Women's Health

Jen Gunter, MD, refuses to stay silent when she sees misleading claims about women’s health products.

In fact, the world’s most famous – and outspoken – ob.gyn. (as described by The Guardian), is on a social media mission to speak up whenever she sees companies or governments “prey on women’s health and vaginal shame.”

With nearly 400,000 followers, Dr. Gunter never shies away from a controversy.

Recently, she railed against vitamin and supplement maker Olly’s vaginal probiotic, taking the company to task for its product premise and objectionable ad copy.

This news organization caught up with the San Francisco–based doctor and author of two books, “The Vagina Bible” and “The Menopause Manifesto.” The following interview has been lightly edited for length and clarity.

Question: So these Olly capsules purport to be “Probiotics for Your Panty Hamster.” What was your reaction to this?

Answer: Seeing the word “panty hamsters” is so egregious. I’m so used to baseline vaginal opportunism, but this was just absolutely egregious and I had to call it out.

Question: What are vaginal probiotics anyway?

Answer: These are one of these big wellness scams where companies try to sell you on somehow hacking your microbiome by taking them. They’re not inexpensive, either, and can range in price from $30 to $150 per month, depending on how bespoke they are. And yet the data isn’t good. There is little to no evidence of the value of these probiotics except to shareholders.

Question: What’s one claim made in the Olly probiotic packaging that bothers you the most?

Answer: The product claims to balance the vaginal pH. To say that is a gross misunderstanding of the vaginal ecosystem. If that tagline is what you’re leading with, what else don’t you know?

Also, if these things worked, we’d recommend them. Vaginitis is complex and often misdiagnosed, and it’s easy for a company to be predatory and swoop in and say they have a product for you.

If I think your product for the vagina is awful and you have not studied it in at least one quality clinical trial (never mind company-funded or not), and your marketing displays a stunning ignorance about vaginal health, don’t approach me about your product. Really.

Question: When there’s a pop culture reference to, say, menstruation, you’re quick to weigh in.

Answer: I saw these viral messages from a boy mom (that’s what she called herself) where she wrote about being disgusted that there were mentions of periods in Turning Red, the animated movie.

Everything is here because of menstruation. If you didn’t menstruate, you wouldn’t have a kid, we wouldn’t have the person who had the intelligence to build the computer you’re spreading this message on. Menstruation is a vital part of human reproduction, and it’s far more complex than people think. For that reason alone, people should know about it.

Question: Do you ever get worried about being so “out there” on social media?

Answer: I have my stalkers I suppose, but the trolls don’t bother me. I don’t care if some whatever art dealer in New York thinks I have mental illness for promoting masks. That’s the best you’ve got? Honestly, this doesn’t even register with me. It’s like throwing a grain of sand at a car.

Question: You also got into an exchange with Dr. Leana Wen, CNN’s medical analyst, about mask wearing.

Answer: She obviously has a different opinion than I do. I think one of the biggest issues in the pandemic is the change in messaging and this idea that somehow people aren’t living their normal lives right now. I was sad to see her promote that concept.

This weekend I went out for lunch, I went furniture shopping, I went to the movies, I took a hike. My family and I wear masks everywhere. I fail to understand how wearing a mask means you’re not living a normal life when it’s clearly linked with the reduced spread of the virus.

Almost everything in medicine is about risk reduction. You can do things to lower your risk of heart disease. It’s not 100% guaranteed, but wouldn’t we want a lower risk of bad things? I’m going to keep wearing a mask forever!

Question: Do you wish more doctors were more vocal like you?

Answer: I wish more doctors would have conversations about health outside of the office in ways they’re comfortable with. Like, you’re at the hairdresser and you share information, or you share information with 15 of your Facebook friends. If you’re a doctor and post an article about COVID-19 and how it impacts the heart, your 15 friends are more likely to read that article than if your friend who’s a lawyer puts that up.

As doctors, I believe we can often influence people in big and small ways.

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

Jen Gunter, MD, refuses to stay silent when she sees misleading claims about women’s health products.

In fact, the world’s most famous – and outspoken – ob.gyn. (as described by The Guardian), is on a social media mission to speak up whenever she sees companies or governments “prey on women’s health and vaginal shame.”

