, 34% reported experiencing episodic migraine and an additional 8% reported having chronic migraine.
“Within this population of women who were not reporting headache as a symptom [to the menopause service until asked in the survey], 42% of them were positive for a diagnosis of migraine,” said Dr. MacGregor. “They were mostly relying on prescribed paracetamol and codeine, or buying it over the counter, and only 22% of them were receiving triptans.
“They are clearly being undertreated,” she added. “Part of this issue is that they didn’t spontaneously report headache as a menopause symptom, so they weren’t consulting for headache to their primary care physicians.”
Correct diagnosis by a consultant is a prerequisite for receiving appropriate migraine treatment. Yet, according to a US study published in 2012, only 45.5% of women with episodic migraine consulted a prescribing healthcare professional. Of those who consulted, 89% were diagnosed correctly, and only 68% of those received the appropriate treatment.
A larger, more recent study confirmed that there is a massive unmet need for improving care in this patient population. The Chronic Migraine Epidemiology and Outcomes (CaMEO) Study, which analyzed data from nearly 90,000 participants, showed that just 4.8% of people with chronic migraine received consultation, correct diagnosis, and treatment, with 89% of women with chronic migraine left undiagnosed.
The OVERCOME Study further revealed that although many people with migraine were repeat consulters, they were consulting their physicians for other health problems.
“This makes it very clear that people in other specialties need to be more aware about picking up and diagnosing headache,” said MacGregor. “That’s where the real need is in managing headache. We have the treatments, but if the patients can’t access them, they’re not much good to them.”
A version of this article appeared on Medscape.com.
BARCELONA, SPAIN — Migraine is widely considered a predominantly female disorder. Its frequency, duration, and severity tend to be higher in women, and women are also more likely than men to receive a migraine diagnosis. However, gender expectations, differences in the likelihood of self-reporting, and problems with how migraine is classified make it difficult to estimate its true prevalence in men and women.
Different Symptoms
Headache disorders are estimated to affect 50% of the general population ; tension-type headache and migraine are the two most common. According to epidemiologic studies, migraine is more prevalent in women, with a female-to-male ratio of 3:1. There are numerous studies of why this might be, most of which focus largely on female-related factors, such as hormones and the menstrual cycle.
“Despite many years of research, there isn’t one clear factor explaining this substantial difference between women and men,” said Tobias Kurth of Charité – Universitätsmedizin Berlin, Germany. “So the question is: Are we missing something else?”
One factor in these perceived sex differences in migraine is that women seem to report their migraines differently from men, and they also have different symptoms. For example, women are more likely than men to report severe pain, and their migraine attacks are more often accompanied by photophobia, phonophobia, and nausea, whereas men’s migraines are more often accompanied by aura.
“By favoring female symptoms, the classification system may not be picking up male symptoms because they’re not being classified in the right way,” Dr. Kurth said, with one consequence being that migraine is underdiagnosed in men. “Before trying to understand the biological and behavioral reasons for these sex differences, we first need to consider these methodological challenges that we all apply knowingly or unknowingly.”
Christian Lampl, professor of neurology at Konventhospital der Barmherzigen Brüder Linz, Austria, and president of the European Headache Federation, said in an interview, “I’m convinced that this 3:1 ratio which has been stated for decades is wrong, but we still don’t have the data. The criteria we have [for classifying migraine] are useful for clinical trials, but they are useless for determining the male-to-female ratio.
“We need a new definition of migraine,” he added. “Migraine is an episode, not an attack. Attacks have a sudden onset, and migraine onset is not sudden — it is an episode with a headache attack.”
Inadequate Menopause Services
Professor Anne MacGregor of St. Bartholomew’s Hospital in London, United Kingdom, specializes in migraine and women’s health. She presented data showing that migraine is underdiagnosed in women; one reason being that the disorder receives inadequate attention from healthcare professionals at specialist menopause services.
Menopause is associated with an increased prevalence of migraine, but women do not discuss headache symptoms at specialist menopause services, Dr. MacGregor said.
She then described unpublished results from a survey of 117 women attending the specialist menopause service at St. Bartholomew’s Hospital. Among the respondents, 34% reported experiencing episodic migraine and an additional 8% reported having chronic migraine.
“Within this population of women who were not reporting headache as a symptom [to the menopause service until asked in the survey], 42% of them were positive for a diagnosis of migraine,” said Dr. MacGregor. “They were mostly relying on prescribed paracetamol and codeine, or buying it over the counter, and only 22% of them were receiving triptans.
“They are clearly being undertreated,” she added. “Part of this issue is that they didn’t spontaneously report headache as a menopause symptom, so they weren’t consulting for headache to their primary care physicians.”
Correct diagnosis by a consultant is a prerequisite for receiving appropriate migraine treatment. Yet, according to a US study published in 2012, only 45.5% of women with episodic migraine consulted a prescribing healthcare professional. Of those who consulted, 89% were diagnosed correctly, and only 68% of those received the appropriate treatment.
A larger, more recent study confirmed that there is a massive unmet need for improving care in this patient population. The Chronic Migraine Epidemiology and Outcomes (CaMEO) Study, which analyzed data from nearly 90,000 participants, showed that just 4.8% of people with chronic migraine received consultation, correct diagnosis, and treatment, with 89% of women with chronic migraine left undiagnosed.
The OVERCOME Study further revealed that although many people with migraine were repeat consulters, they were consulting their physicians for other health problems.
“This makes it very clear that people in other specialties need to be more aware about picking up and diagnosing headache,” said MacGregor. “That’s where the real need is in managing headache. We have the treatments, but if the patients can’t access them, they’re not much good to them.”
A version of this article appeared on Medscape.com.
BARCELONA, SPAIN — Migraine is widely considered a predominantly female disorder. Its frequency, duration, and severity tend to be higher in women, and women are also more likely than men to receive a migraine diagnosis. However, gender expectations, differences in the likelihood of self-reporting, and problems with how migraine is classified make it difficult to estimate its true prevalence in men and women.
Different Symptoms
Headache disorders are estimated to affect 50% of the general population ; tension-type headache and migraine are the two most common. According to epidemiologic studies, migraine is more prevalent in women, with a female-to-male ratio of 3:1. There are numerous studies of why this might be, most of which focus largely on female-related factors, such as hormones and the menstrual cycle.
“Despite many years of research, there isn’t one clear factor explaining this substantial difference between women and men,” said Tobias Kurth of Charité – Universitätsmedizin Berlin, Germany. “So the question is: Are we missing something else?”
One factor in these perceived sex differences in migraine is that women seem to report their migraines differently from men, and they also have different symptoms. For example, women are more likely than men to report severe pain, and their migraine attacks are more often accompanied by photophobia, phonophobia, and nausea, whereas men’s migraines are more often accompanied by aura.
“By favoring female symptoms, the classification system may not be picking up male symptoms because they’re not being classified in the right way,” Dr. Kurth said, with one consequence being that migraine is underdiagnosed in men. “Before trying to understand the biological and behavioral reasons for these sex differences, we first need to consider these methodological challenges that we all apply knowingly or unknowingly.”
Christian Lampl, professor of neurology at Konventhospital der Barmherzigen Brüder Linz, Austria, and president of the European Headache Federation, said in an interview, “I’m convinced that this 3:1 ratio which has been stated for decades is wrong, but we still don’t have the data. The criteria we have [for classifying migraine] are useful for clinical trials, but they are useless for determining the male-to-female ratio.
“We need a new definition of migraine,” he added. “Migraine is an episode, not an attack. Attacks have a sudden onset, and migraine onset is not sudden — it is an episode with a headache attack.”
Inadequate Menopause Services
Professor Anne MacGregor of St. Bartholomew’s Hospital in London, United Kingdom, specializes in migraine and women’s health. She presented data showing that migraine is underdiagnosed in women; one reason being that the disorder receives inadequate attention from healthcare professionals at specialist menopause services.
Menopause is associated with an increased prevalence of migraine, but women do not discuss headache symptoms at specialist menopause services, Dr. MacGregor said.
She then described unpublished results from a survey of 117 women attending the specialist menopause service at St. Bartholomew’s Hospital. Among the respondents, 34% reported experiencing episodic migraine and an additional 8% reported having chronic migraine.
“Within this population of women who were not reporting headache as a symptom [to the menopause service until asked in the survey], 42% of them were positive for a diagnosis of migraine,” said Dr. MacGregor. “They were mostly relying on prescribed paracetamol and codeine, or buying it over the counter, and only 22% of them were receiving triptans.
“They are clearly being undertreated,” she added. “Part of this issue is that they didn’t spontaneously report headache as a menopause symptom, so they weren’t consulting for headache to their primary care physicians.”
Correct diagnosis by a consultant is a prerequisite for receiving appropriate migraine treatment. Yet, according to a US study published in 2012, only 45.5% of women with episodic migraine consulted a prescribing healthcare professional. Of those who consulted, 89% were diagnosed correctly, and only 68% of those received the appropriate treatment.
A larger, more recent study confirmed that there is a massive unmet need for improving care in this patient population. The Chronic Migraine Epidemiology and Outcomes (CaMEO) Study, which analyzed data from nearly 90,000 participants, showed that just 4.8% of people with chronic migraine received consultation, correct diagnosis, and treatment, with 89% of women with chronic migraine left undiagnosed.
The OVERCOME Study further revealed that although many people with migraine were repeat consulters, they were consulting their physicians for other health problems.
“This makes it very clear that people in other specialties need to be more aware about picking up and diagnosing headache,” said MacGregor. “That’s where the real need is in managing headache. We have the treatments, but if the patients can’t access them, they’re not much good to them.”
A version of this article appeared on Medscape.com.
FROM EHC 2023
ADA issues new screening, obesity management recommendations
for 2024.
“The Standards of Care are essentially the global guidelines for the care of individuals with diabetes and those at risk,” ADA chief scientific and medical officer Robert Gabbay, MD, PhD, said during a briefing announcing the new Standards.
The document was developed via a scientific literature review by the ADA’s Professional Practice Committee. The panel comprises 21 professionals, including physicians from many specialties, nurse practitioners, certified diabetes care and education specialists, dietitians, and pharmacists. The chair is Nuha A. El Sayed, MD, ADA’s senior vice president of healthcare improvement.
Specific sections of the 2024 document have been endorsed by the American College of Cardiology, the American Society of Bone and Mineral Research, and the Obesity Society. It was published on December 11, 2023, as a supplement in Diabetes Care.
An introductory section summarizing the changes for 2024 spans six pages. Those addressed during the briefing included the following:
Heart Failure Screening: Two new recommendations have been added to include screening of adults with diabetes for asymptomatic heart failure by measuring natriuretic peptide levels to facilitate the prevention or progression to symptomatic stages of heart failure.
“This is a really important and exciting area. We know that people with type 2 diabetes in particular are at high risk for heart failure,” Dr. Gabbay said, adding that these recommendations “are to really more aggressively screen those at high risk for heart failure with a simple blood test and, based on those values, then be able to move on to further evaluation and echocardiography, for example. The recommendations are really to screen a broad number of individuals with type 2 diabetes because many are at risk, [particularly] those without symptoms.”
PAD Screening: A new strong recommendation is to screen for PAD with ankle-brachial index testing in asymptomatic people with diabetes who are aged ≥ 50 years and have microvascular disease in any location, foot complications, or any end-organ damage from diabetes. The document also advises consideration of PAD screening for all individuals who have had diabetes for ≥ 10 years.
Dr. Gabbay commented, “We know that amputation rates are rising, unlike many other complications. We know that there are incredible health disparities. Blacks are two to four times more likely than Whites to have an amputation.”
Dr. El Sayed added, “Many patients don’t show the common symptoms of peripheral arterial disease. Screening is the most important way to find out if they have it or not because it can be a very devastating disease.”
Type 1 Diabetes Screening: This involves several new recommendations, including a framework for investigating suspected type 1 diabetes in newly diagnosed adults using islet autoantibody tests and diagnostic criteria for preclinical stages based on the recent approval of teplizumab for delaying the onset of type 1 diabetes.
“Screening and capturing disease earlier so that we can intervene is really an important consideration here. That includes screening for type 1 diabetes and thinking about therapeutic options to delay the development of frank type 1 diabetes,” Dr. Gabbay said.
Screening first-degree relatives of people with type 1 diabetes is a high priority because they’re at an elevated risk, he added.
Obesity Management: New recommendations here include the use of anthropomorphic measurements beyond body mass index to include waist circumference and waist:hip ratio and individual assessment of body fat mass and distribution.
