Women's Health

Medroxyprogesterone acetate is an injectable medication indicated for contraception and management of endometriosis-associated pain in females of reproductive age.¹ Medroxyprogesterone inhibits gonadotropin secretion, which prevents follicular maturation and ovulation. This leads to endometrial thinning and a contraceptive effect. Adverse drug reactions (ADRs), such as weight gain, menstrual bleeding irregularities, and bone loss appear to be dose- and time-related. Two formulations of medroxyprogesterone acetate are available: 150 mg depot medroxyprogesterone acetate intramuscular (DMPA-IM) and 104 mg DMPA subcutaneous (DMPA-SC).² Originally, medroxyprogesterone acetate injections required administration by a health care worker. While the current labeling for DMPA-SC still indicates a requirement for administration by a health care worker, data show that the medication can be safe and effective when self-administered.³

Self-Administered Contraception

The 2019 World Health Organization (WHO) guideline on self-care interventions recommends making self-administered injectable contraception available to individuals of reproductive age.³ The WHO recommendation is based on evidence from the Depo Self-Administration Study, which included 401 patients randomized 1:1 to receive self-administered or clinic-administered DMPA-SC. This study concluded that self-administration improved continuation of contraception.⁴

The North Florida/South Georgia Veterans Health System (NFSGVHS) is the largest US Department of Veterans Affairs (VA) health care system, serving > 22,000 female veterans. All primary care practitioners (PCP) have been trained in women’s health (WH). 

The WH patient-aligned care team (PACT) clinical pharmacy practitioner (CPP) proposed using DMPA-SC for outpatient self-administration to increase access, improve patient satisfaction, and reduce burden on patients and nurses for administration appointments. The Pharmacy and Therapeutics Committee (P&T), WH Medical Director, and Chief of Gynecology approved the proposal. DMPA-SC was added to the ordering menu with order sets. The order set included instructions that outlined the 12-week dosing interval, instructions to contact the prescriber if the injection was > 2 weeks overdue (aligning with dosing recommendations for administration every 12 to 14 weeks), and an optional order for a home pregnancy test if necessary. These instructions were designed to ensure proper self-administration of the medication and timely follow-up care. 

The gynecology and PACT health care practitioners (HCPs), including physicians, pharmacists, nurses, and medical assistants, received DMPA-SC education, which consisted of a review of medication, ADRs, contraindications, and administration. An NFSGVHS procedure was developed to ensure patients received self-administration education. DMPA-SC prescriptions were mailed to patients with scheduled nursing appointments. The patient would then bring DMPA-SC to the nursing appointment where they received administration instruction and completed the first injection under nurse supervision to ensure appropriate technique. Patients were offered supplementary educational documents and a calendar to keep track of injection days. The patients were responsible for ordering refills and administering subsequent injections at home. Once all stakeholders received education and order sets were in place, prescribers and nurses could begin offering the option for initiation of self-administered DMPA-SC to patients. All conversions or new prescriptions were initiated by prescribers as a part of usual care.

Medication Use Evaluation

A medication use evaluation was conducted about 1 year after the rollout to assess use, adherence, and impact of DMPA-SC for patient-self administration as a new contraceptive option for NFSGVHS patients.

A retrospective chart review was conducted for patients dispensed DMPA-SC from June 1, 2022, to July 1, 2023. Baseline body mass index (BMI), recorded prior to initiation of DMPA-SC, was compared with the most recent BMI on record at the completion of the study to evaluate weight change. Nursing visit attendance for the first injection was also assessed. Adherence was evaluated by reviewing the date of the initial DMPA-SC prescription, the date of the patient's first nursing visit, and subsequent refill patterns. A 2-week margin of error was established to account for the flexibility within the recommended dosing interval and delays in postal service delivery.

Forty patients were initiated on DMPA-SC for patient self-administration. The mean age of patients was 37.2 years. All 40 patients were female. Twenty-two patients (55%) identified as Black, 17 (43%) as White, and 1 (3%) as Asian. The majority (90%) of patients were non-Hispanic. The mean baseline BMI was 30 and BMI after DMPA-SC initiation was 30.4.

Twenty-eight (70%) patients had a nursing appointment, adhering to the NFSGVHS protocol. Five patients (13%) discontinued use and switched to DMPA-IM administered by an HCP and 4 (10%) discontinued use following an ADR (hives, mood changes, bruising, and menometrorrhagia). Of the 31 patients who continued therapy, 25 (81%) were refilling appropriately (Table). 

Six patients with unidentified reasons for nonadherence were contacted to determine if there were unmet contraceptive needs. This subgroup included patients with an active prescription for DMPA-SC that did not meet refill expectations. Nonadherence was mostly due to forgetfulness, however 1 patient was unable to refill her DMPA-SC in a timely manner due to an outside hospital admission and another was unreachable. These conversations were documented in the electronic health record (EHR) and all patients requesting follow-up, reinitiation of therapy, or alternative regimens, the appropriate parties were notified to coordinate care.

Discussion

The uptake in DMPA-SC prescribing suggests prescribers and patients have embraced self-administration as an option for contraception. Most patients were appropriately scheduled for nursing appointments to reinforce education and ensure appropriate self-injection technique, as outlined in the NFSGVHS procedure.

The need to improve adherence to NFSGVHS procedure was identified because not all patients had scheduled nursing appointments. This is concerning because some patients may have started self-injecting DMPA-SC without proper education, which could lead to improper injection technique and diminished effectiveness. Nursing appointments ensure appropriate self-injection techniques and reinforce the importance of refilling every 12 weeks for proper effectiveness. Nonadherence to contraceptive therapy may result in unintended pregnancy, although no pregnancies were reported by patients in this study. Pharmacist involvement in DMPA-SC initiation and follow-up monitoring may help ensure adherence to local procedure for initiation and improve patient adherence. 

There is limited evidence comparing weight gain related to DMPA-SC vs DMPA-IM. However, in a small, 2-year, randomized study, weight changes were considered comparable for both cohorts with a mean increase of 3.5 kg in the DMPA-IM group vs 3.4 kg in the DMPA-SC group.⁵ While our analysis did not formally evaluate weight changes, BMI data were collected to evaluate for evidence of weight change. The duration of therapy varied per patient and may not have been long enough to see comparable weight changes. 

Strengths of this project include the use of the PACT multidisciplinary approach in primary care including physicians, pharmacists, and nurses. The NFSGVHS EHR is comprehensive, and data including appointments and pharmacy refill information was readily available for collection and evaluation. Limitations included inconsistent documentation in the patient’s EHR which made collection of some data difficult.

Cost Estimates

NFSGVHS had 231 patients prescribed DMPA-IM at the time of DMPA-SC rollout and 40 patients initiated DMPA-SC therapy in the first year. There are possible cost savings associated with the use of DMPA-SC compared to DMPA-IM. Although DMPA-IM costs about $120 annually and DMPA-SC costs about $252 annually, this does not account for indirect costs such as supplies, overhead cost, nursing visits, and patient travel.⁶ Additionally, allowing patients to self-administer the DMPA-SC injection at home provides nurses time to care for other patients.

Moving forward, the PACT and gynecology teams will receive instruction on the importance of adhering to NFSGVHS procedures to ensure new patients prescribed DMPA-SC receive education and present for nursing appointments to ensure appropriate self-injection.

DMPA has historically been administered in the clinic setting by an HCP; therefore, the prescriber was available to assess adherence to therapy based on patient’s attendance to scheduled clinic appointments. Some prescribers may feel apprehensive about shifting the onus of medication adherence to the patient when prescribing DMPA-SC. However, this model is comparable to any other prescription form of birth control, such as combined hormonal contraceptive pills, where the prescriber expects the patient to take the medication as prescribed and refill their prescriptions in a timely manner to avoid gaps in therapy. The findings of this project suggest the majority of patients who were prescribed self-administered DMPA-SC for contraception were adherent to therapy. The utility of self-administration of DMPA-SC for other labeled or off-label indications was not evaluated; however, it is possible that patients who are motivated to self-administer the medication (regardless of indication) would also demonstrate similar adherence rates.

Conclusions

The majority of patients who started DMPA-SC tolerated the medication well and continued to refill therapy within the recommended time period. Patient self-administration of DMPA-SC can enhance access by removing barriers to administration, increase patient autonomy and contraceptive continuation rates. Overall, the increase in DMPA-SC prescriptions suggests that patients and HCPs support the option for DMPA-SC self-administration at NFSGVHS.

Medroxyprogesterone acetate is an injectable medication indicated for contraception and management of endometriosis-associated pain in females of reproductive age.¹ Medroxyprogesterone inhibits gonadotropin secretion, which prevents follicular maturation and ovulation. This leads to endometrial thinning and a contraceptive effect. Adverse drug reactions (ADRs), such as weight gain, menstrual bleeding irregularities, and bone loss appear to be dose- and time-related. Two formulations of medroxyprogesterone acetate are available: 150 mg depot medroxyprogesterone acetate intramuscular (DMPA-IM) and 104 mg DMPA subcutaneous (DMPA-SC).² Originally, medroxyprogesterone acetate injections required administration by a health care worker. While the current labeling for DMPA-SC still indicates a requirement for administration by a health care worker, data show that the medication can be safe and effective when self-administered.³

Self-Administered Contraception

The 2019 World Health Organization (WHO) guideline on self-care interventions recommends making self-administered injectable contraception available to individuals of reproductive age.³ The WHO recommendation is based on evidence from the Depo Self-Administration Study, which included 401 patients randomized 1:1 to receive self-administered or clinic-administered DMPA-SC. This study concluded that self-administration improved continuation of contraception.⁴

The North Florida/South Georgia Veterans Health System (NFSGVHS) is the largest US Department of Veterans Affairs (VA) health care system, serving > 22,000 female veterans. All primary care practitioners (PCP) have been trained in women’s health (WH). 

The WH patient-aligned care team (PACT) clinical pharmacy practitioner (CPP) proposed using DMPA-SC for outpatient self-administration to increase access, improve patient satisfaction, and reduce burden on patients and nurses for administration appointments. The Pharmacy and Therapeutics Committee (P&T), WH Medical Director, and Chief of Gynecology approved the proposal. DMPA-SC was added to the ordering menu with order sets. The order set included instructions that outlined the 12-week dosing interval, instructions to contact the prescriber if the injection was > 2 weeks overdue (aligning with dosing recommendations for administration every 12 to 14 weeks), and an optional order for a home pregnancy test if necessary. These instructions were designed to ensure proper self-administration of the medication and timely follow-up care. 

The gynecology and PACT health care practitioners (HCPs), including physicians, pharmacists, nurses, and medical assistants, received DMPA-SC education, which consisted of a review of medication, ADRs, contraindications, and administration. An NFSGVHS procedure was developed to ensure patients received self-administration education. DMPA-SC prescriptions were mailed to patients with scheduled nursing appointments. The patient would then bring DMPA-SC to the nursing appointment where they received administration instruction and completed the first injection under nurse supervision to ensure appropriate technique. Patients were offered supplementary educational documents and a calendar to keep track of injection days. The patients were responsible for ordering refills and administering subsequent injections at home. Once all stakeholders received education and order sets were in place, prescribers and nurses could begin offering the option for initiation of self-administered DMPA-SC to patients. All conversions or new prescriptions were initiated by prescribers as a part of usual care.

Medication Use Evaluation

A medication use evaluation was conducted about 1 year after the rollout to assess use, adherence, and impact of DMPA-SC for patient-self administration as a new contraceptive option for NFSGVHS patients.

A retrospective chart review was conducted for patients dispensed DMPA-SC from June 1, 2022, to July 1, 2023. Baseline body mass index (BMI), recorded prior to initiation of DMPA-SC, was compared with the most recent BMI on record at the completion of the study to evaluate weight change. Nursing visit attendance for the first injection was also assessed. Adherence was evaluated by reviewing the date of the initial DMPA-SC prescription, the date of the patient's first nursing visit, and subsequent refill patterns. A 2-week margin of error was established to account for the flexibility within the recommended dosing interval and delays in postal service delivery.

Forty patients were initiated on DMPA-SC for patient self-administration. The mean age of patients was 37.2 years. All 40 patients were female. Twenty-two patients (55%) identified as Black, 17 (43%) as White, and 1 (3%) as Asian. The majority (90%) of patients were non-Hispanic. The mean baseline BMI was 30 and BMI after DMPA-SC initiation was 30.4.

Twenty-eight (70%) patients had a nursing appointment, adhering to the NFSGVHS protocol. Five patients (13%) discontinued use and switched to DMPA-IM administered by an HCP and 4 (10%) discontinued use following an ADR (hives, mood changes, bruising, and menometrorrhagia). Of the 31 patients who continued therapy, 25 (81%) were refilling appropriately (Table). 

Six patients with unidentified reasons for nonadherence were contacted to determine if there were unmet contraceptive needs. This subgroup included patients with an active prescription for DMPA-SC that did not meet refill expectations. Nonadherence was mostly due to forgetfulness, however 1 patient was unable to refill her DMPA-SC in a timely manner due to an outside hospital admission and another was unreachable. These conversations were documented in the electronic health record (EHR) and all patients requesting follow-up, reinitiation of therapy, or alternative regimens, the appropriate parties were notified to coordinate care.

Discussion

The uptake in DMPA-SC prescribing suggests prescribers and patients have embraced self-administration as an option for contraception. Most patients were appropriately scheduled for nursing appointments to reinforce education and ensure appropriate self-injection technique, as outlined in the NFSGVHS procedure.

The need to improve adherence to NFSGVHS procedure was identified because not all patients had scheduled nursing appointments. This is concerning because some patients may have started self-injecting DMPA-SC without proper education, which could lead to improper injection technique and diminished effectiveness. Nursing appointments ensure appropriate self-injection techniques and reinforce the importance of refilling every 12 weeks for proper effectiveness. Nonadherence to contraceptive therapy may result in unintended pregnancy, although no pregnancies were reported by patients in this study. Pharmacist involvement in DMPA-SC initiation and follow-up monitoring may help ensure adherence to local procedure for initiation and improve patient adherence. 

There is limited evidence comparing weight gain related to DMPA-SC vs DMPA-IM. However, in a small, 2-year, randomized study, weight changes were considered comparable for both cohorts with a mean increase of 3.5 kg in the DMPA-IM group vs 3.4 kg in the DMPA-SC group.⁵ While our analysis did not formally evaluate weight changes, BMI data were collected to evaluate for evidence of weight change. The duration of therapy varied per patient and may not have been long enough to see comparable weight changes. 

Strengths of this project include the use of the PACT multidisciplinary approach in primary care including physicians, pharmacists, and nurses. The NFSGVHS EHR is comprehensive, and data including appointments and pharmacy refill information was readily available for collection and evaluation. Limitations included inconsistent documentation in the patient’s EHR which made collection of some data difficult.

Cost Estimates

NFSGVHS had 231 patients prescribed DMPA-IM at the time of DMPA-SC rollout and 40 patients initiated DMPA-SC therapy in the first year. There are possible cost savings associated with the use of DMPA-SC compared to DMPA-IM. Although DMPA-IM costs about $120 annually and DMPA-SC costs about $252 annually, this does not account for indirect costs such as supplies, overhead cost, nursing visits, and patient travel.⁶ Additionally, allowing patients to self-administer the DMPA-SC injection at home provides nurses time to care for other patients.

Moving forward, the PACT and gynecology teams will receive instruction on the importance of adhering to NFSGVHS procedures to ensure new patients prescribed DMPA-SC receive education and present for nursing appointments to ensure appropriate self-injection.

