Women's Health

Both race and place of residence affect how soon a woman in North Carolina receives treatment for breast cancer, suggesting the need to target high-risk geographic regions and patient groups to ensure timely care, new research suggests.

Among nearly 33,000 women from North Carolina with stage I-III breast cancer, Black patients were nearly twice as likely has non-Black patients to experience treatment delays of more than 60 days, researchers found.

“Our findings suggest that treatment delays are alarmingly common in patients at high risk for breast cancer death, including young Black women and patients with stage III disease,” the authors note in their article, which was published online in Cancer.

Research shows that breast cancer treatment delays of 30-60 days can lower survival, and Black patients face a “disproportionate risk of treatment delays across the breast cancer care delivery spectrum,” the authors explain.

However, studies exploring whether or how racial disparities in treatment delays relate to geography are more limited.

In the current analysis, researchers amassed a retrospective cohort of all patients with stage I-III breast cancer between 2004 and 2015 in the North Carolina Central Cancer Registry and explored the risk of treatment delay by race and geographic subregion.

The cohort included 32,626 women, 6,190 (19.0%) of whom were Black. Counties were divided into the nine Area Health Education Center regions for North Carolina.

Compared with non‐Black patients, Black patients were more likely to have stage III disease (15.2% vs. 9.3%), hormone receptor–negative tumors (29.3% vs. 15.6%), Medicaid insurance (46.7% vs. 14.9%), and to live within 5 miles of their treatment site (30.6% vs. 25.2%).

Overall, Black patients were almost two times more likely to experience a treatment delay of more than 60 days (15% vs. 8%).

On average, about one in seven Black women experienced a lengthy delay, but the risk varied depending on geographic location. Patients living in certain regions of the state were more likely to experience delays; those in the highest-risk region were about twice as likely to experience a delay as those in the lowest-risk region (relative risk, 2.1 among Black patients; and RR, 1.9 among non-Black patients).

The magnitude of the racial gap in treatment delay varied by region – from 0% to 9.4%. But overall, of patients who experienced treatment delays, a significantly greater proportion were Black patients in every region except region 2, where only 2.7% (93 of 3,362) of patients were Black.

Notably, two regions with the greatest disparities in treatment delay, as well as the highest absolute risk of treatment delay for Black patients, surround large cities.

“These delays weren’t explained by the patients’ distance from cancer treatment facilities, their specific stage of cancer or type of treatment, or what insurance they had,” lead author Katherine Reeder-Hayes, MD, with the University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, said in a news release.

Instead, Dr. Reeder-Hayes said, the findings suggest that the structure of local health care systems, rather than patient characteristics, may better explain why some patients experience treatment delays.

In other words, “if cancer care teams in certain areas say, ‘Oh, it’s particularly hard to treat breast cancer in our area because people are poor or have really advanced stages of cancer when they come in,’ our research does not bear out that explanation,” Dr. Reeder-Hayes said in email to this news organization.

This study “highlights the persistent disparities in treatment delays Black women encounter, which often lead to worse outcomes,” said Kathie-Ann Joseph, MD, MPH, who was not involved in the research.

“Interestingly, the authors could not attribute these delays in treatment to patient-level factors,” said Dr. Joseph, a breast cancer surgeon at NYU Langone Perlmutter Cancer Center, New York. But the authors “did find substantial geographic variation, which suggests the need to address structural barriers contributing to treatment delays in Black women.”

Sara P. Cate, MD, who was not involved with the research, also noted that the study highlights a known issue – “that racial minorities have longer delays in cancer treatment.” And notably, she said, the findings reveal that this disparity persists in areas where access to care is better and more robust.

“The nuances of the delays to care are multifactorial,” said Dr. Cate, a breast cancer surgeon and director of the Breast Surgery Quality Program at Mount Sinai in New York. “We need to do better with this population, and it is a multilevel solution of financial assistance, social work, and patient navigation.”

The study was supported in part by grants from the Susan G. Komen Foundation and the NC State Employees’ Credit Union. Dr. Reeder-Hayes, Dr. Cate, and Dr. Joseph have disclosed no relevant financial relationships.

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

Both race and place of residence affect how soon a woman in North Carolina receives treatment for breast cancer, suggesting the need to target high-risk geographic regions and patient groups to ensure timely care, new research suggests.

Among nearly 33,000 women from North Carolina with stage I-III breast cancer, Black patients were nearly twice as likely has non-Black patients to experience treatment delays of more than 60 days, researchers found.

“Our findings suggest that treatment delays are alarmingly common in patients at high risk for breast cancer death, including young Black women and patients with stage III disease,” the authors note in their article, which was published online in Cancer.

Research shows that breast cancer treatment delays of 30-60 days can lower survival, and Black patients face a “disproportionate risk of treatment delays across the breast cancer care delivery spectrum,” the authors explain.

However, studies exploring whether or how racial disparities in treatment delays relate to geography are more limited.

In the current analysis, researchers amassed a retrospective cohort of all patients with stage I-III breast cancer between 2004 and 2015 in the North Carolina Central Cancer Registry and explored the risk of treatment delay by race and geographic subregion.

The cohort included 32,626 women, 6,190 (19.0%) of whom were Black. Counties were divided into the nine Area Health Education Center regions for North Carolina.

Compared with non‐Black patients, Black patients were more likely to have stage III disease (15.2% vs. 9.3%), hormone receptor–negative tumors (29.3% vs. 15.6%), Medicaid insurance (46.7% vs. 14.9%), and to live within 5 miles of their treatment site (30.6% vs. 25.2%).

Overall, Black patients were almost two times more likely to experience a treatment delay of more than 60 days (15% vs. 8%).

On average, about one in seven Black women experienced a lengthy delay, but the risk varied depending on geographic location. Patients living in certain regions of the state were more likely to experience delays; those in the highest-risk region were about twice as likely to experience a delay as those in the lowest-risk region (relative risk, 2.1 among Black patients; and RR, 1.9 among non-Black patients).

The magnitude of the racial gap in treatment delay varied by region – from 0% to 9.4%. But overall, of patients who experienced treatment delays, a significantly greater proportion were Black patients in every region except region 2, where only 2.7% (93 of 3,362) of patients were Black.

Notably, two regions with the greatest disparities in treatment delay, as well as the highest absolute risk of treatment delay for Black patients, surround large cities.

“These delays weren’t explained by the patients’ distance from cancer treatment facilities, their specific stage of cancer or type of treatment, or what insurance they had,” lead author Katherine Reeder-Hayes, MD, with the University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, said in a news release.

Instead, Dr. Reeder-Hayes said, the findings suggest that the structure of local health care systems, rather than patient characteristics, may better explain why some patients experience treatment delays.

In other words, “if cancer care teams in certain areas say, ‘Oh, it’s particularly hard to treat breast cancer in our area because people are poor or have really advanced stages of cancer when they come in,’ our research does not bear out that explanation,” Dr. Reeder-Hayes said in email to this news organization.

This study “highlights the persistent disparities in treatment delays Black women encounter, which often lead to worse outcomes,” said Kathie-Ann Joseph, MD, MPH, who was not involved in the research.

“Interestingly, the authors could not attribute these delays in treatment to patient-level factors,” said Dr. Joseph, a breast cancer surgeon at NYU Langone Perlmutter Cancer Center, New York. But the authors “did find substantial geographic variation, which suggests the need to address structural barriers contributing to treatment delays in Black women.”

Sara P. Cate, MD, who was not involved with the research, also noted that the study highlights a known issue – “that racial minorities have longer delays in cancer treatment.” And notably, she said, the findings reveal that this disparity persists in areas where access to care is better and more robust.

“The nuances of the delays to care are multifactorial,” said Dr. Cate, a breast cancer surgeon and director of the Breast Surgery Quality Program at Mount Sinai in New York. “We need to do better with this population, and it is a multilevel solution of financial assistance, social work, and patient navigation.”

The study was supported in part by grants from the Susan G. Komen Foundation and the NC State Employees’ Credit Union. Dr. Reeder-Hayes, Dr. Cate, and Dr. Joseph have disclosed no relevant financial relationships.

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

Both race and place of residence affect how soon a woman in North Carolina receives treatment for breast cancer, suggesting the need to target high-risk geographic regions and patient groups to ensure timely care, new research suggests.

Among nearly 33,000 women from North Carolina with stage I-III breast cancer, Black patients were nearly twice as likely has non-Black patients to experience treatment delays of more than 60 days, researchers found.

“Our findings suggest that treatment delays are alarmingly common in patients at high risk for breast cancer death, including young Black women and patients with stage III disease,” the authors note in their article, which was published online in Cancer.

Research shows that breast cancer treatment delays of 30-60 days can lower survival, and Black patients face a “disproportionate risk of treatment delays across the breast cancer care delivery spectrum,” the authors explain.

However, studies exploring whether or how racial disparities in treatment delays relate to geography are more limited.

In the current analysis, researchers amassed a retrospective cohort of all patients with stage I-III breast cancer between 2004 and 2015 in the North Carolina Central Cancer Registry and explored the risk of treatment delay by race and geographic subregion.

The cohort included 32,626 women, 6,190 (19.0%) of whom were Black. Counties were divided into the nine Area Health Education Center regions for North Carolina.

Compared with non‐Black patients, Black patients were more likely to have stage III disease (15.2% vs. 9.3%), hormone receptor–negative tumors (29.3% vs. 15.6%), Medicaid insurance (46.7% vs. 14.9%), and to live within 5 miles of their treatment site (30.6% vs. 25.2%).

Overall, Black patients were almost two times more likely to experience a treatment delay of more than 60 days (15% vs. 8%).

On average, about one in seven Black women experienced a lengthy delay, but the risk varied depending on geographic location. Patients living in certain regions of the state were more likely to experience delays; those in the highest-risk region were about twice as likely to experience a delay as those in the lowest-risk region (relative risk, 2.1 among Black patients; and RR, 1.9 among non-Black patients).

The magnitude of the racial gap in treatment delay varied by region – from 0% to 9.4%. But overall, of patients who experienced treatment delays, a significantly greater proportion were Black patients in every region except region 2, where only 2.7% (93 of 3,362) of patients were Black.

Notably, two regions with the greatest disparities in treatment delay, as well as the highest absolute risk of treatment delay for Black patients, surround large cities.

“These delays weren’t explained by the patients’ distance from cancer treatment facilities, their specific stage of cancer or type of treatment, or what insurance they had,” lead author Katherine Reeder-Hayes, MD, with the University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, said in a news release.

Instead, Dr. Reeder-Hayes said, the findings suggest that the structure of local health care systems, rather than patient characteristics, may better explain why some patients experience treatment delays.

In other words, “if cancer care teams in certain areas say, ‘Oh, it’s particularly hard to treat breast cancer in our area because people are poor or have really advanced stages of cancer when they come in,’ our research does not bear out that explanation,” Dr. Reeder-Hayes said in email to this news organization.

This study “highlights the persistent disparities in treatment delays Black women encounter, which often lead to worse outcomes,” said Kathie-Ann Joseph, MD, MPH, who was not involved in the research.

“Interestingly, the authors could not attribute these delays in treatment to patient-level factors,” said Dr. Joseph, a breast cancer surgeon at NYU Langone Perlmutter Cancer Center, New York. But the authors “did find substantial geographic variation, which suggests the need to address structural barriers contributing to treatment delays in Black women.”

Sara P. Cate, MD, who was not involved with the research, also noted that the study highlights a known issue – “that racial minorities have longer delays in cancer treatment.” And notably, she said, the findings reveal that this disparity persists in areas where access to care is better and more robust.

“The nuances of the delays to care are multifactorial,” said Dr. Cate, a breast cancer surgeon and director of the Breast Surgery Quality Program at Mount Sinai in New York. “We need to do better with this population, and it is a multilevel solution of financial assistance, social work, and patient navigation.”

The study was supported in part by grants from the Susan G. Komen Foundation and the NC State Employees’ Credit Union. Dr. Reeder-Hayes, Dr. Cate, and Dr. Joseph have disclosed no relevant financial relationships.

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

“Congratulations on the baby. You look great!” I enthusiastically proclaimed to my classmate. It was the start of the fall semester of my sophomore year of college.

At my small women’s college, the previous semester’s gossip had been about our classmate, S*. She had gone from being very thin to noticeably gaining a lot of weight in a few months. The rumors were that S was pregnant and gave birth over summer break. As a busy biology premed major, this was my first time hearing the news. So when I saw her standing in the hallway, back to her previous weight, I was excited for her.

In true extravert fashion, I commented on the baby and her new size. But no sooner had the words left my mouth than I regretted them.

The hall grew awkwardly silent as S’s face flushed and she asked, “Excuse me?!” Instantly I knew that the rumors weren’t true.

Thankfully, at that moment, the classroom opened and we walked in. Whew! After class, S asked if we could talk. She explained that she had a thyroid tumor and struggled to adjust to the treatments, which caused her weight fluctuations. She had never been pregnant.

My awkward statement had been the first time anyone on campus had directly mentioned her weight, though she suspected that people were talking about her. We became fast friends after this rocky beginning. Although we lost touch after college, S taught me an invaluable lesson about making assumptions about people’s weight: Ask before you assume.

Now, years later, as an internist and obesity specialist, this lesson continues to be reinforced daily.

In daily life, comments about weight can be perceived as rude. In the clinical setting, however, assumptions about weight are a form of weight bias. Weight bias can lead to weight stigma and even be dangerous to health care.

Let’s discuss the insidious influence of weight bias in health care through two commonly used phrases and then look at a few solutions to address weight bias in health care individually and systematically.
 

Common weight bias assumptions

“Great job, you lost weight!” In checking your patient’s vital signs, you notice that this patient with obesity has a significant weight change. You congratulate them upon entering the room. Unfortunately, their weight loss was a result of minimal eating after losing a loved one. This isn’t healthy weight loss. One of the adverse effects of weight bias is that it infers that weight loss is always a good thing, especially in people with larger bodies. This is a dangerous presumption. Let’s remember that the body favors fat storage, hence why “unintentional weight loss” is a recognized medical condition prompting evaluation. We have to be careful not to celebrate weight loss “at all costs,” such as fad diets that haven’t been shown to improve health outcomes.

Furthermore, patients who lose weight quickly (more than 4-8 lb/month) require closer follow-up and evaluation for secondary causes of weight loss. Patients may lose weight at a faster rate with the new antiobesity medications, but clinicians still should ensure that age-appropriate health maintenance screening is done and be vigilant for secondary causes of weight changes.

“Have you tried losing weight yet?” Three times. That’s how many times Chanté Burkett went to her doctor about her painful, enlarging firm stomach. She was advised to continue working on weight loss, which she did diligently. But Ms. Burkett’s abdomen kept growing and her concerns were dismissed. A visit to urgent care and a CT scan revealed that Ms. Burkett’s excess abdominal “fat” was a 13-lb mucinous cystadenoma. Sadly, cases like hers aren’t rare, isolated events. Weight bias can cause anchoring on one diagnosis, preventing consideration of other diagnostic possibilities. Even worse, anchoring will lead to the wrong intervention, such as prescribing weight loss for presumed increased adiposity instead of ordering the appropriate testing.

It’s also essential to recognize that, even if someone does have the disease of obesity, weight loss isn’t the solution to every medical concern. Even if weight loss is helpful, other, more pressing treatments may still be necessary. Telling a person with obesity who has an acute complaint to “just lose weight” is comparable to telling a patient with coronary artery disease who presents with an 80% vessel occlusion and chest pain to follow a low-fat diet. In both cases, you need to address the acute concern appropriately, then focus on the chronic treatment.
 

Ways to reduce clinical weight bias

How do you reduce clinical weight bias?

Ask, don’t assume. The information from the scale is simply data. Instead of judging it positively or negatively and creating a story, ask the patient. An unbiased way to approach the conversation is to say, “Great to see you. You seem [positive adjective of choice]. How have you been?” Wait until the vitals section to objectively discuss weight unless the patient offers the discussion earlier or their chief complaint lists a weight-related concern.

Order necessary tests to evaluate weight. Weight is the vital sign that people wear externally, so we feel that we can readily interpret it without any further assessment. However, resist the urge to interpret scale data without context. Keeping an open mind helps prevent anchoring and missing critical clues in the clinical history.

Address weight changes effectively. Sometimes there is an indication to prescribe weight loss as part of the treatment plan. However, remember that weight loss isn’t simply “calories in vs. calories out.” Obesity is a complex medical disease that requires a multimodal treatment approach. As clinicians, we have access to the most powerful tools for weight loss. Unfortunately, weight bias contributes to limited prescribing of metabolic medications (“antiobesity medications” or AOMs). In addition, systemic weight bias prevents insurance coverage of AOMs. The Treat and Reduce Obesity Act has been introduced into Congress to help improve life-transforming access to AOMs.

Acknowledge your bias. Our experiences make us all susceptible to bias. The Harvard Weight Implicit Association Test is free and a helpful way to assess your level of weight bias. I take it annually to ensure that I remain objective in my practice.

Addressing weight bias needs to extend beyond the individual level.

Systemically, health care needs to address the following:

Language. Use people-centered language. For example, “People aren’t obese. They have obesity.”

Accessibility. Health care settings must be comfortable and accessible for people of all sizes. Furthermore, improvements to access the services that comprehensive obesity care requires, such as AOMs, bariatric procedures and bariatric surgery, mental health care, nutrition, fitness specialists, health coaches, and more, are needed.