Individualization of obesity management including behavioral, pharmacologic, and surgical approaches is encouraged. The use of a glucagon-like peptide-1 (GLP-1) receptor agonist or a dual glucose-dependent insulinotropic polypeptide and GLP-1 receptor agonist with greater weight loss efficacy is preferred for obesity management in people with diabetes.
“Obesity management is one of the biggest changes over this last year,” Dr. Gabbay commented.
Other New Recommendations: Among the many other revisions in the 2024 document are new recommendations about regular evaluation and treatment for bone health, assessment of disability and guidance for referral, and alignment of guidance for liver disease screening and management with those of other professional societies. Regarding the last item, Dr. Gabbay noted, “I don’t think it’s gotten the attention it deserves. Diabetes and obesity are becoming the leading causes of liver disease.”
Clinicians can also download the Standards of Care app on their smartphones. “That can be really helpful when questions come up since you can’t remember everything in there. Here you can look it up in a matter of seconds,” Dr. Gabbay said.
Dr. El Sayed added that asking patients about their priorities is also important. “If they aren’t brought up during the visit, it’s unlikely to be as fruitful as it should be.”
Dr. El Sayed has no disclosures. Dr. Gabbay serves as a consultant and/or advisor for HealthReveal, Lark Technologies, Onduo, StartUp Health, Sweetech, and Vida Health.
A version of this article appeared on Medscape.com.
for 2024.
“The Standards of Care are essentially the global guidelines for the care of individuals with diabetes and those at risk,” ADA chief scientific and medical officer Robert Gabbay, MD, PhD, said during a briefing announcing the new Standards.
The document was developed via a scientific literature review by the ADA’s Professional Practice Committee. The panel comprises 21 professionals, including physicians from many specialties, nurse practitioners, certified diabetes care and education specialists, dietitians, and pharmacists. The chair is Nuha A. El Sayed, MD, ADA’s senior vice president of healthcare improvement.
Specific sections of the 2024 document have been endorsed by the American College of Cardiology, the American Society of Bone and Mineral Research, and the Obesity Society. It was published on December 11, 2023, as a supplement in Diabetes Care.
An introductory section summarizing the changes for 2024 spans six pages. Those addressed during the briefing included the following:
Heart Failure Screening: Two new recommendations have been added to include screening of adults with diabetes for asymptomatic heart failure by measuring natriuretic peptide levels to facilitate the prevention or progression to symptomatic stages of heart failure.
“This is a really important and exciting area. We know that people with type 2 diabetes in particular are at high risk for heart failure,” Dr. Gabbay said, adding that these recommendations “are to really more aggressively screen those at high risk for heart failure with a simple blood test and, based on those values, then be able to move on to further evaluation and echocardiography, for example. The recommendations are really to screen a broad number of individuals with type 2 diabetes because many are at risk, [particularly] those without symptoms.”
PAD Screening: A new strong recommendation is to screen for PAD with ankle-brachial index testing in asymptomatic people with diabetes who are aged ≥ 50 years and have microvascular disease in any location, foot complications, or any end-organ damage from diabetes. The document also advises consideration of PAD screening for all individuals who have had diabetes for ≥ 10 years.
Dr. Gabbay commented, “We know that amputation rates are rising, unlike many other complications. We know that there are incredible health disparities. Blacks are two to four times more likely than Whites to have an amputation.”
Dr. El Sayed added, “Many patients don’t show the common symptoms of peripheral arterial disease. Screening is the most important way to find out if they have it or not because it can be a very devastating disease.”
Type 1 Diabetes Screening: This involves several new recommendations, including a framework for investigating suspected type 1 diabetes in newly diagnosed adults using islet autoantibody tests and diagnostic criteria for preclinical stages based on the recent approval of teplizumab for delaying the onset of type 1 diabetes.
“Screening and capturing disease earlier so that we can intervene is really an important consideration here. That includes screening for type 1 diabetes and thinking about therapeutic options to delay the development of frank type 1 diabetes,” Dr. Gabbay said.
Screening first-degree relatives of people with type 1 diabetes is a high priority because they’re at an elevated risk, he added.
Obesity Management: New recommendations here include the use of anthropomorphic measurements beyond body mass index to include waist circumference and waist:hip ratio and individual assessment of body fat mass and distribution.
Individualization of obesity management including behavioral, pharmacologic, and surgical approaches is encouraged. The use of a glucagon-like peptide-1 (GLP-1) receptor agonist or a dual glucose-dependent insulinotropic polypeptide and GLP-1 receptor agonist with greater weight loss efficacy is preferred for obesity management in people with diabetes.
“Obesity management is one of the biggest changes over this last year,” Dr. Gabbay commented.
Other New Recommendations: Among the many other revisions in the 2024 document are new recommendations about regular evaluation and treatment for bone health, assessment of disability and guidance for referral, and alignment of guidance for liver disease screening and management with those of other professional societies. Regarding the last item, Dr. Gabbay noted, “I don’t think it’s gotten the attention it deserves. Diabetes and obesity are becoming the leading causes of liver disease.”
Clinicians can also download the Standards of Care app on their smartphones. “That can be really helpful when questions come up since you can’t remember everything in there. Here you can look it up in a matter of seconds,” Dr. Gabbay said.
Dr. El Sayed added that asking patients about their priorities is also important. “If they aren’t brought up during the visit, it’s unlikely to be as fruitful as it should be.”
Dr. El Sayed has no disclosures. Dr. Gabbay serves as a consultant and/or advisor for HealthReveal, Lark Technologies, Onduo, StartUp Health, Sweetech, and Vida Health.
A version of this article appeared on Medscape.com.
for 2024.
“The Standards of Care are essentially the global guidelines for the care of individuals with diabetes and those at risk,” ADA chief scientific and medical officer Robert Gabbay, MD, PhD, said during a briefing announcing the new Standards.
The document was developed via a scientific literature review by the ADA’s Professional Practice Committee. The panel comprises 21 professionals, including physicians from many specialties, nurse practitioners, certified diabetes care and education specialists, dietitians, and pharmacists. The chair is Nuha A. El Sayed, MD, ADA’s senior vice president of healthcare improvement.
Specific sections of the 2024 document have been endorsed by the American College of Cardiology, the American Society of Bone and Mineral Research, and the Obesity Society. It was published on December 11, 2023, as a supplement in Diabetes Care.
An introductory section summarizing the changes for 2024 spans six pages. Those addressed during the briefing included the following:
Heart Failure Screening: Two new recommendations have been added to include screening of adults with diabetes for asymptomatic heart failure by measuring natriuretic peptide levels to facilitate the prevention or progression to symptomatic stages of heart failure.
“This is a really important and exciting area. We know that people with type 2 diabetes in particular are at high risk for heart failure,” Dr. Gabbay said, adding that these recommendations “are to really more aggressively screen those at high risk for heart failure with a simple blood test and, based on those values, then be able to move on to further evaluation and echocardiography, for example. The recommendations are really to screen a broad number of individuals with type 2 diabetes because many are at risk, [particularly] those without symptoms.”
PAD Screening: A new strong recommendation is to screen for PAD with ankle-brachial index testing in asymptomatic people with diabetes who are aged ≥ 50 years and have microvascular disease in any location, foot complications, or any end-organ damage from diabetes. The document also advises consideration of PAD screening for all individuals who have had diabetes for ≥ 10 years.
Dr. Gabbay commented, “We know that amputation rates are rising, unlike many other complications. We know that there are incredible health disparities. Blacks are two to four times more likely than Whites to have an amputation.”
Dr. El Sayed added, “Many patients don’t show the common symptoms of peripheral arterial disease. Screening is the most important way to find out if they have it or not because it can be a very devastating disease.”
Type 1 Diabetes Screening: This involves several new recommendations, including a framework for investigating suspected type 1 diabetes in newly diagnosed adults using islet autoantibody tests and diagnostic criteria for preclinical stages based on the recent approval of teplizumab for delaying the onset of type 1 diabetes.
“Screening and capturing disease earlier so that we can intervene is really an important consideration here. That includes screening for type 1 diabetes and thinking about therapeutic options to delay the development of frank type 1 diabetes,” Dr. Gabbay said.
Screening first-degree relatives of people with type 1 diabetes is a high priority because they’re at an elevated risk, he added.
Obesity Management: New recommendations here include the use of anthropomorphic measurements beyond body mass index to include waist circumference and waist:hip ratio and individual assessment of body fat mass and distribution.
Individualization of obesity management including behavioral, pharmacologic, and surgical approaches is encouraged. The use of a glucagon-like peptide-1 (GLP-1) receptor agonist or a dual glucose-dependent insulinotropic polypeptide and GLP-1 receptor agonist with greater weight loss efficacy is preferred for obesity management in people with diabetes.
“Obesity management is one of the biggest changes over this last year,” Dr. Gabbay commented.
Other New Recommendations: Among the many other revisions in the 2024 document are new recommendations about regular evaluation and treatment for bone health, assessment of disability and guidance for referral, and alignment of guidance for liver disease screening and management with those of other professional societies. Regarding the last item, Dr. Gabbay noted, “I don’t think it’s gotten the attention it deserves. Diabetes and obesity are becoming the leading causes of liver disease.”
Clinicians can also download the Standards of Care app on their smartphones. “That can be really helpful when questions come up since you can’t remember everything in there. Here you can look it up in a matter of seconds,” Dr. Gabbay said.
Dr. El Sayed added that asking patients about their priorities is also important. “If they aren’t brought up during the visit, it’s unlikely to be as fruitful as it should be.”
Dr. El Sayed has no disclosures. Dr. Gabbay serves as a consultant and/or advisor for HealthReveal, Lark Technologies, Onduo, StartUp Health, Sweetech, and Vida Health.
A version of this article appeared on Medscape.com.
Recruiting ObGyns: Starting salary considerations
Evidence continues to show that the number of practicing ObGyns lags the growing and diverse US population of women.1 Furthermore, approximately 1 in every 3 ObGyns will move usually once or twice every 10 years.2 Knowing what to expect in being recruited requires a better understanding of your needs and capabilities and what they may be worth in real time. Some ObGyns elect to use a recruitment firm to begin their search to more objectively assess what is fair and equitable.
Understanding physician compensation involves many factors, such as patient composition, sources of reimbursement, impact of health care systems, and geography.3 Several sources report trends in annual physician compensation, most notably the American Medical Association, medical specialty organizations, and recruitment firms. Sources such as the Medical Group Management Association (MGMA), the American Medical Group Association (AMGA), and Medscape report total compensation.
Determining salaries for new positions
A standard and comprehensive benchmarking resource for salaries in new positions has been the annual review of physician and advanced practitioner recruiting incentives by AMN Healthcare (formerly Merritt Hawkins) Physician Solutions.4 This resource is used by hospitals, medical groups, academics, other health care systems, and others who track trends in physician supply, demand, and compensation. Their 2023 report considered starting salaries for more than 20 medical or surgical specialties.
Specialists’ revenue-generating potential is tracked by annual billings to commercial payers. The average annual billing by a full-time ObGyn ($3.8 million) is about the same as that of other specialties combined.5 As in the past, ObGyns are among the most consistently requested specialists in searches. In 2023, ObGyns were ranked the third most common physician specialists being recruited and tenth as the percentage of physicians per specialty (TABLE).4
Full-time salaries for ObGyns have remained within the middle third of all specialties. They consistently have been higher than primary care physicians’ salaries but remain among the lowest of the surgical specialties. This impression is reinforced by 2023 data shown in FIGURE 1.4 In the past, salaries remained flat compared with other surgical specialties. As with other specialties, starting salaries decreased during the peak 2020 and 2021 COVID-19 years. It is encouraging that averaged full-time salaries for recruiting ObGyns increased by 14.1% from 2020–2021 to 2021–2022 and by 10.5% from 2021–2022 to 2022–2023 (FIGURE 2).4
Special considerations
Incomes tended to be highest for ObGyns practicing in metropolitan areas with population sizes less than 1 million rather than in larger metropolitan areas.3 However, differences in reported incomes do not control for cost of living and other determinants of income (for example, surgeries, deliveries, patient care hours worked). Averaged salaries can vary regionally in the following order from highest to lowest: Midwest/Great Plains, West, Southwest, and Northeast and Southeast.4
Differences in starting salaries between male and female ObGyns are often not reported, although they are a very important consideration.6,7 Both men and women desire “controllable lifestyles” with more flexibility and working in shifts. Sex-based differences in physician salary and compensation can be complex. Explanations may deal with the number of patients seen, number of procedures and surgeries performed, and frequency of after-hours duties. Women constitute most ObGyns, and their salary being at any lower end of the income spectrum may be partially explained by fewer desired work hours or less seniority.