DMPA has historically been administered in the clinic setting by an HCP; therefore, the prescriber was available to assess adherence to therapy based on patient’s attendance to scheduled clinic appointments. Some prescribers may feel apprehensive about shifting the onus of medication adherence to the patient when prescribing DMPA-SC. However, this model is comparable to any other prescription form of birth control, such as combined hormonal contraceptive pills, where the prescriber expects the patient to take the medication as prescribed and refill their prescriptions in a timely manner to avoid gaps in therapy. The findings of this project suggest the majority of patients who were prescribed self-administered DMPA-SC for contraception were adherent to therapy. The utility of self-administration of DMPA-SC for other labeled or off-label indications was not evaluated; however, it is possible that patients who are motivated to self-administer the medication (regardless of indication) would also demonstrate similar adherence rates.

Conclusions

The majority of patients who started DMPA-SC tolerated the medication well and continued to refill therapy within the recommended time period. Patient self-administration of DMPA-SC can enhance access by removing barriers to administration, increase patient autonomy and contraceptive continuation rates. Overall, the increase in DMPA-SC prescriptions suggests that patients and HCPs support the option for DMPA-SC self-administration at NFSGVHS.

Medroxyprogesterone acetate is an injectable medication indicated for contraception and management of endometriosis-associated pain in females of reproductive age.¹ Medroxyprogesterone inhibits gonadotropin secretion, which prevents follicular maturation and ovulation. This leads to endometrial thinning and a contraceptive effect. Adverse drug reactions (ADRs), such as weight gain, menstrual bleeding irregularities, and bone loss appear to be dose- and time-related. Two formulations of medroxyprogesterone acetate are available: 150 mg depot medroxyprogesterone acetate intramuscular (DMPA-IM) and 104 mg DMPA subcutaneous (DMPA-SC).² Originally, medroxyprogesterone acetate injections required administration by a health care worker. While the current labeling for DMPA-SC still indicates a requirement for administration by a health care worker, data show that the medication can be safe and effective when self-administered.³

Self-Administered Contraception

The 2019 World Health Organization (WHO) guideline on self-care interventions recommends making self-administered injectable contraception available to individuals of reproductive age.³ The WHO recommendation is based on evidence from the Depo Self-Administration Study, which included 401 patients randomized 1:1 to receive self-administered or clinic-administered DMPA-SC. This study concluded that self-administration improved continuation of contraception.⁴

The North Florida/South Georgia Veterans Health System (NFSGVHS) is the largest US Department of Veterans Affairs (VA) health care system, serving > 22,000 female veterans. All primary care practitioners (PCP) have been trained in women’s health (WH). 

The WH patient-aligned care team (PACT) clinical pharmacy practitioner (CPP) proposed using DMPA-SC for outpatient self-administration to increase access, improve patient satisfaction, and reduce burden on patients and nurses for administration appointments. The Pharmacy and Therapeutics Committee (P&T), WH Medical Director, and Chief of Gynecology approved the proposal. DMPA-SC was added to the ordering menu with order sets. The order set included instructions that outlined the 12-week dosing interval, instructions to contact the prescriber if the injection was > 2 weeks overdue (aligning with dosing recommendations for administration every 12 to 14 weeks), and an optional order for a home pregnancy test if necessary. These instructions were designed to ensure proper self-administration of the medication and timely follow-up care. 

The gynecology and PACT health care practitioners (HCPs), including physicians, pharmacists, nurses, and medical assistants, received DMPA-SC education, which consisted of a review of medication, ADRs, contraindications, and administration. An NFSGVHS procedure was developed to ensure patients received self-administration education. DMPA-SC prescriptions were mailed to patients with scheduled nursing appointments. The patient would then bring DMPA-SC to the nursing appointment where they received administration instruction and completed the first injection under nurse supervision to ensure appropriate technique. Patients were offered supplementary educational documents and a calendar to keep track of injection days. The patients were responsible for ordering refills and administering subsequent injections at home. Once all stakeholders received education and order sets were in place, prescribers and nurses could begin offering the option for initiation of self-administered DMPA-SC to patients. All conversions or new prescriptions were initiated by prescribers as a part of usual care.

Medication Use Evaluation

A medication use evaluation was conducted about 1 year after the rollout to assess use, adherence, and impact of DMPA-SC for patient-self administration as a new contraceptive option for NFSGVHS patients.

A retrospective chart review was conducted for patients dispensed DMPA-SC from June 1, 2022, to July 1, 2023. Baseline body mass index (BMI), recorded prior to initiation of DMPA-SC, was compared with the most recent BMI on record at the completion of the study to evaluate weight change. Nursing visit attendance for the first injection was also assessed. Adherence was evaluated by reviewing the date of the initial DMPA-SC prescription, the date of the patient's first nursing visit, and subsequent refill patterns. A 2-week margin of error was established to account for the flexibility within the recommended dosing interval and delays in postal service delivery.

Forty patients were initiated on DMPA-SC for patient self-administration. The mean age of patients was 37.2 years. All 40 patients were female. Twenty-two patients (55%) identified as Black, 17 (43%) as White, and 1 (3%) as Asian. The majority (90%) of patients were non-Hispanic. The mean baseline BMI was 30 and BMI after DMPA-SC initiation was 30.4.

Twenty-eight (70%) patients had a nursing appointment, adhering to the NFSGVHS protocol. Five patients (13%) discontinued use and switched to DMPA-IM administered by an HCP and 4 (10%) discontinued use following an ADR (hives, mood changes, bruising, and menometrorrhagia). Of the 31 patients who continued therapy, 25 (81%) were refilling appropriately (Table). 

Six patients with unidentified reasons for nonadherence were contacted to determine if there were unmet contraceptive needs. This subgroup included patients with an active prescription for DMPA-SC that did not meet refill expectations. Nonadherence was mostly due to forgetfulness, however 1 patient was unable to refill her DMPA-SC in a timely manner due to an outside hospital admission and another was unreachable. These conversations were documented in the electronic health record (EHR) and all patients requesting follow-up, reinitiation of therapy, or alternative regimens, the appropriate parties were notified to coordinate care.

Discussion

The uptake in DMPA-SC prescribing suggests prescribers and patients have embraced self-administration as an option for contraception. Most patients were appropriately scheduled for nursing appointments to reinforce education and ensure appropriate self-injection technique, as outlined in the NFSGVHS procedure.

The need to improve adherence to NFSGVHS procedure was identified because not all patients had scheduled nursing appointments. This is concerning because some patients may have started self-injecting DMPA-SC without proper education, which could lead to improper injection technique and diminished effectiveness. Nursing appointments ensure appropriate self-injection techniques and reinforce the importance of refilling every 12 weeks for proper effectiveness. Nonadherence to contraceptive therapy may result in unintended pregnancy, although no pregnancies were reported by patients in this study. Pharmacist involvement in DMPA-SC initiation and follow-up monitoring may help ensure adherence to local procedure for initiation and improve patient adherence. 

There is limited evidence comparing weight gain related to DMPA-SC vs DMPA-IM. However, in a small, 2-year, randomized study, weight changes were considered comparable for both cohorts with a mean increase of 3.5 kg in the DMPA-IM group vs 3.4 kg in the DMPA-SC group.⁵ While our analysis did not formally evaluate weight changes, BMI data were collected to evaluate for evidence of weight change. The duration of therapy varied per patient and may not have been long enough to see comparable weight changes. 

Strengths of this project include the use of the PACT multidisciplinary approach in primary care including physicians, pharmacists, and nurses. The NFSGVHS EHR is comprehensive, and data including appointments and pharmacy refill information was readily available for collection and evaluation. Limitations included inconsistent documentation in the patient’s EHR which made collection of some data difficult.

Cost Estimates

NFSGVHS had 231 patients prescribed DMPA-IM at the time of DMPA-SC rollout and 40 patients initiated DMPA-SC therapy in the first year. There are possible cost savings associated with the use of DMPA-SC compared to DMPA-IM. Although DMPA-IM costs about $120 annually and DMPA-SC costs about $252 annually, this does not account for indirect costs such as supplies, overhead cost, nursing visits, and patient travel.⁶ Additionally, allowing patients to self-administer the DMPA-SC injection at home provides nurses time to care for other patients.

Moving forward, the PACT and gynecology teams will receive instruction on the importance of adhering to NFSGVHS procedures to ensure new patients prescribed DMPA-SC receive education and present for nursing appointments to ensure appropriate self-injection.

DMPA has historically been administered in the clinic setting by an HCP; therefore, the prescriber was available to assess adherence to therapy based on patient’s attendance to scheduled clinic appointments. Some prescribers may feel apprehensive about shifting the onus of medication adherence to the patient when prescribing DMPA-SC. However, this model is comparable to any other prescription form of birth control, such as combined hormonal contraceptive pills, where the prescriber expects the patient to take the medication as prescribed and refill their prescriptions in a timely manner to avoid gaps in therapy. The findings of this project suggest the majority of patients who were prescribed self-administered DMPA-SC for contraception were adherent to therapy. The utility of self-administration of DMPA-SC for other labeled or off-label indications was not evaluated; however, it is possible that patients who are motivated to self-administer the medication (regardless of indication) would also demonstrate similar adherence rates.

Conclusions

The majority of patients who started DMPA-SC tolerated the medication well and continued to refill therapy within the recommended time period. Patient self-administration of DMPA-SC can enhance access by removing barriers to administration, increase patient autonomy and contraceptive continuation rates. Overall, the increase in DMPA-SC prescriptions suggests that patients and HCPs support the option for DMPA-SC self-administration at NFSGVHS.

Click here to view more from Federal Health Care Data Trends 2025.

Click here to view more from Federal Health Care Data Trends 2025.

Click here to view more from Federal Health Care Data Trends 2025.

TOPLINE: A national survey of 8996 females reveals comparable mammography screening rates between those who identify as veterans (57.9%) and nonveterans (55.2%).

METHODOLOGY:

• Researchers analyzed data from the 2019 National Health Interview Survey, a cross-sectional national survey tracking health information.

• Female respondents aged 40 to 74 years without history of breast cancer were included in the analysis.

• Analysis evaluated the association between screening and veteran status through logistic regression, adjusting for potential confounders.

• Survey procedures accounted for complex sampling design to obtain valid estimates for the civilian, noninstitutionalized US population.

TAKEAWAY:

• Analysis included 8996 female survey respondents, including 169 veterans (1.9%) and 320 (3.2%) reported having military health coverage.

• Mammography screening rates within the last year were comparable between veterans (57.9%) and nonveterans (55.2%).

• Veteran status showed no significant association with differences in mammography screening percentages (P = .96).

• Among insured participants, military health insurance demonstrated no significant association with mammography screening percentages (P = .13).

• The authors suggest that radiology practices should design proactive outreach strategies to address the needs of the growing number of female veterans who may face increased breast cancer risk due to military environmental exposures.

IN PRACTICE: “Although the results from our study demonstrate comparable mammography screening percentages, veterans may face additional risk factors for breast cancer due to occupational,” the authors argue.

SOURCE: This summary is based on a preprint published online in the Journal of the American College of Radiology: Milton A, Miles R, Gettle LM, Van Geertruyden P, Narayan AK. Utilization of Mammography Screening in Female Veterans: Cross-Sectional Survey Results from the National Health Interview Survey. J Am Coll Radiol. Published online April 24, 2025. doi:10.1016/j.jacr.2025.04.017

LIMITATIONS: The study relied on self-reported adherence data, which could overestimate screening percentages. Data collection occurred prior to updated United States Preventive Services Task Force guidelines recommending routine mammography screening for women starting at age 40 years every 2 years. The relatively small number of female veteran respondents limited the precision of population estimates. Additionally, the data were collected before the COVID-19 pandemic, which has been associated with reduced mammographic screening, particularly in medically underserved populations.

DISCLOSURES: Anand Narayan disclosed receiving financial support from Susan G. Komen Breast Cancer Foundation and National Academy of Medicine. The study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The remaining authors reported no potential conflicts of interest. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

TOPLINE: A national survey of 8996 females reveals comparable mammography screening rates between those who identify as veterans (57.9%) and nonveterans (55.2%).

METHODOLOGY:

• Researchers analyzed data from the 2019 National Health Interview Survey, a cross-sectional national survey tracking health information.

• Female respondents aged 40 to 74 years without history of breast cancer were included in the analysis.

• Analysis evaluated the association between screening and veteran status through logistic regression, adjusting for potential confounders.

• Survey procedures accounted for complex sampling design to obtain valid estimates for the civilian, noninstitutionalized US population.

TAKEAWAY:

• Analysis included 8996 female survey respondents, including 169 veterans (1.9%) and 320 (3.2%) reported having military health coverage.

• Mammography screening rates within the last year were comparable between veterans (57.9%) and nonveterans (55.2%).

• Veteran status showed no significant association with differences in mammography screening percentages (P = .96).

• Among insured participants, military health insurance demonstrated no significant association with mammography screening percentages (P = .13).

• The authors suggest that radiology practices should design proactive outreach strategies to address the needs of the growing number of female veterans who may face increased breast cancer risk due to military environmental exposures.

IN PRACTICE: “Although the results from our study demonstrate comparable mammography screening percentages, veterans may face additional risk factors for breast cancer due to occupational,” the authors argue.

SOURCE: This summary is based on a preprint published online in the Journal of the American College of Radiology: Milton A, Miles R, Gettle LM, Van Geertruyden P, Narayan AK. Utilization of Mammography Screening in Female Veterans: Cross-Sectional Survey Results from the National Health Interview Survey. J Am Coll Radiol. Published online April 24, 2025. doi:10.1016/j.jacr.2025.04.017

LIMITATIONS: The study relied on self-reported adherence data, which could overestimate screening percentages. Data collection occurred prior to updated United States Preventive Services Task Force guidelines recommending routine mammography screening for women starting at age 40 years every 2 years. The relatively small number of female veteran respondents limited the precision of population estimates. Additionally, the data were collected before the COVID-19 pandemic, which has been associated with reduced mammographic screening, particularly in medically underserved populations.

DISCLOSURES: Anand Narayan disclosed receiving financial support from Susan G. Komen Breast Cancer Foundation and National Academy of Medicine. The study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The remaining authors reported no potential conflicts of interest. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

TOPLINE: A national survey of 8996 females reveals comparable mammography screening rates between those who identify as veterans (57.9%) and nonveterans (55.2%).

METHODOLOGY:

• Researchers analyzed data from the 2019 National Health Interview Survey, a cross-sectional national survey tracking health information.

• Female respondents aged 40 to 74 years without history of breast cancer were included in the analysis.

• Analysis evaluated the association between screening and veteran status through logistic regression, adjusting for potential confounders.

• Survey procedures accounted for complex sampling design to obtain valid estimates for the civilian, noninstitutionalized US population.

TAKEAWAY:

• Analysis included 8996 female survey respondents, including 169 veterans (1.9%) and 320 (3.2%) reported having military health coverage.

• Mammography screening rates within the last year were comparable between veterans (57.9%) and nonveterans (55.2%).

• Veteran status showed no significant association with differences in mammography screening percentages (P = .96).

• Among insured participants, military health insurance demonstrated no significant association with mammography screening percentages (P = .13).

• The authors suggest that radiology practices should design proactive outreach strategies to address the needs of the growing number of female veterans who may face increased breast cancer risk due to military environmental exposures.

IN PRACTICE: “Although the results from our study demonstrate comparable mammography screening percentages, veterans may face additional risk factors for breast cancer due to occupational,” the authors argue.