Education. Medical students and trainees have to learn the newest obesity science and know how to treat obesity effectively. Acknowledge and address biased tools. Recent data have shown that some of our screening tools, such as body mass index, have inherent bias. It’s time to focus on using improved diagnostic tools and personalized treatments.

We are at a pivotal time in our scientific understanding of body weight regulation and the disease of obesity. Clinical weight bias is primarily rooted in flawed science influenced by biased cultural norms and other forms of discrimination, such as racial and gender bias. We must move past assumptions to give our patients the optimal individualized care they need. So next time you observe a weight change, instead of commenting on their weight, say, “Great to see you! How have you been?”

S*: Initial has been changed to protect privacy.

Dr. Gonsahn-Bollie is an integrative obesity specialist focused on individualized solutions for emotional and biological overeating. Connect with her at www.embraceyouweightloss.com or on Instagram @embraceyoumd. Her bestselling book, “Embrace You: Your Guide to Transforming Weight Loss Misconceptions Into Lifelong Wellness”, was Healthline.com’s Best Overall Weight Loss Book of 2022 and one of Livestrong.com’s 8 Best Weight-Loss Books to Read in 2022. She has disclosed no relevant financial relationships. A version of this article originally appeared on Medscape.com.

“Congratulations on the baby. You look great!” I enthusiastically proclaimed to my classmate. It was the start of the fall semester of my sophomore year of college.

At my small women’s college, the previous semester’s gossip had been about our classmate, S*. She had gone from being very thin to noticeably gaining a lot of weight in a few months. The rumors were that S was pregnant and gave birth over summer break. As a busy biology premed major, this was my first time hearing the news. So when I saw her standing in the hallway, back to her previous weight, I was excited for her.

In true extravert fashion, I commented on the baby and her new size. But no sooner had the words left my mouth than I regretted them.

The hall grew awkwardly silent as S’s face flushed and she asked, “Excuse me?!” Instantly I knew that the rumors weren’t true.

Thankfully, at that moment, the classroom opened and we walked in. Whew! After class, S asked if we could talk. She explained that she had a thyroid tumor and struggled to adjust to the treatments, which caused her weight fluctuations. She had never been pregnant.

My awkward statement had been the first time anyone on campus had directly mentioned her weight, though she suspected that people were talking about her. We became fast friends after this rocky beginning. Although we lost touch after college, S taught me an invaluable lesson about making assumptions about people’s weight: Ask before you assume.

Now, years later, as an internist and obesity specialist, this lesson continues to be reinforced daily.

In daily life, comments about weight can be perceived as rude. In the clinical setting, however, assumptions about weight are a form of weight bias. Weight bias can lead to weight stigma and even be dangerous to health care.

Let’s discuss the insidious influence of weight bias in health care through two commonly used phrases and then look at a few solutions to address weight bias in health care individually and systematically.
 

Common weight bias assumptions

“Great job, you lost weight!” In checking your patient’s vital signs, you notice that this patient with obesity has a significant weight change. You congratulate them upon entering the room. Unfortunately, their weight loss was a result of minimal eating after losing a loved one. This isn’t healthy weight loss. One of the adverse effects of weight bias is that it infers that weight loss is always a good thing, especially in people with larger bodies. This is a dangerous presumption. Let’s remember that the body favors fat storage, hence why “unintentional weight loss” is a recognized medical condition prompting evaluation. We have to be careful not to celebrate weight loss “at all costs,” such as fad diets that haven’t been shown to improve health outcomes.

Furthermore, patients who lose weight quickly (more than 4-8 lb/month) require closer follow-up and evaluation for secondary causes of weight loss. Patients may lose weight at a faster rate with the new antiobesity medications, but clinicians still should ensure that age-appropriate health maintenance screening is done and be vigilant for secondary causes of weight changes.

“Have you tried losing weight yet?” Three times. That’s how many times Chanté Burkett went to her doctor about her painful, enlarging firm stomach. She was advised to continue working on weight loss, which she did diligently. But Ms. Burkett’s abdomen kept growing and her concerns were dismissed. A visit to urgent care and a CT scan revealed that Ms. Burkett’s excess abdominal “fat” was a 13-lb mucinous cystadenoma. Sadly, cases like hers aren’t rare, isolated events. Weight bias can cause anchoring on one diagnosis, preventing consideration of other diagnostic possibilities. Even worse, anchoring will lead to the wrong intervention, such as prescribing weight loss for presumed increased adiposity instead of ordering the appropriate testing.

It’s also essential to recognize that, even if someone does have the disease of obesity, weight loss isn’t the solution to every medical concern. Even if weight loss is helpful, other, more pressing treatments may still be necessary. Telling a person with obesity who has an acute complaint to “just lose weight” is comparable to telling a patient with coronary artery disease who presents with an 80% vessel occlusion and chest pain to follow a low-fat diet. In both cases, you need to address the acute concern appropriately, then focus on the chronic treatment.
 

Ways to reduce clinical weight bias

How do you reduce clinical weight bias?

Ask, don’t assume. The information from the scale is simply data. Instead of judging it positively or negatively and creating a story, ask the patient. An unbiased way to approach the conversation is to say, “Great to see you. You seem [positive adjective of choice]. How have you been?” Wait until the vitals section to objectively discuss weight unless the patient offers the discussion earlier or their chief complaint lists a weight-related concern.

Order necessary tests to evaluate weight. Weight is the vital sign that people wear externally, so we feel that we can readily interpret it without any further assessment. However, resist the urge to interpret scale data without context. Keeping an open mind helps prevent anchoring and missing critical clues in the clinical history.

Address weight changes effectively. Sometimes there is an indication to prescribe weight loss as part of the treatment plan. However, remember that weight loss isn’t simply “calories in vs. calories out.” Obesity is a complex medical disease that requires a multimodal treatment approach. As clinicians, we have access to the most powerful tools for weight loss. Unfortunately, weight bias contributes to limited prescribing of metabolic medications (“antiobesity medications” or AOMs). In addition, systemic weight bias prevents insurance coverage of AOMs. The Treat and Reduce Obesity Act has been introduced into Congress to help improve life-transforming access to AOMs.

Acknowledge your bias. Our experiences make us all susceptible to bias. The Harvard Weight Implicit Association Test is free and a helpful way to assess your level of weight bias. I take it annually to ensure that I remain objective in my practice.

Addressing weight bias needs to extend beyond the individual level.

Systemically, health care needs to address the following:

Language. Use people-centered language. For example, “People aren’t obese. They have obesity.”

Accessibility. Health care settings must be comfortable and accessible for people of all sizes. Furthermore, improvements to access the services that comprehensive obesity care requires, such as AOMs, bariatric procedures and bariatric surgery, mental health care, nutrition, fitness specialists, health coaches, and more, are needed.

Education. Medical students and trainees have to learn the newest obesity science and know how to treat obesity effectively. Acknowledge and address biased tools. Recent data have shown that some of our screening tools, such as body mass index, have inherent bias. It’s time to focus on using improved diagnostic tools and personalized treatments.

We are at a pivotal time in our scientific understanding of body weight regulation and the disease of obesity. Clinical weight bias is primarily rooted in flawed science influenced by biased cultural norms and other forms of discrimination, such as racial and gender bias. We must move past assumptions to give our patients the optimal individualized care they need. So next time you observe a weight change, instead of commenting on their weight, say, “Great to see you! How have you been?”

S*: Initial has been changed to protect privacy.

Dr. Gonsahn-Bollie is an integrative obesity specialist focused on individualized solutions for emotional and biological overeating. Connect with her at www.embraceyouweightloss.com or on Instagram @embraceyoumd. Her bestselling book, “Embrace You: Your Guide to Transforming Weight Loss Misconceptions Into Lifelong Wellness”, was Healthline.com’s Best Overall Weight Loss Book of 2022 and one of Livestrong.com’s 8 Best Weight-Loss Books to Read in 2022. She has disclosed no relevant financial relationships. A version of this article originally appeared on Medscape.com.

“Congratulations on the baby. You look great!” I enthusiastically proclaimed to my classmate. It was the start of the fall semester of my sophomore year of college.

At my small women’s college, the previous semester’s gossip had been about our classmate, S*. She had gone from being very thin to noticeably gaining a lot of weight in a few months. The rumors were that S was pregnant and gave birth over summer break. As a busy biology premed major, this was my first time hearing the news. So when I saw her standing in the hallway, back to her previous weight, I was excited for her.

In true extravert fashion, I commented on the baby and her new size. But no sooner had the words left my mouth than I regretted them.

The hall grew awkwardly silent as S’s face flushed and she asked, “Excuse me?!” Instantly I knew that the rumors weren’t true.

Thankfully, at that moment, the classroom opened and we walked in. Whew! After class, S asked if we could talk. She explained that she had a thyroid tumor and struggled to adjust to the treatments, which caused her weight fluctuations. She had never been pregnant.

My awkward statement had been the first time anyone on campus had directly mentioned her weight, though she suspected that people were talking about her. We became fast friends after this rocky beginning. Although we lost touch after college, S taught me an invaluable lesson about making assumptions about people’s weight: Ask before you assume.

Now, years later, as an internist and obesity specialist, this lesson continues to be reinforced daily.

In daily life, comments about weight can be perceived as rude. In the clinical setting, however, assumptions about weight are a form of weight bias. Weight bias can lead to weight stigma and even be dangerous to health care.

Let’s discuss the insidious influence of weight bias in health care through two commonly used phrases and then look at a few solutions to address weight bias in health care individually and systematically.
 

Common weight bias assumptions

“Great job, you lost weight!” In checking your patient’s vital signs, you notice that this patient with obesity has a significant weight change. You congratulate them upon entering the room. Unfortunately, their weight loss was a result of minimal eating after losing a loved one. This isn’t healthy weight loss. One of the adverse effects of weight bias is that it infers that weight loss is always a good thing, especially in people with larger bodies. This is a dangerous presumption. Let’s remember that the body favors fat storage, hence why “unintentional weight loss” is a recognized medical condition prompting evaluation. We have to be careful not to celebrate weight loss “at all costs,” such as fad diets that haven’t been shown to improve health outcomes.

Furthermore, patients who lose weight quickly (more than 4-8 lb/month) require closer follow-up and evaluation for secondary causes of weight loss. Patients may lose weight at a faster rate with the new antiobesity medications, but clinicians still should ensure that age-appropriate health maintenance screening is done and be vigilant for secondary causes of weight changes.

“Have you tried losing weight yet?” Three times. That’s how many times Chanté Burkett went to her doctor about her painful, enlarging firm stomach. She was advised to continue working on weight loss, which she did diligently. But Ms. Burkett’s abdomen kept growing and her concerns were dismissed. A visit to urgent care and a CT scan revealed that Ms. Burkett’s excess abdominal “fat” was a 13-lb mucinous cystadenoma. Sadly, cases like hers aren’t rare, isolated events. Weight bias can cause anchoring on one diagnosis, preventing consideration of other diagnostic possibilities. Even worse, anchoring will lead to the wrong intervention, such as prescribing weight loss for presumed increased adiposity instead of ordering the appropriate testing.

It’s also essential to recognize that, even if someone does have the disease of obesity, weight loss isn’t the solution to every medical concern. Even if weight loss is helpful, other, more pressing treatments may still be necessary. Telling a person with obesity who has an acute complaint to “just lose weight” is comparable to telling a patient with coronary artery disease who presents with an 80% vessel occlusion and chest pain to follow a low-fat diet. In both cases, you need to address the acute concern appropriately, then focus on the chronic treatment.
 

Ways to reduce clinical weight bias

How do you reduce clinical weight bias?

Ask, don’t assume. The information from the scale is simply data. Instead of judging it positively or negatively and creating a story, ask the patient. An unbiased way to approach the conversation is to say, “Great to see you. You seem [positive adjective of choice]. How have you been?” Wait until the vitals section to objectively discuss weight unless the patient offers the discussion earlier or their chief complaint lists a weight-related concern.

Order necessary tests to evaluate weight. Weight is the vital sign that people wear externally, so we feel that we can readily interpret it without any further assessment. However, resist the urge to interpret scale data without context. Keeping an open mind helps prevent anchoring and missing critical clues in the clinical history.

Address weight changes effectively. Sometimes there is an indication to prescribe weight loss as part of the treatment plan. However, remember that weight loss isn’t simply “calories in vs. calories out.” Obesity is a complex medical disease that requires a multimodal treatment approach. As clinicians, we have access to the most powerful tools for weight loss. Unfortunately, weight bias contributes to limited prescribing of metabolic medications (“antiobesity medications” or AOMs). In addition, systemic weight bias prevents insurance coverage of AOMs. The Treat and Reduce Obesity Act has been introduced into Congress to help improve life-transforming access to AOMs.

Acknowledge your bias. Our experiences make us all susceptible to bias. The Harvard Weight Implicit Association Test is free and a helpful way to assess your level of weight bias. I take it annually to ensure that I remain objective in my practice.

Addressing weight bias needs to extend beyond the individual level.

Systemically, health care needs to address the following:

Language. Use people-centered language. For example, “People aren’t obese. They have obesity.”

Accessibility. Health care settings must be comfortable and accessible for people of all sizes. Furthermore, improvements to access the services that comprehensive obesity care requires, such as AOMs, bariatric procedures and bariatric surgery, mental health care, nutrition, fitness specialists, health coaches, and more, are needed.

Education. Medical students and trainees have to learn the newest obesity science and know how to treat obesity effectively. Acknowledge and address biased tools. Recent data have shown that some of our screening tools, such as body mass index, have inherent bias. It’s time to focus on using improved diagnostic tools and personalized treatments.

We are at a pivotal time in our scientific understanding of body weight regulation and the disease of obesity. Clinical weight bias is primarily rooted in flawed science influenced by biased cultural norms and other forms of discrimination, such as racial and gender bias. We must move past assumptions to give our patients the optimal individualized care they need. So next time you observe a weight change, instead of commenting on their weight, say, “Great to see you! How have you been?”

S*: Initial has been changed to protect privacy.

Dr. Gonsahn-Bollie is an integrative obesity specialist focused on individualized solutions for emotional and biological overeating. Connect with her at www.embraceyouweightloss.com or on Instagram @embraceyoumd. Her bestselling book, “Embrace You: Your Guide to Transforming Weight Loss Misconceptions Into Lifelong Wellness”, was Healthline.com’s Best Overall Weight Loss Book of 2022 and one of Livestrong.com’s 8 Best Weight-Loss Books to Read in 2022. She has disclosed no relevant financial relationships. A version of this article originally appeared on Medscape.com.

Montrouge, France – Four in five women will be infected by one or more human papillomavirus (HPV) strains during their lifetimes. For most of these women, the HPV will be cleared from the body, but 5% of them will develop precancerous lesions in the cervix. The role of vaginal flora in persistent HPV has been brought into focus by research studies carried out over the past few years.

At a press conference ahead of the 46th meeting of the French Colposcopy and Cervical and Vaginal Diseases Society, Julia Maruani, MD, a medical gynecologist in Marseille, France, took the opportunity to discuss the importance of vaginal flora and the need to treat cases of bacterial vaginosis.
 

Striking a balance

Essential for reducing the risk of sexually transmitted infections, a healthy vaginal flora is made up of millions of microorganisms, mainly lactobacilli, as well as other bacteria (Gardnerella vaginalis, Atopobium vaginae, Prevotella, streptococcus, gonococcus), HPV, and fungi.

Lactobacilli produce lactic acid, which reduces the vagina’s pH, as well as hydrogen peroxide, which is toxic to the other bacteria.

Different factors, such as alcohol, a diet rich in polyunsaturated fatty acids and sugar, and especially smoking, can lead to an imbalance of the bacteria in the vaginal flora and thus result in vaginosis. What occurs is an abnormal multiplication of different types of anaerobic bacteria that are normally present in much lower numbers. There is a relative reduction in lactobacilli, which results in an increased vaginal pH, a greater risk of contracting an STI, and reduced clearance of the HPV infection. “Women who smoke probably experience persistent HPV infections due to an imbalance in vaginal flora,” said Dr. Maruani.
 

Vaginosis and HPV

When there are fewer lactobacilli than there should be, these bacteria can no longer protect the vaginal mucosa, which is disrupted by other bacteria. “HPV then has access to the basal cells,” said Dr. Maruani, acknowledging that the relationship between bacterial vaginosis and persistent HPV infections has been the subject of numerous research studies over the past decade or so. “For years, I would see this same link in my patients. Those with persistent vaginosis were also the ones with persistent HPV. And I’m not the only one to notice this. Studies have also been carried out investigating this exact correlation,” she added.

These studies have shown that HPV infections persist in cases of vaginosis, resulting in the appearance of epithelial lesions. Additionally, the lesions are more severe when dysbiosis is more severe.

What about probiotics? Can they treat dysbiosis and an HPV infection at the same time? “Probiotics work very well for vaginosis, provided they are used for a long time. We know that they lessen HPV infections and low-grade lesions,” said Dr. Maruani, although no randomized studies support this conclusion. “It’s not a one size fits all. We aren’t about to treat patients with precancerous lesions with probiotics.” There are currently no data concerning the efficacy of probiotics on high-grade lesions. These days, Dr. Maruani has been thinking about a new issue: the benefit of diagnosing cases of asymptomatic vaginosis – because treating them would reduce the risk of persistent HPV infection.

This article was translated from the Medscape French edition. A version of this article appeared on Medscape.com.