Annual earnings can vary and are positively related to the number of working hours, being in the middle of one’s career (aged 42–51 years), working in a moderately large practice rather than in a solo or self-employed practice, and being board certified.3 A lower starting salary would be anticipated for a recent graduate. However, the resident going into a hard-to-fill position may be offered a higher salary than an experienced ObGyn who takes a relatively easy-to-fill position in a popular location. Practices would be more desirable in which patient volume is sufficient to invest in nonphysician clinicians and revenue-generating ancillary services that do not require costly layers of administration.
Information on physician salaries for new positions from individual recruiting or research firms can serve as a starting point for negotiation, although it may not entirely be representative. Sample sizes can be small, and information in some specialties may not separate salaries of physicians in academic versus nonacademic positions and generalists versus subspecialists. The information in this article reflects the average salaries offered to attract physicians to new practice settings rather than what they might earn and report on their tax return.
Continue to: Incentives...
Incentives
Negotiations involve incentives along with a starting salary. Signing bonuses, movingallowances, continuing education time and allowances, and medical education loan repayments are important incentives. Recent signing bonuses (average, $37,472) likely reflect efforts to bring physicians back to health care facilities post-COVID-19 or, more commonly, when candidates are considering multiple opportunities.4 It is important to clarify at the beginning any coverage for health insurance and professional liability insurance.
Relocation allowances are for those being recruited outside their current area of residence. The average continuing medical education allowance was $3,840 in 2023.4 Medical school debt is common, being approximately $200,000 at graduation for many. An educational loan repayment (average, $98,665) is typically an exchange for a commitment to stay in the community for a given period.
Starting employment contracts with hospitals or large medical groups often feature a production bonus to reward additional clinical work performed or an adherence to quality protocol or guidelines, rather than income guarantees alone. Metrics are usually volume driven (for example, relative value units, net collections, gross billings, patients seen). Initiatives by payers and health care organizations have included quality metrics, such as high patient satisfaction scores, low morbidity rates, and low readmission rates. Production-based formulas are straightforward, while use of quality-based formulas (up to 14% of total compensation) can be less clear to define.4 ●
- Rayburn WF, Xierali IM. Expanded fellowship training and residency graduates’ availability for women’s general health needs. Obstet Gynecol. 2021;137:1119-1121.
- Xierali IM, Nivett MA, Rayburn WF. Relocation of obstetriciangynecologists in the United States, 2005-2015. Obstet Gynecol. 2017;129:543-550.
- Rayburn WF. The Obstetrician-Gynecologist Workforce in the United States: Facts, Figures, and Implications. 2nd ed. American College of Obstetricians and Gynecologists; 2017.
- AMN Healthcare. 2023 Review of physician and advanced practitioner recruiting incentives. July 24, 2023. Accessed October 3, 2023. https://www.amnhealthcare.com/amn -insights/physician/surveys/2023-physician-and-ap -recruiting-incentives/
- AMN Healthcare. 2023 Physician billing report. March 21, 2023. Accessed October 7, 2023. https://www.amnhealthcare. com/amn-insights/physician/whitepapers/2023-physician -billing-report/
- Bravender T, Selkie E, Sturza J, et al. Association of salary differences between medical specialties with sex distribution. JAMA Pediatr. 2021;175:524-525.
- Lo Sasso AT, Armstrong D, Forte G, et al. Differences in starting pay for male and female physicians persist; explanations for the gender gap remain elusive. Health Aff. 2020;39:256-263.
Evidence continues to show that the number of practicing ObGyns lags the growing and diverse US population of women.1 Furthermore, approximately 1 in every 3 ObGyns will move usually once or twice every 10 years.2 Knowing what to expect in being recruited requires a better understanding of your needs and capabilities and what they may be worth in real time. Some ObGyns elect to use a recruitment firm to begin their search to more objectively assess what is fair and equitable.
Understanding physician compensation involves many factors, such as patient composition, sources of reimbursement, impact of health care systems, and geography.3 Several sources report trends in annual physician compensation, most notably the American Medical Association, medical specialty organizations, and recruitment firms. Sources such as the Medical Group Management Association (MGMA), the American Medical Group Association (AMGA), and Medscape report total compensation.
Determining salaries for new positions
A standard and comprehensive benchmarking resource for salaries in new positions has been the annual review of physician and advanced practitioner recruiting incentives by AMN Healthcare (formerly Merritt Hawkins) Physician Solutions.4 This resource is used by hospitals, medical groups, academics, other health care systems, and others who track trends in physician supply, demand, and compensation. Their 2023 report considered starting salaries for more than 20 medical or surgical specialties.
Specialists’ revenue-generating potential is tracked by annual billings to commercial payers. The average annual billing by a full-time ObGyn ($3.8 million) is about the same as that of other specialties combined.5 As in the past, ObGyns are among the most consistently requested specialists in searches. In 2023, ObGyns were ranked the third most common physician specialists being recruited and tenth as the percentage of physicians per specialty (TABLE).4
Full-time salaries for ObGyns have remained within the middle third of all specialties. They consistently have been higher than primary care physicians’ salaries but remain among the lowest of the surgical specialties. This impression is reinforced by 2023 data shown in FIGURE 1.4 In the past, salaries remained flat compared with other surgical specialties. As with other specialties, starting salaries decreased during the peak 2020 and 2021 COVID-19 years. It is encouraging that averaged full-time salaries for recruiting ObGyns increased by 14.1% from 2020–2021 to 2021–2022 and by 10.5% from 2021–2022 to 2022–2023 (FIGURE 2).4
Special considerations
Incomes tended to be highest for ObGyns practicing in metropolitan areas with population sizes less than 1 million rather than in larger metropolitan areas.3 However, differences in reported incomes do not control for cost of living and other determinants of income (for example, surgeries, deliveries, patient care hours worked). Averaged salaries can vary regionally in the following order from highest to lowest: Midwest/Great Plains, West, Southwest, and Northeast and Southeast.4
Differences in starting salaries between male and female ObGyns are often not reported, although they are a very important consideration.6,7 Both men and women desire “controllable lifestyles” with more flexibility and working in shifts. Sex-based differences in physician salary and compensation can be complex. Explanations may deal with the number of patients seen, number of procedures and surgeries performed, and frequency of after-hours duties. Women constitute most ObGyns, and their salary being at any lower end of the income spectrum may be partially explained by fewer desired work hours or less seniority.
Annual earnings can vary and are positively related to the number of working hours, being in the middle of one’s career (aged 42–51 years), working in a moderately large practice rather than in a solo or self-employed practice, and being board certified.3 A lower starting salary would be anticipated for a recent graduate. However, the resident going into a hard-to-fill position may be offered a higher salary than an experienced ObGyn who takes a relatively easy-to-fill position in a popular location. Practices would be more desirable in which patient volume is sufficient to invest in nonphysician clinicians and revenue-generating ancillary services that do not require costly layers of administration.
Information on physician salaries for new positions from individual recruiting or research firms can serve as a starting point for negotiation, although it may not entirely be representative. Sample sizes can be small, and information in some specialties may not separate salaries of physicians in academic versus nonacademic positions and generalists versus subspecialists. The information in this article reflects the average salaries offered to attract physicians to new practice settings rather than what they might earn and report on their tax return.
Continue to: Incentives...
Incentives
Negotiations involve incentives along with a starting salary. Signing bonuses, movingallowances, continuing education time and allowances, and medical education loan repayments are important incentives. Recent signing bonuses (average, $37,472) likely reflect efforts to bring physicians back to health care facilities post-COVID-19 or, more commonly, when candidates are considering multiple opportunities.4 It is important to clarify at the beginning any coverage for health insurance and professional liability insurance.
Relocation allowances are for those being recruited outside their current area of residence. The average continuing medical education allowance was $3,840 in 2023.4 Medical school debt is common, being approximately $200,000 at graduation for many. An educational loan repayment (average, $98,665) is typically an exchange for a commitment to stay in the community for a given period.
Starting employment contracts with hospitals or large medical groups often feature a production bonus to reward additional clinical work performed or an adherence to quality protocol or guidelines, rather than income guarantees alone. Metrics are usually volume driven (for example, relative value units, net collections, gross billings, patients seen). Initiatives by payers and health care organizations have included quality metrics, such as high patient satisfaction scores, low morbidity rates, and low readmission rates. Production-based formulas are straightforward, while use of quality-based formulas (up to 14% of total compensation) can be less clear to define.4 ●
Evidence continues to show that the number of practicing ObGyns lags the growing and diverse US population of women.1 Furthermore, approximately 1 in every 3 ObGyns will move usually once or twice every 10 years.2 Knowing what to expect in being recruited requires a better understanding of your needs and capabilities and what they may be worth in real time. Some ObGyns elect to use a recruitment firm to begin their search to more objectively assess what is fair and equitable.
Understanding physician compensation involves many factors, such as patient composition, sources of reimbursement, impact of health care systems, and geography.3 Several sources report trends in annual physician compensation, most notably the American Medical Association, medical specialty organizations, and recruitment firms. Sources such as the Medical Group Management Association (MGMA), the American Medical Group Association (AMGA), and Medscape report total compensation.
Determining salaries for new positions
A standard and comprehensive benchmarking resource for salaries in new positions has been the annual review of physician and advanced practitioner recruiting incentives by AMN Healthcare (formerly Merritt Hawkins) Physician Solutions.4 This resource is used by hospitals, medical groups, academics, other health care systems, and others who track trends in physician supply, demand, and compensation. Their 2023 report considered starting salaries for more than 20 medical or surgical specialties.
Specialists’ revenue-generating potential is tracked by annual billings to commercial payers. The average annual billing by a full-time ObGyn ($3.8 million) is about the same as that of other specialties combined.5 As in the past, ObGyns are among the most consistently requested specialists in searches. In 2023, ObGyns were ranked the third most common physician specialists being recruited and tenth as the percentage of physicians per specialty (TABLE).4
Full-time salaries for ObGyns have remained within the middle third of all specialties. They consistently have been higher than primary care physicians’ salaries but remain among the lowest of the surgical specialties. This impression is reinforced by 2023 data shown in FIGURE 1.4 In the past, salaries remained flat compared with other surgical specialties. As with other specialties, starting salaries decreased during the peak 2020 and 2021 COVID-19 years. It is encouraging that averaged full-time salaries for recruiting ObGyns increased by 14.1% from 2020–2021 to 2021–2022 and by 10.5% from 2021–2022 to 2022–2023 (FIGURE 2).4
Special considerations
Incomes tended to be highest for ObGyns practicing in metropolitan areas with population sizes less than 1 million rather than in larger metropolitan areas.3 However, differences in reported incomes do not control for cost of living and other determinants of income (for example, surgeries, deliveries, patient care hours worked). Averaged salaries can vary regionally in the following order from highest to lowest: Midwest/Great Plains, West, Southwest, and Northeast and Southeast.4
Differences in starting salaries between male and female ObGyns are often not reported, although they are a very important consideration.6,7 Both men and women desire “controllable lifestyles” with more flexibility and working in shifts. Sex-based differences in physician salary and compensation can be complex. Explanations may deal with the number of patients seen, number of procedures and surgeries performed, and frequency of after-hours duties. Women constitute most ObGyns, and their salary being at any lower end of the income spectrum may be partially explained by fewer desired work hours or less seniority.
Annual earnings can vary and are positively related to the number of working hours, being in the middle of one’s career (aged 42–51 years), working in a moderately large practice rather than in a solo or self-employed practice, and being board certified.3 A lower starting salary would be anticipated for a recent graduate. However, the resident going into a hard-to-fill position may be offered a higher salary than an experienced ObGyn who takes a relatively easy-to-fill position in a popular location. Practices would be more desirable in which patient volume is sufficient to invest in nonphysician clinicians and revenue-generating ancillary services that do not require costly layers of administration.
Information on physician salaries for new positions from individual recruiting or research firms can serve as a starting point for negotiation, although it may not entirely be representative. Sample sizes can be small, and information in some specialties may not separate salaries of physicians in academic versus nonacademic positions and generalists versus subspecialists. The information in this article reflects the average salaries offered to attract physicians to new practice settings rather than what they might earn and report on their tax return.
Continue to: Incentives...