SOURCE: This summary is based on a preprint published online in the Journal of the American College of Radiology: Milton A, Miles R, Gettle LM, Van Geertruyden P, Narayan AK. Utilization of Mammography Screening in Female Veterans: Cross-Sectional Survey Results from the National Health Interview Survey. J Am Coll Radiol. Published online April 24, 2025. doi:10.1016/j.jacr.2025.04.017

LIMITATIONS: The study relied on self-reported adherence data, which could overestimate screening percentages. Data collection occurred prior to updated United States Preventive Services Task Force guidelines recommending routine mammography screening for women starting at age 40 years every 2 years. The relatively small number of female veteran respondents limited the precision of population estimates. Additionally, the data were collected before the COVID-19 pandemic, which has been associated with reduced mammographic screening, particularly in medically underserved populations.

DISCLOSURES: Anand Narayan disclosed receiving financial support from Susan G. Komen Breast Cancer Foundation and National Academy of Medicine. The study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The remaining authors reported no potential conflicts of interest. Additional disclosures are noted in the original article.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

The number of sexual assaults in the US military dropped for the first time in a decade, according an annual report from the Pentagon, while benefits claims for assault survivors are on the rise. 

     Records show that 29,000 active-duty members reported being sexually assaulted in 2023, or 7000 fewer than in 2021. A confidential survey also found the number of service members who experienced some type of unwanted sexual contact dropped nearly 20%, leaving the Pentagon “cautiously optimistic“ its investments in preventing sexual assault and building a healthy climate are having an impact.

     Despite these investments, issues persist. An Army anesthesiologist recently pleaded guilty to 41 charges of sexual misconduct involving 21 victims at Madigan Army Medical Center at Joint Base Lewis-McChord in Washington. The alleged incidents occurred between 2019 and 2022 and involved the doctor unnecessarily focusing on the genital area of patients during what he described as routine examinations. Maj. Michael Stockin faces nearly 14 years in prison, should the judge accept the plea agreement Stockin and his attorneys made with government prosecutors.

     Additionally, a report from the Watson Institute of International and Public Affairs at Brown University indicated that 24% of active-duty women and 1.9% of active-duty men experienced sexual assault from 2001 to 2021.During post-9/11 wars, “the prioritization of force readiness above all else allowed the problem of sexual assault to fester, papering over internal violence and gender inequalities within military institutions,” the report said. There was also a slight uptick in reports of military sexual assaults in 2020, when troops were largely on lockdown as a result of the COVID-19 pandemic.

     Efforts to address sexual assault in the military have increased in the past 10 years to the tune of 10 Department of Defense Inspector General engagements, 60 Government Accountability Office recommendations, > 200 government panel and task force recommendations, > 150 Congressional provisions, and > 50 Secretary of Defense initiatives. Additionally, the 2022 National Defense Authorization gave authority in sexual assault cases to independent prosecutors rather than commanders. Other reforms have included incorporating trauma-informed practices in the claims process.

     Meanwhile, the US Department of Veterans Affairs (VA) has also been attempting to convince more sexual assault survivors to file claims for benefits. Assistant Deputy Under Secretary for Field Operations Kenesha Britton said in December that the VA has held 3500 events in the past 14 months focused on benefits for victims of military sexual assault and harassment. It appears to be working, as the VA received 57,400 claims for military sexual trauma in fiscal year 2024 (an 18% increase from 2023), and approved > 63% of them, compared to 40% more than a decade ago. Prior to Oct. 1, VA staffers processed > 11,000 cases in a single day twice. Since that date, they have processed that amount on 9 separate occasions.

     “We recognize the remarkable courage it takes for survivors of military sexual trauma to seek the benefits and support they’ve earned,” Britton said. “Our mission is driven by a commitment to ensure survivors are met with care, dignity and sensitivity throughout the claims process.”

     The increase in trust is a byproduct of the outreach campaigns, VA Under Secretary for Benefits Josh Jacobs said: “[M]ore veterans are coming in to apply for benefits and I think that has to do with building trust because we are actively trying to reach veterans telling them we want to connect them with their earned benefits.”

The number of sexual assaults in the US military dropped for the first time in a decade, according an annual report from the Pentagon, while benefits claims for assault survivors are on the rise. 

     Records show that 29,000 active-duty members reported being sexually assaulted in 2023, or 7000 fewer than in 2021. A confidential survey also found the number of service members who experienced some type of unwanted sexual contact dropped nearly 20%, leaving the Pentagon “cautiously optimistic“ its investments in preventing sexual assault and building a healthy climate are having an impact.

     Despite these investments, issues persist. An Army anesthesiologist recently pleaded guilty to 41 charges of sexual misconduct involving 21 victims at Madigan Army Medical Center at Joint Base Lewis-McChord in Washington. The alleged incidents occurred between 2019 and 2022 and involved the doctor unnecessarily focusing on the genital area of patients during what he described as routine examinations. Maj. Michael Stockin faces nearly 14 years in prison, should the judge accept the plea agreement Stockin and his attorneys made with government prosecutors.

     Additionally, a report from the Watson Institute of International and Public Affairs at Brown University indicated that 24% of active-duty women and 1.9% of active-duty men experienced sexual assault from 2001 to 2021.During post-9/11 wars, “the prioritization of force readiness above all else allowed the problem of sexual assault to fester, papering over internal violence and gender inequalities within military institutions,” the report said. There was also a slight uptick in reports of military sexual assaults in 2020, when troops were largely on lockdown as a result of the COVID-19 pandemic.

     Efforts to address sexual assault in the military have increased in the past 10 years to the tune of 10 Department of Defense Inspector General engagements, 60 Government Accountability Office recommendations, > 200 government panel and task force recommendations, > 150 Congressional provisions, and > 50 Secretary of Defense initiatives. Additionally, the 2022 National Defense Authorization gave authority in sexual assault cases to independent prosecutors rather than commanders. Other reforms have included incorporating trauma-informed practices in the claims process.

     Meanwhile, the US Department of Veterans Affairs (VA) has also been attempting to convince more sexual assault survivors to file claims for benefits. Assistant Deputy Under Secretary for Field Operations Kenesha Britton said in December that the VA has held 3500 events in the past 14 months focused on benefits for victims of military sexual assault and harassment. It appears to be working, as the VA received 57,400 claims for military sexual trauma in fiscal year 2024 (an 18% increase from 2023), and approved > 63% of them, compared to 40% more than a decade ago. Prior to Oct. 1, VA staffers processed > 11,000 cases in a single day twice. Since that date, they have processed that amount on 9 separate occasions.

     “We recognize the remarkable courage it takes for survivors of military sexual trauma to seek the benefits and support they’ve earned,” Britton said. “Our mission is driven by a commitment to ensure survivors are met with care, dignity and sensitivity throughout the claims process.”

     The increase in trust is a byproduct of the outreach campaigns, VA Under Secretary for Benefits Josh Jacobs said: “[M]ore veterans are coming in to apply for benefits and I think that has to do with building trust because we are actively trying to reach veterans telling them we want to connect them with their earned benefits.”

The number of sexual assaults in the US military dropped for the first time in a decade, according an annual report from the Pentagon, while benefits claims for assault survivors are on the rise. 

     Records show that 29,000 active-duty members reported being sexually assaulted in 2023, or 7000 fewer than in 2021. A confidential survey also found the number of service members who experienced some type of unwanted sexual contact dropped nearly 20%, leaving the Pentagon “cautiously optimistic“ its investments in preventing sexual assault and building a healthy climate are having an impact.

     Despite these investments, issues persist. An Army anesthesiologist recently pleaded guilty to 41 charges of sexual misconduct involving 21 victims at Madigan Army Medical Center at Joint Base Lewis-McChord in Washington. The alleged incidents occurred between 2019 and 2022 and involved the doctor unnecessarily focusing on the genital area of patients during what he described as routine examinations. Maj. Michael Stockin faces nearly 14 years in prison, should the judge accept the plea agreement Stockin and his attorneys made with government prosecutors.

     Additionally, a report from the Watson Institute of International and Public Affairs at Brown University indicated that 24% of active-duty women and 1.9% of active-duty men experienced sexual assault from 2001 to 2021.During post-9/11 wars, “the prioritization of force readiness above all else allowed the problem of sexual assault to fester, papering over internal violence and gender inequalities within military institutions,” the report said. There was also a slight uptick in reports of military sexual assaults in 2020, when troops were largely on lockdown as a result of the COVID-19 pandemic.

     Efforts to address sexual assault in the military have increased in the past 10 years to the tune of 10 Department of Defense Inspector General engagements, 60 Government Accountability Office recommendations, > 200 government panel and task force recommendations, > 150 Congressional provisions, and > 50 Secretary of Defense initiatives. Additionally, the 2022 National Defense Authorization gave authority in sexual assault cases to independent prosecutors rather than commanders. Other reforms have included incorporating trauma-informed practices in the claims process.

     Meanwhile, the US Department of Veterans Affairs (VA) has also been attempting to convince more sexual assault survivors to file claims for benefits. Assistant Deputy Under Secretary for Field Operations Kenesha Britton said in December that the VA has held 3500 events in the past 14 months focused on benefits for victims of military sexual assault and harassment. It appears to be working, as the VA received 57,400 claims for military sexual trauma in fiscal year 2024 (an 18% increase from 2023), and approved > 63% of them, compared to 40% more than a decade ago. Prior to Oct. 1, VA staffers processed > 11,000 cases in a single day twice. Since that date, they have processed that amount on 9 separate occasions.

     “We recognize the remarkable courage it takes for survivors of military sexual trauma to seek the benefits and support they’ve earned,” Britton said. “Our mission is driven by a commitment to ensure survivors are met with care, dignity and sensitivity throughout the claims process.”

     The increase in trust is a byproduct of the outreach campaigns, VA Under Secretary for Benefits Josh Jacobs said: “[M]ore veterans are coming in to apply for benefits and I think that has to do with building trust because we are actively trying to reach veterans telling them we want to connect them with their earned benefits.”

New data link higher county-level radon exposure to gestational diabetes (GD) in women who haven’t previously given birth, emphasizing the need to consider environmental risks in maternal and fetal healthcare.

Yijia Zhang, PhD, with the Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons at Columbia University Irving Medical Center in New York, and colleagues found in a study of 9107 nulliparous pregnant women that those living in US counties with higher radon levels (2 picocuries [pCi]/L) had higher odds of developing GD than those in counties with lower (< 1 pCi/L) radon levels (odds ratio [OR], 1.37; 95% CI, 1.02-1.84.) The researchers used three radon categories, and the middle level was 1 to < 2 pCi/L.

Findings were published online on January 10 in JAMA Network Open. The researchers used data from The Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b), a multicenter, prospective cohort study that examines factors associated with pregnancy-related outcomes.

“To our knowledge, this is the first study to examine the association between radon exposure and the risk of GD,” the authors wrote.

The researchers also found higher odds of GD in women who had ever smoked who lived in counties with a higher (2 pCi/L) radon level (OR, 2.09; 95% CI, 1.41-3.11) and women living in counties with both higher radon and fine particulate matter air pollutants (PM2.5) levels (OR, 1.93; 95% CI, 1.31-2.83), though no statistically significant interactions were observed. 

 

GD Affects 10% of Pregnancies

GD affects about 10% of pregnancies every year in the United States, according to the Centers for Disease Control and Prevention, and can affect women and offspring long term as it raises mothers’ risk of type 2 diabetes and cardiovascular disease and raises the risk for childhood obesity. Radon exposure’s link with lung cancer risk has been well established, but its link to other health risks is uncertain, the authors note.

The authors said their findings are hypothesis-generating and said, “It is vital to conduct studies that incorporate individual-level indoor radon exposure data,” to get closer to understanding the underlying mechanisms.

 

Individual-Level Exposure Measures Needed

They note that the average radon level in a county might not reflect an individual’s exposure and individual-level residential factors involved with radon exposure, such as household mitigation, and whether a dwelling has a basement, for instance, “are crucial for enhancing the precision of exposure assessment.”

In an invited commentary, Alberto Ruano-Ravina, PhD, and Lucía Martín-Gisbert, MSc, both with the Department of Preventive Medicine and Public Health at the University of Santiago de Compostela in Galicia, Spain, also urged that individual-level studies be conducted to further investigate radon’s link to health risks, noting that “[r]adon is possibly the most prevalent indoor carcinogen to which human beings are exposed.”

“There is no reason for not having these studies once we have some evidence of an association from ecological studies,” they wrote. They point out that reliable radon assessments are easy and inexpensive.

“The potential association of radon exposure with gestational diabetes or any other disease should be better analyzed using exclusively radon-prone areas. An observance of a dose-response effect may be indicative of a causal relationship, and it could be easily evidenced in radon-prone areas should such a relationship exist,” the commenters wrote.

Such areas have low, medium, high, and extremely high concentration levels, the commenters wrote. Zhang’s team, they point out, had to use only three exposure levels because the number of residents in high-exposure areas (exceeding 3 pCi/L) was too small.

“It is time now to move forward and really understand the full implications of radon exposure for health,” they concluded.

One coauthor reported serving on the board of directors for Merck for Mothers and as a board member for March for Moms outside the submitted work. One coauthor reported grants from the National Heart, Lung, and Blood Institute and the National Institutes of Health (NIH) during the conduct of the study. Four coauthors reported grants from the NIH during the conduct of the study. One coauthor reported grants from the NIH during the conduct of the study and being a cofounder of Naima Health and receiving personal fees from Organon outside the submitted work. Both commenters reported no relevant financial disclosures.

A version of this article appeared on Medscape.com.

New data link higher county-level radon exposure to gestational diabetes (GD) in women who haven’t previously given birth, emphasizing the need to consider environmental risks in maternal and fetal healthcare.

Yijia Zhang, PhD, with the Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons at Columbia University Irving Medical Center in New York, and colleagues found in a study of 9107 nulliparous pregnant women that those living in US counties with higher radon levels (2 picocuries [pCi]/L) had higher odds of developing GD than those in counties with lower (< 1 pCi/L) radon levels (odds ratio [OR], 1.37; 95% CI, 1.02-1.84.) The researchers used three radon categories, and the middle level was 1 to < 2 pCi/L.

Findings were published online on January 10 in JAMA Network Open. The researchers used data from The Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b), a multicenter, prospective cohort study that examines factors associated with pregnancy-related outcomes.

“To our knowledge, this is the first study to examine the association between radon exposure and the risk of GD,” the authors wrote.

The researchers also found higher odds of GD in women who had ever smoked who lived in counties with a higher (2 pCi/L) radon level (OR, 2.09; 95% CI, 1.41-3.11) and women living in counties with both higher radon and fine particulate matter air pollutants (PM2.5) levels (OR, 1.93; 95% CI, 1.31-2.83), though no statistically significant interactions were observed. 

 

GD Affects 10% of Pregnancies

GD affects about 10% of pregnancies every year in the United States, according to the Centers for Disease Control and Prevention, and can affect women and offspring long term as it raises mothers’ risk of type 2 diabetes and cardiovascular disease and raises the risk for childhood obesity. Radon exposure’s link with lung cancer risk has been well established, but its link to other health risks is uncertain, the authors note.

The authors said their findings are hypothesis-generating and said, “It is vital to conduct studies that incorporate individual-level indoor radon exposure data,” to get closer to understanding the underlying mechanisms.

 

Individual-Level Exposure Measures Needed

They note that the average radon level in a county might not reflect an individual’s exposure and individual-level residential factors involved with radon exposure, such as household mitigation, and whether a dwelling has a basement, for instance, “are crucial for enhancing the precision of exposure assessment.”

In an invited commentary, Alberto Ruano-Ravina, PhD, and Lucía Martín-Gisbert, MSc, both with the Department of Preventive Medicine and Public Health at the University of Santiago de Compostela in Galicia, Spain, also urged that individual-level studies be conducted to further investigate radon’s link to health risks, noting that “[r]adon is possibly the most prevalent indoor carcinogen to which human beings are exposed.”

“There is no reason for not having these studies once we have some evidence of an association from ecological studies,” they wrote. They point out that reliable radon assessments are easy and inexpensive.