With nearly 400,000 followers, Dr. Gunter never shies away from a controversy.

Recently, she railed against vitamin and supplement maker Olly’s vaginal probiotic, taking the company to task for its product premise and objectionable ad copy.

This news organization caught up with the San Francisco–based doctor and author of two books, “The Vagina Bible” and “The Menopause Manifesto.” The following interview has been lightly edited for length and clarity.

Question: So these Olly capsules purport to be “Probiotics for Your Panty Hamster.” What was your reaction to this?

Answer: Seeing the word “panty hamsters” is so egregious. I’m so used to baseline vaginal opportunism, but this was just absolutely egregious and I had to call it out.

Question: What are vaginal probiotics anyway?

Answer: These are one of these big wellness scams where companies try to sell you on somehow hacking your microbiome by taking them. They’re not inexpensive, either, and can range in price from $30 to $150 per month, depending on how bespoke they are. And yet the data isn’t good. There is little to no evidence of the value of these probiotics except to shareholders.

Question: What’s one claim made in the Olly probiotic packaging that bothers you the most?

Answer: The product claims to balance the vaginal pH. To say that is a gross misunderstanding of the vaginal ecosystem. If that tagline is what you’re leading with, what else don’t you know?

Also, if these things worked, we’d recommend them. Vaginitis is complex and often misdiagnosed, and it’s easy for a company to be predatory and swoop in and say they have a product for you.

If I think your product for the vagina is awful and you have not studied it in at least one quality clinical trial (never mind company-funded or not), and your marketing displays a stunning ignorance about vaginal health, don’t approach me about your product. Really.

Question: When there’s a pop culture reference to, say, menstruation, you’re quick to weigh in.

Answer: I saw these viral messages from a boy mom (that’s what she called herself) where she wrote about being disgusted that there were mentions of periods in Turning Red, the animated movie.

Everything is here because of menstruation. If you didn’t menstruate, you wouldn’t have a kid, we wouldn’t have the person who had the intelligence to build the computer you’re spreading this message on. Menstruation is a vital part of human reproduction, and it’s far more complex than people think. For that reason alone, people should know about it.

Question: Do you ever get worried about being so “out there” on social media?

Answer: I have my stalkers I suppose, but the trolls don’t bother me. I don’t care if some whatever art dealer in New York thinks I have mental illness for promoting masks. That’s the best you’ve got? Honestly, this doesn’t even register with me. It’s like throwing a grain of sand at a car.

Question: You also got into an exchange with Dr. Leana Wen, CNN’s medical analyst, about mask wearing.

Answer: She obviously has a different opinion than I do. I think one of the biggest issues in the pandemic is the change in messaging and this idea that somehow people aren’t living their normal lives right now. I was sad to see her promote that concept.

This weekend I went out for lunch, I went furniture shopping, I went to the movies, I took a hike. My family and I wear masks everywhere. I fail to understand how wearing a mask means you’re not living a normal life when it’s clearly linked with the reduced spread of the virus.

Almost everything in medicine is about risk reduction. You can do things to lower your risk of heart disease. It’s not 100% guaranteed, but wouldn’t we want a lower risk of bad things? I’m going to keep wearing a mask forever!

Question: Do you wish more doctors were more vocal like you?

Answer: I wish more doctors would have conversations about health outside of the office in ways they’re comfortable with. Like, you’re at the hairdresser and you share information, or you share information with 15 of your Facebook friends. If you’re a doctor and post an article about COVID-19 and how it impacts the heart, your 15 friends are more likely to read that article than if your friend who’s a lawyer puts that up.

As doctors, I believe we can often influence people in big and small ways.

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

Jen Gunter, MD, refuses to stay silent when she sees misleading claims about women’s health products.

In fact, the world’s most famous – and outspoken – ob.gyn. (as described by The Guardian), is on a social media mission to speak up whenever she sees companies or governments “prey on women’s health and vaginal shame.”

With nearly 400,000 followers, Dr. Gunter never shies away from a controversy.

Recently, she railed against vitamin and supplement maker Olly’s vaginal probiotic, taking the company to task for its product premise and objectionable ad copy.