Incentives
Negotiations involve incentives along with a starting salary. Signing bonuses, movingallowances, continuing education time and allowances, and medical education loan repayments are important incentives. Recent signing bonuses (average, $37,472) likely reflect efforts to bring physicians back to health care facilities post-COVID-19 or, more commonly, when candidates are considering multiple opportunities.4 It is important to clarify at the beginning any coverage for health insurance and professional liability insurance.
Relocation allowances are for those being recruited outside their current area of residence. The average continuing medical education allowance was $3,840 in 2023.4 Medical school debt is common, being approximately $200,000 at graduation for many. An educational loan repayment (average, $98,665) is typically an exchange for a commitment to stay in the community for a given period.
Starting employment contracts with hospitals or large medical groups often feature a production bonus to reward additional clinical work performed or an adherence to quality protocol or guidelines, rather than income guarantees alone. Metrics are usually volume driven (for example, relative value units, net collections, gross billings, patients seen). Initiatives by payers and health care organizations have included quality metrics, such as high patient satisfaction scores, low morbidity rates, and low readmission rates. Production-based formulas are straightforward, while use of quality-based formulas (up to 14% of total compensation) can be less clear to define.4 ●
- Rayburn WF, Xierali IM. Expanded fellowship training and residency graduates’ availability for women’s general health needs. Obstet Gynecol. 2021;137:1119-1121.
- Xierali IM, Nivett MA, Rayburn WF. Relocation of obstetriciangynecologists in the United States, 2005-2015. Obstet Gynecol. 2017;129:543-550.
- Rayburn WF. The Obstetrician-Gynecologist Workforce in the United States: Facts, Figures, and Implications. 2nd ed. American College of Obstetricians and Gynecologists; 2017.
- AMN Healthcare. 2023 Review of physician and advanced practitioner recruiting incentives. July 24, 2023. Accessed October 3, 2023. https://www.amnhealthcare.com/amn -insights/physician/surveys/2023-physician-and-ap -recruiting-incentives/
- AMN Healthcare. 2023 Physician billing report. March 21, 2023. Accessed October 7, 2023. https://www.amnhealthcare. com/amn-insights/physician/whitepapers/2023-physician -billing-report/
- Bravender T, Selkie E, Sturza J, et al. Association of salary differences between medical specialties with sex distribution. JAMA Pediatr. 2021;175:524-525.
- Lo Sasso AT, Armstrong D, Forte G, et al. Differences in starting pay for male and female physicians persist; explanations for the gender gap remain elusive. Health Aff. 2020;39:256-263.
- Rayburn WF, Xierali IM. Expanded fellowship training and residency graduates’ availability for women’s general health needs. Obstet Gynecol. 2021;137:1119-1121.
- Xierali IM, Nivett MA, Rayburn WF. Relocation of obstetriciangynecologists in the United States, 2005-2015. Obstet Gynecol. 2017;129:543-550.
- Rayburn WF. The Obstetrician-Gynecologist Workforce in the United States: Facts, Figures, and Implications. 2nd ed. American College of Obstetricians and Gynecologists; 2017.
- AMN Healthcare. 2023 Review of physician and advanced practitioner recruiting incentives. July 24, 2023. Accessed October 3, 2023. https://www.amnhealthcare.com/amn -insights/physician/surveys/2023-physician-and-ap -recruiting-incentives/
- AMN Healthcare. 2023 Physician billing report. March 21, 2023. Accessed October 7, 2023. https://www.amnhealthcare. com/amn-insights/physician/whitepapers/2023-physician -billing-report/
- Bravender T, Selkie E, Sturza J, et al. Association of salary differences between medical specialties with sex distribution. JAMA Pediatr. 2021;175:524-525.
- Lo Sasso AT, Armstrong D, Forte G, et al. Differences in starting pay for male and female physicians persist; explanations for the gender gap remain elusive. Health Aff. 2020;39:256-263.
LGBTQI+: Special considerations for reproductive health care
CASE A new patient office visit
A new patient is waiting for you in the exam room. You review the chart and see the sex demographic field is blank, and the patient’s name is Alex. As an ObGyn, most of your patients are female, but you have treated your patients’ partners for sexually transmitted infections. As you enter the room, you see 2 androgynously dressed individuals; you introduce yourself and ask,
“What brings you in today, and who is your friend?”
“This is my partner Charlie, and we are worried I have an STD.”
Estimates suggest that between 7% to 12% of the US population identifies as lesbian, gay, bisexual, transgender/non-binary, queer/questioning, intersex, or asexual (LGBTQI+).1 If you practice in an urban area, the odds are quite high that you have encountered an LGBTQI+ person who openly identified as such; if you are in a rural area, you also likely have had an LGBTQI+ patient, but they may not have disclosed this about themselves.2 Maybe you have had training in cultural relevance or are a member of this community and you feel confident in providing quality care to LGBTQI+ patients. Or maybe you think that, as a responsibly practicing health care clinician, you treat all patients the same, so whether or not you know their sexual orientation or gender identity does not impact the care you provide. As the proportion of US adults who identify as LGBTQI+ increases,1 it becomes more important for health care clinicians to understand the challenges these patients face when trying to access health care. To start, let’s review the meaning of LGBTQI+, the history of the community, what it means to be culturally relevant or humble, and how to create a welcoming and safe practice environment.
LGBTQI+ terms and definitions
The first step in providing quality care to LGBTQI+ patients is to understand the terminology associated with sexual orientation, gender identity, and gender expression.3–5
Sexual orientation refers to whom a person is sexually attracted. The term straight/heterosexual suggests a person is sexually attracted to a person of the opposite gender. Lesbian or gay refers to those who are attracted to their same gender. Some people use bisexual (attracted to both the same and opposite gender) and pansexual (attracted to all humans regardless of gender). Still others refer to themselves as queer—people who identify as someone who is not heterosexual or cisgender. A variety of other terms exist to describe one’s sexual attraction. There are also some people who identify as asexual, which suggests they are not sexually attracted to anyone.
Gender identity relates to how one views their own gender. If you were assigned female at birth and identify as a woman, you are cisgender. If you were assigned male at birth and identify as a woman, you may identify as transgender whether or not you have had gender transitioning surgery or have taken hormones. Some people do not identify with the terms male or female and may view themselves as nonbinary. The terms gender queer, gender fluid, gender diverse, and gender non-conforming also may be used to describe various ways that an individual may not identify as male or female. We also can refer to people as “assigned female at birth” or “assigned male at birth”. People with intersex conditions may require taking a unique medical history that includes asking about genetic testing (eg, 46,XX congenital adrenal hyperplasia or 46,XY complete gonadal dysgenesis).
Gender expression refers to how one pre-sents themselves to others through appearance, dress, and behavior. A person may be assigned female at birth, dress in a conventional male fashion, and still identify as a woman. Still others may choose to express their gender in a variety of ways that may not have anything to do with their sexual orientation or gender identity, such as dressing in ways that represent their culture.
People may be fluid in their sexual orientation or gender identity; it may change from day to day, month to month, or even year to year.6,7
*The term LGBTQI+ is not used consistently in the literature. Throughout this article, the terminology used matches that used in the cited reference(s).
Continue to: Health care and the LGBTQI+ community...
Health care and the LGBTQI+ community
The LGBTQI+ community has a history of experiencing societal discrimination and stigma, which stems from medical mistrust often due to a lack of understanding of their medical and psychosocial needs.8,9 A 2019 survey of US LGBTQ adults, found that about 50% of people who identified as transgender reported having negative or discriminatory experiences with a health care clinician.10 About 18% of transgender people anticipated being refused medical care due to their gender identity.10 About 18% of LGBTQ individuals avoid any type of medical care, fearing discrimination.10 Lesbian women are 3 times more likely to have not seen an ObGyn than women who identify as straight.11 Sixty-two percent of lesbian women have biological children and received prenatal care; however, of those, 47% do not receive routine cancer screenings.10,11 Only 45% of age-eligible lesbian women have received at least 1 dose of the HPV vaccine, compared with 60% of straight women.10,11
Due to societal stigma, more than 40% of transgender people have attempted suicide.12 Felt or perceived stigma is also associated with risky health behaviors that contribute to health disparities. LGBTQI+ people are more likely to use substances,13 lesbian women are more likely to be obese,14 and 19% of transgender men are living with HIV/AIDS.15 Rates of unintended pregnancy among lesbian women and transgender men are 28%, compared with 6% in straight women, and 12% in heterosexual teens.15,16
In addition to real or perceived discrimination, there are medical misperceptions among the LGBTQI+ community. For instance, sexual minority women (SMW) are less likely to receive regular screening for cervical cancer. In one survey of more than 400 SMW, about 25% reported not receiving regular screening. SMW may mistakenly believe they do not need Pap testing and pelvic exams because they do not have penile-vaginal intercourse.17,18 Transgender men may not identify with having a cervix, or may perceive ObGyns to be “gendered” toward people who identify as women.18
Embracing cultural humility
Cultural humility expands upon the term cultural competence, with the idea that one can never be fully competent in the culture of another person.19,20 The National Institutes of Health defines cultural humility as “a lifelong process of self-reflection and self-critique whereby the individual not only learns about another’s culture, but one starts with an examination of his/her own beliefs and cultural identities.”21
Having cultural humility is the recognition that, in order to treat your ObGyn patient as a whole person and engage in shared medical decision making in the office setting, you need to know their sexual orientation and gender identity. Treating each patient the same is not providing equitable care (equality does not equal equity) because each patient has different medical and psychosocial needs. Embracing cultural humility is the first step in creating safe and welcoming spaces in the ObGyn office.20
CASE Ways to better introduce yourself
To revisit the case, what options does the clinician have to start off on a best foot to create a safe space for Alex?
- Open with your own preferred pronouns. For instance, for an introduction, consider: “I’m Dr. X, my pronouns are she/her.”
- Don’t assume. Do not make assumptions about the relationship between Alex and the person accompanying them.
4 ways for creating welcoming and affirming spaces in ObGyn
- Make sure your intake form is inclusive. Include a space for pronouns and the patient’s preferred name (which may differ from their legal name). Also allow patients to choose more than 1 sexual orientation and gender identity.20 (An example form is available from the LGBT National Health Education Center: https://www.lgbtqiahealtheducation.org/publication/focus-forms-policy-creating-inclusive-environment-lgbt-patients/.)
- Create a safe environment in the waiting area. Try to ensure that at least 1 bathroom is labeled “All Gender” or “Family.” Gendered bathrooms (eg, Ladies’ or Men’s rooms) are not welcoming. Make sure your non-discrimination policy is displayed and includes sexual orientation and gender identity. Review the patient education and reading materials in your waiting room to ensure they are inclusive. Do they show people with varied gender expression? Do they show same-sex couples or interracial couples?
- Use a trauma-informed approach when taking a sexual history and while conducting a physical exam. Determine if a pelvic exam is necessary at this visit or can it be postponed for another visit, when trust has been established with the patient. Explain each part of the pelvic/vaginal exam prior to conducting and again while performing the exam. Before taking a sexual history, explain why you are asking the questions and be sure to remain neutral with your questioning. For instance, you can say, “It’s important for me to understand your medical history in detail to provide you with the best health care possible.” Instead of asking, “Do you have sex with men, women, or both?” ask, “Do you have sex with people with a penis, vagina, or both? Do you have anal sex?” Recognize that some patients may be in a polyamorous relationship and may have more than 1 committed partner. For sexually active patients consider asking if they have ever exchanged sex for money or other goods, making sure to avoid judgmental body language or wording. Patients who do engage in “survival sex” may benefit from a discussion on pre-exposure prophylaxis to reduce HIV transmission.22
- Provide appropriate counsel based on their feedback.
- Explain their risk for HPV infection and vaccination options.
- Respectfully ask if there is a need for contraception and review options appropriate for their situation.
- Ask about the use of “toys” and provide guidance on sanitation and risk of infection with shared toys.
- Determine current or past hormone use for patients who identify as transgender and nonbinary (although many do not take hormones and have not had gender-affirming procedures, some may be considering these procedures). Be sure to ask these patients if they have had any surgeries or other procedures.
The receipt of gynecologic care can be traumatic for some LGBTQI+ people. Explain to the patient why you are doing everything during your examination and how it might feel. If a pelvic exam is not absolutely necessary that day, perhaps the patient can return another time. For transgender men who have been taking testosterone,vaginal atrophy may be a concern, and you could consider a pediatric speculum.