“The potential association of radon exposure with gestational diabetes or any other disease should be better analyzed using exclusively radon-prone areas. An observance of a dose-response effect may be indicative of a causal relationship, and it could be easily evidenced in radon-prone areas should such a relationship exist,” the commenters wrote.

Such areas have low, medium, high, and extremely high concentration levels, the commenters wrote. Zhang’s team, they point out, had to use only three exposure levels because the number of residents in high-exposure areas (exceeding 3 pCi/L) was too small.

“It is time now to move forward and really understand the full implications of radon exposure for health,” they concluded.

One coauthor reported serving on the board of directors for Merck for Mothers and as a board member for March for Moms outside the submitted work. One coauthor reported grants from the National Heart, Lung, and Blood Institute and the National Institutes of Health (NIH) during the conduct of the study. Four coauthors reported grants from the NIH during the conduct of the study. One coauthor reported grants from the NIH during the conduct of the study and being a cofounder of Naima Health and receiving personal fees from Organon outside the submitted work. Both commenters reported no relevant financial disclosures.

A version of this article appeared on Medscape.com.

New data link higher county-level radon exposure to gestational diabetes (GD) in women who haven’t previously given birth, emphasizing the need to consider environmental risks in maternal and fetal healthcare.

Yijia Zhang, PhD, with the Department of Obstetrics and Gynecology, Vagelos College of Physicians and Surgeons at Columbia University Irving Medical Center in New York, and colleagues found in a study of 9107 nulliparous pregnant women that those living in US counties with higher radon levels (2 picocuries [pCi]/L) had higher odds of developing GD than those in counties with lower (< 1 pCi/L) radon levels (odds ratio [OR], 1.37; 95% CI, 1.02-1.84.) The researchers used three radon categories, and the middle level was 1 to < 2 pCi/L.

Findings were published online on January 10 in JAMA Network Open. The researchers used data from The Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b), a multicenter, prospective cohort study that examines factors associated with pregnancy-related outcomes.

“To our knowledge, this is the first study to examine the association between radon exposure and the risk of GD,” the authors wrote.

The researchers also found higher odds of GD in women who had ever smoked who lived in counties with a higher (2 pCi/L) radon level (OR, 2.09; 95% CI, 1.41-3.11) and women living in counties with both higher radon and fine particulate matter air pollutants (PM2.5) levels (OR, 1.93; 95% CI, 1.31-2.83), though no statistically significant interactions were observed. 

 

GD Affects 10% of Pregnancies

GD affects about 10% of pregnancies every year in the United States, according to the Centers for Disease Control and Prevention, and can affect women and offspring long term as it raises mothers’ risk of type 2 diabetes and cardiovascular disease and raises the risk for childhood obesity. Radon exposure’s link with lung cancer risk has been well established, but its link to other health risks is uncertain, the authors note.

The authors said their findings are hypothesis-generating and said, “It is vital to conduct studies that incorporate individual-level indoor radon exposure data,” to get closer to understanding the underlying mechanisms.

 

Individual-Level Exposure Measures Needed

They note that the average radon level in a county might not reflect an individual’s exposure and individual-level residential factors involved with radon exposure, such as household mitigation, and whether a dwelling has a basement, for instance, “are crucial for enhancing the precision of exposure assessment.”

In an invited commentary, Alberto Ruano-Ravina, PhD, and Lucía Martín-Gisbert, MSc, both with the Department of Preventive Medicine and Public Health at the University of Santiago de Compostela in Galicia, Spain, also urged that individual-level studies be conducted to further investigate radon’s link to health risks, noting that “[r]adon is possibly the most prevalent indoor carcinogen to which human beings are exposed.”

“There is no reason for not having these studies once we have some evidence of an association from ecological studies,” they wrote. They point out that reliable radon assessments are easy and inexpensive.

“The potential association of radon exposure with gestational diabetes or any other disease should be better analyzed using exclusively radon-prone areas. An observance of a dose-response effect may be indicative of a causal relationship, and it could be easily evidenced in radon-prone areas should such a relationship exist,” the commenters wrote.

Such areas have low, medium, high, and extremely high concentration levels, the commenters wrote. Zhang’s team, they point out, had to use only three exposure levels because the number of residents in high-exposure areas (exceeding 3 pCi/L) was too small.

“It is time now to move forward and really understand the full implications of radon exposure for health,” they concluded.

One coauthor reported serving on the board of directors for Merck for Mothers and as a board member for March for Moms outside the submitted work. One coauthor reported grants from the National Heart, Lung, and Blood Institute and the National Institutes of Health (NIH) during the conduct of the study. Four coauthors reported grants from the NIH during the conduct of the study. One coauthor reported grants from the NIH during the conduct of the study and being a cofounder of Naima Health and receiving personal fees from Organon outside the submitted work. Both commenters reported no relevant financial disclosures.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity. 

I want to talk about something that’s extremely controversial, but something that needs public discussion, in my view, as sometimes it doesn’t get the attention it deserves. That is: Are you ever too old to become a parent? 

In my experience, this topic comes up when women — often, single women — decide that they haven’t had a child and they consider pursuing fertility services using in vitro fertilization, donor sperm, a younger woman’s egg, or an egg they’ve preserved, and they say they’d like to have a child. 

I don’t have any huge objection to a younger woman with good health and energy trying to pursue parenting, but we’ve seen women try to do this in their 60s. It does seem to me, biologically, that is a high risk for anyone to undertake a pregnancy at that age. I think there’s agreement from obstetricians that they’re high risk. 

I think it’s dangerous, if you’re going to be the single parent at that age, that you may wind up entering a nursing home by the time your child enters, say, high school. In thinking about parenting, sure, we want to think about our own values and what we want, and normally, people don’t tell us what to do. I’m not calling for any legislation here. I’m calling for an ethical discussion about the rights and wrongs of parenting at older age. 

In response to the case I made against single women over age 60 trying to have children, it’s often brought up to me that men do it. Recently, there was a story about Al Pacino, who had a kid — I think he’s now 84, so he must have had the child at 83.

In an interview with Newsweek, he said he had this child with his ex, who was 30, a woman named Noor Alfallah. He also said he doesn’t see the child very much. He communicates mainly with that child as a co-parent through digital texting and internet contact. He said he uses video basically as a parent.

Why that is, I’m not sure. Did he have a falling out with his ex and has he been excluded? Is he in poor health such that he can’t really do parenting anymore? 

I cite his case, and there are many other celebrities that we’ve heard about over the years who’ve had kids in their 80s, such as the former talk show host Larry King and, I believe, Clint Eastwood. There are cases that hit the news all the time about older men.

I think the same question should apply ethically. Again, I’m not saying we’re going to ban it or outlaw it, but it’s something we have to discuss and think through. I think doctors involved in helping a very old parent should raise the questions so that people can at least discuss them.

If you’re going to have a kid at 84, it means you’re not going to be around in any competent way by the time the kid hits high school. I’m not sure that’s in the child’s best interest. Certainly, there is the case that a younger woman could adequately raise the kid, but if something happens to her, you’re not going to be around in that age category to parent at all. 

It’s also the case that older parents, if you’re using your sperm, may have the same issues as women, whose eggs age in their late 30s into their 40s; you’re more likely to transmit a genetic disease. We don’t talk about it often, but it is a fact that someone who’s thinking about parenting either naturally or using infertility techniques really should be responsible and think about it.

Bottom line: Am I going to say we should let Congress or a state legislature step in and say, you’re going to go to jail if you have a kid at age X? No. Ethics is there for a reason; it’s trying to make sure that you don’t do things that harm or hurt the interests of a kid. 

If two older people have a child and they’re not likely to be there for a crucial period — say, the teenage years — and they haven’t made provisions for the care of the child, if both die, that’s a problem. 

If one person who’s very old tries to do it, they’re not likely to be alive and/or in good health when the kid enters puberty or into the teenage years; that’s something that you have to think about. Am I doing this because I’m just going to do what I want to do, or am I going to really look out for the best interests of any child I might create? 

This is food for thought about the question of when anyone is too old to parent. I know that’s partly determined by partner, resources, and many other variables, but I don’t believe that we should ignore the discussion of the ethics of the decision just out of respect for the idea that we’re not going to legislate.

Dr. Caplan is with the Division of Medical Ethics at New York University’s Grossman School of Medicine. He has disclosed relevant financial relationships with Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position) and Medscape.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity. 

I want to talk about something that’s extremely controversial, but something that needs public discussion, in my view, as sometimes it doesn’t get the attention it deserves. That is: Are you ever too old to become a parent? 

In my experience, this topic comes up when women — often, single women — decide that they haven’t had a child and they consider pursuing fertility services using in vitro fertilization, donor sperm, a younger woman’s egg, or an egg they’ve preserved, and they say they’d like to have a child. 

I don’t have any huge objection to a younger woman with good health and energy trying to pursue parenting, but we’ve seen women try to do this in their 60s. It does seem to me, biologically, that is a high risk for anyone to undertake a pregnancy at that age. I think there’s agreement from obstetricians that they’re high risk. 

I think it’s dangerous, if you’re going to be the single parent at that age, that you may wind up entering a nursing home by the time your child enters, say, high school. In thinking about parenting, sure, we want to think about our own values and what we want, and normally, people don’t tell us what to do. I’m not calling for any legislation here. I’m calling for an ethical discussion about the rights and wrongs of parenting at older age. 

In response to the case I made against single women over age 60 trying to have children, it’s often brought up to me that men do it. Recently, there was a story about Al Pacino, who had a kid — I think he’s now 84, so he must have had the child at 83.

In an interview with Newsweek, he said he had this child with his ex, who was 30, a woman named Noor Alfallah. He also said he doesn’t see the child very much. He communicates mainly with that child as a co-parent through digital texting and internet contact. He said he uses video basically as a parent.

Why that is, I’m not sure. Did he have a falling out with his ex and has he been excluded? Is he in poor health such that he can’t really do parenting anymore? 

I cite his case, and there are many other celebrities that we’ve heard about over the years who’ve had kids in their 80s, such as the former talk show host Larry King and, I believe, Clint Eastwood. There are cases that hit the news all the time about older men.

I think the same question should apply ethically. Again, I’m not saying we’re going to ban it or outlaw it, but it’s something we have to discuss and think through. I think doctors involved in helping a very old parent should raise the questions so that people can at least discuss them.

If you’re going to have a kid at 84, it means you’re not going to be around in any competent way by the time the kid hits high school. I’m not sure that’s in the child’s best interest. Certainly, there is the case that a younger woman could adequately raise the kid, but if something happens to her, you’re not going to be around in that age category to parent at all. 

It’s also the case that older parents, if you’re using your sperm, may have the same issues as women, whose eggs age in their late 30s into their 40s; you’re more likely to transmit a genetic disease. We don’t talk about it often, but it is a fact that someone who’s thinking about parenting either naturally or using infertility techniques really should be responsible and think about it.

Bottom line: Am I going to say we should let Congress or a state legislature step in and say, you’re going to go to jail if you have a kid at age X? No. Ethics is there for a reason; it’s trying to make sure that you don’t do things that harm or hurt the interests of a kid. 

If two older people have a child and they’re not likely to be there for a crucial period — say, the teenage years — and they haven’t made provisions for the care of the child, if both die, that’s a problem. 

If one person who’s very old tries to do it, they’re not likely to be alive and/or in good health when the kid enters puberty or into the teenage years; that’s something that you have to think about. Am I doing this because I’m just going to do what I want to do, or am I going to really look out for the best interests of any child I might create? 

This is food for thought about the question of when anyone is too old to parent. I know that’s partly determined by partner, resources, and many other variables, but I don’t believe that we should ignore the discussion of the ethics of the decision just out of respect for the idea that we’re not going to legislate.

Dr. Caplan is with the Division of Medical Ethics at New York University’s Grossman School of Medicine. He has disclosed relevant financial relationships with Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position) and Medscape.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity. 

I want to talk about something that’s extremely controversial, but something that needs public discussion, in my view, as sometimes it doesn’t get the attention it deserves. That is: Are you ever too old to become a parent? 

In my experience, this topic comes up when women — often, single women — decide that they haven’t had a child and they consider pursuing fertility services using in vitro fertilization, donor sperm, a younger woman’s egg, or an egg they’ve preserved, and they say they’d like to have a child. 

I don’t have any huge objection to a younger woman with good health and energy trying to pursue parenting, but we’ve seen women try to do this in their 60s. It does seem to me, biologically, that is a high risk for anyone to undertake a pregnancy at that age. I think there’s agreement from obstetricians that they’re high risk. 

I think it’s dangerous, if you’re going to be the single parent at that age, that you may wind up entering a nursing home by the time your child enters, say, high school. In thinking about parenting, sure, we want to think about our own values and what we want, and normally, people don’t tell us what to do. I’m not calling for any legislation here. I’m calling for an ethical discussion about the rights and wrongs of parenting at older age. 

In response to the case I made against single women over age 60 trying to have children, it’s often brought up to me that men do it. Recently, there was a story about Al Pacino, who had a kid — I think he’s now 84, so he must have had the child at 83.

In an interview with Newsweek, he said he had this child with his ex, who was 30, a woman named Noor Alfallah. He also said he doesn’t see the child very much. He communicates mainly with that child as a co-parent through digital texting and internet contact. He said he uses video basically as a parent.

Why that is, I’m not sure. Did he have a falling out with his ex and has he been excluded? Is he in poor health such that he can’t really do parenting anymore? 

I cite his case, and there are many other celebrities that we’ve heard about over the years who’ve had kids in their 80s, such as the former talk show host Larry King and, I believe, Clint Eastwood. There are cases that hit the news all the time about older men.

I think the same question should apply ethically. Again, I’m not saying we’re going to ban it or outlaw it, but it’s something we have to discuss and think through. I think doctors involved in helping a very old parent should raise the questions so that people can at least discuss them.

If you’re going to have a kid at 84, it means you’re not going to be around in any competent way by the time the kid hits high school. I’m not sure that’s in the child’s best interest. Certainly, there is the case that a younger woman could adequately raise the kid, but if something happens to her, you’re not going to be around in that age category to parent at all. 

It’s also the case that older parents, if you’re using your sperm, may have the same issues as women, whose eggs age in their late 30s into their 40s; you’re more likely to transmit a genetic disease. We don’t talk about it often, but it is a fact that someone who’s thinking about parenting either naturally or using infertility techniques really should be responsible and think about it.

Bottom line: Am I going to say we should let Congress or a state legislature step in and say, you’re going to go to jail if you have a kid at age X? No. Ethics is there for a reason; it’s trying to make sure that you don’t do things that harm or hurt the interests of a kid. 

If two older people have a child and they’re not likely to be there for a crucial period — say, the teenage years — and they haven’t made provisions for the care of the child, if both die, that’s a problem. 

If one person who’s very old tries to do it, they’re not likely to be alive and/or in good health when the kid enters puberty or into the teenage years; that’s something that you have to think about. Am I doing this because I’m just going to do what I want to do, or am I going to really look out for the best interests of any child I might create? 

This is food for thought about the question of when anyone is too old to parent. I know that’s partly determined by partner, resources, and many other variables, but I don’t believe that we should ignore the discussion of the ethics of the decision just out of respect for the idea that we’re not going to legislate.

Dr. Caplan is with the Division of Medical Ethics at New York University’s Grossman School of Medicine. He has disclosed relevant financial relationships with Johnson & Johnson’s Panel for Compassionate Drug Use (unpaid position) and Medscape.

A version of this article appeared on Medscape.com.

Is there a connection between antibiotics taken before conception and adverse outcomes, such as reduced fertility, miscarriages, and congenital malformations?