Montrouge, France – Four in five women will be infected by one or more human papillomavirus (HPV) strains during their lifetimes. For most of these women, the HPV will be cleared from the body, but 5% of them will develop precancerous lesions in the cervix. The role of vaginal flora in persistent HPV has been brought into focus by research studies carried out over the past few years.

At a press conference ahead of the 46th meeting of the French Colposcopy and Cervical and Vaginal Diseases Society, Julia Maruani, MD, a medical gynecologist in Marseille, France, took the opportunity to discuss the importance of vaginal flora and the need to treat cases of bacterial vaginosis.
 

Striking a balance

Essential for reducing the risk of sexually transmitted infections, a healthy vaginal flora is made up of millions of microorganisms, mainly lactobacilli, as well as other bacteria (Gardnerella vaginalis, Atopobium vaginae, Prevotella, streptococcus, gonococcus), HPV, and fungi.

Lactobacilli produce lactic acid, which reduces the vagina’s pH, as well as hydrogen peroxide, which is toxic to the other bacteria.

Different factors, such as alcohol, a diet rich in polyunsaturated fatty acids and sugar, and especially smoking, can lead to an imbalance of the bacteria in the vaginal flora and thus result in vaginosis. What occurs is an abnormal multiplication of different types of anaerobic bacteria that are normally present in much lower numbers. There is a relative reduction in lactobacilli, which results in an increased vaginal pH, a greater risk of contracting an STI, and reduced clearance of the HPV infection. “Women who smoke probably experience persistent HPV infections due to an imbalance in vaginal flora,” said Dr. Maruani.
 

Vaginosis and HPV

When there are fewer lactobacilli than there should be, these bacteria can no longer protect the vaginal mucosa, which is disrupted by other bacteria. “HPV then has access to the basal cells,” said Dr. Maruani, acknowledging that the relationship between bacterial vaginosis and persistent HPV infections has been the subject of numerous research studies over the past decade or so. “For years, I would see this same link in my patients. Those with persistent vaginosis were also the ones with persistent HPV. And I’m not the only one to notice this. Studies have also been carried out investigating this exact correlation,” she added.

These studies have shown that HPV infections persist in cases of vaginosis, resulting in the appearance of epithelial lesions. Additionally, the lesions are more severe when dysbiosis is more severe.

What about probiotics? Can they treat dysbiosis and an HPV infection at the same time? “Probiotics work very well for vaginosis, provided they are used for a long time. We know that they lessen HPV infections and low-grade lesions,” said Dr. Maruani, although no randomized studies support this conclusion. “It’s not a one size fits all. We aren’t about to treat patients with precancerous lesions with probiotics.” There are currently no data concerning the efficacy of probiotics on high-grade lesions. These days, Dr. Maruani has been thinking about a new issue: the benefit of diagnosing cases of asymptomatic vaginosis – because treating them would reduce the risk of persistent HPV infection.

This article was translated from the Medscape French edition. A version of this article appeared on Medscape.com.

Montrouge, France – Four in five women will be infected by one or more human papillomavirus (HPV) strains during their lifetimes. For most of these women, the HPV will be cleared from the body, but 5% of them will develop precancerous lesions in the cervix. The role of vaginal flora in persistent HPV has been brought into focus by research studies carried out over the past few years.

At a press conference ahead of the 46th meeting of the French Colposcopy and Cervical and Vaginal Diseases Society, Julia Maruani, MD, a medical gynecologist in Marseille, France, took the opportunity to discuss the importance of vaginal flora and the need to treat cases of bacterial vaginosis.
 

Striking a balance

Essential for reducing the risk of sexually transmitted infections, a healthy vaginal flora is made up of millions of microorganisms, mainly lactobacilli, as well as other bacteria (Gardnerella vaginalis, Atopobium vaginae, Prevotella, streptococcus, gonococcus), HPV, and fungi.

Lactobacilli produce lactic acid, which reduces the vagina’s pH, as well as hydrogen peroxide, which is toxic to the other bacteria.

Different factors, such as alcohol, a diet rich in polyunsaturated fatty acids and sugar, and especially smoking, can lead to an imbalance of the bacteria in the vaginal flora and thus result in vaginosis. What occurs is an abnormal multiplication of different types of anaerobic bacteria that are normally present in much lower numbers. There is a relative reduction in lactobacilli, which results in an increased vaginal pH, a greater risk of contracting an STI, and reduced clearance of the HPV infection. “Women who smoke probably experience persistent HPV infections due to an imbalance in vaginal flora,” said Dr. Maruani.
 

Vaginosis and HPV

When there are fewer lactobacilli than there should be, these bacteria can no longer protect the vaginal mucosa, which is disrupted by other bacteria. “HPV then has access to the basal cells,” said Dr. Maruani, acknowledging that the relationship between bacterial vaginosis and persistent HPV infections has been the subject of numerous research studies over the past decade or so. “For years, I would see this same link in my patients. Those with persistent vaginosis were also the ones with persistent HPV. And I’m not the only one to notice this. Studies have also been carried out investigating this exact correlation,” she added.

These studies have shown that HPV infections persist in cases of vaginosis, resulting in the appearance of epithelial lesions. Additionally, the lesions are more severe when dysbiosis is more severe.

What about probiotics? Can they treat dysbiosis and an HPV infection at the same time? “Probiotics work very well for vaginosis, provided they are used for a long time. We know that they lessen HPV infections and low-grade lesions,” said Dr. Maruani, although no randomized studies support this conclusion. “It’s not a one size fits all. We aren’t about to treat patients with precancerous lesions with probiotics.” There are currently no data concerning the efficacy of probiotics on high-grade lesions. These days, Dr. Maruani has been thinking about a new issue: the benefit of diagnosing cases of asymptomatic vaginosis – because treating them would reduce the risk of persistent HPV infection.

This article was translated from the Medscape French edition. A version of this article appeared on Medscape.com.

Pregnancy-associated deaths, including drug-related deaths and homicide, were up 35% in 2020, compared with prepandemic 2019, new research indicates.

The data also show a 7.1% decrease in pregnancy-related suicides in 2020 from 2019.

The study, led by Claire E. Margerison, PhD, with the department of epidemiology and biostatistics at Michigan State University, East Lansing, included 4,528 pregnancy-associated deaths. The rate of deaths per 100,000 live births from April to December 2020 was 66.9 (95% confidence interval, 63.9-70.1). The comparative rate from April to December 2019 was 49.6. Researchers looked at that time period because the pandemic started in March 2020.

The findings were published online in JAMA Open Network.
 

Drug-related deaths up 55.3%

During the study period, drug deaths increased 55.3% and deaths from homicide increased 41.2%. Deaths from obstetric and other causes (mainly vehicle crashes) increased 28.4% and 56.7%, respectively, according to Dr. Margerison's group.

“Although pregnancy-associated deaths increased over time, increases from 2019 to 2020 were substantially larger than increases from 2018 to 2019,” the authors wrote.

The findings align with deaths in the general population in that time frame, they added.

Another study – this one looking at all-cause and cause-specific mortality from 2019 to 2020 in recently pregnant women, also published in JAMA Network Open, found significant racial and ethnic disparities in rates and cause of death.

According to the study, “Compared with non-Hispanic White women, mortality rates were three- to fivefold higher among American Indian or Alaska Native women for every cause, including suicide. Likewise, these findings suggest that non-Hispanic Black women experienced significantly higher mortality rates across causes, with the highest rates for homicide.”

Dr. Margerison and colleagues did not try to answer what caused the increases but pointed to the fentanyl epidemic, the murder of George Floyd, and COVID-19–related economic strain as potential stressors. They also suggest fewer screenings during the pandemic may have played a role.
 

Prevention opportunities missed

“Although pregnancy is considered an opportunity for screening and prevention related to physical, mental, and behavioral health, our data suggest that such opportunities were missed for hundreds of pregnant people during the pandemic,” the authors wrote.

Researchers analyzed cross-sectional U.S. death certificates from Jan. 1, 2018, to Dec. 31, 2020, for female U.S. residents ages 15-44 years. They then obtained the count for live births for the same population and time frame from the Centers for Disease Control and Prevention WONDER database.

They were able to identify pregnancy-associated deaths as the 2003 Revised Death Certificate contains a standardized pregnancy checkbox that asks whether the person was pregnant at the time of death, within 42 days of death, or within 43 days to 1 year of death.

Researchers also included deaths with ICD-10 codes linked with death from obstetric causes.

Deaths from overdose, suicide, and homicide are making up large and growing proportions of all deaths during pregnancy and in the first year postpartum, the authors report.

Dr. Margerison and coauthors, in research published in 2022, reported that these causes account for more than one-fifth of all pregnancy-related deaths. They also reported that drug-related deaths and homicides in this population have increased over the past 10 years.

“Substantial racial and ethnic inequities in these deaths exist,” they wrote in that paper.

The authors concluded in the current research: “Our study findings suggest that there is a need for prevention and intervention efforts, including harm-reduction strategies, tailored to pregnant and postpartum women, particularly during times of population stress and decreased utilization of preventive care, such as a pandemic.”

Dr. Margerison and coauthors reported receiving grant support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development during the study. One coauthor received personal fees from the World Health Organization and Population Reference Bureau outside the submitted work. One coauthor reported receiving grant support from the National Institutes of Mental Health during the study.

*This story was updated on 2/1.

Pregnancy-associated deaths, including drug-related deaths and homicide, were up 35% in 2020, compared with prepandemic 2019, new research indicates.

The data also show a 7.1% decrease in pregnancy-related suicides in 2020 from 2019.

The study, led by Claire E. Margerison, PhD, with the department of epidemiology and biostatistics at Michigan State University, East Lansing, included 4,528 pregnancy-associated deaths. The rate of deaths per 100,000 live births from April to December 2020 was 66.9 (95% confidence interval, 63.9-70.1). The comparative rate from April to December 2019 was 49.6. Researchers looked at that time period because the pandemic started in March 2020.

The findings were published online in JAMA Open Network.
 

Drug-related deaths up 55.3%

During the study period, drug deaths increased 55.3% and deaths from homicide increased 41.2%. Deaths from obstetric and other causes (mainly vehicle crashes) increased 28.4% and 56.7%, respectively, according to Dr. Margerison's group.

“Although pregnancy-associated deaths increased over time, increases from 2019 to 2020 were substantially larger than increases from 2018 to 2019,” the authors wrote.

The findings align with deaths in the general population in that time frame, they added.

Another study – this one looking at all-cause and cause-specific mortality from 2019 to 2020 in recently pregnant women, also published in JAMA Network Open, found significant racial and ethnic disparities in rates and cause of death.

According to the study, “Compared with non-Hispanic White women, mortality rates were three- to fivefold higher among American Indian or Alaska Native women for every cause, including suicide. Likewise, these findings suggest that non-Hispanic Black women experienced significantly higher mortality rates across causes, with the highest rates for homicide.”

Dr. Margerison and colleagues did not try to answer what caused the increases but pointed to the fentanyl epidemic, the murder of George Floyd, and COVID-19–related economic strain as potential stressors. They also suggest fewer screenings during the pandemic may have played a role.
 

Prevention opportunities missed

“Although pregnancy is considered an opportunity for screening and prevention related to physical, mental, and behavioral health, our data suggest that such opportunities were missed for hundreds of pregnant people during the pandemic,” the authors wrote.

Researchers analyzed cross-sectional U.S. death certificates from Jan. 1, 2018, to Dec. 31, 2020, for female U.S. residents ages 15-44 years. They then obtained the count for live births for the same population and time frame from the Centers for Disease Control and Prevention WONDER database.

They were able to identify pregnancy-associated deaths as the 2003 Revised Death Certificate contains a standardized pregnancy checkbox that asks whether the person was pregnant at the time of death, within 42 days of death, or within 43 days to 1 year of death.

Researchers also included deaths with ICD-10 codes linked with death from obstetric causes.

Deaths from overdose, suicide, and homicide are making up large and growing proportions of all deaths during pregnancy and in the first year postpartum, the authors report.

Dr. Margerison and coauthors, in research published in 2022, reported that these causes account for more than one-fifth of all pregnancy-related deaths. They also reported that drug-related deaths and homicides in this population have increased over the past 10 years.

“Substantial racial and ethnic inequities in these deaths exist,” they wrote in that paper.

The authors concluded in the current research: “Our study findings suggest that there is a need for prevention and intervention efforts, including harm-reduction strategies, tailored to pregnant and postpartum women, particularly during times of population stress and decreased utilization of preventive care, such as a pandemic.”

Dr. Margerison and coauthors reported receiving grant support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development during the study. One coauthor received personal fees from the World Health Organization and Population Reference Bureau outside the submitted work. One coauthor reported receiving grant support from the National Institutes of Mental Health during the study.

*This story was updated on 2/1.

Pregnancy-associated deaths, including drug-related deaths and homicide, were up 35% in 2020, compared with prepandemic 2019, new research indicates.

The data also show a 7.1% decrease in pregnancy-related suicides in 2020 from 2019.

The study, led by Claire E. Margerison, PhD, with the department of epidemiology and biostatistics at Michigan State University, East Lansing, included 4,528 pregnancy-associated deaths. The rate of deaths per 100,000 live births from April to December 2020 was 66.9 (95% confidence interval, 63.9-70.1). The comparative rate from April to December 2019 was 49.6. Researchers looked at that time period because the pandemic started in March 2020.

The findings were published online in JAMA Open Network.
 

Drug-related deaths up 55.3%

During the study period, drug deaths increased 55.3% and deaths from homicide increased 41.2%. Deaths from obstetric and other causes (mainly vehicle crashes) increased 28.4% and 56.7%, respectively, according to Dr. Margerison's group.

“Although pregnancy-associated deaths increased over time, increases from 2019 to 2020 were substantially larger than increases from 2018 to 2019,” the authors wrote.

The findings align with deaths in the general population in that time frame, they added.

Another study – this one looking at all-cause and cause-specific mortality from 2019 to 2020 in recently pregnant women, also published in JAMA Network Open, found significant racial and ethnic disparities in rates and cause of death.

According to the study, “Compared with non-Hispanic White women, mortality rates were three- to fivefold higher among American Indian or Alaska Native women for every cause, including suicide. Likewise, these findings suggest that non-Hispanic Black women experienced significantly higher mortality rates across causes, with the highest rates for homicide.”

Dr. Margerison and colleagues did not try to answer what caused the increases but pointed to the fentanyl epidemic, the murder of George Floyd, and COVID-19–related economic strain as potential stressors. They also suggest fewer screenings during the pandemic may have played a role.
 

Prevention opportunities missed

“Although pregnancy is considered an opportunity for screening and prevention related to physical, mental, and behavioral health, our data suggest that such opportunities were missed for hundreds of pregnant people during the pandemic,” the authors wrote.

Researchers analyzed cross-sectional U.S. death certificates from Jan. 1, 2018, to Dec. 31, 2020, for female U.S. residents ages 15-44 years. They then obtained the count for live births for the same population and time frame from the Centers for Disease Control and Prevention WONDER database.

They were able to identify pregnancy-associated deaths as the 2003 Revised Death Certificate contains a standardized pregnancy checkbox that asks whether the person was pregnant at the time of death, within 42 days of death, or within 43 days to 1 year of death.

Researchers also included deaths with ICD-10 codes linked with death from obstetric causes.

Deaths from overdose, suicide, and homicide are making up large and growing proportions of all deaths during pregnancy and in the first year postpartum, the authors report.

Dr. Margerison and coauthors, in research published in 2022, reported that these causes account for more than one-fifth of all pregnancy-related deaths. They also reported that drug-related deaths and homicides in this population have increased over the past 10 years.

“Substantial racial and ethnic inequities in these deaths exist,” they wrote in that paper.

The authors concluded in the current research: “Our study findings suggest that there is a need for prevention and intervention efforts, including harm-reduction strategies, tailored to pregnant and postpartum women, particularly during times of population stress and decreased utilization of preventive care, such as a pandemic.”

Dr. Margerison and coauthors reported receiving grant support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development during the study. One coauthor received personal fees from the World Health Organization and Population Reference Bureau outside the submitted work. One coauthor reported receiving grant support from the National Institutes of Mental Health during the study.

*This story was updated on 2/1.

Female physicians often spend their child-bearing years in medical training and developing their careers, and this can create problems.  

In a survey of just over 1,000 female oncologists, 95% said their career plans were at least somewhat associated with the timing of when to start a family.

The most striking finding was that one third of respondents had miscarried and another one third reported difficulty with infertility that required fertility counseling and/or treatment.

One third reported experiencing discrimination during pregnancy, and another third said they experienced discrimination for taking maternity leave, and having more than one child increased the likelihood of this.

The most common negative factor associated with family planning was long work hours and heavy workload (66.6%),

These findings suggest there are systemic changes needed not only in the healthcare setting but in society as a whole around women in the workplace and their choices of childbearing, say the authors.

The study was published online in JAMA Network Open and led by Anna Lee MD, MPH, from the department of radiation oncology, University of Texas MD Anderson Cancer Center, Houston. 

In an invited commentary, Mona Saleh, MD, and Stephanie Blank, MD, from the department of obstetrics, gynecology, and reproductive science at the Icahn School of Medicine at Mount Sinai in New York, suggest that cultural changes are needed that go beyond women in medicine.

“These cultural values are so deeply pervasive (one could also say invasive) that they affect even these most educated and wealthy professional women, such as those who participated in this survey,” the editorialists write.