In summary, the number of people who identify as lesbian, gay, bisexual, transgender/nonbinary, queer/questioning, intersex, or asexual is not insignificant. Many of these patients or their partners may present for ObGyn care at your office. Clinicians need to understand that there is a new language relative to sexual orientation and gender identity. Incorporating cultural humility into one’s practice requires personal introspection and is a first step to creating safe and welcoming spaces in the ObGyn office. ●
- Jones JM. LGBT identification in US ticks up to 7.1%. Gallup News. February 17, 2022. Accessed July 11, 2023. https://news.gallup .com/poll/389792/lgbt-identification-ticks -up.aspx
- Patterson JG, Tree JMJ, and Kamen C. Cultural competency and microaggressions in the provision of care to LGBT patients in rural and Appalachian Tennessee. Patient Educ Couns. 2019;102:2081-2090. doi: 10.1016/j.pec .2019.06.003
- Grasso C, Funk D. Collecting sexual orientation and gender identity (SO/GI) data in electronic health records. The National LGBT Health Education Center. Accessed October 12, 2023. https://fenwayhealth.org/wp-content/uploads /4.-Collecting-SOGI-Data.pdf
- Glossary of terms: LGBTQ. GLAAD website. Accessed October 16, 2023. https://glaad.org /reference/terms.
- LGBTQI+. Social protection and human rights website. Accessed November 2, 2023. https ://socialprotection-humanrights.org/key -issues/disadvantaged-and-vulnerable-groups /lgbtqi/
- Goldberg AE, Manley MH, Ellawala T, et al. Sexuality and sexual identity across the first year of parenthood among male-partnered plurisexual women. Psychol Sex Orientat Gend Divers. 2019;6:75.
- Campbell A, Perales F, Hughes TL, et al. Sexual fluidity and psychological distress: what happens when young women’s sexual identities change? J Health Soc Behav. 2022;63:577-593.
- Gessner M, Bishop MD, Martos A, et al. Sexual minority people’s perspectives of sexual health care: understanding minority stress in sexual health settings. Sex Res Social Policy. 2020;17:607618. doi: 10.1007/s13178-019-00418-9
- Carpenter E. “The health system just wasn’t built for us”: queer cisgender women and gender expansive individuals’ strategies for navigating reproductive health care. Womens Health Issues. 2021;31:478-484. doi: 10.1016 /j.whi.2021.06.004
- Casey LS, Reisner SL, Findling MG, et al. Discrimination in the United States: experiences of lesbian, gay, bisexual, transgender, and queer Americans. Health Serv Res. 2019;54(suppl 2):1454-1466. doi: 10.1111/1475-6773.13229
- Grasso C, Goldhammer H, Brown RJ, et al. Using sexual orientation and gender identity data in electronic health records to assess for disparities in preventive health screening services. Int J Med Inform. 2020:142:104245. doi: 10.1016 /j.ijmedinf.2020.104245
- Austin A, Craig SL, D’Souza S, et al. Suicidality among transgender youth: elucidating the role of interpersonal risk factors. J Interpers Violence. 2022;37:NP2696-NP2718. doi: 10.1177 /0886260520915554. Published correction appears in J Interpers Violence. 2020:8862 60520946128.
- Hibbert MP, Hillis A, Brett CE, et al. A narrative systematic review of sexualised drug use and sexual health outcomes among LGBT people. Int J Drug Policy. 2021;93:103187. doi: 10.1016 /j.drugpo.2021.103187
- Azagba S, Shan L, Latham K. Overweight and obesity among sexual minority adults in the United States. Int J Environ Res Public Health. 2019;16:1828. doi: 10.3390/ijerph16101828
- Klein PW, Psihopaidas D, Xavier J, et al. HIVrelated outcome disparities between transgender women living with HIV and cisgender people living with HIV served by the Health Resources and Services Administration’s Ryan White HIV/ AIDS Program: a retrospective study. PLoS Med. 2020;17:e1003125. doi: 10.1371/journal.pmed .1003125
- Jung C, Hunter A, Saleh M, et al. Breaking the binary: how clinicians can ensure everyone receives high quality reproductive health services. Open Access J Contracept. 2023:14:23-39. doi: 10.2147/OAJC.S368621
- Bustamante G, Reiter PL, McRee AL. Cervical cancer screening among sexual minority women: findings from a national survey. Cancer Causes Control. 2021;32:911-917. doi: 10.1007 /s10552-021-01442-0
- Dhillon N, Oliffe JL, Kelly MT, et al. Bridging barriers to cervical cancer screening in transgender men: a scoping review. Am J Mens Health. 2020;14:1557988320925691. doi: 10.1177/1557988320925691
- Stubbe DE. Practicing cultural competence and cultural humility in the care of diverse patients. Focus (Am Psychiatr Publ). 2020;18:49-51. doi: 10.1176/appi.focus.20190041
- Alpert A, Kamen C, Schabath MB, et al. What exactly are we measuring? Evaluating sexual and gender minority cultural humility training for oncology care clinicians. J Clin Oncol. 2020;38:2605-2609. doi: 10.1200/JCO.19.03300
- Yeager KA, Bauer-Wu S. Cultural humility: essential foundation for clinical researchers. Appl Nurs Res. 2013;26:251-256. doi: 10.1016 /j.apnr.2013.06.008
- Nagle-Yang S, Sachdeva J, Zhao LX, et al. Traumainformed care for obstetric and gynecologic settings. Matern Child Health J. 2022;26:2362-2369.
CASE A new patient office visit
A new patient is waiting for you in the exam room. You review the chart and see the sex demographic field is blank, and the patient’s name is Alex. As an ObGyn, most of your patients are female, but you have treated your patients’ partners for sexually transmitted infections. As you enter the room, you see 2 androgynously dressed individuals; you introduce yourself and ask,
“What brings you in today, and who is your friend?”
“This is my partner Charlie, and we are worried I have an STD.”
Estimates suggest that between 7% to 12% of the US population identifies as lesbian, gay, bisexual, transgender/non-binary, queer/questioning, intersex, or asexual (LGBTQI+).1 If you practice in an urban area, the odds are quite high that you have encountered an LGBTQI+ person who openly identified as such; if you are in a rural area, you also likely have had an LGBTQI+ patient, but they may not have disclosed this about themselves.2 Maybe you have had training in cultural relevance or are a member of this community and you feel confident in providing quality care to LGBTQI+ patients. Or maybe you think that, as a responsibly practicing health care clinician, you treat all patients the same, so whether or not you know their sexual orientation or gender identity does not impact the care you provide. As the proportion of US adults who identify as LGBTQI+ increases,1 it becomes more important for health care clinicians to understand the challenges these patients face when trying to access health care. To start, let’s review the meaning of LGBTQI+, the history of the community, what it means to be culturally relevant or humble, and how to create a welcoming and safe practice environment.
LGBTQI+ terms and definitions
The first step in providing quality care to LGBTQI+ patients is to understand the terminology associated with sexual orientation, gender identity, and gender expression.3–5
Sexual orientation refers to whom a person is sexually attracted. The term straight/heterosexual suggests a person is sexually attracted to a person of the opposite gender. Lesbian or gay refers to those who are attracted to their same gender. Some people use bisexual (attracted to both the same and opposite gender) and pansexual (attracted to all humans regardless of gender). Still others refer to themselves as queer—people who identify as someone who is not heterosexual or cisgender. A variety of other terms exist to describe one’s sexual attraction. There are also some people who identify as asexual, which suggests they are not sexually attracted to anyone.
Gender identity relates to how one views their own gender. If you were assigned female at birth and identify as a woman, you are cisgender. If you were assigned male at birth and identify as a woman, you may identify as transgender whether or not you have had gender transitioning surgery or have taken hormones. Some people do not identify with the terms male or female and may view themselves as nonbinary. The terms gender queer, gender fluid, gender diverse, and gender non-conforming also may be used to describe various ways that an individual may not identify as male or female. We also can refer to people as “assigned female at birth” or “assigned male at birth”. People with intersex conditions may require taking a unique medical history that includes asking about genetic testing (eg, 46,XX congenital adrenal hyperplasia or 46,XY complete gonadal dysgenesis).
Gender expression refers to how one pre-sents themselves to others through appearance, dress, and behavior. A person may be assigned female at birth, dress in a conventional male fashion, and still identify as a woman. Still others may choose to express their gender in a variety of ways that may not have anything to do with their sexual orientation or gender identity, such as dressing in ways that represent their culture.
People may be fluid in their sexual orientation or gender identity; it may change from day to day, month to month, or even year to year.6,7
*The term LGBTQI+ is not used consistently in the literature. Throughout this article, the terminology used matches that used in the cited reference(s).
Continue to: Health care and the LGBTQI+ community...
Health care and the LGBTQI+ community
The LGBTQI+ community has a history of experiencing societal discrimination and stigma, which stems from medical mistrust often due to a lack of understanding of their medical and psychosocial needs.8,9 A 2019 survey of US LGBTQ adults, found that about 50% of people who identified as transgender reported having negative or discriminatory experiences with a health care clinician.10 About 18% of transgender people anticipated being refused medical care due to their gender identity.10 About 18% of LGBTQ individuals avoid any type of medical care, fearing discrimination.10 Lesbian women are 3 times more likely to have not seen an ObGyn than women who identify as straight.11 Sixty-two percent of lesbian women have biological children and received prenatal care; however, of those, 47% do not receive routine cancer screenings.10,11 Only 45% of age-eligible lesbian women have received at least 1 dose of the HPV vaccine, compared with 60% of straight women.10,11
Due to societal stigma, more than 40% of transgender people have attempted suicide.12 Felt or perceived stigma is also associated with risky health behaviors that contribute to health disparities. LGBTQI+ people are more likely to use substances,13 lesbian women are more likely to be obese,14 and 19% of transgender men are living with HIV/AIDS.15 Rates of unintended pregnancy among lesbian women and transgender men are 28%, compared with 6% in straight women, and 12% in heterosexual teens.15,16
In addition to real or perceived discrimination, there are medical misperceptions among the LGBTQI+ community. For instance, sexual minority women (SMW) are less likely to receive regular screening for cervical cancer. In one survey of more than 400 SMW, about 25% reported not receiving regular screening. SMW may mistakenly believe they do not need Pap testing and pelvic exams because they do not have penile-vaginal intercourse.17,18 Transgender men may not identify with having a cervix, or may perceive ObGyns to be “gendered” toward people who identify as women.18
Embracing cultural humility
Cultural humility expands upon the term cultural competence, with the idea that one can never be fully competent in the culture of another person.19,20 The National Institutes of Health defines cultural humility as “a lifelong process of self-reflection and self-critique whereby the individual not only learns about another’s culture, but one starts with an examination of his/her own beliefs and cultural identities.”21
Having cultural humility is the recognition that, in order to treat your ObGyn patient as a whole person and engage in shared medical decision making in the office setting, you need to know their sexual orientation and gender identity. Treating each patient the same is not providing equitable care (equality does not equal equity) because each patient has different medical and psychosocial needs. Embracing cultural humility is the first step in creating safe and welcoming spaces in the ObGyn office.20
CASE Ways to better introduce yourself
To revisit the case, what options does the clinician have to start off on a best foot to create a safe space for Alex?
- Open with your own preferred pronouns. For instance, for an introduction, consider: “I’m Dr. X, my pronouns are she/her.”
- Don’t assume. Do not make assumptions about the relationship between Alex and the person accompanying them.
4 ways for creating welcoming and affirming spaces in ObGyn
- Make sure your intake form is inclusive. Include a space for pronouns and the patient’s preferred name (which may differ from their legal name). Also allow patients to choose more than 1 sexual orientation and gender identity.20 (An example form is available from the LGBT National Health Education Center: https://www.lgbtqiahealtheducation.org/publication/focus-forms-policy-creating-inclusive-environment-lgbt-patients/.)
- Create a safe environment in the waiting area. Try to ensure that at least 1 bathroom is labeled “All Gender” or “Family.” Gendered bathrooms (eg, Ladies’ or Men’s rooms) are not welcoming. Make sure your non-discrimination policy is displayed and includes sexual orientation and gender identity. Review the patient education and reading materials in your waiting room to ensure they are inclusive. Do they show people with varied gender expression? Do they show same-sex couples or interracial couples?