A meta-analysis published in the journal eClinicalMedicine suggests a potential link between antibiotics taken before conception and negative outcomes, such as reduced fertility, miscarriages, and congenital malformations. However, a German expert in reproductive toxicology warned against drawing false conclusions.

“It would be fatal if women who want to have children refused necessary antibiotic treatment because they are afraid of infertility, miscarriages, and malformations,” said Wolfgang Paulus, MD, from the Reproductive Toxicology Advisory Center at the University Women’s Hospital in Ulm, Germany. In an interview, the expert criticized not only the authors’ conclusions but also the selection of studies included in the meta-analysis.

 

Confusion Over Use and Exposure

The meta-analysis, conducted by Bekalu Kassie Alemu, PhD, and colleagues from the Department of Obstetrics and Gynecology at The Chinese University of Hong Kong included 15 studies involving over 1.2 million women to examine how preconception antibiotic use affects fertility and pregnancy outcomes. In most studies (n = 11) that were included in the meta-analysis, fertility was examined as an endpoint, primarily in infertile women. One study involved Danish pharmacy employees who handled antibiotics at work.

“Not only was the therapeutic use of antibiotics not examined in this study, but the biological plausibility is completely lacking in this context,” Paulus noted.

The possible effects of preconception antibiotics on miscarriages were investigated in four studies, while two studies focused on congenital malformations as an endpoint.

 

Mixed Findings on Infertility

Regarding infertility, the authors reported abnormalities in macrolides and sulfonamides. Women who had received macrolide antibiotics, such as azithromycin, before conception showed a 35% reduction in fertility rates.

However, Paulus questioned whether this was solely because of macrolides. “Macrolide antibiotics are typically used for chlamydia, and chlamydia infection is a significant factor in women with unmet fertility desires,” he explained. Often, the chlamydia has already caused damage, such as inflammatory processes in the fallopian tubes, contributing to infertility that cannot be resolved by administering antibiotics.

The meta-analysis also showed that women who received sulfonamide before conception had a 2.35-fold increased likelihood of infertility. However, this association is not always one-sided. The results for tetracyclines were heterogeneous; while chlortetracycline appeared to increase the risk for infertility, exposure to oxytetracycline appeared to decrease it.

Treatment with oxytetracycline and beta-lactam antibiotics (except penicillin G) was associated with a 64% lower likelihood of infertility. The authors also found that fluoroquinolone antibiotics were associated with a 13% lower likelihood of infertility.

 

Miscarriage and Malformation Risks

Alemu and colleagues found a significant association between the use of antibiotics before conception and adverse pregnancy outcomes, showing a 34% increased risk for miscarriages and an 85% higher risk for congenital malformations with the use of trimethoprim during preconception. These findings highlight the need for caution regarding antibiotic use in women who are planning to conceive.

“Most antibiotics have half-lives of only a few hours. Therefore, antibiotics administered before conception can hardly have a direct effect on embryonic development,” Paulus noted. He pointed out that extensive data exist on most antibiotic classes included in this meta-analysis regarding childhood anomalies when used during the sensitive phase of organ development. These data do not indicate an increased risk for malformation. Therefore, the increased risk for malformations due to exposure before conception seems less plausible.

Alemu and colleagues assumed that antibiotics might negatively affect female reproductive health by disrupting the gut microbiome. The reasons for the reduced risk for infertility associated with beta-lactams and fluoroquinolones require further investigation. They reach a significant conclusion: “Preconception antibiotics exposure in females increases the risk of infertility, miscarriage, and congenital anomalies.” However, differences exist between the antibiotic classes. While the risk for infertility, spontaneous miscarriages, and congenital malformations increases with the use of macrolide antibiotics, sulfonamides, and trimethoprim, it decreases with the use of beta-lactams and fluoroquinolone antibiotics.

 

Expert Disagreement

“It is conceivable that the use of antibiotics damages the physiological environment, such as in the vaginal area. This may allow unwanted microbes to establish themselves, leading to more adverse outcomes such as infertility and miscarriages,” Paulus acknowledged.

Disruption of the microbiome due to antibiotic therapy could also result in a deficiency in relevant vitamins and trace elements (eg, folic acid), which could contribute to organogenesis disorders. Therefore, it may be beneficial to stabilize the gut and vaginal flora using probiotics after antibiotic treatment.

However, Paulus disagrees with the study conclusions. First, the studies included in the meta-analysis, which were largely observational, did not allow for the direct effect of antibiotics on the examined outcomes. Second, “quinolone antibiotics are highlighted as positive here, as if they were less problematic for patients trying to have children.”

Quinolone antibiotics are generally “frowned upon,” regardless of whether the patient wants to have children, as they can cause damage to the tendons, muscles, joints, and nervous system. They are currently used only as reserve medications.

“Quinolone antibiotics should not be administered during pregnancy, as they have already caused problems in animal studies, and they should not be used before pregnancy because of their side-effect profile,” Paulus stressed.

 

Serious Consequences

Paulus clarified: “The message must not be that women trying to conceive should avoid antibiotics. This applies to treating bacterial infections regardless of fertility desires, as well as for women trying to conceive who have problematic pathogens found in vaginal swabs.”

In these cases, antibiotic treatment is appropriate, and there should be no fear of adverse effects on fertility or pregnancy outcomes. “If antibiotics are not given and the infection worsens, the patient will be even less likely to conceive successfully.”

This story was translated from Medscape’s German edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Is there a connection between antibiotics taken before conception and adverse outcomes, such as reduced fertility, miscarriages, and congenital malformations?

A meta-analysis published in the journal eClinicalMedicine suggests a potential link between antibiotics taken before conception and negative outcomes, such as reduced fertility, miscarriages, and congenital malformations. However, a German expert in reproductive toxicology warned against drawing false conclusions.

“It would be fatal if women who want to have children refused necessary antibiotic treatment because they are afraid of infertility, miscarriages, and malformations,” said Wolfgang Paulus, MD, from the Reproductive Toxicology Advisory Center at the University Women’s Hospital in Ulm, Germany. In an interview, the expert criticized not only the authors’ conclusions but also the selection of studies included in the meta-analysis.

 

Confusion Over Use and Exposure

The meta-analysis, conducted by Bekalu Kassie Alemu, PhD, and colleagues from the Department of Obstetrics and Gynecology at The Chinese University of Hong Kong included 15 studies involving over 1.2 million women to examine how preconception antibiotic use affects fertility and pregnancy outcomes. In most studies (n = 11) that were included in the meta-analysis, fertility was examined as an endpoint, primarily in infertile women. One study involved Danish pharmacy employees who handled antibiotics at work.

“Not only was the therapeutic use of antibiotics not examined in this study, but the biological plausibility is completely lacking in this context,” Paulus noted.

The possible effects of preconception antibiotics on miscarriages were investigated in four studies, while two studies focused on congenital malformations as an endpoint.

 

Mixed Findings on Infertility

Regarding infertility, the authors reported abnormalities in macrolides and sulfonamides. Women who had received macrolide antibiotics, such as azithromycin, before conception showed a 35% reduction in fertility rates.

However, Paulus questioned whether this was solely because of macrolides. “Macrolide antibiotics are typically used for chlamydia, and chlamydia infection is a significant factor in women with unmet fertility desires,” he explained. Often, the chlamydia has already caused damage, such as inflammatory processes in the fallopian tubes, contributing to infertility that cannot be resolved by administering antibiotics.

The meta-analysis also showed that women who received sulfonamide before conception had a 2.35-fold increased likelihood of infertility. However, this association is not always one-sided. The results for tetracyclines were heterogeneous; while chlortetracycline appeared to increase the risk for infertility, exposure to oxytetracycline appeared to decrease it.

Treatment with oxytetracycline and beta-lactam antibiotics (except penicillin G) was associated with a 64% lower likelihood of infertility. The authors also found that fluoroquinolone antibiotics were associated with a 13% lower likelihood of infertility.

 

Miscarriage and Malformation Risks

Alemu and colleagues found a significant association between the use of antibiotics before conception and adverse pregnancy outcomes, showing a 34% increased risk for miscarriages and an 85% higher risk for congenital malformations with the use of trimethoprim during preconception. These findings highlight the need for caution regarding antibiotic use in women who are planning to conceive.

“Most antibiotics have half-lives of only a few hours. Therefore, antibiotics administered before conception can hardly have a direct effect on embryonic development,” Paulus noted. He pointed out that extensive data exist on most antibiotic classes included in this meta-analysis regarding childhood anomalies when used during the sensitive phase of organ development. These data do not indicate an increased risk for malformation. Therefore, the increased risk for malformations due to exposure before conception seems less plausible.

Alemu and colleagues assumed that antibiotics might negatively affect female reproductive health by disrupting the gut microbiome. The reasons for the reduced risk for infertility associated with beta-lactams and fluoroquinolones require further investigation. They reach a significant conclusion: “Preconception antibiotics exposure in females increases the risk of infertility, miscarriage, and congenital anomalies.” However, differences exist between the antibiotic classes. While the risk for infertility, spontaneous miscarriages, and congenital malformations increases with the use of macrolide antibiotics, sulfonamides, and trimethoprim, it decreases with the use of beta-lactams and fluoroquinolone antibiotics.

 

Expert Disagreement

“It is conceivable that the use of antibiotics damages the physiological environment, such as in the vaginal area. This may allow unwanted microbes to establish themselves, leading to more adverse outcomes such as infertility and miscarriages,” Paulus acknowledged.

Disruption of the microbiome due to antibiotic therapy could also result in a deficiency in relevant vitamins and trace elements (eg, folic acid), which could contribute to organogenesis disorders. Therefore, it may be beneficial to stabilize the gut and vaginal flora using probiotics after antibiotic treatment.

However, Paulus disagrees with the study conclusions. First, the studies included in the meta-analysis, which were largely observational, did not allow for the direct effect of antibiotics on the examined outcomes. Second, “quinolone antibiotics are highlighted as positive here, as if they were less problematic for patients trying to have children.”

Quinolone antibiotics are generally “frowned upon,” regardless of whether the patient wants to have children, as they can cause damage to the tendons, muscles, joints, and nervous system. They are currently used only as reserve medications.

“Quinolone antibiotics should not be administered during pregnancy, as they have already caused problems in animal studies, and they should not be used before pregnancy because of their side-effect profile,” Paulus stressed.

 

Serious Consequences

Paulus clarified: “The message must not be that women trying to conceive should avoid antibiotics. This applies to treating bacterial infections regardless of fertility desires, as well as for women trying to conceive who have problematic pathogens found in vaginal swabs.”

In these cases, antibiotic treatment is appropriate, and there should be no fear of adverse effects on fertility or pregnancy outcomes. “If antibiotics are not given and the infection worsens, the patient will be even less likely to conceive successfully.”

This story was translated from Medscape’s German edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Is there a connection between antibiotics taken before conception and adverse outcomes, such as reduced fertility, miscarriages, and congenital malformations?

A meta-analysis published in the journal eClinicalMedicine suggests a potential link between antibiotics taken before conception and negative outcomes, such as reduced fertility, miscarriages, and congenital malformations. However, a German expert in reproductive toxicology warned against drawing false conclusions.

“It would be fatal if women who want to have children refused necessary antibiotic treatment because they are afraid of infertility, miscarriages, and malformations,” said Wolfgang Paulus, MD, from the Reproductive Toxicology Advisory Center at the University Women’s Hospital in Ulm, Germany. In an interview, the expert criticized not only the authors’ conclusions but also the selection of studies included in the meta-analysis.

 

Confusion Over Use and Exposure

The meta-analysis, conducted by Bekalu Kassie Alemu, PhD, and colleagues from the Department of Obstetrics and Gynecology at The Chinese University of Hong Kong included 15 studies involving over 1.2 million women to examine how preconception antibiotic use affects fertility and pregnancy outcomes. In most studies (n = 11) that were included in the meta-analysis, fertility was examined as an endpoint, primarily in infertile women. One study involved Danish pharmacy employees who handled antibiotics at work.

“Not only was the therapeutic use of antibiotics not examined in this study, but the biological plausibility is completely lacking in this context,” Paulus noted.

The possible effects of preconception antibiotics on miscarriages were investigated in four studies, while two studies focused on congenital malformations as an endpoint.

 

Mixed Findings on Infertility

Regarding infertility, the authors reported abnormalities in macrolides and sulfonamides. Women who had received macrolide antibiotics, such as azithromycin, before conception showed a 35% reduction in fertility rates.

However, Paulus questioned whether this was solely because of macrolides. “Macrolide antibiotics are typically used for chlamydia, and chlamydia infection is a significant factor in women with unmet fertility desires,” he explained. Often, the chlamydia has already caused damage, such as inflammatory processes in the fallopian tubes, contributing to infertility that cannot be resolved by administering antibiotics.

The meta-analysis also showed that women who received sulfonamide before conception had a 2.35-fold increased likelihood of infertility. However, this association is not always one-sided. The results for tetracyclines were heterogeneous; while chlortetracycline appeared to increase the risk for infertility, exposure to oxytetracycline appeared to decrease it.

Treatment with oxytetracycline and beta-lactam antibiotics (except penicillin G) was associated with a 64% lower likelihood of infertility. The authors also found that fluoroquinolone antibiotics were associated with a 13% lower likelihood of infertility.

 

Miscarriage and Malformation Risks

Alemu and colleagues found a significant association between the use of antibiotics before conception and adverse pregnancy outcomes, showing a 34% increased risk for miscarriages and an 85% higher risk for congenital malformations with the use of trimethoprim during preconception. These findings highlight the need for caution regarding antibiotic use in women who are planning to conceive.

“Most antibiotics have half-lives of only a few hours. Therefore, antibiotics administered before conception can hardly have a direct effect on embryonic development,” Paulus noted. He pointed out that extensive data exist on most antibiotic classes included in this meta-analysis regarding childhood anomalies when used during the sensitive phase of organ development. These data do not indicate an increased risk for malformation. Therefore, the increased risk for malformations due to exposure before conception seems less plausible.

Alemu and colleagues assumed that antibiotics might negatively affect female reproductive health by disrupting the gut microbiome. The reasons for the reduced risk for infertility associated with beta-lactams and fluoroquinolones require further investigation. They reach a significant conclusion: “Preconception antibiotics exposure in females increases the risk of infertility, miscarriage, and congenital anomalies.” However, differences exist between the antibiotic classes. While the risk for infertility, spontaneous miscarriages, and congenital malformations increases with the use of macrolide antibiotics, sulfonamides, and trimethoprim, it decreases with the use of beta-lactams and fluoroquinolone antibiotics.

 

Expert Disagreement

“It is conceivable that the use of antibiotics damages the physiological environment, such as in the vaginal area. This may allow unwanted microbes to establish themselves, leading to more adverse outcomes such as infertility and miscarriages,” Paulus acknowledged.

Disruption of the microbiome due to antibiotic therapy could also result in a deficiency in relevant vitamins and trace elements (eg, folic acid), which could contribute to organogenesis disorders. Therefore, it may be beneficial to stabilize the gut and vaginal flora using probiotics after antibiotic treatment.

However, Paulus disagrees with the study conclusions. First, the studies included in the meta-analysis, which were largely observational, did not allow for the direct effect of antibiotics on the examined outcomes. Second, “quinolone antibiotics are highlighted as positive here, as if they were less problematic for patients trying to have children.”

Quinolone antibiotics are generally “frowned upon,” regardless of whether the patient wants to have children, as they can cause damage to the tendons, muscles, joints, and nervous system. They are currently used only as reserve medications.

“Quinolone antibiotics should not be administered during pregnancy, as they have already caused problems in animal studies, and they should not be used before pregnancy because of their side-effect profile,” Paulus stressed.