“[The researchers] advocate for early education on assisted reproductive technology (ART) risks, benefits, and success rates, but this is not getting at the underlying issue: Pregnancy discrimination and unfair distribution of childbearing responsibilities are a reflection of a larger problematic culture rather than an issue specific to women in medicine,” they add.
 

Survey details

The survey comprised a novel 39-item questionnaire distributed to 1,004 U.S. female oncologists from May 7 to June 30, 2020, via email and social media channels.

Most respondents (84.4%) were married, and 71% were currently working full-time.

About one-third (35%) worked in radiation oncology, another third (34.3%) in medical oncology, 18.4% in surgical oncology, and 9.1% in pediatric oncology.

A total of 768 respondents (76.5%) had children, and of these, 415 (41.3%) first gave birth during postgraduate training and 275 (27.4%) gave birth in years 1-5 as an attending physician.

Of all respondents who had been pregnant, approximately two-thirds (65.7%) had some type of pregnancy complication. About one-third of respondents (31.7%) reported having experienced a miscarriage after a confirmed pregnancy; of those, 61.6% reported one miscarriage, while the remainder had two or more miscarriages (38.4%).

Approximately one-third (31.4%) of respondents reported difficulty with infertility that required fertility counseling and/or treatment.

The questionnaire also asked about assisted reproductive technology, and 164 participants (16.3%) reported the use of fertility medications, and 53 (5.3%) reported cryopreservation of eggs. Nearly 13% reported the use of intrauterine insemination and 13.2% reported the use of in vivo fertilization. Among those who experienced fertility concerns, 36.6% (232 of 634) reported facing financial burdens because of fertility or pregnancy that was in some way associated with their career choice.

When asked on the survey if fertility preservation should be discussed with women during medical school and/or residency, 65.7% of respondents stated that it should.

However, the editorialists suggest that “encouraging formal and directed education regarding the infertility risks specifically toward female physicians (which Lee et al. recommend) could be perceived as a blanket recommendation that it is best for women in medicine to delay childbearing and pursue ART.”

“Medical schools and residency and fellowship training programs should instead focus their energy on creating a framework and culture that normalizes conception during these points in training while also subsidizing and supporting trainees and physicians who prefer to use ART and delay fertility until after training,” they suggest.

The editorialists also emphasized that women may choose to become pregnant at any point during the years that it takes to go from being a medical student to resident/fellow to attending physician, and they should be supported by their workplace on their decisions.

The study was funded by grants from National Institutes of Health/National Cancer Institute Cancer Center.

Dr. Lee and coauthors reported no relevant financial relationships. Dr. Blank reported receiving grants from AstraZeneca, Aravive, Akesobio, GlaxoSmithKline, Merck, and Seattle Genetics outside the submitted work. Dr. Saleh reports no relevant financial relationships.

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

Female physicians often spend their child-bearing years in medical training and developing their careers, and this can create problems.  

In a survey of just over 1,000 female oncologists, 95% said their career plans were at least somewhat associated with the timing of when to start a family.

The most striking finding was that one third of respondents had miscarried and another one third reported difficulty with infertility that required fertility counseling and/or treatment.

One third reported experiencing discrimination during pregnancy, and another third said they experienced discrimination for taking maternity leave, and having more than one child increased the likelihood of this.

The most common negative factor associated with family planning was long work hours and heavy workload (66.6%),

These findings suggest there are systemic changes needed not only in the healthcare setting but in society as a whole around women in the workplace and their choices of childbearing, say the authors.

The study was published online in JAMA Network Open and led by Anna Lee MD, MPH, from the department of radiation oncology, University of Texas MD Anderson Cancer Center, Houston. 

In an invited commentary, Mona Saleh, MD, and Stephanie Blank, MD, from the department of obstetrics, gynecology, and reproductive science at the Icahn School of Medicine at Mount Sinai in New York, suggest that cultural changes are needed that go beyond women in medicine.

“These cultural values are so deeply pervasive (one could also say invasive) that they affect even these most educated and wealthy professional women, such as those who participated in this survey,” the editorialists write.

“[The researchers] advocate for early education on assisted reproductive technology (ART) risks, benefits, and success rates, but this is not getting at the underlying issue: Pregnancy discrimination and unfair distribution of childbearing responsibilities are a reflection of a larger problematic culture rather than an issue specific to women in medicine,” they add.
 

Survey details

The survey comprised a novel 39-item questionnaire distributed to 1,004 U.S. female oncologists from May 7 to June 30, 2020, via email and social media channels.

Most respondents (84.4%) were married, and 71% were currently working full-time.

About one-third (35%) worked in radiation oncology, another third (34.3%) in medical oncology, 18.4% in surgical oncology, and 9.1% in pediatric oncology.

A total of 768 respondents (76.5%) had children, and of these, 415 (41.3%) first gave birth during postgraduate training and 275 (27.4%) gave birth in years 1-5 as an attending physician.

Of all respondents who had been pregnant, approximately two-thirds (65.7%) had some type of pregnancy complication. About one-third of respondents (31.7%) reported having experienced a miscarriage after a confirmed pregnancy; of those, 61.6% reported one miscarriage, while the remainder had two or more miscarriages (38.4%).

Approximately one-third (31.4%) of respondents reported difficulty with infertility that required fertility counseling and/or treatment.

The questionnaire also asked about assisted reproductive technology, and 164 participants (16.3%) reported the use of fertility medications, and 53 (5.3%) reported cryopreservation of eggs. Nearly 13% reported the use of intrauterine insemination and 13.2% reported the use of in vivo fertilization. Among those who experienced fertility concerns, 36.6% (232 of 634) reported facing financial burdens because of fertility or pregnancy that was in some way associated with their career choice.

When asked on the survey if fertility preservation should be discussed with women during medical school and/or residency, 65.7% of respondents stated that it should.

However, the editorialists suggest that “encouraging formal and directed education regarding the infertility risks specifically toward female physicians (which Lee et al. recommend) could be perceived as a blanket recommendation that it is best for women in medicine to delay childbearing and pursue ART.”

“Medical schools and residency and fellowship training programs should instead focus their energy on creating a framework and culture that normalizes conception during these points in training while also subsidizing and supporting trainees and physicians who prefer to use ART and delay fertility until after training,” they suggest.

The editorialists also emphasized that women may choose to become pregnant at any point during the years that it takes to go from being a medical student to resident/fellow to attending physician, and they should be supported by their workplace on their decisions.

The study was funded by grants from National Institutes of Health/National Cancer Institute Cancer Center.

Dr. Lee and coauthors reported no relevant financial relationships. Dr. Blank reported receiving grants from AstraZeneca, Aravive, Akesobio, GlaxoSmithKline, Merck, and Seattle Genetics outside the submitted work. Dr. Saleh reports no relevant financial relationships.

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

Female physicians often spend their child-bearing years in medical training and developing their careers, and this can create problems.  

In a survey of just over 1,000 female oncologists, 95% said their career plans were at least somewhat associated with the timing of when to start a family.

The most striking finding was that one third of respondents had miscarried and another one third reported difficulty with infertility that required fertility counseling and/or treatment.

One third reported experiencing discrimination during pregnancy, and another third said they experienced discrimination for taking maternity leave, and having more than one child increased the likelihood of this.

The most common negative factor associated with family planning was long work hours and heavy workload (66.6%),

These findings suggest there are systemic changes needed not only in the healthcare setting but in society as a whole around women in the workplace and their choices of childbearing, say the authors.

The study was published online in JAMA Network Open and led by Anna Lee MD, MPH, from the department of radiation oncology, University of Texas MD Anderson Cancer Center, Houston. 

In an invited commentary, Mona Saleh, MD, and Stephanie Blank, MD, from the department of obstetrics, gynecology, and reproductive science at the Icahn School of Medicine at Mount Sinai in New York, suggest that cultural changes are needed that go beyond women in medicine.

“These cultural values are so deeply pervasive (one could also say invasive) that they affect even these most educated and wealthy professional women, such as those who participated in this survey,” the editorialists write.

“[The researchers] advocate for early education on assisted reproductive technology (ART) risks, benefits, and success rates, but this is not getting at the underlying issue: Pregnancy discrimination and unfair distribution of childbearing responsibilities are a reflection of a larger problematic culture rather than an issue specific to women in medicine,” they add.
 

Survey details

The survey comprised a novel 39-item questionnaire distributed to 1,004 U.S. female oncologists from May 7 to June 30, 2020, via email and social media channels.

Most respondents (84.4%) were married, and 71% were currently working full-time.

About one-third (35%) worked in radiation oncology, another third (34.3%) in medical oncology, 18.4% in surgical oncology, and 9.1% in pediatric oncology.

A total of 768 respondents (76.5%) had children, and of these, 415 (41.3%) first gave birth during postgraduate training and 275 (27.4%) gave birth in years 1-5 as an attending physician.

Of all respondents who had been pregnant, approximately two-thirds (65.7%) had some type of pregnancy complication. About one-third of respondents (31.7%) reported having experienced a miscarriage after a confirmed pregnancy; of those, 61.6% reported one miscarriage, while the remainder had two or more miscarriages (38.4%).

Approximately one-third (31.4%) of respondents reported difficulty with infertility that required fertility counseling and/or treatment.

The questionnaire also asked about assisted reproductive technology, and 164 participants (16.3%) reported the use of fertility medications, and 53 (5.3%) reported cryopreservation of eggs. Nearly 13% reported the use of intrauterine insemination and 13.2% reported the use of in vivo fertilization. Among those who experienced fertility concerns, 36.6% (232 of 634) reported facing financial burdens because of fertility or pregnancy that was in some way associated with their career choice.

When asked on the survey if fertility preservation should be discussed with women during medical school and/or residency, 65.7% of respondents stated that it should.

However, the editorialists suggest that “encouraging formal and directed education regarding the infertility risks specifically toward female physicians (which Lee et al. recommend) could be perceived as a blanket recommendation that it is best for women in medicine to delay childbearing and pursue ART.”

“Medical schools and residency and fellowship training programs should instead focus their energy on creating a framework and culture that normalizes conception during these points in training while also subsidizing and supporting trainees and physicians who prefer to use ART and delay fertility until after training,” they suggest.

The editorialists also emphasized that women may choose to become pregnant at any point during the years that it takes to go from being a medical student to resident/fellow to attending physician, and they should be supported by their workplace on their decisions.

The study was funded by grants from National Institutes of Health/National Cancer Institute Cancer Center.

Dr. Lee and coauthors reported no relevant financial relationships. Dr. Blank reported receiving grants from AstraZeneca, Aravive, Akesobio, GlaxoSmithKline, Merck, and Seattle Genetics outside the submitted work. Dr. Saleh reports no relevant financial relationships.

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

In 2021, Eugene Kim, MD, division director of pediatric surgery and vice chair in the department of surgery at Cedars-Sinai Medical Center, Los Angeles, gave his presidential address to the Association for Academic Surgery.

“Presidents tend to give a message of hope or inspiration; I probably took it in a different way,” he said.

Dr. Kim told the story of one of his clinical partners, Eveline Shue, who, after five rounds of in vitro fertilization (IVF), became pregnant with twins. A high-achiever in her field, Ms. Shue continued working the grueling hours required by her job throughout pregnancy until she noticed concerning symptoms – musculoskeletal issues, extreme swelling, and more. She and her group decided that she should step back from work in her third trimester. A few days later, Ms. Shue suffered a stroke. She was rushed to the hospital where her babies were delivered by emergency C-section. Ms. Shue underwent brain surgery but later recovered and is still practicing in Southern California.

“I remember being at her bedside thinking, ‘How could we have let this happen? How could we have prevented this?’ ”

Dr. Kim’s speech kicked off a firestorm of awareness about pregnancy complications among physicians. “I got scores of emails from women around the country, surgeons in particular, who felt like their issues had been seen. The conversation was long overdue,” he said.

Family planning issues, pregnancy complications, infertility, and pregnancy loss are common, pervasive, and often silent issues in medicine. In July 2021, Dr. Kim and a group of other researchers published a study in JAMA Surgery. It revealed staggering truths: When compared to non-surgeons, female surgeons were more likely to delay pregnancy, use assisted reproductive technology such as IVF, have non-elective C-sections, and suffer pregnancy loss. In the study, 42% of surgeons had experienced pregnancy loss – more than double the rate of the general population. Almost half had serious pregnancy complications.

Research has found that female physicians in general have a significantly greater incidence of miscarriage, infertility, and pregnancy complications than the general population. According to a 2016 survey in the Journal of Women’s Health, the infertility rate for physicians is nearly 1 in 4, about double the rate of the general public.
 

The barriers to starting a family

Physicians face significant professional barriers that impact family planning. Demanding jobs with exhausting and often unpredictable hours contribute to a culture that, traditionally, has been far from family friendly. As a result, many physicians start families later. “For a pediatric surgeon, you finish training at age 35 – minimum,” says Dr. Kim. “Simply being a surgeon makes you a high-risk pregnancy candidate just because of the career.”

In 2020, Ariela L. Marshall, MD, an associate professor of clinical medicine at the University of Pennsylvania’s Perelman school of medicine, co-authored a commentary article in Academic Medicine titled “Physician Fertility: A Call to Action” which was based on her own experiences with infertility. Dr. Marshall was 34 when she and her husband decided to start a family, and she says her infertility diagnosis “came as a shock.”

“I never stopped to think about the consequences of a career path where I’m not going to be established until my 30s,” Dr. Marshall says. “I never thought about how long hours, overnight shifts, or working all the time could impact my fertility.”

It would take four cycles of IVF egg retrieval to create embryos and one failed implantation before Dr. Marshall became pregnant with her son.

When it comes to the timing of pregnancy, medical culture also plays a role. “There’s a lot of messaging around when it’s appropriate to carry a baby – and it’s not until after training is done,” says Arghavan Salles, MD, PhD, a clinical associate professor and special advisor for DEI programs at Stanford (Calif.) University’s department of medicine.

There are always exceptions. Some institutions are more flexible than others about pregnancy during residency. But Dr. Salles notes that this attitude is “not universal,” partly because of the lack of a comprehensive approach to pregnancy or parenthood in the United States. “There’s no federal paid parental leave in this country,” reminds Dr. Salles. “That signals that we don’t value parenting.”

The trickle-down effect of this in medicine is more like a waterfall. Some physicians complain when other physicians are out on leave. There’s an additional burden of work when people take time away, and there are often no support structures in place for backup or fill-in care. Dr. Salles said doctors often tell her that they were responsible for finding coverage for any time off during pregnancy or after becoming a parent. A paper of hers published in JAMA Surgery found that, for physicians, a fear of burdening others was a major barrier to getting pregnant during residency in the first place.
 

The physical consequences

Although research supports the benefits of physical activity throughout pregnancy, a job such as surgery that requires being on your feet for long periods of time “is not the same as exercise,” explains Erika Lu Rangel, MD, a gastrointestinal surgeon at Brigham and Women’s Hospital, Boston, and Dr. Kim’s lead author on the JAMA Surgery article.

Surgeons operating for more than 12 hours a week are at higher risk for pregnancy complications, the study found. Dr. Rangel also cites data suggesting that night shifts or swing shifts (the hours between day and night) put women at higher risk for pregnancy complications.

Equally alarming: Medical trainees appear to have “almost as high a rate of pregnancy complications as surgeons who have already completed their training,” said Dr. Rangel. It is a concerning finding since, as a younger cohort, they should have lower complication rates based on their age. But doctors in training may be on their feet even more than surgeons during long shifts.

Like Dr. Salles, Dr. Rangel sees these issues as part of a pervasive culture of “presenteeism” in medicine, and she points out that many surgeons don’t even take time off to grieve pregnancy loss or physically recover from it. “We work even when we’re sick and even when it’s not good for our health,” she said. “I think that’s an unhealthy behavior that we cultivate from the time that we’re trainees, and we carry it on through when we’re in practice.”

Penn Medicine’s Dr. Marshall remembers that her own maternity leave was “not an easy process to navigate.” From her hospital room on a magnesium drip for preeclampsia, she still attended Zoom meetings with her colleagues. “Nobody says, ‘Oh, you have to do this,’ ” Dr. Marshall explains, “but you wind up feeling guilty if you’re not there at all moments for everyone. That’s also something that needs to change.” 

Dr. Rangel was pregnant with her oldest son as a fourth-year surgery resident. The day she gave birth to him she remembers waking up with a flu-like illness and a fever. She went to work anyway, because “you don’t call in sick as a resident.” She was barely able to complete her rounds and then had to lie down between cases. A co-resident found her and took her to labor and delivery. She had gone into premature labor at 37 weeks, and her son went into the NICU with complications.

“I remember feeling this enormous guilt,” says Dr. Rangel. “I’d been a mom for just a few minutes, and I felt like I had already failed him because I had prioritized what the residency thought of me above what I knew was necessary for his health.”
 

Hope for the future

Disturbed by the status quo, many physicians are pushing for change. “I think there’s a really important and positive conversation going on in the medical community right now about ways that we need to support new parent physicians,” said Dr. Rangel.

Parental leave is a key part of that support. Last year, The American Board of Medical Specialties enacted a mandate that all specialty boards 2 years or more in duration must provide at least 6 weeks of parental and caregiver leave. In 2023, the Accreditation Council for Graduate Medical Education (ACGME) required that all training programs match that policy. “This sends a message to policymakers and leaders in American medicine that this is a priority,” said Dr. Rangel.