- Use a trauma-informed approach when taking a sexual history and while conducting a physical exam. Determine if a pelvic exam is necessary at this visit or can it be postponed for another visit, when trust has been established with the patient. Explain each part of the pelvic/vaginal exam prior to conducting and again while performing the exam. Before taking a sexual history, explain why you are asking the questions and be sure to remain neutral with your questioning. For instance, you can say, “It’s important for me to understand your medical history in detail to provide you with the best health care possible.” Instead of asking, “Do you have sex with men, women, or both?” ask, “Do you have sex with people with a penis, vagina, or both? Do you have anal sex?” Recognize that some patients may be in a polyamorous relationship and may have more than 1 committed partner. For sexually active patients consider asking if they have ever exchanged sex for money or other goods, making sure to avoid judgmental body language or wording. Patients who do engage in “survival sex” may benefit from a discussion on pre-exposure prophylaxis to reduce HIV transmission.22
- Provide appropriate counsel based on their feedback.
- Explain their risk for HPV infection and vaccination options.
- Respectfully ask if there is a need for contraception and review options appropriate for their situation.
- Ask about the use of “toys” and provide guidance on sanitation and risk of infection with shared toys.
- Determine current or past hormone use for patients who identify as transgender and nonbinary (although many do not take hormones and have not had gender-affirming procedures, some may be considering these procedures). Be sure to ask these patients if they have had any surgeries or other procedures.
The receipt of gynecologic care can be traumatic for some LGBTQI+ people. Explain to the patient why you are doing everything during your examination and how it might feel. If a pelvic exam is not absolutely necessary that day, perhaps the patient can return another time. For transgender men who have been taking testosterone,vaginal atrophy may be a concern, and you could consider a pediatric speculum.
In summary, the number of people who identify as lesbian, gay, bisexual, transgender/nonbinary, queer/questioning, intersex, or asexual is not insignificant. Many of these patients or their partners may present for ObGyn care at your office. Clinicians need to understand that there is a new language relative to sexual orientation and gender identity. Incorporating cultural humility into one’s practice requires personal introspection and is a first step to creating safe and welcoming spaces in the ObGyn office. ●
CASE A new patient office visit
A new patient is waiting for you in the exam room. You review the chart and see the sex demographic field is blank, and the patient’s name is Alex. As an ObGyn, most of your patients are female, but you have treated your patients’ partners for sexually transmitted infections. As you enter the room, you see 2 androgynously dressed individuals; you introduce yourself and ask,
“What brings you in today, and who is your friend?”
“This is my partner Charlie, and we are worried I have an STD.”
Estimates suggest that between 7% to 12% of the US population identifies as lesbian, gay, bisexual, transgender/non-binary, queer/questioning, intersex, or asexual (LGBTQI+).1 If you practice in an urban area, the odds are quite high that you have encountered an LGBTQI+ person who openly identified as such; if you are in a rural area, you also likely have had an LGBTQI+ patient, but they may not have disclosed this about themselves.2 Maybe you have had training in cultural relevance or are a member of this community and you feel confident in providing quality care to LGBTQI+ patients. Or maybe you think that, as a responsibly practicing health care clinician, you treat all patients the same, so whether or not you know their sexual orientation or gender identity does not impact the care you provide. As the proportion of US adults who identify as LGBTQI+ increases,1 it becomes more important for health care clinicians to understand the challenges these patients face when trying to access health care. To start, let’s review the meaning of LGBTQI+, the history of the community, what it means to be culturally relevant or humble, and how to create a welcoming and safe practice environment.
LGBTQI+ terms and definitions
The first step in providing quality care to LGBTQI+ patients is to understand the terminology associated with sexual orientation, gender identity, and gender expression.3–5
Sexual orientation refers to whom a person is sexually attracted. The term straight/heterosexual suggests a person is sexually attracted to a person of the opposite gender. Lesbian or gay refers to those who are attracted to their same gender. Some people use bisexual (attracted to both the same and opposite gender) and pansexual (attracted to all humans regardless of gender). Still others refer to themselves as queer—people who identify as someone who is not heterosexual or cisgender. A variety of other terms exist to describe one’s sexual attraction. There are also some people who identify as asexual, which suggests they are not sexually attracted to anyone.
Gender identity relates to how one views their own gender. If you were assigned female at birth and identify as a woman, you are cisgender. If you were assigned male at birth and identify as a woman, you may identify as transgender whether or not you have had gender transitioning surgery or have taken hormones. Some people do not identify with the terms male or female and may view themselves as nonbinary. The terms gender queer, gender fluid, gender diverse, and gender non-conforming also may be used to describe various ways that an individual may not identify as male or female. We also can refer to people as “assigned female at birth” or “assigned male at birth”. People with intersex conditions may require taking a unique medical history that includes asking about genetic testing (eg, 46,XX congenital adrenal hyperplasia or 46,XY complete gonadal dysgenesis).
Gender expression refers to how one pre-sents themselves to others through appearance, dress, and behavior. A person may be assigned female at birth, dress in a conventional male fashion, and still identify as a woman. Still others may choose to express their gender in a variety of ways that may not have anything to do with their sexual orientation or gender identity, such as dressing in ways that represent their culture.
People may be fluid in their sexual orientation or gender identity; it may change from day to day, month to month, or even year to year.6,7
*The term LGBTQI+ is not used consistently in the literature. Throughout this article, the terminology used matches that used in the cited reference(s).
Continue to: Health care and the LGBTQI+ community...
Health care and the LGBTQI+ community
The LGBTQI+ community has a history of experiencing societal discrimination and stigma, which stems from medical mistrust often due to a lack of understanding of their medical and psychosocial needs.8,9 A 2019 survey of US LGBTQ adults, found that about 50% of people who identified as transgender reported having negative or discriminatory experiences with a health care clinician.10 About 18% of transgender people anticipated being refused medical care due to their gender identity.10 About 18% of LGBTQ individuals avoid any type of medical care, fearing discrimination.10 Lesbian women are 3 times more likely to have not seen an ObGyn than women who identify as straight.11 Sixty-two percent of lesbian women have biological children and received prenatal care; however, of those, 47% do not receive routine cancer screenings.10,11 Only 45% of age-eligible lesbian women have received at least 1 dose of the HPV vaccine, compared with 60% of straight women.10,11
Due to societal stigma, more than 40% of transgender people have attempted suicide.12 Felt or perceived stigma is also associated with risky health behaviors that contribute to health disparities. LGBTQI+ people are more likely to use substances,13 lesbian women are more likely to be obese,14 and 19% of transgender men are living with HIV/AIDS.15 Rates of unintended pregnancy among lesbian women and transgender men are 28%, compared with 6% in straight women, and 12% in heterosexual teens.15,16
In addition to real or perceived discrimination, there are medical misperceptions among the LGBTQI+ community. For instance, sexual minority women (SMW) are less likely to receive regular screening for cervical cancer. In one survey of more than 400 SMW, about 25% reported not receiving regular screening. SMW may mistakenly believe they do not need Pap testing and pelvic exams because they do not have penile-vaginal intercourse.17,18 Transgender men may not identify with having a cervix, or may perceive ObGyns to be “gendered” toward people who identify as women.18
Embracing cultural humility
Cultural humility expands upon the term cultural competence, with the idea that one can never be fully competent in the culture of another person.19,20 The National Institutes of Health defines cultural humility as “a lifelong process of self-reflection and self-critique whereby the individual not only learns about another’s culture, but one starts with an examination of his/her own beliefs and cultural identities.”21
Having cultural humility is the recognition that, in order to treat your ObGyn patient as a whole person and engage in shared medical decision making in the office setting, you need to know their sexual orientation and gender identity. Treating each patient the same is not providing equitable care (equality does not equal equity) because each patient has different medical and psychosocial needs. Embracing cultural humility is the first step in creating safe and welcoming spaces in the ObGyn office.20
CASE Ways to better introduce yourself
To revisit the case, what options does the clinician have to start off on a best foot to create a safe space for Alex?
- Open with your own preferred pronouns. For instance, for an introduction, consider: “I’m Dr. X, my pronouns are she/her.”
- Don’t assume. Do not make assumptions about the relationship between Alex and the person accompanying them.
4 ways for creating welcoming and affirming spaces in ObGyn
- Make sure your intake form is inclusive. Include a space for pronouns and the patient’s preferred name (which may differ from their legal name). Also allow patients to choose more than 1 sexual orientation and gender identity.20 (An example form is available from the LGBT National Health Education Center: https://www.lgbtqiahealtheducation.org/publication/focus-forms-policy-creating-inclusive-environment-lgbt-patients/.)
- Create a safe environment in the waiting area. Try to ensure that at least 1 bathroom is labeled “All Gender” or “Family.” Gendered bathrooms (eg, Ladies’ or Men’s rooms) are not welcoming. Make sure your non-discrimination policy is displayed and includes sexual orientation and gender identity. Review the patient education and reading materials in your waiting room to ensure they are inclusive. Do they show people with varied gender expression? Do they show same-sex couples or interracial couples?
- Use a trauma-informed approach when taking a sexual history and while conducting a physical exam. Determine if a pelvic exam is necessary at this visit or can it be postponed for another visit, when trust has been established with the patient. Explain each part of the pelvic/vaginal exam prior to conducting and again while performing the exam. Before taking a sexual history, explain why you are asking the questions and be sure to remain neutral with your questioning. For instance, you can say, “It’s important for me to understand your medical history in detail to provide you with the best health care possible.” Instead of asking, “Do you have sex with men, women, or both?” ask, “Do you have sex with people with a penis, vagina, or both? Do you have anal sex?” Recognize that some patients may be in a polyamorous relationship and may have more than 1 committed partner. For sexually active patients consider asking if they have ever exchanged sex for money or other goods, making sure to avoid judgmental body language or wording. Patients who do engage in “survival sex” may benefit from a discussion on pre-exposure prophylaxis to reduce HIV transmission.22
- Provide appropriate counsel based on their feedback.
- Explain their risk for HPV infection and vaccination options.
- Respectfully ask if there is a need for contraception and review options appropriate for their situation.
- Ask about the use of “toys” and provide guidance on sanitation and risk of infection with shared toys.
- Determine current or past hormone use for patients who identify as transgender and nonbinary (although many do not take hormones and have not had gender-affirming procedures, some may be considering these procedures). Be sure to ask these patients if they have had any surgeries or other procedures.
The receipt of gynecologic care can be traumatic for some LGBTQI+ people. Explain to the patient why you are doing everything during your examination and how it might feel. If a pelvic exam is not absolutely necessary that day, perhaps the patient can return another time. For transgender men who have been taking testosterone,vaginal atrophy may be a concern, and you could consider a pediatric speculum.
In summary, the number of people who identify as lesbian, gay, bisexual, transgender/nonbinary, queer/questioning, intersex, or asexual is not insignificant. Many of these patients or their partners may present for ObGyn care at your office. Clinicians need to understand that there is a new language relative to sexual orientation and gender identity. Incorporating cultural humility into one’s practice requires personal introspection and is a first step to creating safe and welcoming spaces in the ObGyn office. ●
- Jones JM. LGBT identification in US ticks up to 7.1%. Gallup News. February 17, 2022. Accessed July 11, 2023. https://news.gallup .com/poll/389792/lgbt-identification-ticks -up.aspx
- Patterson JG, Tree JMJ, and Kamen C. Cultural competency and microaggressions in the provision of care to LGBT patients in rural and Appalachian Tennessee. Patient Educ Couns. 2019;102:2081-2090. doi: 10.1016/j.pec .2019.06.003
- Grasso C, Funk D. Collecting sexual orientation and gender identity (SO/GI) data in electronic health records. The National LGBT Health Education Center. Accessed October 12, 2023. https://fenwayhealth.org/wp-content/uploads /4.-Collecting-SOGI-Data.pdf
- Glossary of terms: LGBTQ. GLAAD website. Accessed October 16, 2023. https://glaad.org /reference/terms.
- LGBTQI+. Social protection and human rights website. Accessed November 2, 2023. https ://socialprotection-humanrights.org/key -issues/disadvantaged-and-vulnerable-groups /lgbtqi/
- Goldberg AE, Manley MH, Ellawala T, et al. Sexuality and sexual identity across the first year of parenthood among male-partnered plurisexual women. Psychol Sex Orientat Gend Divers. 2019;6:75.
- Campbell A, Perales F, Hughes TL, et al. Sexual fluidity and psychological distress: what happens when young women’s sexual identities change? J Health Soc Behav. 2022;63:577-593.