 

Serious Consequences

Paulus clarified: “The message must not be that women trying to conceive should avoid antibiotics. This applies to treating bacterial infections regardless of fertility desires, as well as for women trying to conceive who have problematic pathogens found in vaginal swabs.”

In these cases, antibiotic treatment is appropriate, and there should be no fear of adverse effects on fertility or pregnancy outcomes. “If antibiotics are not given and the infection worsens, the patient will be even less likely to conceive successfully.”

This story was translated from Medscape’s German edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

SAN ANTONIO — Adding the CDK 4/6 blocker palbociclib to standard endocrine and antihuman epidermal growth factor receptor 2 (HER2) therapies in metastatic hormone receptor (HR)–positive, HER2-positive breast cancer extended patients’ median progression-free survival more than a year, according to the results of the phase 3 PATINA study.

This regimen “may represent a new standard of care” for these patients, said principal investigator and presenter Otto Metzger, MD, a medical breast oncologist at the Dana-Farber Cancer Institute in Boston, Massachusetts, who presented the findings at the San Antonio Breast Cancer Symposium (SABCS) 2024.

The open-label PATINA trial, which was conducted in Europe, Australia, New Zealand, and the United States, included a total of 518 patients. Patients received first-line treatment of six to eight cycles of induction chemotherapy plus anti-HER2 therapy. Researchers then randomized patients to either palbociclib plus anti-HER2 and endocrine therapy (n = 261) or to anti-HER2 and endocrine therapy alone (n = 257).

Patients did not progress on induction therapy, which likely would have signaled early resistance to anti-HER2 treatment. For anti-HER2 therapy, 97.3% received a combination of trastuzumab and pertuzumab. For endocrine therapy, 90.9% received an aromatase inhibitor.

Metzger and colleagues found that median progression-free survival was 1.3 years longer in patients receiving palbociclib — 3.7 years in the palbociclib arm vs 2.4 years in the control group (hazard ratio [HR], 0.74; P = .0074).

Although overall survival outcomes are immature, 5-year survival rates were slightly better in the palbociclib arm — 74.3% with palbociclib vs 69.8% without it — but the difference was not statistically significant.

Grade 3 neutropenia was the most frequent adverse event in the palbociclib arm (63.2% vs 2%). Grades 2 and 3 fatigue, stomatitis, and diarrhea were also more common with palbociclib. Grade 4 adverse events occurred in 12.3% of those receiving palbociclib and 8.9% of those who did not. There were no treatment-related deaths.

“We’re very impressed with the results,” said Metzger.

On the basis of previous studies, it’s believed that CDK 4/6 inhibition counteracts the development of resistance to anti-HER2 and endocrine therapies, which likely explains the benefit found in the trial.

But even without CDK 4/6 inhibition, the progression-free survival of 2.4 years in the control arm “far exceed[ed] our expectations,” Metzger reported. This may have occurred because the control arm received endocrine therapy, something previous trials of anti-HER2 therapy have avoided because of tolerability and other concerns.

These findings, however, support “the common use of endocrine therapy,” Metzger said.

 

‘Incredible’ Results

The progression-free survival as well as overall survival results in the trial are “incredible,” said study discussant Sara Hurvitz, MD, a medical breast oncologist at the Fred Hutch Cancer Center in Seattle, Washington. This is “historic and very important data.”

Hurvitz even suggested the results might mean that patients who fit the PATINA criteria can avoid the toxicity of upfront trastuzumab deruxtecan and use the PATINA regimen instead, potentially preserving their quality of life for longer.

Another study discussant, Virginia Kaklamani, MD, a medical breast oncologist at the University of Texas MD Anderson Cancer Center, San Antonio, had a similar thought.

In PATINA, “we’re talking about patients being on a treatment that’s well tolerated, where patients continue to work and continue with their lives despite being on treatment for metastatic breast cancer for 4 years, which is remarkable,” Kaklamani said.

Many of us have dabbled with giving CDK 4/6 inhibitors in triple-positive breast cancer, but “now we have more definitive data,” she said. The approach can help “maintain the quality of life of our patients for a longer period of time” and delay the use of chemotherapy in the second line, she added.

Metzger said Pfizer, the maker of palbociclib, plans to file for a HER2-positive indication with the Food and Drug Administration based on the trial results.

For now, the CDK 4/6 blocker is only indicated in combination with endocrine therapy for HR-positive, HER2-negative metastatic disease.

In response to a question about using the PATINA regimen in patients who don’t get chemotherapy induction, Metzger noted that, “while the study didn’t test this directly, I would argue that this data is quite compelling” for using palbociclib plus anti-HER2 and endocrine therapy, even without chemotherapy induction.

The work was funded by palbociclib maker Pfizer. Metzger had no disclosures. Hurvitz has numerous industry ties, including being a researcher and advisor to Pfizer. Kaklamani also has numerous industry ties, including reporting personal/consulting fees from Pfizer Canada.

A version of this article first appeared on Medscape.com.

SAN ANTONIO — Adding the CDK 4/6 blocker palbociclib to standard endocrine and antihuman epidermal growth factor receptor 2 (HER2) therapies in metastatic hormone receptor (HR)–positive, HER2-positive breast cancer extended patients’ median progression-free survival more than a year, according to the results of the phase 3 PATINA study.

This regimen “may represent a new standard of care” for these patients, said principal investigator and presenter Otto Metzger, MD, a medical breast oncologist at the Dana-Farber Cancer Institute in Boston, Massachusetts, who presented the findings at the San Antonio Breast Cancer Symposium (SABCS) 2024.

The open-label PATINA trial, which was conducted in Europe, Australia, New Zealand, and the United States, included a total of 518 patients. Patients received first-line treatment of six to eight cycles of induction chemotherapy plus anti-HER2 therapy. Researchers then randomized patients to either palbociclib plus anti-HER2 and endocrine therapy (n = 261) or to anti-HER2 and endocrine therapy alone (n = 257).

Patients did not progress on induction therapy, which likely would have signaled early resistance to anti-HER2 treatment. For anti-HER2 therapy, 97.3% received a combination of trastuzumab and pertuzumab. For endocrine therapy, 90.9% received an aromatase inhibitor.

Metzger and colleagues found that median progression-free survival was 1.3 years longer in patients receiving palbociclib — 3.7 years in the palbociclib arm vs 2.4 years in the control group (hazard ratio [HR], 0.74; P = .0074).

Although overall survival outcomes are immature, 5-year survival rates were slightly better in the palbociclib arm — 74.3% with palbociclib vs 69.8% without it — but the difference was not statistically significant.

Grade 3 neutropenia was the most frequent adverse event in the palbociclib arm (63.2% vs 2%). Grades 2 and 3 fatigue, stomatitis, and diarrhea were also more common with palbociclib. Grade 4 adverse events occurred in 12.3% of those receiving palbociclib and 8.9% of those who did not. There were no treatment-related deaths.

“We’re very impressed with the results,” said Metzger.

On the basis of previous studies, it’s believed that CDK 4/6 inhibition counteracts the development of resistance to anti-HER2 and endocrine therapies, which likely explains the benefit found in the trial.

But even without CDK 4/6 inhibition, the progression-free survival of 2.4 years in the control arm “far exceed[ed] our expectations,” Metzger reported. This may have occurred because the control arm received endocrine therapy, something previous trials of anti-HER2 therapy have avoided because of tolerability and other concerns.

These findings, however, support “the common use of endocrine therapy,” Metzger said.

 

‘Incredible’ Results

The progression-free survival as well as overall survival results in the trial are “incredible,” said study discussant Sara Hurvitz, MD, a medical breast oncologist at the Fred Hutch Cancer Center in Seattle, Washington. This is “historic and very important data.”

Hurvitz even suggested the results might mean that patients who fit the PATINA criteria can avoid the toxicity of upfront trastuzumab deruxtecan and use the PATINA regimen instead, potentially preserving their quality of life for longer.

Another study discussant, Virginia Kaklamani, MD, a medical breast oncologist at the University of Texas MD Anderson Cancer Center, San Antonio, had a similar thought.

In PATINA, “we’re talking about patients being on a treatment that’s well tolerated, where patients continue to work and continue with their lives despite being on treatment for metastatic breast cancer for 4 years, which is remarkable,” Kaklamani said.

Many of us have dabbled with giving CDK 4/6 inhibitors in triple-positive breast cancer, but “now we have more definitive data,” she said. The approach can help “maintain the quality of life of our patients for a longer period of time” and delay the use of chemotherapy in the second line, she added.

Metzger said Pfizer, the maker of palbociclib, plans to file for a HER2-positive indication with the Food and Drug Administration based on the trial results.

For now, the CDK 4/6 blocker is only indicated in combination with endocrine therapy for HR-positive, HER2-negative metastatic disease.

In response to a question about using the PATINA regimen in patients who don’t get chemotherapy induction, Metzger noted that, “while the study didn’t test this directly, I would argue that this data is quite compelling” for using palbociclib plus anti-HER2 and endocrine therapy, even without chemotherapy induction.

The work was funded by palbociclib maker Pfizer. Metzger had no disclosures. Hurvitz has numerous industry ties, including being a researcher and advisor to Pfizer. Kaklamani also has numerous industry ties, including reporting personal/consulting fees from Pfizer Canada.

A version of this article first appeared on Medscape.com.

SAN ANTONIO — Adding the CDK 4/6 blocker palbociclib to standard endocrine and antihuman epidermal growth factor receptor 2 (HER2) therapies in metastatic hormone receptor (HR)–positive, HER2-positive breast cancer extended patients’ median progression-free survival more than a year, according to the results of the phase 3 PATINA study.

This regimen “may represent a new standard of care” for these patients, said principal investigator and presenter Otto Metzger, MD, a medical breast oncologist at the Dana-Farber Cancer Institute in Boston, Massachusetts, who presented the findings at the San Antonio Breast Cancer Symposium (SABCS) 2024.

The open-label PATINA trial, which was conducted in Europe, Australia, New Zealand, and the United States, included a total of 518 patients. Patients received first-line treatment of six to eight cycles of induction chemotherapy plus anti-HER2 therapy. Researchers then randomized patients to either palbociclib plus anti-HER2 and endocrine therapy (n = 261) or to anti-HER2 and endocrine therapy alone (n = 257).

Patients did not progress on induction therapy, which likely would have signaled early resistance to anti-HER2 treatment. For anti-HER2 therapy, 97.3% received a combination of trastuzumab and pertuzumab. For endocrine therapy, 90.9% received an aromatase inhibitor.

Metzger and colleagues found that median progression-free survival was 1.3 years longer in patients receiving palbociclib — 3.7 years in the palbociclib arm vs 2.4 years in the control group (hazard ratio [HR], 0.74; P = .0074).

Although overall survival outcomes are immature, 5-year survival rates were slightly better in the palbociclib arm — 74.3% with palbociclib vs 69.8% without it — but the difference was not statistically significant.

Grade 3 neutropenia was the most frequent adverse event in the palbociclib arm (63.2% vs 2%). Grades 2 and 3 fatigue, stomatitis, and diarrhea were also more common with palbociclib. Grade 4 adverse events occurred in 12.3% of those receiving palbociclib and 8.9% of those who did not. There were no treatment-related deaths.

“We’re very impressed with the results,” said Metzger.

On the basis of previous studies, it’s believed that CDK 4/6 inhibition counteracts the development of resistance to anti-HER2 and endocrine therapies, which likely explains the benefit found in the trial.

But even without CDK 4/6 inhibition, the progression-free survival of 2.4 years in the control arm “far exceed[ed] our expectations,” Metzger reported. This may have occurred because the control arm received endocrine therapy, something previous trials of anti-HER2 therapy have avoided because of tolerability and other concerns.

These findings, however, support “the common use of endocrine therapy,” Metzger said.

 

‘Incredible’ Results

The progression-free survival as well as overall survival results in the trial are “incredible,” said study discussant Sara Hurvitz, MD, a medical breast oncologist at the Fred Hutch Cancer Center in Seattle, Washington. This is “historic and very important data.”

Hurvitz even suggested the results might mean that patients who fit the PATINA criteria can avoid the toxicity of upfront trastuzumab deruxtecan and use the PATINA regimen instead, potentially preserving their quality of life for longer.

Another study discussant, Virginia Kaklamani, MD, a medical breast oncologist at the University of Texas MD Anderson Cancer Center, San Antonio, had a similar thought.

In PATINA, “we’re talking about patients being on a treatment that’s well tolerated, where patients continue to work and continue with their lives despite being on treatment for metastatic breast cancer for 4 years, which is remarkable,” Kaklamani said.

Many of us have dabbled with giving CDK 4/6 inhibitors in triple-positive breast cancer, but “now we have more definitive data,” she said. The approach can help “maintain the quality of life of our patients for a longer period of time” and delay the use of chemotherapy in the second line, she added.

Metzger said Pfizer, the maker of palbociclib, plans to file for a HER2-positive indication with the Food and Drug Administration based on the trial results.

For now, the CDK 4/6 blocker is only indicated in combination with endocrine therapy for HR-positive, HER2-negative metastatic disease.

In response to a question about using the PATINA regimen in patients who don’t get chemotherapy induction, Metzger noted that, “while the study didn’t test this directly, I would argue that this data is quite compelling” for using palbociclib plus anti-HER2 and endocrine therapy, even without chemotherapy induction.

The work was funded by palbociclib maker Pfizer. Metzger had no disclosures. Hurvitz has numerous industry ties, including being a researcher and advisor to Pfizer. Kaklamani also has numerous industry ties, including reporting personal/consulting fees from Pfizer Canada.

A version of this article first appeared on Medscape.com.

In 2024, the Guttmacher Institute reported that eight states enacted or proposed limits on contraceptive access. Currently, more than 19 million women aged 13-44 years in the United States live in “contraceptive deserts” or places that lack access to a full range of birth control methods. About 1.2 million of those women live in counties that don’t have a single health center that has complete birth control services.

Providing contraceptive care in primary care settings has long been deemed a best practice by the Centers for Disease Control and Prevention (CDC). But the percentage of primary care physicians (PCPs) prescribing contraception or offering contraceptive procedures is strikingly low.

 

Only Half of Family Physicians (FPs) Prescribe Contraceptives

Research by Candice Chen, MD, MPH, and colleagues found that while 73.1% of obstetrician-gynecologists (OB/GYNs) and 72.6% of nurse-midwives prescribed the pill, patch, or vaginal ring; only 51% of FPs, 32.4% of pediatricians, and 19.8% of internal medicine physicians did so. And while 92.8% of OB/GYNs provided intrauterine device (IUD) services, only 16.4% of FPs, 2.6% of internists, and 0.6% of pediatricians did so.

One reason primary care is positioned so well to fill contraception gaps is found in the sheer numbers of PCPs. Chen and colleagues found that while the percentage of FPs prescribing contraception was much smaller (51.4%) than the percentage of OB/GYN prescribers (72.6%), the numbers translate to 72,725 FPs prescribing contraceptives, which is nearly double the number of OB/GYNs prescribing them (36,887).

Access to contraception services took a big hit with the COVID-19 pandemic as did access to healthcare in general. And the 2022 Supreme Court ruling that struck down Roe V. Wade has shaken up the landscape for reproductive services with potential consequences for contraceptive access.

 

Why Aren’t More PCPs Offering Contraceptive Services?

Reasons for the relatively low numbers of PCPs prescribing contraceptives include lack of training in residency, health systems’ financial choices, insurance barriers, and expectation by some physicians and many patients that birth control belongs in the OB/GYN sector. Access, patient awareness that PCPs can provide the care, expectations, and options vary by states and regions.

Angeline Ti, MD, an FP who teaches in a residency program at Wellstar Douglasville Medical Center in Douglasville, Georgia, told this news organization that the awareness issue might be the easiest change for PCPs as many patients aren’t aware you can get contraceptive services in primary care.