In January 2022, a group from the University of Michigan also published an article in the Annals of Surgery called “Safe and Supported Pregnancy: A Call to Action for Surgery Chairs and Program Directors”. The essay urged leading groups such as the ACGME and the American Board of Surgery to “directly address the health and safety of pregnant trainees” and specifically, to “allow for further flexibility during training for pregnancy and peripartum periods,” calling these “fundamental necessities for cultural progress.”

Others have recommended allowing pregnant trainees more flexibility in their schedules or front-loading certain parts of the training that may be more difficult as a pregnancy progresses. Insurance coverage for fertility preservation and reproductive endocrinology services, and support for reentry (including lactation and childcare) are also issues that must be addressed, says Dr. Salles.

A new paper of Dr. Rangel’s, published in JAMA Surgery, suggests that things like mentorship for residents from faculty can also be important pieces of the puzzle.

Education about reproductive health must start earlier, too – as early as medical school. Research suggests only 8% of physicians receive education on the risks of delaying pregnancy. Those who do are significantly less likely to experience pregnancy loss or seek infertility treatment.

Dr. Salles recalls sitting in a classroom learning about advanced maternal age at a time when age 35 seemed unimaginably distant. “It was never taught – at least to my recollection – in a way that was like, ‘this could be your future,’ ” Dr. Salles says.” It was more like this abstract patient who might have advanced maternal age and what the consequences would be. Maybe some of my colleagues put two and two together, but I definitely didn’t.”

Dr. Marshall is the curriculum chair for the IGNITEMed Initiative, which aims to educate medical students about issues not discussed in traditional medical school curricula. Dr. Marshall and her colleague Julia Files, MD, talk with IGNITEMed students about reproductive life planning.

“Raising awareness is a very big thing. That’s not just true for medical students but for professionals at every level of medicine,” Dr. Marshall said. “Residency and fellowship training program directors, department chairs, and hospital CEOs all need to understand that these issues are very common in the people they oversee – and that they are medical issues, like any other medical issue, where people need time off and support.”

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

In 2021, Eugene Kim, MD, division director of pediatric surgery and vice chair in the department of surgery at Cedars-Sinai Medical Center, Los Angeles, gave his presidential address to the Association for Academic Surgery.

“Presidents tend to give a message of hope or inspiration; I probably took it in a different way,” he said.

Dr. Kim told the story of one of his clinical partners, Eveline Shue, who, after five rounds of in vitro fertilization (IVF), became pregnant with twins. A high-achiever in her field, Ms. Shue continued working the grueling hours required by her job throughout pregnancy until she noticed concerning symptoms – musculoskeletal issues, extreme swelling, and more. She and her group decided that she should step back from work in her third trimester. A few days later, Ms. Shue suffered a stroke. She was rushed to the hospital where her babies were delivered by emergency C-section. Ms. Shue underwent brain surgery but later recovered and is still practicing in Southern California.

“I remember being at her bedside thinking, ‘How could we have let this happen? How could we have prevented this?’ ”

Dr. Kim’s speech kicked off a firestorm of awareness about pregnancy complications among physicians. “I got scores of emails from women around the country, surgeons in particular, who felt like their issues had been seen. The conversation was long overdue,” he said.

Family planning issues, pregnancy complications, infertility, and pregnancy loss are common, pervasive, and often silent issues in medicine. In July 2021, Dr. Kim and a group of other researchers published a study in JAMA Surgery. It revealed staggering truths: When compared to non-surgeons, female surgeons were more likely to delay pregnancy, use assisted reproductive technology such as IVF, have non-elective C-sections, and suffer pregnancy loss. In the study, 42% of surgeons had experienced pregnancy loss – more than double the rate of the general population. Almost half had serious pregnancy complications.

Research has found that female physicians in general have a significantly greater incidence of miscarriage, infertility, and pregnancy complications than the general population. According to a 2016 survey in the Journal of Women’s Health, the infertility rate for physicians is nearly 1 in 4, about double the rate of the general public.
 

The barriers to starting a family

Physicians face significant professional barriers that impact family planning. Demanding jobs with exhausting and often unpredictable hours contribute to a culture that, traditionally, has been far from family friendly. As a result, many physicians start families later. “For a pediatric surgeon, you finish training at age 35 – minimum,” says Dr. Kim. “Simply being a surgeon makes you a high-risk pregnancy candidate just because of the career.”

In 2020, Ariela L. Marshall, MD, an associate professor of clinical medicine at the University of Pennsylvania’s Perelman school of medicine, co-authored a commentary article in Academic Medicine titled “Physician Fertility: A Call to Action” which was based on her own experiences with infertility. Dr. Marshall was 34 when she and her husband decided to start a family, and she says her infertility diagnosis “came as a shock.”

“I never stopped to think about the consequences of a career path where I’m not going to be established until my 30s,” Dr. Marshall says. “I never thought about how long hours, overnight shifts, or working all the time could impact my fertility.”

It would take four cycles of IVF egg retrieval to create embryos and one failed implantation before Dr. Marshall became pregnant with her son.

When it comes to the timing of pregnancy, medical culture also plays a role. “There’s a lot of messaging around when it’s appropriate to carry a baby – and it’s not until after training is done,” says Arghavan Salles, MD, PhD, a clinical associate professor and special advisor for DEI programs at Stanford (Calif.) University’s department of medicine.

There are always exceptions. Some institutions are more flexible than others about pregnancy during residency. But Dr. Salles notes that this attitude is “not universal,” partly because of the lack of a comprehensive approach to pregnancy or parenthood in the United States. “There’s no federal paid parental leave in this country,” reminds Dr. Salles. “That signals that we don’t value parenting.”

The trickle-down effect of this in medicine is more like a waterfall. Some physicians complain when other physicians are out on leave. There’s an additional burden of work when people take time away, and there are often no support structures in place for backup or fill-in care. Dr. Salles said doctors often tell her that they were responsible for finding coverage for any time off during pregnancy or after becoming a parent. A paper of hers published in JAMA Surgery found that, for physicians, a fear of burdening others was a major barrier to getting pregnant during residency in the first place.
 

The physical consequences

Although research supports the benefits of physical activity throughout pregnancy, a job such as surgery that requires being on your feet for long periods of time “is not the same as exercise,” explains Erika Lu Rangel, MD, a gastrointestinal surgeon at Brigham and Women’s Hospital, Boston, and Dr. Kim’s lead author on the JAMA Surgery article.

Surgeons operating for more than 12 hours a week are at higher risk for pregnancy complications, the study found. Dr. Rangel also cites data suggesting that night shifts or swing shifts (the hours between day and night) put women at higher risk for pregnancy complications.

Equally alarming: Medical trainees appear to have “almost as high a rate of pregnancy complications as surgeons who have already completed their training,” said Dr. Rangel. It is a concerning finding since, as a younger cohort, they should have lower complication rates based on their age. But doctors in training may be on their feet even more than surgeons during long shifts.

Like Dr. Salles, Dr. Rangel sees these issues as part of a pervasive culture of “presenteeism” in medicine, and she points out that many surgeons don’t even take time off to grieve pregnancy loss or physically recover from it. “We work even when we’re sick and even when it’s not good for our health,” she said. “I think that’s an unhealthy behavior that we cultivate from the time that we’re trainees, and we carry it on through when we’re in practice.”

Penn Medicine’s Dr. Marshall remembers that her own maternity leave was “not an easy process to navigate.” From her hospital room on a magnesium drip for preeclampsia, she still attended Zoom meetings with her colleagues. “Nobody says, ‘Oh, you have to do this,’ ” Dr. Marshall explains, “but you wind up feeling guilty if you’re not there at all moments for everyone. That’s also something that needs to change.” 

Dr. Rangel was pregnant with her oldest son as a fourth-year surgery resident. The day she gave birth to him she remembers waking up with a flu-like illness and a fever. She went to work anyway, because “you don’t call in sick as a resident.” She was barely able to complete her rounds and then had to lie down between cases. A co-resident found her and took her to labor and delivery. She had gone into premature labor at 37 weeks, and her son went into the NICU with complications.

“I remember feeling this enormous guilt,” says Dr. Rangel. “I’d been a mom for just a few minutes, and I felt like I had already failed him because I had prioritized what the residency thought of me above what I knew was necessary for his health.”
 

Hope for the future

Disturbed by the status quo, many physicians are pushing for change. “I think there’s a really important and positive conversation going on in the medical community right now about ways that we need to support new parent physicians,” said Dr. Rangel.

Parental leave is a key part of that support. Last year, The American Board of Medical Specialties enacted a mandate that all specialty boards 2 years or more in duration must provide at least 6 weeks of parental and caregiver leave. In 2023, the Accreditation Council for Graduate Medical Education (ACGME) required that all training programs match that policy. “This sends a message to policymakers and leaders in American medicine that this is a priority,” said Dr. Rangel.

In January 2022, a group from the University of Michigan also published an article in the Annals of Surgery called “Safe and Supported Pregnancy: A Call to Action for Surgery Chairs and Program Directors”. The essay urged leading groups such as the ACGME and the American Board of Surgery to “directly address the health and safety of pregnant trainees” and specifically, to “allow for further flexibility during training for pregnancy and peripartum periods,” calling these “fundamental necessities for cultural progress.”

Others have recommended allowing pregnant trainees more flexibility in their schedules or front-loading certain parts of the training that may be more difficult as a pregnancy progresses. Insurance coverage for fertility preservation and reproductive endocrinology services, and support for reentry (including lactation and childcare) are also issues that must be addressed, says Dr. Salles.

A new paper of Dr. Rangel’s, published in JAMA Surgery, suggests that things like mentorship for residents from faculty can also be important pieces of the puzzle.

Education about reproductive health must start earlier, too – as early as medical school. Research suggests only 8% of physicians receive education on the risks of delaying pregnancy. Those who do are significantly less likely to experience pregnancy loss or seek infertility treatment.

Dr. Salles recalls sitting in a classroom learning about advanced maternal age at a time when age 35 seemed unimaginably distant. “It was never taught – at least to my recollection – in a way that was like, ‘this could be your future,’ ” Dr. Salles says.” It was more like this abstract patient who might have advanced maternal age and what the consequences would be. Maybe some of my colleagues put two and two together, but I definitely didn’t.”

Dr. Marshall is the curriculum chair for the IGNITEMed Initiative, which aims to educate medical students about issues not discussed in traditional medical school curricula. Dr. Marshall and her colleague Julia Files, MD, talk with IGNITEMed students about reproductive life planning.

“Raising awareness is a very big thing. That’s not just true for medical students but for professionals at every level of medicine,” Dr. Marshall said. “Residency and fellowship training program directors, department chairs, and hospital CEOs all need to understand that these issues are very common in the people they oversee – and that they are medical issues, like any other medical issue, where people need time off and support.”

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

In 2021, Eugene Kim, MD, division director of pediatric surgery and vice chair in the department of surgery at Cedars-Sinai Medical Center, Los Angeles, gave his presidential address to the Association for Academic Surgery.

“Presidents tend to give a message of hope or inspiration; I probably took it in a different way,” he said.

Dr. Kim told the story of one of his clinical partners, Eveline Shue, who, after five rounds of in vitro fertilization (IVF), became pregnant with twins. A high-achiever in her field, Ms. Shue continued working the grueling hours required by her job throughout pregnancy until she noticed concerning symptoms – musculoskeletal issues, extreme swelling, and more. She and her group decided that she should step back from work in her third trimester. A few days later, Ms. Shue suffered a stroke. She was rushed to the hospital where her babies were delivered by emergency C-section. Ms. Shue underwent brain surgery but later recovered and is still practicing in Southern California.

“I remember being at her bedside thinking, ‘How could we have let this happen? How could we have prevented this?’ ”

Dr. Kim’s speech kicked off a firestorm of awareness about pregnancy complications among physicians. “I got scores of emails from women around the country, surgeons in particular, who felt like their issues had been seen. The conversation was long overdue,” he said.

Family planning issues, pregnancy complications, infertility, and pregnancy loss are common, pervasive, and often silent issues in medicine. In July 2021, Dr. Kim and a group of other researchers published a study in JAMA Surgery. It revealed staggering truths: When compared to non-surgeons, female surgeons were more likely to delay pregnancy, use assisted reproductive technology such as IVF, have non-elective C-sections, and suffer pregnancy loss. In the study, 42% of surgeons had experienced pregnancy loss – more than double the rate of the general population. Almost half had serious pregnancy complications.

Research has found that female physicians in general have a significantly greater incidence of miscarriage, infertility, and pregnancy complications than the general population. According to a 2016 survey in the Journal of Women’s Health, the infertility rate for physicians is nearly 1 in 4, about double the rate of the general public.
 

The barriers to starting a family

Physicians face significant professional barriers that impact family planning. Demanding jobs with exhausting and often unpredictable hours contribute to a culture that, traditionally, has been far from family friendly. As a result, many physicians start families later. “For a pediatric surgeon, you finish training at age 35 – minimum,” says Dr. Kim. “Simply being a surgeon makes you a high-risk pregnancy candidate just because of the career.”

In 2020, Ariela L. Marshall, MD, an associate professor of clinical medicine at the University of Pennsylvania’s Perelman school of medicine, co-authored a commentary article in Academic Medicine titled “Physician Fertility: A Call to Action” which was based on her own experiences with infertility. Dr. Marshall was 34 when she and her husband decided to start a family, and she says her infertility diagnosis “came as a shock.”

“I never stopped to think about the consequences of a career path where I’m not going to be established until my 30s,” Dr. Marshall says. “I never thought about how long hours, overnight shifts, or working all the time could impact my fertility.”

It would take four cycles of IVF egg retrieval to create embryos and one failed implantation before Dr. Marshall became pregnant with her son.

When it comes to the timing of pregnancy, medical culture also plays a role. “There’s a lot of messaging around when it’s appropriate to carry a baby – and it’s not until after training is done,” says Arghavan Salles, MD, PhD, a clinical associate professor and special advisor for DEI programs at Stanford (Calif.) University’s department of medicine.

There are always exceptions. Some institutions are more flexible than others about pregnancy during residency. But Dr. Salles notes that this attitude is “not universal,” partly because of the lack of a comprehensive approach to pregnancy or parenthood in the United States. “There’s no federal paid parental leave in this country,” reminds Dr. Salles. “That signals that we don’t value parenting.”

The trickle-down effect of this in medicine is more like a waterfall. Some physicians complain when other physicians are out on leave. There’s an additional burden of work when people take time away, and there are often no support structures in place for backup or fill-in care. Dr. Salles said doctors often tell her that they were responsible for finding coverage for any time off during pregnancy or after becoming a parent. A paper of hers published in JAMA Surgery found that, for physicians, a fear of burdening others was a major barrier to getting pregnant during residency in the first place.
 

The physical consequences

Although research supports the benefits of physical activity throughout pregnancy, a job such as surgery that requires being on your feet for long periods of time “is not the same as exercise,” explains Erika Lu Rangel, MD, a gastrointestinal surgeon at Brigham and Women’s Hospital, Boston, and Dr. Kim’s lead author on the JAMA Surgery article.

Surgeons operating for more than 12 hours a week are at higher risk for pregnancy complications, the study found. Dr. Rangel also cites data suggesting that night shifts or swing shifts (the hours between day and night) put women at higher risk for pregnancy complications.

Equally alarming: Medical trainees appear to have “almost as high a rate of pregnancy complications as surgeons who have already completed their training,” said Dr. Rangel. It is a concerning finding since, as a younger cohort, they should have lower complication rates based on their age. But doctors in training may be on their feet even more than surgeons during long shifts.

Like Dr. Salles, Dr. Rangel sees these issues as part of a pervasive culture of “presenteeism” in medicine, and she points out that many surgeons don’t even take time off to grieve pregnancy loss or physically recover from it. “We work even when we’re sick and even when it’s not good for our health,” she said. “I think that’s an unhealthy behavior that we cultivate from the time that we’re trainees, and we carry it on through when we’re in practice.”

Penn Medicine’s Dr. Marshall remembers that her own maternity leave was “not an easy process to navigate.” From her hospital room on a magnesium drip for preeclampsia, she still attended Zoom meetings with her colleagues. “Nobody says, ‘Oh, you have to do this,’ ” Dr. Marshall explains, “but you wind up feeling guilty if you’re not there at all moments for everyone. That’s also something that needs to change.” 

Dr. Rangel was pregnant with her oldest son as a fourth-year surgery resident. The day she gave birth to him she remembers waking up with a flu-like illness and a fever. She went to work anyway, because “you don’t call in sick as a resident.” She was barely able to complete her rounds and then had to lie down between cases. A co-resident found her and took her to labor and delivery. She had gone into premature labor at 37 weeks, and her son went into the NICU with complications.

“I remember feeling this enormous guilt,” says Dr. Rangel. “I’d been a mom for just a few minutes, and I felt like I had already failed him because I had prioritized what the residency thought of me above what I knew was necessary for his health.”
 

Hope for the future

Disturbed by the status quo, many physicians are pushing for change. “I think there’s a really important and positive conversation going on in the medical community right now about ways that we need to support new parent physicians,” said Dr. Rangel.

Parental leave is a key part of that support. Last year, The American Board of Medical Specialties enacted a mandate that all specialty boards 2 years or more in duration must provide at least 6 weeks of parental and caregiver leave. In 2023, the Accreditation Council for Graduate Medical Education (ACGME) required that all training programs match that policy. “This sends a message to policymakers and leaders in American medicine that this is a priority,” said Dr. Rangel.