- Gessner M, Bishop MD, Martos A, et al. Sexual minority people’s perspectives of sexual health care: understanding minority stress in sexual health settings. Sex Res Social Policy. 2020;17:607618. doi: 10.1007/s13178-019-00418-9
- Carpenter E. “The health system just wasn’t built for us”: queer cisgender women and gender expansive individuals’ strategies for navigating reproductive health care. Womens Health Issues. 2021;31:478-484. doi: 10.1016 /j.whi.2021.06.004
- Casey LS, Reisner SL, Findling MG, et al. Discrimination in the United States: experiences of lesbian, gay, bisexual, transgender, and queer Americans. Health Serv Res. 2019;54(suppl 2):1454-1466. doi: 10.1111/1475-6773.13229
- Grasso C, Goldhammer H, Brown RJ, et al. Using sexual orientation and gender identity data in electronic health records to assess for disparities in preventive health screening services. Int J Med Inform. 2020:142:104245. doi: 10.1016 /j.ijmedinf.2020.104245
- Austin A, Craig SL, D’Souza S, et al. Suicidality among transgender youth: elucidating the role of interpersonal risk factors. J Interpers Violence. 2022;37:NP2696-NP2718. doi: 10.1177 /0886260520915554. Published correction appears in J Interpers Violence. 2020:8862 60520946128.
- Hibbert MP, Hillis A, Brett CE, et al. A narrative systematic review of sexualised drug use and sexual health outcomes among LGBT people. Int J Drug Policy. 2021;93:103187. doi: 10.1016 /j.drugpo.2021.103187
- Azagba S, Shan L, Latham K. Overweight and obesity among sexual minority adults in the United States. Int J Environ Res Public Health. 2019;16:1828. doi: 10.3390/ijerph16101828
- Klein PW, Psihopaidas D, Xavier J, et al. HIVrelated outcome disparities between transgender women living with HIV and cisgender people living with HIV served by the Health Resources and Services Administration’s Ryan White HIV/ AIDS Program: a retrospective study. PLoS Med. 2020;17:e1003125. doi: 10.1371/journal.pmed .1003125
- Jung C, Hunter A, Saleh M, et al. Breaking the binary: how clinicians can ensure everyone receives high quality reproductive health services. Open Access J Contracept. 2023:14:23-39. doi: 10.2147/OAJC.S368621
- Bustamante G, Reiter PL, McRee AL. Cervical cancer screening among sexual minority women: findings from a national survey. Cancer Causes Control. 2021;32:911-917. doi: 10.1007 /s10552-021-01442-0
- Dhillon N, Oliffe JL, Kelly MT, et al. Bridging barriers to cervical cancer screening in transgender men: a scoping review. Am J Mens Health. 2020;14:1557988320925691. doi: 10.1177/1557988320925691
- Stubbe DE. Practicing cultural competence and cultural humility in the care of diverse patients. Focus (Am Psychiatr Publ). 2020;18:49-51. doi: 10.1176/appi.focus.20190041
- Alpert A, Kamen C, Schabath MB, et al. What exactly are we measuring? Evaluating sexual and gender minority cultural humility training for oncology care clinicians. J Clin Oncol. 2020;38:2605-2609. doi: 10.1200/JCO.19.03300
- Yeager KA, Bauer-Wu S. Cultural humility: essential foundation for clinical researchers. Appl Nurs Res. 2013;26:251-256. doi: 10.1016 /j.apnr.2013.06.008
- Nagle-Yang S, Sachdeva J, Zhao LX, et al. Traumainformed care for obstetric and gynecologic settings. Matern Child Health J. 2022;26:2362-2369.
- Jones JM. LGBT identification in US ticks up to 7.1%. Gallup News. February 17, 2022. Accessed July 11, 2023. https://news.gallup .com/poll/389792/lgbt-identification-ticks -up.aspx
- Patterson JG, Tree JMJ, and Kamen C. Cultural competency and microaggressions in the provision of care to LGBT patients in rural and Appalachian Tennessee. Patient Educ Couns. 2019;102:2081-2090. doi: 10.1016/j.pec .2019.06.003
- Grasso C, Funk D. Collecting sexual orientation and gender identity (SO/GI) data in electronic health records. The National LGBT Health Education Center. Accessed October 12, 2023. https://fenwayhealth.org/wp-content/uploads /4.-Collecting-SOGI-Data.pdf
- Glossary of terms: LGBTQ. GLAAD website. Accessed October 16, 2023. https://glaad.org /reference/terms.
- LGBTQI+. Social protection and human rights website. Accessed November 2, 2023. https ://socialprotection-humanrights.org/key -issues/disadvantaged-and-vulnerable-groups /lgbtqi/
- Goldberg AE, Manley MH, Ellawala T, et al. Sexuality and sexual identity across the first year of parenthood among male-partnered plurisexual women. Psychol Sex Orientat Gend Divers. 2019;6:75.
- Campbell A, Perales F, Hughes TL, et al. Sexual fluidity and psychological distress: what happens when young women’s sexual identities change? J Health Soc Behav. 2022;63:577-593.
- Gessner M, Bishop MD, Martos A, et al. Sexual minority people’s perspectives of sexual health care: understanding minority stress in sexual health settings. Sex Res Social Policy. 2020;17:607618. doi: 10.1007/s13178-019-00418-9
- Carpenter E. “The health system just wasn’t built for us”: queer cisgender women and gender expansive individuals’ strategies for navigating reproductive health care. Womens Health Issues. 2021;31:478-484. doi: 10.1016 /j.whi.2021.06.004
- Casey LS, Reisner SL, Findling MG, et al. Discrimination in the United States: experiences of lesbian, gay, bisexual, transgender, and queer Americans. Health Serv Res. 2019;54(suppl 2):1454-1466. doi: 10.1111/1475-6773.13229
- Grasso C, Goldhammer H, Brown RJ, et al. Using sexual orientation and gender identity data in electronic health records to assess for disparities in preventive health screening services. Int J Med Inform. 2020:142:104245. doi: 10.1016 /j.ijmedinf.2020.104245
- Austin A, Craig SL, D’Souza S, et al. Suicidality among transgender youth: elucidating the role of interpersonal risk factors. J Interpers Violence. 2022;37:NP2696-NP2718. doi: 10.1177 /0886260520915554. Published correction appears in J Interpers Violence. 2020:8862 60520946128.
- Hibbert MP, Hillis A, Brett CE, et al. A narrative systematic review of sexualised drug use and sexual health outcomes among LGBT people. Int J Drug Policy. 2021;93:103187. doi: 10.1016 /j.drugpo.2021.103187
- Azagba S, Shan L, Latham K. Overweight and obesity among sexual minority adults in the United States. Int J Environ Res Public Health. 2019;16:1828. doi: 10.3390/ijerph16101828
- Klein PW, Psihopaidas D, Xavier J, et al. HIVrelated outcome disparities between transgender women living with HIV and cisgender people living with HIV served by the Health Resources and Services Administration’s Ryan White HIV/ AIDS Program: a retrospective study. PLoS Med. 2020;17:e1003125. doi: 10.1371/journal.pmed .1003125
- Jung C, Hunter A, Saleh M, et al. Breaking the binary: how clinicians can ensure everyone receives high quality reproductive health services. Open Access J Contracept. 2023:14:23-39. doi: 10.2147/OAJC.S368621
- Bustamante G, Reiter PL, McRee AL. Cervical cancer screening among sexual minority women: findings from a national survey. Cancer Causes Control. 2021;32:911-917. doi: 10.1007 /s10552-021-01442-0
- Dhillon N, Oliffe JL, Kelly MT, et al. Bridging barriers to cervical cancer screening in transgender men: a scoping review. Am J Mens Health. 2020;14:1557988320925691. doi: 10.1177/1557988320925691
- Stubbe DE. Practicing cultural competence and cultural humility in the care of diverse patients. Focus (Am Psychiatr Publ). 2020;18:49-51. doi: 10.1176/appi.focus.20190041
- Alpert A, Kamen C, Schabath MB, et al. What exactly are we measuring? Evaluating sexual and gender minority cultural humility training for oncology care clinicians. J Clin Oncol. 2020;38:2605-2609. doi: 10.1200/JCO.19.03300
- Yeager KA, Bauer-Wu S. Cultural humility: essential foundation for clinical researchers. Appl Nurs Res. 2013;26:251-256. doi: 10.1016 /j.apnr.2013.06.008
- Nagle-Yang S, Sachdeva J, Zhao LX, et al. Traumainformed care for obstetric and gynecologic settings. Matern Child Health J. 2022;26:2362-2369.
Announcement from the publisher
Dear OBG Management Reader:
Frontline Medical Communications Inc has made the difficult decision to discontinue publication of
The online archive of clinical content for
For the latest news and information on obstetrics and gynecology, continue to turn to MDedge ObGyn.
Goodbye to OBG Management
Robert L. Barbieri, MD
OBG
Over 4 decades, the work of the
Our editorial board members are nationally recognized experts in our field and innovators in clinical care. Our editorial members include: Arnold P. Advincula, MD; Linda D. Bradley, MD; Amy L. Garcia, MD; Steven R. Goldstein, MD, MSCP, CCD; Andrew M. Kaunitz, MD, MSCP; Barbara Levy, MD; David G. Mutch, MD; Errol R. Norwitz, MD, PhD, MBA; Jaimey Pauli, MD; JoAnn V. Pinkerton, MD, MSCP; Joseph S. Sanfilippo, MD; and James A. Simon, MD, CCD, IF, MSCP. Prior to his retirement, Dr. John Repke was an important member of our editorial board. Over the past decade our editorial team—Lila O’Connor, Editorial Manager, and Kathy Christie, Senior Medical Content Editor—have ensured that the articles written by our authors are expertly prepared for publication and presentation to our readers.
In clinical practice, we sometimes do not achieve the optimal patient outcomes we desire. Over the past 4 decades, the
Dear OBG Management Reader:
Frontline Medical Communications Inc has made the difficult decision to discontinue publication of
The online archive of clinical content for
For the latest news and information on obstetrics and gynecology, continue to turn to MDedge ObGyn.
Goodbye to OBG Management
Robert L. Barbieri, MD
OBG
Over 4 decades, the work of the
Our editorial board members are nationally recognized experts in our field and innovators in clinical care. Our editorial members include: Arnold P. Advincula, MD; Linda D. Bradley, MD; Amy L. Garcia, MD; Steven R. Goldstein, MD, MSCP, CCD; Andrew M. Kaunitz, MD, MSCP; Barbara Levy, MD; David G. Mutch, MD; Errol R. Norwitz, MD, PhD, MBA; Jaimey Pauli, MD; JoAnn V. Pinkerton, MD, MSCP; Joseph S. Sanfilippo, MD; and James A. Simon, MD, CCD, IF, MSCP. Prior to his retirement, Dr. John Repke was an important member of our editorial board. Over the past decade our editorial team—Lila O’Connor, Editorial Manager, and Kathy Christie, Senior Medical Content Editor—have ensured that the articles written by our authors are expertly prepared for publication and presentation to our readers.
In clinical practice, we sometimes do not achieve the optimal patient outcomes we desire. Over the past 4 decades, the
Dear OBG Management Reader:
Frontline Medical Communications Inc has made the difficult decision to discontinue publication of
The online archive of clinical content for
For the latest news and information on obstetrics and gynecology, continue to turn to MDedge ObGyn.
Goodbye to OBG Management
Robert L. Barbieri, MD
OBG
Over 4 decades, the work of the
Our editorial board members are nationally recognized experts in our field and innovators in clinical care. Our editorial members include: Arnold P. Advincula, MD; Linda D. Bradley, MD; Amy L. Garcia, MD; Steven R. Goldstein, MD, MSCP, CCD; Andrew M. Kaunitz, MD, MSCP; Barbara Levy, MD; David G. Mutch, MD; Errol R. Norwitz, MD, PhD, MBA; Jaimey Pauli, MD; JoAnn V. Pinkerton, MD, MSCP; Joseph S. Sanfilippo, MD; and James A. Simon, MD, CCD, IF, MSCP. Prior to his retirement, Dr. John Repke was an important member of our editorial board. Over the past decade our editorial team—Lila O’Connor, Editorial Manager, and Kathy Christie, Senior Medical Content Editor—have ensured that the articles written by our authors are expertly prepared for publication and presentation to our readers.
In clinical practice, we sometimes do not achieve the optimal patient outcomes we desire. Over the past 4 decades, the
Answering the unknowns of taxanes for breast cancer during pregnancy
San Antonio – The findings shed light on a relatively unstudied topic. “Our cohort with 103 patients represents the most extensive study to date, and our main goal was to have homogeneous reporting of adverse events,” Ana Ferrigno Guajardo, MD, said in an interview. She presented the results at the San Antonio Breast Cancer Symposium.