This news organization caught up with the San Francisco–based doctor and author of two books, “The Vagina Bible” and “The Menopause Manifesto.” The following interview has been lightly edited for length and clarity.

Question: So these Olly capsules purport to be “Probiotics for Your Panty Hamster.” What was your reaction to this?

Answer: Seeing the word “panty hamsters” is so egregious. I’m so used to baseline vaginal opportunism, but this was just absolutely egregious and I had to call it out.

Question: What are vaginal probiotics anyway?

Answer: These are one of these big wellness scams where companies try to sell you on somehow hacking your microbiome by taking them. They’re not inexpensive, either, and can range in price from $30 to $150 per month, depending on how bespoke they are. And yet the data isn’t good. There is little to no evidence of the value of these probiotics except to shareholders.

Question: What’s one claim made in the Olly probiotic packaging that bothers you the most?

Answer: The product claims to balance the vaginal pH. To say that is a gross misunderstanding of the vaginal ecosystem. If that tagline is what you’re leading with, what else don’t you know?

Also, if these things worked, we’d recommend them. Vaginitis is complex and often misdiagnosed, and it’s easy for a company to be predatory and swoop in and say they have a product for you.

If I think your product for the vagina is awful and you have not studied it in at least one quality clinical trial (never mind company-funded or not), and your marketing displays a stunning ignorance about vaginal health, don’t approach me about your product. Really.

Question: When there’s a pop culture reference to, say, menstruation, you’re quick to weigh in.

Answer: I saw these viral messages from a boy mom (that’s what she called herself) where she wrote about being disgusted that there were mentions of periods in Turning Red, the animated movie.

Everything is here because of menstruation. If you didn’t menstruate, you wouldn’t have a kid, we wouldn’t have the person who had the intelligence to build the computer you’re spreading this message on. Menstruation is a vital part of human reproduction, and it’s far more complex than people think. For that reason alone, people should know about it.

Question: Do you ever get worried about being so “out there” on social media?

Answer: I have my stalkers I suppose, but the trolls don’t bother me. I don’t care if some whatever art dealer in New York thinks I have mental illness for promoting masks. That’s the best you’ve got? Honestly, this doesn’t even register with me. It’s like throwing a grain of sand at a car.

Question: You also got into an exchange with Dr. Leana Wen, CNN’s medical analyst, about mask wearing.

Answer: She obviously has a different opinion than I do. I think one of the biggest issues in the pandemic is the change in messaging and this idea that somehow people aren’t living their normal lives right now. I was sad to see her promote that concept.

This weekend I went out for lunch, I went furniture shopping, I went to the movies, I took a hike. My family and I wear masks everywhere. I fail to understand how wearing a mask means you’re not living a normal life when it’s clearly linked with the reduced spread of the virus.

Almost everything in medicine is about risk reduction. You can do things to lower your risk of heart disease. It’s not 100% guaranteed, but wouldn’t we want a lower risk of bad things? I’m going to keep wearing a mask forever!

Question: Do you wish more doctors were more vocal like you?

Answer: I wish more doctors would have conversations about health outside of the office in ways they’re comfortable with. Like, you’re at the hairdresser and you share information, or you share information with 15 of your Facebook friends. If you’re a doctor and post an article about COVID-19 and how it impacts the heart, your 15 friends are more likely to read that article than if your friend who’s a lawyer puts that up.

As doctors, I believe we can often influence people in big and small ways.

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

Children prenatally exposed to opioids alone have an increased risk of attention-deficit/hyperactivity disorder (ADHD), but interactions between opioids and both cannabis use and alcohol use were linked to varying levels of ADHD risk as well, according to findings published March 11 in JAMA Network Open.

While many prenatal exposure studies examine associations with one substance, the results of this case-control study “suggest that it is important to consider prenatal exposure to multiple substances and the interactions between these substances when counseling women regarding substance use during pregnancy,” wrote Henri M. Garrison-Desany of the Johns Hopkins University, Baltimore, and colleagues.