In January 2022, a group from the University of Michigan also published an article in the Annals of Surgery called “Safe and Supported Pregnancy: A Call to Action for Surgery Chairs and Program Directors”. The essay urged leading groups such as the ACGME and the American Board of Surgery to “directly address the health and safety of pregnant trainees” and specifically, to “allow for further flexibility during training for pregnancy and peripartum periods,” calling these “fundamental necessities for cultural progress.”

Others have recommended allowing pregnant trainees more flexibility in their schedules or front-loading certain parts of the training that may be more difficult as a pregnancy progresses. Insurance coverage for fertility preservation and reproductive endocrinology services, and support for reentry (including lactation and childcare) are also issues that must be addressed, says Dr. Salles.

A new paper of Dr. Rangel’s, published in JAMA Surgery, suggests that things like mentorship for residents from faculty can also be important pieces of the puzzle.

Education about reproductive health must start earlier, too – as early as medical school. Research suggests only 8% of physicians receive education on the risks of delaying pregnancy. Those who do are significantly less likely to experience pregnancy loss or seek infertility treatment.

Dr. Salles recalls sitting in a classroom learning about advanced maternal age at a time when age 35 seemed unimaginably distant. “It was never taught – at least to my recollection – in a way that was like, ‘this could be your future,’ ” Dr. Salles says.” It was more like this abstract patient who might have advanced maternal age and what the consequences would be. Maybe some of my colleagues put two and two together, but I definitely didn’t.”

Dr. Marshall is the curriculum chair for the IGNITEMed Initiative, which aims to educate medical students about issues not discussed in traditional medical school curricula. Dr. Marshall and her colleague Julia Files, MD, talk with IGNITEMed students about reproductive life planning.

“Raising awareness is a very big thing. That’s not just true for medical students but for professionals at every level of medicine,” Dr. Marshall said. “Residency and fellowship training program directors, department chairs, and hospital CEOs all need to understand that these issues are very common in the people they oversee – and that they are medical issues, like any other medical issue, where people need time off and support.”

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

Montrouge, France – Whether you are a cisgender woman or a transgender man who has kept his uterus, regardless of the sex of your partner, and even if you are a woman who is no longer sexually active, you must take part in cervical cancer screening. This is the reminder issued by Julia Maruani, MD, a medical gynecologist in Marseille, France, at a press conference ahead of the 46th meeting of the French Colposcopy and Cervical-Vaginal Diseases Society (SFCPCV).

Cervical screening currently targets asymptomatic, immunocompetent, and sexually active women between ages 25 and 65 years. During her presentation, Dr. Maruani insisted that screening should not discriminate based on a patient’s sexual activity.
 

Sex between women

There is a widely held belief that only men can transmit human papillomavirus (HPV). “If you are in a sexual relationship with a man, then yes, you can get HPV from him. But it’s also possible for HPV to be transmitted in a sexual relationship between two women via touch, bodily fluids, or sex toys,” said Dr. Maruani, who pointed out that 20% of lesbians and 30% of bisexual women are HPV carriers.

Because women who have sexual relationships with other women have the mistaken view that their demographic is less affected, they are less likely to take part in cervical screening. They also present more often with advanced lesions and with cancer because of the lack of screening in this group.
 

Transgender men

Dr. Maruani defines transgender men as “women who have changed gender and who have become men.” Why are they affected by cervical screening? Not all of them are. Those who’ve had their uterus removed no longer have a cervix, so this screening doesn’t affect them. But hysterectomies are rarely performed, as they’re not required in most European countries to legally change gender.

The figures are concerning: 27% of transgender men are screened versus 60% of cisgender females.

“For this demographic, specialist gynecology appointments are hard to come by. Sitting in a women’s waiting room is not easy,” said Dr. Maruani, recalling that often discussion about the transition phase takes up the entire appointment time. It’s also usually the case that any medical problems or health care prevention issues not related to the topic of transitioning are not discussed.

Moreover, the online appointment-booking software doesn’t allow transgender men who have kept their cervix and legally identify as men to make an appointment. “Gynecologists must disable this default option,” said Dr. Maruani.

Likewise, transgender men will not receive an invitation to take part in cervical or breast cancer screening, as they are identified as male by social security services and screening sites. Furthermore, in what Dr. Maruani referred to as an “administrative head-scratcher that needs to change,” some medical procedures are not funded for men.

Yet the risk of contracting HPV is higher among transgender men than in the rest of the population because of different sexual practices in this demographic, as well as the propensity to have multiple sexual partners. The risk of finding abnormalities on cytology screening is greater.

Although data regarding cancer are lacking, “if screening is inadequate but the risk of infection with HPV is great, logic tells us that there will be more lesions, more cancer” in this demographic, said Dr. Maruani.
 

Celibate women

Nowadays, screening drops with age in women, especially after menopause. This is especially true for women who are no longer sexually active. Another preconceived notion to be addressed is that women who are no longer sexually active no longer need screening. But this concept completely goes against the natural history of HPV infection. “There are years, at least 5, between infection and the development of precancerous lesions. There is a further 5 years between a precancerous lesion and cancer,” said Dr. Maruani.

A woman could still be at risk even 20 years after contracting HPV. Approximately 80% of women are exposed to HPV, and 5%-10% have a persistent infection that could lead to the development of precancerous lesions.

“So, a woman who is no longer sexually active can’t stop participating in cervical screening, especially since there aren’t any symptoms until a fairly advanced stage of cancer.” No longer having sex does not mean that screening can be stopped.

What treatment is appropriate for partners of a woman who is no longer sexually active? None. During the press conference, the specialists agreed that a positive HPV test would be of importance to her partner. Even so, they recalled that the infection would generally be an old one and that the woman’s partner (whether male or female) would therefore have probably already been exposed to it. Patients should also be reminded that, in the past, cytology testing did not look for HPV, so the virus could already have been there. According to these specialists, you don’t need to change your sexual habits, just continue to monitor yourself.

This article was translated from the Medscape French edition and a version first appeared on Medscape.com.

Montrouge, France – Whether you are a cisgender woman or a transgender man who has kept his uterus, regardless of the sex of your partner, and even if you are a woman who is no longer sexually active, you must take part in cervical cancer screening. This is the reminder issued by Julia Maruani, MD, a medical gynecologist in Marseille, France, at a press conference ahead of the 46th meeting of the French Colposcopy and Cervical-Vaginal Diseases Society (SFCPCV).

Cervical screening currently targets asymptomatic, immunocompetent, and sexually active women between ages 25 and 65 years. During her presentation, Dr. Maruani insisted that screening should not discriminate based on a patient’s sexual activity.
 

Sex between women

There is a widely held belief that only men can transmit human papillomavirus (HPV). “If you are in a sexual relationship with a man, then yes, you can get HPV from him. But it’s also possible for HPV to be transmitted in a sexual relationship between two women via touch, bodily fluids, or sex toys,” said Dr. Maruani, who pointed out that 20% of lesbians and 30% of bisexual women are HPV carriers.

Because women who have sexual relationships with other women have the mistaken view that their demographic is less affected, they are less likely to take part in cervical screening. They also present more often with advanced lesions and with cancer because of the lack of screening in this group.
 

Transgender men

Dr. Maruani defines transgender men as “women who have changed gender and who have become men.” Why are they affected by cervical screening? Not all of them are. Those who’ve had their uterus removed no longer have a cervix, so this screening doesn’t affect them. But hysterectomies are rarely performed, as they’re not required in most European countries to legally change gender.

The figures are concerning: 27% of transgender men are screened versus 60% of cisgender females.

“For this demographic, specialist gynecology appointments are hard to come by. Sitting in a women’s waiting room is not easy,” said Dr. Maruani, recalling that often discussion about the transition phase takes up the entire appointment time. It’s also usually the case that any medical problems or health care prevention issues not related to the topic of transitioning are not discussed.

Moreover, the online appointment-booking software doesn’t allow transgender men who have kept their cervix and legally identify as men to make an appointment. “Gynecologists must disable this default option,” said Dr. Maruani.

Likewise, transgender men will not receive an invitation to take part in cervical or breast cancer screening, as they are identified as male by social security services and screening sites. Furthermore, in what Dr. Maruani referred to as an “administrative head-scratcher that needs to change,” some medical procedures are not funded for men.

Yet the risk of contracting HPV is higher among transgender men than in the rest of the population because of different sexual practices in this demographic, as well as the propensity to have multiple sexual partners. The risk of finding abnormalities on cytology screening is greater.

Although data regarding cancer are lacking, “if screening is inadequate but the risk of infection with HPV is great, logic tells us that there will be more lesions, more cancer” in this demographic, said Dr. Maruani.
 

Celibate women

Nowadays, screening drops with age in women, especially after menopause. This is especially true for women who are no longer sexually active. Another preconceived notion to be addressed is that women who are no longer sexually active no longer need screening. But this concept completely goes against the natural history of HPV infection. “There are years, at least 5, between infection and the development of precancerous lesions. There is a further 5 years between a precancerous lesion and cancer,” said Dr. Maruani.

A woman could still be at risk even 20 years after contracting HPV. Approximately 80% of women are exposed to HPV, and 5%-10% have a persistent infection that could lead to the development of precancerous lesions.

“So, a woman who is no longer sexually active can’t stop participating in cervical screening, especially since there aren’t any symptoms until a fairly advanced stage of cancer.” No longer having sex does not mean that screening can be stopped.

What treatment is appropriate for partners of a woman who is no longer sexually active? None. During the press conference, the specialists agreed that a positive HPV test would be of importance to her partner. Even so, they recalled that the infection would generally be an old one and that the woman’s partner (whether male or female) would therefore have probably already been exposed to it. Patients should also be reminded that, in the past, cytology testing did not look for HPV, so the virus could already have been there. According to these specialists, you don’t need to change your sexual habits, just continue to monitor yourself.

This article was translated from the Medscape French edition and a version first appeared on Medscape.com.

Montrouge, France – Whether you are a cisgender woman or a transgender man who has kept his uterus, regardless of the sex of your partner, and even if you are a woman who is no longer sexually active, you must take part in cervical cancer screening. This is the reminder issued by Julia Maruani, MD, a medical gynecologist in Marseille, France, at a press conference ahead of the 46th meeting of the French Colposcopy and Cervical-Vaginal Diseases Society (SFCPCV).

Cervical screening currently targets asymptomatic, immunocompetent, and sexually active women between ages 25 and 65 years. During her presentation, Dr. Maruani insisted that screening should not discriminate based on a patient’s sexual activity.
 

Sex between women

There is a widely held belief that only men can transmit human papillomavirus (HPV). “If you are in a sexual relationship with a man, then yes, you can get HPV from him. But it’s also possible for HPV to be transmitted in a sexual relationship between two women via touch, bodily fluids, or sex toys,” said Dr. Maruani, who pointed out that 20% of lesbians and 30% of bisexual women are HPV carriers.

Because women who have sexual relationships with other women have the mistaken view that their demographic is less affected, they are less likely to take part in cervical screening. They also present more often with advanced lesions and with cancer because of the lack of screening in this group.
 

Transgender men

Dr. Maruani defines transgender men as “women who have changed gender and who have become men.” Why are they affected by cervical screening? Not all of them are. Those who’ve had their uterus removed no longer have a cervix, so this screening doesn’t affect them. But hysterectomies are rarely performed, as they’re not required in most European countries to legally change gender.

The figures are concerning: 27% of transgender men are screened versus 60% of cisgender females.

“For this demographic, specialist gynecology appointments are hard to come by. Sitting in a women’s waiting room is not easy,” said Dr. Maruani, recalling that often discussion about the transition phase takes up the entire appointment time. It’s also usually the case that any medical problems or health care prevention issues not related to the topic of transitioning are not discussed.

Moreover, the online appointment-booking software doesn’t allow transgender men who have kept their cervix and legally identify as men to make an appointment. “Gynecologists must disable this default option,” said Dr. Maruani.

Likewise, transgender men will not receive an invitation to take part in cervical or breast cancer screening, as they are identified as male by social security services and screening sites. Furthermore, in what Dr. Maruani referred to as an “administrative head-scratcher that needs to change,” some medical procedures are not funded for men.

Yet the risk of contracting HPV is higher among transgender men than in the rest of the population because of different sexual practices in this demographic, as well as the propensity to have multiple sexual partners. The risk of finding abnormalities on cytology screening is greater.

Although data regarding cancer are lacking, “if screening is inadequate but the risk of infection with HPV is great, logic tells us that there will be more lesions, more cancer” in this demographic, said Dr. Maruani.
 

Celibate women

Nowadays, screening drops with age in women, especially after menopause. This is especially true for women who are no longer sexually active. Another preconceived notion to be addressed is that women who are no longer sexually active no longer need screening. But this concept completely goes against the natural history of HPV infection. “There are years, at least 5, between infection and the development of precancerous lesions. There is a further 5 years between a precancerous lesion and cancer,” said Dr. Maruani.

A woman could still be at risk even 20 years after contracting HPV. Approximately 80% of women are exposed to HPV, and 5%-10% have a persistent infection that could lead to the development of precancerous lesions.

“So, a woman who is no longer sexually active can’t stop participating in cervical screening, especially since there aren’t any symptoms until a fairly advanced stage of cancer.” No longer having sex does not mean that screening can be stopped.

What treatment is appropriate for partners of a woman who is no longer sexually active? None. During the press conference, the specialists agreed that a positive HPV test would be of importance to her partner. Even so, they recalled that the infection would generally be an old one and that the woman’s partner (whether male or female) would therefore have probably already been exposed to it. Patients should also be reminded that, in the past, cytology testing did not look for HPV, so the virus could already have been there. According to these specialists, you don’t need to change your sexual habits, just continue to monitor yourself.

This article was translated from the Medscape French edition and a version first appeared on Medscape.com.

Despite improvements in access to health coverage under the Affordable Care Act (ACA), racial disparities in breast cancer mortality rates persist and the underuse of advanced breast imaging may be one culprit, experts say.
 

In a recent position statement, researchers highlighted the disproportionally high breast cancer mortality rates among Black women in Louisiana – a state that has one of the highest breast cancer mortality rates in the nation. In 2019, the breast cancer mortality rate among Black women in Louisiana was 29.3 per 100,000 women compared with the national rate of 19.4 per 100,000.

Although Louisiana has made strides in improving access to breast cancer screening in recent years, the use of advanced imaging – specifically breast MRI – remains underused in this high-risk population. A major barrier to wider use of breast MRI has been cost, and ACA expansion led to higher, not lower, out-of-pocket costs for this screening modality.

“Breast MRI is a powerful imaging tool for early detection and for screening women at high risk for breast cancer,” wrote the researchers, led by Brooke L. Morrell, MD, of Louisiana State University Health and Sciences Center, New Orleans.

However, greater access to health care has not necessarily translated to increased breast MRI screening or improved survival among Black women. Even years after the adoption of the ACA, “Black women in Louisiana continue to die of breast cancer at rates significantly greater than the national average,” the authors wrote.

The position statement was published in Cancer.

Breast MRI is known to provide the highest rate of breast cancer detection among commonly used imaging options, with a sensitivity ranging from 81% to 100%. That’s about twice as high as the sensitivity range for mammography after factoring in breast density.

“This is of particular importance when we consider the risk‐based screening of younger populations, in which dense breasts are more prevalent,” the authors explained.

For Black women in particular, studies show nearly a quarter (23%) who develop breast cancer are diagnosed under the age of 50, compared with 16% of White women. Black women are also more likely to develop more aggressive, premenopausal breast cancers, including triple-negative breast cancer, that are more easily detected on MRI.

“Adding supplemental screening breast MRI to annual mammography in higher risk women has been shown to detect up to 18 additional cancers out of 1,000 patients,” Dr. Morrell said. And “many of these cancers are detected much earlier than with mammography alone.”

Still, with ACA expansion, out-of-pocket costs for breast MRI actually increased. This increase likely occurred, in part, because the financial protections outlined in the ACA’s Women’s Preventive Services Guidelines covered mammograms but not breast MRI.

More specifically, under the ACA, Medicaid and most private health insurance plans are required to provide coverage for mammograms at no cost to the patient. The percentage of health plans providing zero cost sharing for mammograms increased under the ACA from 81.9% to 96.8%, but the corresponding rates of zero cost sharing for breast MRI screening went in the opposite direction – from 43.1% in 2009 to only 26.2% in 2017, a 2022 study found.

This study also highlighted geographic variations in zero cost sharing and out-of-pocket costs for screening breast MRI, with a higher financial burden observed for women living in the South. In addition, studies have demonstrated that race and socioeconomic factors, including education and income, play a role in the underuse of screening, including breast MRI.

These factors all likely contribute to screening breast MRI remaining inaccessible to many women, Dr. Morrell and colleagues said.

The authors also outlined three key action items that could help address barriers to MRI breast screening, which include reducing the high cost of breast MRI, lobbying to include breast MRI in ACA protections, and addressing knowledge gaps among patients and clinicians to better identify women who might benefit from breast MRI.

On the financial front, the team explained that a central driver for high costs is the scan time for breast MRI, which could be substantially reduced from 30 to 5 minutes, using an abbreviated protocol.

“Widespread use of low‐cost breast abbreviated MRI screening could remove the cost barrier of adding breast MRI screening to ACA coverage,” without compromising diagnostic accuracy, the authors noted.