 

Things PCPs ‘Could Do Tomorrow’

Those physicians who want to add those services might want to start with universal screening, Ti said — having conversations with patients about contraceptive needs and letting them know they don’t have to get those prescriptions from an OB/GYN. The conversations could center on laying out the options and counseling on risks and benefits of various options and providing referrals, if that is the best option. “There are definitely things that you could do tomorrow,” she said.

PCPs should be familiar with the CDC’s Contraceptive Guidance for Health Care Providers and the federal Office of Population Affairs’ Quality Family Planning Recommendations for providers, which offer practice-level information, Ti said.

PCPs should not feel they need to be able to provide same-day contraceptive care to get started. Having nurses and medical assistants and practice managers on board who are passionate about adding the services can also help bring about change with a team approach, she said.

Even when the provider is enthusiastic about providing the care and is trained to do so, however, insurance barriers may exist, Ti acknowledged. For example, at her clinic a common IUD insertion requires prior authorization.

 

Including Other Providers

Julia Strasser, DrPH, MPH, a member of the core faculty at the Fitzhugh Mullan Institute for Health Workforce Equity in Washington, DC, told this news organization that including other clinicians could help expand contraceptive services in primary care. Her research showed that the proportion of the contraception workforce that is made up of advanced practice clinicians and nurse practitioners is increasing, whereas the proportion that includes physicians is either static or declining.

A paper by her team found that although OB/GYNs and nurse-midwives were more likely to prescribe the pill, patch, or ring, the largest numbers of contraception prescribers were FPs (72,725) and advanced practice nurses (70,115).

“We also know that pharmacists can safely prescribe contraception, and some states have authorized this practice, but uptake is low and policies vary by state,” she said. “Some health systems have pharmacists embedded in their practice — for example in federally qualified health centers and others.”

It’s important, she said, not to frame the gaps in contraceptive care as a failure on the part of individual clinicians but rather as: “How can we change some of the system-level factors that have gotten us to this point?”

Yalda Jabbarpour, MD, an FP and director of the Robert Graham Center of the American Academy of Family Physicians, said sometimes it’s the health center’s cost analysis that stands in the way. She gave an example from her own health system.

“The health system doesn’t want to pay for us to have the IUDs stored in our offices and provide that procedure because they feel it’s more cost effective if the OB/GYNs do it.” IUD insertions take more appointment time than the standard appointment, which also goes into the cost analysis. “Even though you’re trained to do it, you can’t necessarily do it when you get to the real world,” Jabbarpour said.

She said the thinking is that while OB/GYNs focus on women, FPs cover all ages and family members, so having the equipment and the storage space is best left to the OB/GYNs. She said that thinking may be short sighted.

“We have good data that the highest number of office visits in the United States actually happen in the family physician’s office,” she said. Not providing the services injects a barrier into the system as women are being referred for a simple procedure to a physician they’ve never seen. “That’s not very patient centered,” Jabbarpour noted.

In systems that refer contraceptive procedures to OB/GYNs, doctors also can’t practice skills they learned in residency and then may not feel comfortable performing the procedures when they enter a health system that offers the procedures in primary care.

 

Number of FPs Prescribing Long-Acting Contraception Growing

Jabbarpour said there has been some improvement in that area in terms of long-acting reversible contraception.

She pointed to a study of recertifying FPs that found that the percent of FPs who offer either IUDs or implants increased from 23.9% in 2018 to 30% in 2022. The share of FPs providing implant insertion increased from 12.9% to 20.8%; those providing IUDs also increased from 22.9% to 25.5% from 2018 to 2022.

FPs also have the advantage of being more widely distributed in rural and remote areas than OB/GYNs, she noted. “They are in almost every county in the United States.”

Jabbarpour said the education must start with health system leaders. If they deem it important to offer these services in primary care, then residency programs will see that their residents must be appropriately trained to provide it.

“Right now, it’s not an expectation of many of the employers that primary care physicians should do this,” she said.

Ti said that expectation should change. The value proposition for all PCPs and health systems, she said, is this: “Most of contraceptive care is well within the scope of primary care providers. This is care that we can do, and it’s care that we should be doing. So why aren’t we doing it?”

Ti, Strasser, and Jabbarpour reported no relevant financial disclosures.

A version of this article appeared on Medscape.com.

In 2024, the Guttmacher Institute reported that eight states enacted or proposed limits on contraceptive access. Currently, more than 19 million women aged 13-44 years in the United States live in “contraceptive deserts” or places that lack access to a full range of birth control methods. About 1.2 million of those women live in counties that don’t have a single health center that has complete birth control services.

Providing contraceptive care in primary care settings has long been deemed a best practice by the Centers for Disease Control and Prevention (CDC). But the percentage of primary care physicians (PCPs) prescribing contraception or offering contraceptive procedures is strikingly low.

 

Only Half of Family Physicians (FPs) Prescribe Contraceptives

Research by Candice Chen, MD, MPH, and colleagues found that while 73.1% of obstetrician-gynecologists (OB/GYNs) and 72.6% of nurse-midwives prescribed the pill, patch, or vaginal ring; only 51% of FPs, 32.4% of pediatricians, and 19.8% of internal medicine physicians did so. And while 92.8% of OB/GYNs provided intrauterine device (IUD) services, only 16.4% of FPs, 2.6% of internists, and 0.6% of pediatricians did so.

One reason primary care is positioned so well to fill contraception gaps is found in the sheer numbers of PCPs. Chen and colleagues found that while the percentage of FPs prescribing contraception was much smaller (51.4%) than the percentage of OB/GYN prescribers (72.6%), the numbers translate to 72,725 FPs prescribing contraceptives, which is nearly double the number of OB/GYNs prescribing them (36,887).

Access to contraception services took a big hit with the COVID-19 pandemic as did access to healthcare in general. And the 2022 Supreme Court ruling that struck down Roe V. Wade has shaken up the landscape for reproductive services with potential consequences for contraceptive access.

 

Why Aren’t More PCPs Offering Contraceptive Services?

Reasons for the relatively low numbers of PCPs prescribing contraceptives include lack of training in residency, health systems’ financial choices, insurance barriers, and expectation by some physicians and many patients that birth control belongs in the OB/GYN sector. Access, patient awareness that PCPs can provide the care, expectations, and options vary by states and regions.

Angeline Ti, MD, an FP who teaches in a residency program at Wellstar Douglasville Medical Center in Douglasville, Georgia, told this news organization that the awareness issue might be the easiest change for PCPs as many patients aren’t aware you can get contraceptive services in primary care.

 

Things PCPs ‘Could Do Tomorrow’

Those physicians who want to add those services might want to start with universal screening, Ti said — having conversations with patients about contraceptive needs and letting them know they don’t have to get those prescriptions from an OB/GYN. The conversations could center on laying out the options and counseling on risks and benefits of various options and providing referrals, if that is the best option. “There are definitely things that you could do tomorrow,” she said.

PCPs should be familiar with the CDC’s Contraceptive Guidance for Health Care Providers and the federal Office of Population Affairs’ Quality Family Planning Recommendations for providers, which offer practice-level information, Ti said.

PCPs should not feel they need to be able to provide same-day contraceptive care to get started. Having nurses and medical assistants and practice managers on board who are passionate about adding the services can also help bring about change with a team approach, she said.

Even when the provider is enthusiastic about providing the care and is trained to do so, however, insurance barriers may exist, Ti acknowledged. For example, at her clinic a common IUD insertion requires prior authorization.

 

Including Other Providers

Julia Strasser, DrPH, MPH, a member of the core faculty at the Fitzhugh Mullan Institute for Health Workforce Equity in Washington, DC, told this news organization that including other clinicians could help expand contraceptive services in primary care. Her research showed that the proportion of the contraception workforce that is made up of advanced practice clinicians and nurse practitioners is increasing, whereas the proportion that includes physicians is either static or declining.

A paper by her team found that although OB/GYNs and nurse-midwives were more likely to prescribe the pill, patch, or ring, the largest numbers of contraception prescribers were FPs (72,725) and advanced practice nurses (70,115).

“We also know that pharmacists can safely prescribe contraception, and some states have authorized this practice, but uptake is low and policies vary by state,” she said. “Some health systems have pharmacists embedded in their practice — for example in federally qualified health centers and others.”

It’s important, she said, not to frame the gaps in contraceptive care as a failure on the part of individual clinicians but rather as: “How can we change some of the system-level factors that have gotten us to this point?”

Yalda Jabbarpour, MD, an FP and director of the Robert Graham Center of the American Academy of Family Physicians, said sometimes it’s the health center’s cost analysis that stands in the way. She gave an example from her own health system.

“The health system doesn’t want to pay for us to have the IUDs stored in our offices and provide that procedure because they feel it’s more cost effective if the OB/GYNs do it.” IUD insertions take more appointment time than the standard appointment, which also goes into the cost analysis. “Even though you’re trained to do it, you can’t necessarily do it when you get to the real world,” Jabbarpour said.

She said the thinking is that while OB/GYNs focus on women, FPs cover all ages and family members, so having the equipment and the storage space is best left to the OB/GYNs. She said that thinking may be short sighted.

“We have good data that the highest number of office visits in the United States actually happen in the family physician’s office,” she said. Not providing the services injects a barrier into the system as women are being referred for a simple procedure to a physician they’ve never seen. “That’s not very patient centered,” Jabbarpour noted.

In systems that refer contraceptive procedures to OB/GYNs, doctors also can’t practice skills they learned in residency and then may not feel comfortable performing the procedures when they enter a health system that offers the procedures in primary care.

 

Number of FPs Prescribing Long-Acting Contraception Growing

Jabbarpour said there has been some improvement in that area in terms of long-acting reversible contraception.

She pointed to a study of recertifying FPs that found that the percent of FPs who offer either IUDs or implants increased from 23.9% in 2018 to 30% in 2022. The share of FPs providing implant insertion increased from 12.9% to 20.8%; those providing IUDs also increased from 22.9% to 25.5% from 2018 to 2022.

FPs also have the advantage of being more widely distributed in rural and remote areas than OB/GYNs, she noted. “They are in almost every county in the United States.”

Jabbarpour said the education must start with health system leaders. If they deem it important to offer these services in primary care, then residency programs will see that their residents must be appropriately trained to provide it.

“Right now, it’s not an expectation of many of the employers that primary care physicians should do this,” she said.

Ti said that expectation should change. The value proposition for all PCPs and health systems, she said, is this: “Most of contraceptive care is well within the scope of primary care providers. This is care that we can do, and it’s care that we should be doing. So why aren’t we doing it?”

Ti, Strasser, and Jabbarpour reported no relevant financial disclosures.

A version of this article appeared on Medscape.com.

In 2024, the Guttmacher Institute reported that eight states enacted or proposed limits on contraceptive access. Currently, more than 19 million women aged 13-44 years in the United States live in “contraceptive deserts” or places that lack access to a full range of birth control methods. About 1.2 million of those women live in counties that don’t have a single health center that has complete birth control services.

Providing contraceptive care in primary care settings has long been deemed a best practice by the Centers for Disease Control and Prevention (CDC). But the percentage of primary care physicians (PCPs) prescribing contraception or offering contraceptive procedures is strikingly low.

 

Only Half of Family Physicians (FPs) Prescribe Contraceptives

Research by Candice Chen, MD, MPH, and colleagues found that while 73.1% of obstetrician-gynecologists (OB/GYNs) and 72.6% of nurse-midwives prescribed the pill, patch, or vaginal ring; only 51% of FPs, 32.4% of pediatricians, and 19.8% of internal medicine physicians did so. And while 92.8% of OB/GYNs provided intrauterine device (IUD) services, only 16.4% of FPs, 2.6% of internists, and 0.6% of pediatricians did so.

One reason primary care is positioned so well to fill contraception gaps is found in the sheer numbers of PCPs. Chen and colleagues found that while the percentage of FPs prescribing contraception was much smaller (51.4%) than the percentage of OB/GYN prescribers (72.6%), the numbers translate to 72,725 FPs prescribing contraceptives, which is nearly double the number of OB/GYNs prescribing them (36,887).

Access to contraception services took a big hit with the COVID-19 pandemic as did access to healthcare in general. And the 2022 Supreme Court ruling that struck down Roe V. Wade has shaken up the landscape for reproductive services with potential consequences for contraceptive access.

 

Why Aren’t More PCPs Offering Contraceptive Services?

Reasons for the relatively low numbers of PCPs prescribing contraceptives include lack of training in residency, health systems’ financial choices, insurance barriers, and expectation by some physicians and many patients that birth control belongs in the OB/GYN sector. Access, patient awareness that PCPs can provide the care, expectations, and options vary by states and regions.

Angeline Ti, MD, an FP who teaches in a residency program at Wellstar Douglasville Medical Center in Douglasville, Georgia, told this news organization that the awareness issue might be the easiest change for PCPs as many patients aren’t aware you can get contraceptive services in primary care.

 

Things PCPs ‘Could Do Tomorrow’

Those physicians who want to add those services might want to start with universal screening, Ti said — having conversations with patients about contraceptive needs and letting them know they don’t have to get those prescriptions from an OB/GYN. The conversations could center on laying out the options and counseling on risks and benefits of various options and providing referrals, if that is the best option. “There are definitely things that you could do tomorrow,” she said.

PCPs should be familiar with the CDC’s Contraceptive Guidance for Health Care Providers and the federal Office of Population Affairs’ Quality Family Planning Recommendations for providers, which offer practice-level information, Ti said.

PCPs should not feel they need to be able to provide same-day contraceptive care to get started. Having nurses and medical assistants and practice managers on board who are passionate about adding the services can also help bring about change with a team approach, she said.

Even when the provider is enthusiastic about providing the care and is trained to do so, however, insurance barriers may exist, Ti acknowledged. For example, at her clinic a common IUD insertion requires prior authorization.

 

Including Other Providers

Julia Strasser, DrPH, MPH, a member of the core faculty at the Fitzhugh Mullan Institute for Health Workforce Equity in Washington, DC, told this news organization that including other clinicians could help expand contraceptive services in primary care. Her research showed that the proportion of the contraception workforce that is made up of advanced practice clinicians and nurse practitioners is increasing, whereas the proportion that includes physicians is either static or declining.

A paper by her team found that although OB/GYNs and nurse-midwives were more likely to prescribe the pill, patch, or ring, the largest numbers of contraception prescribers were FPs (72,725) and advanced practice nurses (70,115).

“We also know that pharmacists can safely prescribe contraception, and some states have authorized this practice, but uptake is low and policies vary by state,” she said. “Some health systems have pharmacists embedded in their practice — for example in federally qualified health centers and others.”

It’s important, she said, not to frame the gaps in contraceptive care as a failure on the part of individual clinicians but rather as: “How can we change some of the system-level factors that have gotten us to this point?”

Yalda Jabbarpour, MD, an FP and director of the Robert Graham Center of the American Academy of Family Physicians, said sometimes it’s the health center’s cost analysis that stands in the way. She gave an example from her own health system.

“The health system doesn’t want to pay for us to have the IUDs stored in our offices and provide that procedure because they feel it’s more cost effective if the OB/GYNs do it.” IUD insertions take more appointment time than the standard appointment, which also goes into the cost analysis. “Even though you’re trained to do it, you can’t necessarily do it when you get to the real world,” Jabbarpour said.

She said the thinking is that while OB/GYNs focus on women, FPs cover all ages and family members, so having the equipment and the storage space is best left to the OB/GYNs. She said that thinking may be short sighted.

“We have good data that the highest number of office visits in the United States actually happen in the family physician’s office,” she said. Not providing the services injects a barrier into the system as women are being referred for a simple procedure to a physician they’ve never seen. “That’s not very patient centered,” Jabbarpour noted.