“Breast cancer during pregnancy is a very challenging clinical situation as the expected antineoplastic effects of treatment must be carefully balanced against potential detrimental consequences on the developing fetus,” said Dr. Guajardo. She is a resident physician at Yale University School of Medicine.
Anthracycline-based chemotherapy agents are generally used during pregnancy because there is more safety data available for them, but some studies have shown that taxanes may have better efficacy in some clinical situations. “Cohort studies that have been done in the past [show] that taxane use is mostly deferred to the postpartum period, and we are not really sure of the impact that can have on survival in patients postponing treatment,” said Dr. Guajardo.
There are potential safety concerns with taxanes because neonates lack the cytochrome enzymes to metabolize the drugs, which creates a theoretical risk of adverse effects due to prolonged activity. On the other hand, pregnant women metabolize taxanes faster, and there are placental barriers that can inhibit high molecular weight molecules like taxanes from reaching the fetus, according to Dr. Guajardo.
In addition to pregnancy outcomes, the researchers followed 28 infants, and found that 87% were found to be completely healthy, “so we were relatively reassured. But of course we think that there’s a need for prospective studies that validate our findings regarding the safety taxanes,” said Dr. Guajardo.
Although there is no direct comparison group, the findings correlate well with studies of the general population and other chemotherapy agents. “We have large cohorts with mostly anthracycline-based chemotherapy agents during pregnancy that we can compare our results to, and overall, we were reassured that the prevalence of complications that we found in our cohort was very similar or even lower to those reported in the literature with patients treated with anthracycline-based therapy,” said Dr. Guajardo.
Compared with the general population, the team found higher rates of preterm births, neonatal ICU admissions, and premature membrane rupture, and infants that are small for gestational age. However, with the exception of the latter, all of these risks have been seen in pregnant women treated with other types of chemotherapy. “Perhaps it would be interesting to see if the incidence of small for gestational age neonates might be a bit higher in this population when compared to anthracycline-based therapy agents, but that does require a study that has a comparator group,” said Dr. Guajardo.
The researchers recruited 103 women with an average age of 34 years from 10 centers in 6 countries: United States, France, Spain, Mexico, Italy, and Costa Rica. The great majority were also treated with anthracyclines during gestation, and nearly all (97%) were treated with paclitaxel. The live birth rate was 98%, and 43.4% were preterm, 24% were small for gestational age, 16% were admitted to the neonate ICU, and 12.5% had hyperbilirubinemia.
Obstetric complications included intrauterine growth restriction (9%), preterm premature rupture of membranes (5%), gestational diabetes mellitus (5%), hypertensive disorders (4%), and pregnancy loss (2%).
After the presentation, Virginia Borges, MD, professor of medical oncology at University of Colorado Anschutz Medical Center, served as a discussant.
“Highlights of this study [include] that it is an international cohort from over six countries with over 100 cases of women included specifically focusing on the use of paclitaxel. They demonstrated safe outcomes for the pregnancies and the mothers,” Dr. Borges said during her presentation.
She went on to highlight several key points that physicians should consider when treating pregnancy-related breast cancer. “We want to achieve prepartum treatment wherever feasible to tackle that cancer before delivery of the child to prevent a pregnancy-related breast cancer from potentially turning into a postpartum breast cancer,” she said.
“If the tumor is ER+/HER2-, we now see we can safely give anthracyclines and taxanes from 12 to about 35 weeks of gestation. We don’t want to get too close to the delivery with chemotherapy. If a patient is HER2+, I prefer to give the anthracycline portion while the person is pregnant and then after delivery incorporate the taxane with the HER2 targeted therapies as there’s some older data showing concurrent therapy looks a bit better than sequential. In triple negative breast cancer, again I prefer to give the anthracycline and delay the taxane and carboplatin to overlap with immunotherapy so we are getting the necessary synergy there as well,” Dr. Borges added.
Dr. Guajardo has no relevant financial disclosures. Dr. Borges has consulted for SeaGen, Gilead, and AstraZeneca, and has received research funding from AstraZeneca, Gilead, Olema, and SeaGen.
San Antonio – The findings shed light on a relatively unstudied topic. “Our cohort with 103 patients represents the most extensive study to date, and our main goal was to have homogeneous reporting of adverse events,” Ana Ferrigno Guajardo, MD, said in an interview. She presented the results at the San Antonio Breast Cancer Symposium.
“Breast cancer during pregnancy is a very challenging clinical situation as the expected antineoplastic effects of treatment must be carefully balanced against potential detrimental consequences on the developing fetus,” said Dr. Guajardo. She is a resident physician at Yale University School of Medicine.
Anthracycline-based chemotherapy agents are generally used during pregnancy because there is more safety data available for them, but some studies have shown that taxanes may have better efficacy in some clinical situations. “Cohort studies that have been done in the past [show] that taxane use is mostly deferred to the postpartum period, and we are not really sure of the impact that can have on survival in patients postponing treatment,” said Dr. Guajardo.
There are potential safety concerns with taxanes because neonates lack the cytochrome enzymes to metabolize the drugs, which creates a theoretical risk of adverse effects due to prolonged activity. On the other hand, pregnant women metabolize taxanes faster, and there are placental barriers that can inhibit high molecular weight molecules like taxanes from reaching the fetus, according to Dr. Guajardo.
In addition to pregnancy outcomes, the researchers followed 28 infants, and found that 87% were found to be completely healthy, “so we were relatively reassured. But of course we think that there’s a need for prospective studies that validate our findings regarding the safety taxanes,” said Dr. Guajardo.
Although there is no direct comparison group, the findings correlate well with studies of the general population and other chemotherapy agents. “We have large cohorts with mostly anthracycline-based chemotherapy agents during pregnancy that we can compare our results to, and overall, we were reassured that the prevalence of complications that we found in our cohort was very similar or even lower to those reported in the literature with patients treated with anthracycline-based therapy,” said Dr. Guajardo.
Compared with the general population, the team found higher rates of preterm births, neonatal ICU admissions, and premature membrane rupture, and infants that are small for gestational age. However, with the exception of the latter, all of these risks have been seen in pregnant women treated with other types of chemotherapy. “Perhaps it would be interesting to see if the incidence of small for gestational age neonates might be a bit higher in this population when compared to anthracycline-based therapy agents, but that does require a study that has a comparator group,” said Dr. Guajardo.
The researchers recruited 103 women with an average age of 34 years from 10 centers in 6 countries: United States, France, Spain, Mexico, Italy, and Costa Rica. The great majority were also treated with anthracyclines during gestation, and nearly all (97%) were treated with paclitaxel. The live birth rate was 98%, and 43.4% were preterm, 24% were small for gestational age, 16% were admitted to the neonate ICU, and 12.5% had hyperbilirubinemia.
Obstetric complications included intrauterine growth restriction (9%), preterm premature rupture of membranes (5%), gestational diabetes mellitus (5%), hypertensive disorders (4%), and pregnancy loss (2%).
After the presentation, Virginia Borges, MD, professor of medical oncology at University of Colorado Anschutz Medical Center, served as a discussant.
“Highlights of this study [include] that it is an international cohort from over six countries with over 100 cases of women included specifically focusing on the use of paclitaxel. They demonstrated safe outcomes for the pregnancies and the mothers,” Dr. Borges said during her presentation.
She went on to highlight several key points that physicians should consider when treating pregnancy-related breast cancer. “We want to achieve prepartum treatment wherever feasible to tackle that cancer before delivery of the child to prevent a pregnancy-related breast cancer from potentially turning into a postpartum breast cancer,” she said.
“If the tumor is ER+/HER2-, we now see we can safely give anthracyclines and taxanes from 12 to about 35 weeks of gestation. We don’t want to get too close to the delivery with chemotherapy. If a patient is HER2+, I prefer to give the anthracycline portion while the person is pregnant and then after delivery incorporate the taxane with the HER2 targeted therapies as there’s some older data showing concurrent therapy looks a bit better than sequential. In triple negative breast cancer, again I prefer to give the anthracycline and delay the taxane and carboplatin to overlap with immunotherapy so we are getting the necessary synergy there as well,” Dr. Borges added.
Dr. Guajardo has no relevant financial disclosures. Dr. Borges has consulted for SeaGen, Gilead, and AstraZeneca, and has received research funding from AstraZeneca, Gilead, Olema, and SeaGen.
San Antonio – The findings shed light on a relatively unstudied topic. “Our cohort with 103 patients represents the most extensive study to date, and our main goal was to have homogeneous reporting of adverse events,” Ana Ferrigno Guajardo, MD, said in an interview. She presented the results at the San Antonio Breast Cancer Symposium.
“Breast cancer during pregnancy is a very challenging clinical situation as the expected antineoplastic effects of treatment must be carefully balanced against potential detrimental consequences on the developing fetus,” said Dr. Guajardo. She is a resident physician at Yale University School of Medicine.
Anthracycline-based chemotherapy agents are generally used during pregnancy because there is more safety data available for them, but some studies have shown that taxanes may have better efficacy in some clinical situations. “Cohort studies that have been done in the past [show] that taxane use is mostly deferred to the postpartum period, and we are not really sure of the impact that can have on survival in patients postponing treatment,” said Dr. Guajardo.
There are potential safety concerns with taxanes because neonates lack the cytochrome enzymes to metabolize the drugs, which creates a theoretical risk of adverse effects due to prolonged activity. On the other hand, pregnant women metabolize taxanes faster, and there are placental barriers that can inhibit high molecular weight molecules like taxanes from reaching the fetus, according to Dr. Guajardo.
In addition to pregnancy outcomes, the researchers followed 28 infants, and found that 87% were found to be completely healthy, “so we were relatively reassured. But of course we think that there’s a need for prospective studies that validate our findings regarding the safety taxanes,” said Dr. Guajardo.
Although there is no direct comparison group, the findings correlate well with studies of the general population and other chemotherapy agents. “We have large cohorts with mostly anthracycline-based chemotherapy agents during pregnancy that we can compare our results to, and overall, we were reassured that the prevalence of complications that we found in our cohort was very similar or even lower to those reported in the literature with patients treated with anthracycline-based therapy,” said Dr. Guajardo.
Compared with the general population, the team found higher rates of preterm births, neonatal ICU admissions, and premature membrane rupture, and infants that are small for gestational age. However, with the exception of the latter, all of these risks have been seen in pregnant women treated with other types of chemotherapy. “Perhaps it would be interesting to see if the incidence of small for gestational age neonates might be a bit higher in this population when compared to anthracycline-based therapy agents, but that does require a study that has a comparator group,” said Dr. Guajardo.
The researchers recruited 103 women with an average age of 34 years from 10 centers in 6 countries: United States, France, Spain, Mexico, Italy, and Costa Rica. The great majority were also treated with anthracyclines during gestation, and nearly all (97%) were treated with paclitaxel. The live birth rate was 98%, and 43.4% were preterm, 24% were small for gestational age, 16% were admitted to the neonate ICU, and 12.5% had hyperbilirubinemia.
Obstetric complications included intrauterine growth restriction (9%), preterm premature rupture of membranes (5%), gestational diabetes mellitus (5%), hypertensive disorders (4%), and pregnancy loss (2%).
After the presentation, Virginia Borges, MD, professor of medical oncology at University of Colorado Anschutz Medical Center, served as a discussant.
“Highlights of this study [include] that it is an international cohort from over six countries with over 100 cases of women included specifically focusing on the use of paclitaxel. They demonstrated safe outcomes for the pregnancies and the mothers,” Dr. Borges said during her presentation.
She went on to highlight several key points that physicians should consider when treating pregnancy-related breast cancer. “We want to achieve prepartum treatment wherever feasible to tackle that cancer before delivery of the child to prevent a pregnancy-related breast cancer from potentially turning into a postpartum breast cancer,” she said.
“If the tumor is ER+/HER2-, we now see we can safely give anthracyclines and taxanes from 12 to about 35 weeks of gestation. We don’t want to get too close to the delivery with chemotherapy. If a patient is HER2+, I prefer to give the anthracycline portion while the person is pregnant and then after delivery incorporate the taxane with the HER2 targeted therapies as there’s some older data showing concurrent therapy looks a bit better than sequential. In triple negative breast cancer, again I prefer to give the anthracycline and delay the taxane and carboplatin to overlap with immunotherapy so we are getting the necessary synergy there as well,” Dr. Borges added.
Dr. Guajardo has no relevant financial disclosures. Dr. Borges has consulted for SeaGen, Gilead, and AstraZeneca, and has received research funding from AstraZeneca, Gilead, Olema, and SeaGen.
FROM SABCS 2023