Further efforts should focus on overcoming cultural barriers, including fear and mistrust of the health care system among Black women. Outreach efforts could include public campaigns or town hall and church gatherings that enlist patient navigators, advocates, or community members.

“Our visibility in the community builds trust and affords us the opportunity to share knowledge that may empower women to be their own health advocates,” the authors wrote.

In terms of the feasibility of revising ACA policies to improve breast MRI access and affordability, Dr. Morrell pointed to improvements made in colon cancer screening.

“Studies have demonstrated that after ACA policy changes lowering out-of-pocket cost for colonoscopies, screening colonoscopy rates significantly increased among men, predominantly in socioeconomically disadvantaged population,” she noted. “Similarly, we should investigate how to this can be applied to screening breast MRI.”

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

Despite improvements in access to health coverage under the Affordable Care Act (ACA), racial disparities in breast cancer mortality rates persist and the underuse of advanced breast imaging may be one culprit, experts say.
 

In a recent position statement, researchers highlighted the disproportionally high breast cancer mortality rates among Black women in Louisiana – a state that has one of the highest breast cancer mortality rates in the nation. In 2019, the breast cancer mortality rate among Black women in Louisiana was 29.3 per 100,000 women compared with the national rate of 19.4 per 100,000.

Although Louisiana has made strides in improving access to breast cancer screening in recent years, the use of advanced imaging – specifically breast MRI – remains underused in this high-risk population. A major barrier to wider use of breast MRI has been cost, and ACA expansion led to higher, not lower, out-of-pocket costs for this screening modality.

“Breast MRI is a powerful imaging tool for early detection and for screening women at high risk for breast cancer,” wrote the researchers, led by Brooke L. Morrell, MD, of Louisiana State University Health and Sciences Center, New Orleans.

However, greater access to health care has not necessarily translated to increased breast MRI screening or improved survival among Black women. Even years after the adoption of the ACA, “Black women in Louisiana continue to die of breast cancer at rates significantly greater than the national average,” the authors wrote.

The position statement was published in Cancer.

Breast MRI is known to provide the highest rate of breast cancer detection among commonly used imaging options, with a sensitivity ranging from 81% to 100%. That’s about twice as high as the sensitivity range for mammography after factoring in breast density.

“This is of particular importance when we consider the risk‐based screening of younger populations, in which dense breasts are more prevalent,” the authors explained.

For Black women in particular, studies show nearly a quarter (23%) who develop breast cancer are diagnosed under the age of 50, compared with 16% of White women. Black women are also more likely to develop more aggressive, premenopausal breast cancers, including triple-negative breast cancer, that are more easily detected on MRI.

“Adding supplemental screening breast MRI to annual mammography in higher risk women has been shown to detect up to 18 additional cancers out of 1,000 patients,” Dr. Morrell said. And “many of these cancers are detected much earlier than with mammography alone.”

Still, with ACA expansion, out-of-pocket costs for breast MRI actually increased. This increase likely occurred, in part, because the financial protections outlined in the ACA’s Women’s Preventive Services Guidelines covered mammograms but not breast MRI.

More specifically, under the ACA, Medicaid and most private health insurance plans are required to provide coverage for mammograms at no cost to the patient. The percentage of health plans providing zero cost sharing for mammograms increased under the ACA from 81.9% to 96.8%, but the corresponding rates of zero cost sharing for breast MRI screening went in the opposite direction – from 43.1% in 2009 to only 26.2% in 2017, a 2022 study found.

This study also highlighted geographic variations in zero cost sharing and out-of-pocket costs for screening breast MRI, with a higher financial burden observed for women living in the South. In addition, studies have demonstrated that race and socioeconomic factors, including education and income, play a role in the underuse of screening, including breast MRI.

These factors all likely contribute to screening breast MRI remaining inaccessible to many women, Dr. Morrell and colleagues said.

The authors also outlined three key action items that could help address barriers to MRI breast screening, which include reducing the high cost of breast MRI, lobbying to include breast MRI in ACA protections, and addressing knowledge gaps among patients and clinicians to better identify women who might benefit from breast MRI.

On the financial front, the team explained that a central driver for high costs is the scan time for breast MRI, which could be substantially reduced from 30 to 5 minutes, using an abbreviated protocol.

“Widespread use of low‐cost breast abbreviated MRI screening could remove the cost barrier of adding breast MRI screening to ACA coverage,” without compromising diagnostic accuracy, the authors noted.

Further efforts should focus on overcoming cultural barriers, including fear and mistrust of the health care system among Black women. Outreach efforts could include public campaigns or town hall and church gatherings that enlist patient navigators, advocates, or community members.

“Our visibility in the community builds trust and affords us the opportunity to share knowledge that may empower women to be their own health advocates,” the authors wrote.

In terms of the feasibility of revising ACA policies to improve breast MRI access and affordability, Dr. Morrell pointed to improvements made in colon cancer screening.

“Studies have demonstrated that after ACA policy changes lowering out-of-pocket cost for colonoscopies, screening colonoscopy rates significantly increased among men, predominantly in socioeconomically disadvantaged population,” she noted. “Similarly, we should investigate how to this can be applied to screening breast MRI.”

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

Despite improvements in access to health coverage under the Affordable Care Act (ACA), racial disparities in breast cancer mortality rates persist and the underuse of advanced breast imaging may be one culprit, experts say.
 

In a recent position statement, researchers highlighted the disproportionally high breast cancer mortality rates among Black women in Louisiana – a state that has one of the highest breast cancer mortality rates in the nation. In 2019, the breast cancer mortality rate among Black women in Louisiana was 29.3 per 100,000 women compared with the national rate of 19.4 per 100,000.

Although Louisiana has made strides in improving access to breast cancer screening in recent years, the use of advanced imaging – specifically breast MRI – remains underused in this high-risk population. A major barrier to wider use of breast MRI has been cost, and ACA expansion led to higher, not lower, out-of-pocket costs for this screening modality.

“Breast MRI is a powerful imaging tool for early detection and for screening women at high risk for breast cancer,” wrote the researchers, led by Brooke L. Morrell, MD, of Louisiana State University Health and Sciences Center, New Orleans.

However, greater access to health care has not necessarily translated to increased breast MRI screening or improved survival among Black women. Even years after the adoption of the ACA, “Black women in Louisiana continue to die of breast cancer at rates significantly greater than the national average,” the authors wrote.

The position statement was published in Cancer.

Breast MRI is known to provide the highest rate of breast cancer detection among commonly used imaging options, with a sensitivity ranging from 81% to 100%. That’s about twice as high as the sensitivity range for mammography after factoring in breast density.

“This is of particular importance when we consider the risk‐based screening of younger populations, in which dense breasts are more prevalent,” the authors explained.

For Black women in particular, studies show nearly a quarter (23%) who develop breast cancer are diagnosed under the age of 50, compared with 16% of White women. Black women are also more likely to develop more aggressive, premenopausal breast cancers, including triple-negative breast cancer, that are more easily detected on MRI.

“Adding supplemental screening breast MRI to annual mammography in higher risk women has been shown to detect up to 18 additional cancers out of 1,000 patients,” Dr. Morrell said. And “many of these cancers are detected much earlier than with mammography alone.”

Still, with ACA expansion, out-of-pocket costs for breast MRI actually increased. This increase likely occurred, in part, because the financial protections outlined in the ACA’s Women’s Preventive Services Guidelines covered mammograms but not breast MRI.

More specifically, under the ACA, Medicaid and most private health insurance plans are required to provide coverage for mammograms at no cost to the patient. The percentage of health plans providing zero cost sharing for mammograms increased under the ACA from 81.9% to 96.8%, but the corresponding rates of zero cost sharing for breast MRI screening went in the opposite direction – from 43.1% in 2009 to only 26.2% in 2017, a 2022 study found.

This study also highlighted geographic variations in zero cost sharing and out-of-pocket costs for screening breast MRI, with a higher financial burden observed for women living in the South. In addition, studies have demonstrated that race and socioeconomic factors, including education and income, play a role in the underuse of screening, including breast MRI.

These factors all likely contribute to screening breast MRI remaining inaccessible to many women, Dr. Morrell and colleagues said.

The authors also outlined three key action items that could help address barriers to MRI breast screening, which include reducing the high cost of breast MRI, lobbying to include breast MRI in ACA protections, and addressing knowledge gaps among patients and clinicians to better identify women who might benefit from breast MRI.

On the financial front, the team explained that a central driver for high costs is the scan time for breast MRI, which could be substantially reduced from 30 to 5 minutes, using an abbreviated protocol.

“Widespread use of low‐cost breast abbreviated MRI screening could remove the cost barrier of adding breast MRI screening to ACA coverage,” without compromising diagnostic accuracy, the authors noted.

Further efforts should focus on overcoming cultural barriers, including fear and mistrust of the health care system among Black women. Outreach efforts could include public campaigns or town hall and church gatherings that enlist patient navigators, advocates, or community members.

“Our visibility in the community builds trust and affords us the opportunity to share knowledge that may empower women to be their own health advocates,” the authors wrote.

In terms of the feasibility of revising ACA policies to improve breast MRI access and affordability, Dr. Morrell pointed to improvements made in colon cancer screening.

“Studies have demonstrated that after ACA policy changes lowering out-of-pocket cost for colonoscopies, screening colonoscopy rates significantly increased among men, predominantly in socioeconomically disadvantaged population,” she noted. “Similarly, we should investigate how to this can be applied to screening breast MRI.”

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

Women who experience preeclampsia during pregnancy are almost twice as likely to have a heart attack or stroke within 20 years of giving birth as pregnant women who did not, according to a new study published in the European Journal of Preventive Cardiology. The risks are especially high in the first decade after giving birth, the researchers found.
 

Preeclampsia is the onset of high blood pressure after the 20th week of pregnancy combined with signs of organ damage, such as excess protein in the urine. It can occur in up to 8% of pregnancies, and the association between preeclampsia and long-term cardiac risks is well-known. But new research suggests these risks appear much earlier in life than expected – as early as age 30 – at a time when women are often not screened for signs of heart trouble

“Targeted interventions cannot wait until women with preeclampsia become eligible for conventional screening programs in middle age,” Sara Hallum, PhD, a coauthor of the study, told this news organization.

Dr. Hallum, who was an epidemiologist at the University of Copenhagen at the time of the study, and colleagues evaluated the medical histories of more than 1.1 million women in Denmark who became pregnant once or twice between 1978 and 2017. Of this group, 3% had experienced preeclampsia. They compared rates of heart attack and stroke between the two groups over time.

While 1.2% of the entire study population had experienced a heart attack or stroke within 20 years of giving birth, 2% of the women with a history of preeclampsia had such an event. Within the first decade after delivery, women with a history of preeclampsia were four times as likely to have a heart attack and three times as likely to have a stroke as other women.

Women aged 30-39 with a history of preeclampsia were nearly five times as likely to have a heart attack and three times as likely to have a stroke as similar-aged women. And if a woman gave birth twice and had preeclampsia only during the second pregnancy, she was at especially high risk for a heart attack, the researchers found.

“Women with a history of preeclampsia should be monitored routinely for modifiable risk factors, particularly for increased blood pressure,” Dr. Hallum said.

The Danish study population is racially homogeneous, so the researchers were not able to distinguish the effects of preeclampsia by racial group. In the United States, strong evidence shows that Black women experience the effects of preeclampsia more than others.
 

A useful clue to cardiac risk

Ellen Seely, MD, an endocrinologist at Brigham and Women’s Hospital in Boston, who specializes in preeclampsia, said physicians are less likely to ask women who have been pregnant if they had experienced preeclampsia than to ask if they smoke or have a family history of heart attacks. As a result, they may miss a looming cardiovascular event, especially in younger women who appear healthy.

“Emerging high blood pressure shouldn’t be ignored” in a seemingly healthy young woman, Dr. Seely said, particularly if that woman has divulged a history of preeclampsia. The doctor’s first step should be to verify hypertension, Dr. Seely said. If high blood pressure is evident, immediate treatment – such as encouraging more physical activity and a healthier diet – should follow. Watchful waiting in such cases is inappropriate, she added.

Although the experience of having preeclampsia is unpleasant and scary, Dr. Seely noted that in at least one way it can prove advantageous. Some women who did not experience preeclampsia will end up having a heart attack, sometimes with no prior warning that anything was amiss. At least a history of preeclampsia provides a clue that women should take care of their hearts.

“The patient carries their history with them wherever they go,” Dr. Seely said. For now, this reality often requires women to mention their pregnancy history even if a provider doesn’t ask. Someday, Dr. Seely said, asking about that history will become just as routine for providers as asking about family history.

The study was funded by the Danish Heart Foundation. Dr. Hallum and Dr. Seely have reported no relevant financial relationships.

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

Women who experience preeclampsia during pregnancy are almost twice as likely to have a heart attack or stroke within 20 years of giving birth as pregnant women who did not, according to a new study published in the European Journal of Preventive Cardiology. The risks are especially high in the first decade after giving birth, the researchers found.
 

Preeclampsia is the onset of high blood pressure after the 20th week of pregnancy combined with signs of organ damage, such as excess protein in the urine. It can occur in up to 8% of pregnancies, and the association between preeclampsia and long-term cardiac risks is well-known. But new research suggests these risks appear much earlier in life than expected – as early as age 30 – at a time when women are often not screened for signs of heart trouble

“Targeted interventions cannot wait until women with preeclampsia become eligible for conventional screening programs in middle age,” Sara Hallum, PhD, a coauthor of the study, told this news organization.

Dr. Hallum, who was an epidemiologist at the University of Copenhagen at the time of the study, and colleagues evaluated the medical histories of more than 1.1 million women in Denmark who became pregnant once or twice between 1978 and 2017. Of this group, 3% had experienced preeclampsia. They compared rates of heart attack and stroke between the two groups over time.

While 1.2% of the entire study population had experienced a heart attack or stroke within 20 years of giving birth, 2% of the women with a history of preeclampsia had such an event. Within the first decade after delivery, women with a history of preeclampsia were four times as likely to have a heart attack and three times as likely to have a stroke as other women.

Women aged 30-39 with a history of preeclampsia were nearly five times as likely to have a heart attack and three times as likely to have a stroke as similar-aged women. And if a woman gave birth twice and had preeclampsia only during the second pregnancy, she was at especially high risk for a heart attack, the researchers found.

“Women with a history of preeclampsia should be monitored routinely for modifiable risk factors, particularly for increased blood pressure,” Dr. Hallum said.

The Danish study population is racially homogeneous, so the researchers were not able to distinguish the effects of preeclampsia by racial group. In the United States, strong evidence shows that Black women experience the effects of preeclampsia more than others.
 

A useful clue to cardiac risk

Ellen Seely, MD, an endocrinologist at Brigham and Women’s Hospital in Boston, who specializes in preeclampsia, said physicians are less likely to ask women who have been pregnant if they had experienced preeclampsia than to ask if they smoke or have a family history of heart attacks. As a result, they may miss a looming cardiovascular event, especially in younger women who appear healthy.

“Emerging high blood pressure shouldn’t be ignored” in a seemingly healthy young woman, Dr. Seely said, particularly if that woman has divulged a history of preeclampsia. The doctor’s first step should be to verify hypertension, Dr. Seely said. If high blood pressure is evident, immediate treatment – such as encouraging more physical activity and a healthier diet – should follow. Watchful waiting in such cases is inappropriate, she added.

Although the experience of having preeclampsia is unpleasant and scary, Dr. Seely noted that in at least one way it can prove advantageous. Some women who did not experience preeclampsia will end up having a heart attack, sometimes with no prior warning that anything was amiss. At least a history of preeclampsia provides a clue that women should take care of their hearts.

“The patient carries their history with them wherever they go,” Dr. Seely said. For now, this reality often requires women to mention their pregnancy history even if a provider doesn’t ask. Someday, Dr. Seely said, asking about that history will become just as routine for providers as asking about family history.

The study was funded by the Danish Heart Foundation. Dr. Hallum and Dr. Seely have reported no relevant financial relationships.

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

Women who experience preeclampsia during pregnancy are almost twice as likely to have a heart attack or stroke within 20 years of giving birth as pregnant women who did not, according to a new study published in the European Journal of Preventive Cardiology. The risks are especially high in the first decade after giving birth, the researchers found.
 

Preeclampsia is the onset of high blood pressure after the 20th week of pregnancy combined with signs of organ damage, such as excess protein in the urine. It can occur in up to 8% of pregnancies, and the association between preeclampsia and long-term cardiac risks is well-known. But new research suggests these risks appear much earlier in life than expected – as early as age 30 – at a time when women are often not screened for signs of heart trouble

“Targeted interventions cannot wait until women with preeclampsia become eligible for conventional screening programs in middle age,” Sara Hallum, PhD, a coauthor of the study, told this news organization.

Dr. Hallum, who was an epidemiologist at the University of Copenhagen at the time of the study, and colleagues evaluated the medical histories of more than 1.1 million women in Denmark who became pregnant once or twice between 1978 and 2017. Of this group, 3% had experienced preeclampsia. They compared rates of heart attack and stroke between the two groups over time.

While 1.2% of the entire study population had experienced a heart attack or stroke within 20 years of giving birth, 2% of the women with a history of preeclampsia had such an event. Within the first decade after delivery, women with a history of preeclampsia were four times as likely to have a heart attack and three times as likely to have a stroke as other women.