In systems that refer contraceptive procedures to OB/GYNs, doctors also can’t practice skills they learned in residency and then may not feel comfortable performing the procedures when they enter a health system that offers the procedures in primary care.

 

Number of FPs Prescribing Long-Acting Contraception Growing

Jabbarpour said there has been some improvement in that area in terms of long-acting reversible contraception.

She pointed to a study of recertifying FPs that found that the percent of FPs who offer either IUDs or implants increased from 23.9% in 2018 to 30% in 2022. The share of FPs providing implant insertion increased from 12.9% to 20.8%; those providing IUDs also increased from 22.9% to 25.5% from 2018 to 2022.

FPs also have the advantage of being more widely distributed in rural and remote areas than OB/GYNs, she noted. “They are in almost every county in the United States.”

Jabbarpour said the education must start with health system leaders. If they deem it important to offer these services in primary care, then residency programs will see that their residents must be appropriately trained to provide it.

“Right now, it’s not an expectation of many of the employers that primary care physicians should do this,” she said.

Ti said that expectation should change. The value proposition for all PCPs and health systems, she said, is this: “Most of contraceptive care is well within the scope of primary care providers. This is care that we can do, and it’s care that we should be doing. So why aren’t we doing it?”

Ti, Strasser, and Jabbarpour reported no relevant financial disclosures.

A version of this article appeared on Medscape.com.

Could an artificial intelligence (AI)–driven tool that mines medical records for suspected cases of osteoporosis be so successful that it becomes a potential liability? Yes, according to Christopher White, PhD, executive director of Maridulu Budyari Gumal, the Sydney Partnership for Health, Education, Research, and Enterprise, a research translation center in Liverpool, Australia.

In a thought-provoking presentation at the Endocrine Society’s AI in Healthcare Virtual Summit, White described the results after his fracture liaison team at Prince of Wales Hospital in Randwick, Australia, tried to plug the “osteoporosis treatment gap” by mining medical records to identify patients with the disorder.

 

‘Be Careful What You Wish For’

White and colleagues developed a robust standalone database over 20 years that informed fracture risk among patients with osteoporosis in Sydney. The database included all relevant clinical information, as well as bone density measurements, on about 30,000 patients and could be interrogated for randomized controlled trial recruitment.

However, a “crisis” occurred around 2011, when the team received a recruitment request for the first head-to-head comparison of alendronate with romosozumab. “We had numerous postmenopausal women in the age range with the required bone density, but we hadn’t captured the severity of their vertebral fracture or how many they actually had,” White told the this news organization. For recruitment into the study, participants must have had at least two moderate or severe vertebral fractures or a proximal vertebral fracture that was sustained between 3 and 24 months before recruitment.

White turned to his hospital’s mainframe, which had coding data and time intervals for patients who were admitted with vertebral or hip fractures. He calculated how many patients who met the study criteria had been discharged and how many of those he thought he’d be able to capture through the mainframe. He was confident he would have enough, but he was wrong. He underrecruited and could not participate in the trial.

Determined not to wind up in a similar situation in the future, he investigated and found that other centers were struggling with similar problems. This led to a collaboration with four investigators who were using AI and Advanced Encryption Standard (AES) coding to identify patients at risk for osteoporotic fractures. White, meanwhile, had developed a natural language processing tool called XRAIT that also identified patients at fracture risk. A study comparing the two electronic search programs, which screen medical records for fractures, found that both reliably identified patients who had had a fracture. White and his colleagues concluded that hybrid tools combining XRAIT and AES would likely improve the identification of patients with osteoporosis who would require follow-up or might participate in future trials.

Those patients were not being identified sooner for multiple reasons, White explained. Sometimes, the radiologist would report osteoporosis, but it wouldn’t get coded. Or, in the emergency department, a patient with a fracture would be treated and then sent home, and the possibility of osteoporosis wasn’t reported.

“As we went deeper and deeper with our tools into the medical record, we found more and more patients who hadn’t been coded or reported but who actually had osteoporosis,” White said. “It was incredibly prevalent.”

But the number of patients identified was more than the hospital could comfortably handle.

Ironically, he added, “To my relief and probably not to the benefit of the patients, there was a system upgrade of the radiology reporting system, which was incompatible with the natural language processing technology that I had installed. The AI was turned off at that point, but I had a look over the edge and into the mine pit.”

“The lesson learned,” White told this news organization, is “If you mine the medical record for unidentified patients before you know what to do with the output, you create a medico-legal minefield. You need to be careful what you wish for with technology, because it may actually come true.”

 

Grappling With the Treatment Gap

An (over)abundance of patients is likely contributing to the “osteoporosis treatment gap” that Australia’s fracture liaison services, which handle many of these patients, are grappling with. One recent meta-analysis showed that not all eligible patients are treated and that not all patients who are treated actually start treatment. Another study showed that only a minority of patients — anywhere between 20% and 40% — who start are still persisting at about 3 years, White said.

Various types of fracture liaison services exist, he noted. The model that has been shown to best promote adherence is the one requiring clinicians to “identify, educate [usually, the primary care physician], evaluate, start treatment, continue treatment, and follow-up at 12 months for to confirm that there is adherence.”

What’s happening now, he said, is that the technology is identifying a high number of vertebral crush fractures, and there’s no education or evaluation. “The radiologist just refers the patient to a primary care physician and hopes for the best. AI isn’t contributing to solving the treatment gap problem; it’s amplifying it. It’s ahead of the ability of organizations to accommodate the findings.”

Solutions, he said, would require support at the top of health systems and organizations, and funding to proceed; data surveys concentrating on vertical integration of the medical record to follow patients wherever they are — eg, hospital, primary care — in their health journeys; a workflow with synchronous diagnosis and treatment planning, delivery, monitoring, and payment; and clinical and community champions advocating and “leading the charge in health tech.”

Furthermore, he advised, organizations need to be “very, very careful with safety and security — that is, managing the digital risks.”

“Oscar Wilde said there are two tragedies in life: One is not getting what one wants, and the other is getting it,” White concluded. “In my career, we’ve moved on from not knowing how to treat osteoporosis to knowing how to treat it. And that is both an asset and a liability.”

A version of this article first appeared on Medscape.com.

Could an artificial intelligence (AI)–driven tool that mines medical records for suspected cases of osteoporosis be so successful that it becomes a potential liability? Yes, according to Christopher White, PhD, executive director of Maridulu Budyari Gumal, the Sydney Partnership for Health, Education, Research, and Enterprise, a research translation center in Liverpool, Australia.

In a thought-provoking presentation at the Endocrine Society’s AI in Healthcare Virtual Summit, White described the results after his fracture liaison team at Prince of Wales Hospital in Randwick, Australia, tried to plug the “osteoporosis treatment gap” by mining medical records to identify patients with the disorder.

 

‘Be Careful What You Wish For’

White and colleagues developed a robust standalone database over 20 years that informed fracture risk among patients with osteoporosis in Sydney. The database included all relevant clinical information, as well as bone density measurements, on about 30,000 patients and could be interrogated for randomized controlled trial recruitment.

However, a “crisis” occurred around 2011, when the team received a recruitment request for the first head-to-head comparison of alendronate with romosozumab. “We had numerous postmenopausal women in the age range with the required bone density, but we hadn’t captured the severity of their vertebral fracture or how many they actually had,” White told the this news organization. For recruitment into the study, participants must have had at least two moderate or severe vertebral fractures or a proximal vertebral fracture that was sustained between 3 and 24 months before recruitment.

White turned to his hospital’s mainframe, which had coding data and time intervals for patients who were admitted with vertebral or hip fractures. He calculated how many patients who met the study criteria had been discharged and how many of those he thought he’d be able to capture through the mainframe. He was confident he would have enough, but he was wrong. He underrecruited and could not participate in the trial.

Determined not to wind up in a similar situation in the future, he investigated and found that other centers were struggling with similar problems. This led to a collaboration with four investigators who were using AI and Advanced Encryption Standard (AES) coding to identify patients at risk for osteoporotic fractures. White, meanwhile, had developed a natural language processing tool called XRAIT that also identified patients at fracture risk. A study comparing the two electronic search programs, which screen medical records for fractures, found that both reliably identified patients who had had a fracture. White and his colleagues concluded that hybrid tools combining XRAIT and AES would likely improve the identification of patients with osteoporosis who would require follow-up or might participate in future trials.

Those patients were not being identified sooner for multiple reasons, White explained. Sometimes, the radiologist would report osteoporosis, but it wouldn’t get coded. Or, in the emergency department, a patient with a fracture would be treated and then sent home, and the possibility of osteoporosis wasn’t reported.

“As we went deeper and deeper with our tools into the medical record, we found more and more patients who hadn’t been coded or reported but who actually had osteoporosis,” White said. “It was incredibly prevalent.”

But the number of patients identified was more than the hospital could comfortably handle.

Ironically, he added, “To my relief and probably not to the benefit of the patients, there was a system upgrade of the radiology reporting system, which was incompatible with the natural language processing technology that I had installed. The AI was turned off at that point, but I had a look over the edge and into the mine pit.”

“The lesson learned,” White told this news organization, is “If you mine the medical record for unidentified patients before you know what to do with the output, you create a medico-legal minefield. You need to be careful what you wish for with technology, because it may actually come true.”

 

Grappling With the Treatment Gap

An (over)abundance of patients is likely contributing to the “osteoporosis treatment gap” that Australia’s fracture liaison services, which handle many of these patients, are grappling with. One recent meta-analysis showed that not all eligible patients are treated and that not all patients who are treated actually start treatment. Another study showed that only a minority of patients — anywhere between 20% and 40% — who start are still persisting at about 3 years, White said.

Various types of fracture liaison services exist, he noted. The model that has been shown to best promote adherence is the one requiring clinicians to “identify, educate [usually, the primary care physician], evaluate, start treatment, continue treatment, and follow-up at 12 months for to confirm that there is adherence.”

What’s happening now, he said, is that the technology is identifying a high number of vertebral crush fractures, and there’s no education or evaluation. “The radiologist just refers the patient to a primary care physician and hopes for the best. AI isn’t contributing to solving the treatment gap problem; it’s amplifying it. It’s ahead of the ability of organizations to accommodate the findings.”

Solutions, he said, would require support at the top of health systems and organizations, and funding to proceed; data surveys concentrating on vertical integration of the medical record to follow patients wherever they are — eg, hospital, primary care — in their health journeys; a workflow with synchronous diagnosis and treatment planning, delivery, monitoring, and payment; and clinical and community champions advocating and “leading the charge in health tech.”

Furthermore, he advised, organizations need to be “very, very careful with safety and security — that is, managing the digital risks.”

“Oscar Wilde said there are two tragedies in life: One is not getting what one wants, and the other is getting it,” White concluded. “In my career, we’ve moved on from not knowing how to treat osteoporosis to knowing how to treat it. And that is both an asset and a liability.”

A version of this article first appeared on Medscape.com.

Could an artificial intelligence (AI)–driven tool that mines medical records for suspected cases of osteoporosis be so successful that it becomes a potential liability? Yes, according to Christopher White, PhD, executive director of Maridulu Budyari Gumal, the Sydney Partnership for Health, Education, Research, and Enterprise, a research translation center in Liverpool, Australia.

In a thought-provoking presentation at the Endocrine Society’s AI in Healthcare Virtual Summit, White described the results after his fracture liaison team at Prince of Wales Hospital in Randwick, Australia, tried to plug the “osteoporosis treatment gap” by mining medical records to identify patients with the disorder.

 

‘Be Careful What You Wish For’

White and colleagues developed a robust standalone database over 20 years that informed fracture risk among patients with osteoporosis in Sydney. The database included all relevant clinical information, as well as bone density measurements, on about 30,000 patients and could be interrogated for randomized controlled trial recruitment.

However, a “crisis” occurred around 2011, when the team received a recruitment request for the first head-to-head comparison of alendronate with romosozumab. “We had numerous postmenopausal women in the age range with the required bone density, but we hadn’t captured the severity of their vertebral fracture or how many they actually had,” White told the this news organization. For recruitment into the study, participants must have had at least two moderate or severe vertebral fractures or a proximal vertebral fracture that was sustained between 3 and 24 months before recruitment.

White turned to his hospital’s mainframe, which had coding data and time intervals for patients who were admitted with vertebral or hip fractures. He calculated how many patients who met the study criteria had been discharged and how many of those he thought he’d be able to capture through the mainframe. He was confident he would have enough, but he was wrong. He underrecruited and could not participate in the trial.

Determined not to wind up in a similar situation in the future, he investigated and found that other centers were struggling with similar problems. This led to a collaboration with four investigators who were using AI and Advanced Encryption Standard (AES) coding to identify patients at risk for osteoporotic fractures. White, meanwhile, had developed a natural language processing tool called XRAIT that also identified patients at fracture risk. A study comparing the two electronic search programs, which screen medical records for fractures, found that both reliably identified patients who had had a fracture. White and his colleagues concluded that hybrid tools combining XRAIT and AES would likely improve the identification of patients with osteoporosis who would require follow-up or might participate in future trials.

Those patients were not being identified sooner for multiple reasons, White explained. Sometimes, the radiologist would report osteoporosis, but it wouldn’t get coded. Or, in the emergency department, a patient with a fracture would be treated and then sent home, and the possibility of osteoporosis wasn’t reported.

“As we went deeper and deeper with our tools into the medical record, we found more and more patients who hadn’t been coded or reported but who actually had osteoporosis,” White said. “It was incredibly prevalent.”

But the number of patients identified was more than the hospital could comfortably handle.

Ironically, he added, “To my relief and probably not to the benefit of the patients, there was a system upgrade of the radiology reporting system, which was incompatible with the natural language processing technology that I had installed. The AI was turned off at that point, but I had a look over the edge and into the mine pit.”

“The lesson learned,” White told this news organization, is “If you mine the medical record for unidentified patients before you know what to do with the output, you create a medico-legal minefield. You need to be careful what you wish for with technology, because it may actually come true.”

 

Grappling With the Treatment Gap

An (over)abundance of patients is likely contributing to the “osteoporosis treatment gap” that Australia’s fracture liaison services, which handle many of these patients, are grappling with. One recent meta-analysis showed that not all eligible patients are treated and that not all patients who are treated actually start treatment. Another study showed that only a minority of patients — anywhere between 20% and 40% — who start are still persisting at about 3 years, White said.

Various types of fracture liaison services exist, he noted. The model that has been shown to best promote adherence is the one requiring clinicians to “identify, educate [usually, the primary care physician], evaluate, start treatment, continue treatment, and follow-up at 12 months for to confirm that there is adherence.”

What’s happening now, he said, is that the technology is identifying a high number of vertebral crush fractures, and there’s no education or evaluation. “The radiologist just refers the patient to a primary care physician and hopes for the best. AI isn’t contributing to solving the treatment gap problem; it’s amplifying it. It’s ahead of the ability of organizations to accommodate the findings.”

Solutions, he said, would require support at the top of health systems and organizations, and funding to proceed; data surveys concentrating on vertical integration of the medical record to follow patients wherever they are — eg, hospital, primary care — in their health journeys; a workflow with synchronous diagnosis and treatment planning, delivery, monitoring, and payment; and clinical and community champions advocating and “leading the charge in health tech.”

Furthermore, he advised, organizations need to be “very, very careful with safety and security — that is, managing the digital risks.”

“Oscar Wilde said there are two tragedies in life: One is not getting what one wants, and the other is getting it,” White concluded. “In my career, we’ve moved on from not knowing how to treat osteoporosis to knowing how to treat it. And that is both an asset and a liability.”

A version of this article first appeared on Medscape.com.