Women aged 30-39 with a history of preeclampsia were nearly five times as likely to have a heart attack and three times as likely to have a stroke as similar-aged women. And if a woman gave birth twice and had preeclampsia only during the second pregnancy, she was at especially high risk for a heart attack, the researchers found.

“Women with a history of preeclampsia should be monitored routinely for modifiable risk factors, particularly for increased blood pressure,” Dr. Hallum said.

The Danish study population is racially homogeneous, so the researchers were not able to distinguish the effects of preeclampsia by racial group. In the United States, strong evidence shows that Black women experience the effects of preeclampsia more than others.
 

A useful clue to cardiac risk

Ellen Seely, MD, an endocrinologist at Brigham and Women’s Hospital in Boston, who specializes in preeclampsia, said physicians are less likely to ask women who have been pregnant if they had experienced preeclampsia than to ask if they smoke or have a family history of heart attacks. As a result, they may miss a looming cardiovascular event, especially in younger women who appear healthy.

“Emerging high blood pressure shouldn’t be ignored” in a seemingly healthy young woman, Dr. Seely said, particularly if that woman has divulged a history of preeclampsia. The doctor’s first step should be to verify hypertension, Dr. Seely said. If high blood pressure is evident, immediate treatment – such as encouraging more physical activity and a healthier diet – should follow. Watchful waiting in such cases is inappropriate, she added.

Although the experience of having preeclampsia is unpleasant and scary, Dr. Seely noted that in at least one way it can prove advantageous. Some women who did not experience preeclampsia will end up having a heart attack, sometimes with no prior warning that anything was amiss. At least a history of preeclampsia provides a clue that women should take care of their hearts.

“The patient carries their history with them wherever they go,” Dr. Seely said. For now, this reality often requires women to mention their pregnancy history even if a provider doesn’t ask. Someday, Dr. Seely said, asking about that history will become just as routine for providers as asking about family history.

The study was funded by the Danish Heart Foundation. Dr. Hallum and Dr. Seely have reported no relevant financial relationships.

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

The selective estrogen receptor modulator ospemifene appears to improve the vaginal microbiome of postmenopausal women with vulvovaginal atrophy (VVA), according to results from a small Italian case-control study in the journal Menopause.

The study sheds microbiological light on the mechanisms of ospemifene and low-dose systemic hormone therapy, which are widely used to treat genitourinary symptoms. Both had a positive effect on vaginal well-being, likely by reducing potentially harmful bacteria and increasing health-promoting acid-friendly microorganisms, writes a group led by M. Cristina Meriggiola, MD, PhD, of the gynecology and physiopathology of human reproduction unit at the University of Bologna, Italy.

VVA occurs in about 50% of postmenopausal women and produces a less favorable, less acidic vaginal microbiome profile than that of unaffected women. “The loss of estrogen leads to lower concentrations of Lactobacilli, bacteria that lower the pH. As a result, other bacterial species fill in the void,” explained Stephanie S. Faubion, MD, MBA, director of the Mayo Clinic Center for Women’s Health in Jacksonville, Fla., and medical director of the North American Menopause Society.

Added Tina Murphy, APN, a NAMS-certified menopause practitioner at Northwestern Medicine Orland Park in Illinois, “When this protective flora declines, then pathogenic bacteria can predominate the microbiome, which can contribute to vaginal irritation, infection, UTI’s, dyspareunia, and discomfort. Balancing and restoring the microbiome can mitigate the effects of estrogen depletion on the vaginal tissue and prevent the untoward effects of the hypoestrogenic state.” While ospemifene and hormone therapy are common therapies for the genitourinary symptoms of menopause, the focus has been on their treatment efficacy, not their effect on the microbiome profile, added Dr. Faubion. Only about 9% of women with menopause-related genitourinary symptoms receive prescription treatment, she added.
 

The study

Of 67 eligible postmenopausal participants in their mid-50s enrolled at a gynecology clinic from April 2019 to February 2020, 39 were diagnosed with VVA and 28 were considered healthy controls. In the atrophic group, 20 were prescribed ospemifene and 19 received hormone treatment.

Only those women with VVA but no menopausal vasomotor symptoms received ospemifene (60 mg/day); symptomatic women received hormone therapy according to guidelines.

The researchers calculated the women’s vaginal health index (VHI) based on elasticity, secretions, pH level, epithelial mucosa, and hydration. They used swabs to assess vaginal maturation index (VMI) by percentages of superficial, intermediate, and parabasal cells. Evaluation of the vaginal microbiome was done with 16S rRNA gene sequencing, and clinical and microbiological analyses were repeated after 3 months.

The vaginal microbiome of atrophic women was characterized by a significant reduction of benign Lactobacillus bacteria (P = .002) and an increase of potentially pathogenic Streptococcus (P = .008) and Sneathia (P = .02) bacteria.

The vaginal microbiome of women with VVA was depleted, within the Lactobacillus genus, in the L. crispatus species, a hallmark of vaginal health that has significant antimicrobial activity against endogenous and exogenous pathogens.

Furthermore, there was a positive correlation between the VHI/VMI and Lactobacillus abundance (P = .002 and P = 0.035, respectively).

While the lactic acid–producing Lactobacillus and Bifidobacterium genera were strongly associated with healthy controls, the characteristics of VVA patients were strongly associated with Streptococcus, Prevotella, Alloscardovia, and Staphylococcus.

Both therapeutic approaches effectively improved vaginal indices but by different routes. Systemic hormone treatment induced changes in minority bacterial groups in the vaginal microbiome, whereas ospemifene eliminated specific harmful bacterial taxa, such as Staphylococcus (P = .04) and Clostridium (P = .01). Both treatments induced a trend in the increase of beneficial Bifidobacteria.

A 2022 study reported that vaginal estradiol tablets significantly changed the vaginal microbiota in postmenopausal women compared with vaginal moisturizer or placebo, but the reductions in bothersome symptoms were similar.
 

The future

“Areas for future study include the assessment of changes in the vaginal microbiome, proteomic profiles, and immunologic markers with various treatments and the associations between these changes and genitourinary symptoms,” Dr. Faubion said. She added that, while there may be a role at some point for oral or topical probiotics, “Thus far, probiotics have not demonstrated significant benefits.”

Meanwhile, said Ms. Murphy, “There are many options available that may benefit our patients. As a provider, meeting with your patient, discussing her concerns and individual risk factors is the most important part of choosing the correct treatment plan.”

The authors call for further studies to confirm the observed modifications of the vaginal ecosystem. In the meantime, Dr. Meriggiola said in an interview, “My best advice to physicians is to ask women if they have this problem. Do not ignore it; be proactive and treat. There are many options on the market for genitourinary symptoms – not just for postmenopausal women but breast cancer survivors as well.”

Dr. Meriggiola’s group is planning to study ospemifene in cancer patients, whose quality of life is severely affected by VVA.

This study received no financial support. Dr. Meriggiola reported past financial relationships with Shionogi Limited, Teramex, Organon, Italfarmaco, MDS Italia, and Bayer. Coauthor Dr. Baldassarre disclosed past financial relationships with Shionogi. Ms. Murphy disclosed no relevant conflicts of interest with respect to her comments. Dr. Faubion is medical director of the North American Menopause Society and editor of the journal Menopause.

The selective estrogen receptor modulator ospemifene appears to improve the vaginal microbiome of postmenopausal women with vulvovaginal atrophy (VVA), according to results from a small Italian case-control study in the journal Menopause.

The study sheds microbiological light on the mechanisms of ospemifene and low-dose systemic hormone therapy, which are widely used to treat genitourinary symptoms. Both had a positive effect on vaginal well-being, likely by reducing potentially harmful bacteria and increasing health-promoting acid-friendly microorganisms, writes a group led by M. Cristina Meriggiola, MD, PhD, of the gynecology and physiopathology of human reproduction unit at the University of Bologna, Italy.

VVA occurs in about 50% of postmenopausal women and produces a less favorable, less acidic vaginal microbiome profile than that of unaffected women. “The loss of estrogen leads to lower concentrations of Lactobacilli, bacteria that lower the pH. As a result, other bacterial species fill in the void,” explained Stephanie S. Faubion, MD, MBA, director of the Mayo Clinic Center for Women’s Health in Jacksonville, Fla., and medical director of the North American Menopause Society.

Added Tina Murphy, APN, a NAMS-certified menopause practitioner at Northwestern Medicine Orland Park in Illinois, “When this protective flora declines, then pathogenic bacteria can predominate the microbiome, which can contribute to vaginal irritation, infection, UTI’s, dyspareunia, and discomfort. Balancing and restoring the microbiome can mitigate the effects of estrogen depletion on the vaginal tissue and prevent the untoward effects of the hypoestrogenic state.” While ospemifene and hormone therapy are common therapies for the genitourinary symptoms of menopause, the focus has been on their treatment efficacy, not their effect on the microbiome profile, added Dr. Faubion. Only about 9% of women with menopause-related genitourinary symptoms receive prescription treatment, she added.
 

The study

Of 67 eligible postmenopausal participants in their mid-50s enrolled at a gynecology clinic from April 2019 to February 2020, 39 were diagnosed with VVA and 28 were considered healthy controls. In the atrophic group, 20 were prescribed ospemifene and 19 received hormone treatment.

Only those women with VVA but no menopausal vasomotor symptoms received ospemifene (60 mg/day); symptomatic women received hormone therapy according to guidelines.

The researchers calculated the women’s vaginal health index (VHI) based on elasticity, secretions, pH level, epithelial mucosa, and hydration. They used swabs to assess vaginal maturation index (VMI) by percentages of superficial, intermediate, and parabasal cells. Evaluation of the vaginal microbiome was done with 16S rRNA gene sequencing, and clinical and microbiological analyses were repeated after 3 months.

The vaginal microbiome of atrophic women was characterized by a significant reduction of benign Lactobacillus bacteria (P = .002) and an increase of potentially pathogenic Streptococcus (P = .008) and Sneathia (P = .02) bacteria.

The vaginal microbiome of women with VVA was depleted, within the Lactobacillus genus, in the L. crispatus species, a hallmark of vaginal health that has significant antimicrobial activity against endogenous and exogenous pathogens.

Furthermore, there was a positive correlation between the VHI/VMI and Lactobacillus abundance (P = .002 and P = 0.035, respectively).

While the lactic acid–producing Lactobacillus and Bifidobacterium genera were strongly associated with healthy controls, the characteristics of VVA patients were strongly associated with Streptococcus, Prevotella, Alloscardovia, and Staphylococcus.

Both therapeutic approaches effectively improved vaginal indices but by different routes. Systemic hormone treatment induced changes in minority bacterial groups in the vaginal microbiome, whereas ospemifene eliminated specific harmful bacterial taxa, such as Staphylococcus (P = .04) and Clostridium (P = .01). Both treatments induced a trend in the increase of beneficial Bifidobacteria.

A 2022 study reported that vaginal estradiol tablets significantly changed the vaginal microbiota in postmenopausal women compared with vaginal moisturizer or placebo, but the reductions in bothersome symptoms were similar.
 

The future

“Areas for future study include the assessment of changes in the vaginal microbiome, proteomic profiles, and immunologic markers with various treatments and the associations between these changes and genitourinary symptoms,” Dr. Faubion said. She added that, while there may be a role at some point for oral or topical probiotics, “Thus far, probiotics have not demonstrated significant benefits.”

Meanwhile, said Ms. Murphy, “There are many options available that may benefit our patients. As a provider, meeting with your patient, discussing her concerns and individual risk factors is the most important part of choosing the correct treatment plan.”

The authors call for further studies to confirm the observed modifications of the vaginal ecosystem. In the meantime, Dr. Meriggiola said in an interview, “My best advice to physicians is to ask women if they have this problem. Do not ignore it; be proactive and treat. There are many options on the market for genitourinary symptoms – not just for postmenopausal women but breast cancer survivors as well.”

Dr. Meriggiola’s group is planning to study ospemifene in cancer patients, whose quality of life is severely affected by VVA.

This study received no financial support. Dr. Meriggiola reported past financial relationships with Shionogi Limited, Teramex, Organon, Italfarmaco, MDS Italia, and Bayer. Coauthor Dr. Baldassarre disclosed past financial relationships with Shionogi. Ms. Murphy disclosed no relevant conflicts of interest with respect to her comments. Dr. Faubion is medical director of the North American Menopause Society and editor of the journal Menopause.

The selective estrogen receptor modulator ospemifene appears to improve the vaginal microbiome of postmenopausal women with vulvovaginal atrophy (VVA), according to results from a small Italian case-control study in the journal Menopause.

The study sheds microbiological light on the mechanisms of ospemifene and low-dose systemic hormone therapy, which are widely used to treat genitourinary symptoms. Both had a positive effect on vaginal well-being, likely by reducing potentially harmful bacteria and increasing health-promoting acid-friendly microorganisms, writes a group led by M. Cristina Meriggiola, MD, PhD, of the gynecology and physiopathology of human reproduction unit at the University of Bologna, Italy.

VVA occurs in about 50% of postmenopausal women and produces a less favorable, less acidic vaginal microbiome profile than that of unaffected women. “The loss of estrogen leads to lower concentrations of Lactobacilli, bacteria that lower the pH. As a result, other bacterial species fill in the void,” explained Stephanie S. Faubion, MD, MBA, director of the Mayo Clinic Center for Women’s Health in Jacksonville, Fla., and medical director of the North American Menopause Society.

Added Tina Murphy, APN, a NAMS-certified menopause practitioner at Northwestern Medicine Orland Park in Illinois, “When this protective flora declines, then pathogenic bacteria can predominate the microbiome, which can contribute to vaginal irritation, infection, UTI’s, dyspareunia, and discomfort. Balancing and restoring the microbiome can mitigate the effects of estrogen depletion on the vaginal tissue and prevent the untoward effects of the hypoestrogenic state.” While ospemifene and hormone therapy are common therapies for the genitourinary symptoms of menopause, the focus has been on their treatment efficacy, not their effect on the microbiome profile, added Dr. Faubion. Only about 9% of women with menopause-related genitourinary symptoms receive prescription treatment, she added.
 

The study

Of 67 eligible postmenopausal participants in their mid-50s enrolled at a gynecology clinic from April 2019 to February 2020, 39 were diagnosed with VVA and 28 were considered healthy controls. In the atrophic group, 20 were prescribed ospemifene and 19 received hormone treatment.

Only those women with VVA but no menopausal vasomotor symptoms received ospemifene (60 mg/day); symptomatic women received hormone therapy according to guidelines.

The researchers calculated the women’s vaginal health index (VHI) based on elasticity, secretions, pH level, epithelial mucosa, and hydration. They used swabs to assess vaginal maturation index (VMI) by percentages of superficial, intermediate, and parabasal cells. Evaluation of the vaginal microbiome was done with 16S rRNA gene sequencing, and clinical and microbiological analyses were repeated after 3 months.

The vaginal microbiome of atrophic women was characterized by a significant reduction of benign Lactobacillus bacteria (P = .002) and an increase of potentially pathogenic Streptococcus (P = .008) and Sneathia (P = .02) bacteria.

The vaginal microbiome of women with VVA was depleted, within the Lactobacillus genus, in the L. crispatus species, a hallmark of vaginal health that has significant antimicrobial activity against endogenous and exogenous pathogens.

Furthermore, there was a positive correlation between the VHI/VMI and Lactobacillus abundance (P = .002 and P = 0.035, respectively).

While the lactic acid–producing Lactobacillus and Bifidobacterium genera were strongly associated with healthy controls, the characteristics of VVA patients were strongly associated with Streptococcus, Prevotella, Alloscardovia, and Staphylococcus.

Both therapeutic approaches effectively improved vaginal indices but by different routes. Systemic hormone treatment induced changes in minority bacterial groups in the vaginal microbiome, whereas ospemifene eliminated specific harmful bacterial taxa, such as Staphylococcus (P = .04) and Clostridium (P = .01). Both treatments induced a trend in the increase of beneficial Bifidobacteria.

A 2022 study reported that vaginal estradiol tablets significantly changed the vaginal microbiota in postmenopausal women compared with vaginal moisturizer or placebo, but the reductions in bothersome symptoms were similar.
 

The future

“Areas for future study include the assessment of changes in the vaginal microbiome, proteomic profiles, and immunologic markers with various treatments and the associations between these changes and genitourinary symptoms,” Dr. Faubion said. She added that, while there may be a role at some point for oral or topical probiotics, “Thus far, probiotics have not demonstrated significant benefits.”

Meanwhile, said Ms. Murphy, “There are many options available that may benefit our patients. As a provider, meeting with your patient, discussing her concerns and individual risk factors is the most important part of choosing the correct treatment plan.”

The authors call for further studies to confirm the observed modifications of the vaginal ecosystem. In the meantime, Dr. Meriggiola said in an interview, “My best advice to physicians is to ask women if they have this problem. Do not ignore it; be proactive and treat. There are many options on the market for genitourinary symptoms – not just for postmenopausal women but breast cancer survivors as well.”

Dr. Meriggiola’s group is planning to study ospemifene in cancer patients, whose quality of life is severely affected by VVA.

This study received no financial support. Dr. Meriggiola reported past financial relationships with Shionogi Limited, Teramex, Organon, Italfarmaco, MDS Italia, and Bayer. Coauthor Dr. Baldassarre disclosed past financial relationships with Shionogi. Ms. Murphy disclosed no relevant conflicts of interest with respect to her comments. Dr. Faubion is medical director of the North American Menopause Society and editor of the journal Menopause.