Using data from children in the prospective Boston Birth Cohort between 1998 and 2019, the researchers did a secondary analysis on the 3,138 children (50.4% of whom were male) with at least 2 years of follow-up, excluding children from multiple-gestation pregnancies, in vitro fertilization pregnancies, and deliveries involving major maternal trauma or major chromosomal anomalies. Mothers answered a questionnaire within 24-72 hours of delivery regarding their demographics, substance use, pregnancy history, and health status. Among the mothers, 58.6% were Black, 22.3% were Hispanic, 7.2% were White, 1.5% were Asian, and 10.4% were other races/ethnicities.

The children’s electronic medical records were used to identify those with ADHD diagnoses. The researchers did not assess prescription opioid exposure during pregnancy, but they based opioid exposure on mothers’ reports of recreationally using heroin or oxycodone, mothers’ reports of receiving methadone treatment, or a newborn diagnosis of neonatal abstinence syndrome or neonatal opioid withdrawal syndrome.

Just under a quarter of the women (24.2%) reported using at least one substance during pregnancy. After tobacco smoking (18.5%), the next most reported substances were alcohol (8.1%), cannabis (3.9%), and opioids (1.9%). With a median 12 years of follow-up, 15.5% of the children had been diagnosed with ADHD, most of whom (71.6%) were male.

Before considering interaction of different substances, children exposed to opioids had a little over twice the risk of ADHD (hazard ratio [HR], 2.19) compared to those with no prenatal substance exposure. Although neither cannabis nor alcohol was independently associated with ADHD, smoking had a 40% increased risk, and researchers found a 21% increase in risk of ADHD with each additional substance mothers used during pregnancy. The researchers had adjusted these findings for maternal age, race/ethnicity, marital status, educational level, annual household income, parity, number of perinatal visits, and general stress during pregnancy, based on a structured interview.

When the researchers considered all the substances together, opioid exposure increased risk of ADHD by 60% (HR, 1.6), opioids with cannabis increased risk by 42%, opioids with alcohol increased risk by 15%, and opioids with smoking increased risk by 17%.

”Our findings suggest opioids may interact with other substances (including cannabis), which may be particularly deleterious,” the researchers reported. “It is not clear whether this interaction is owing to biological or environmental factors, such as whether individuals with illicit polysubstance use are more likely to use more substances or whether they have other characteristics that may impact child development.”

The authors noted that cannabis exposure has been linked to other neurodevelopmental outcomes, including reduced executive and motor function in infants. ”Notably, although we did not find a significant independent association between cannabis exposure and ADHD, children exposed to both cannabis and opioids had a 23% greater risk than expected from either exposure individually,” they reported.

The researchers suggest that their findings provide data for considering harm reduction approaches that reduce use of any single substance during pregnancy. “Focusing on the most obviously harmful exposures may be a useful way to reduce the risk of ADHD,” they wrote. “Further work is needed to directly investigate this hypothesis and examine whether reduction in the use of any substance among those with polysubstance use could be acceptable compared with abstinence.”

In an invited commentary, Angela Lupattelli, PhD, and Nhung T. H. Trinh, PhD, both of the department of pharmacy at the University of Oslo, noted the methodological challenges of assessing exposures and associations from multiple different substances during pregnancy.

“First, how can we disentangle the consequences of individual and/or combined substance exposures during pregnancy from the underlying risks?” they asked. In addition to differences in baseline characteristic between those who use opioids or cannabis, Dr. Lupattelli and Dr. Trinh noted that other important unmeasured factors, such as genetics and family environment, may confound the effect size estimates for ADHD.

They also noted the need to consider intensity, dose, duration, and timing of substance use during pregnancy.

“Understanding the longer-term safety of substance use during pregnancy is paramount to inform prevention policy and shape counseling strategies. Observational studies, despite their limitations, are a necessary piece of the puzzle,” they wrote. “However, the study findings should be interpreted with caution, as the use of advanced analytical methods cannot overcome the unavailability of some important confounding factors and exposure information.”

The research was funded by the U.S. Department of Health and Human Services and the National Institutes of Health. The authors had no industry-related disclosures.

Children prenatally exposed to opioids alone have an increased risk of attention-deficit/hyperactivity disorder (ADHD), but interactions between opioids and both cannabis use and alcohol use were linked to varying levels of ADHD risk as well, according to findings published March 11 in JAMA Network Open.

While many prenatal exposure studies examine associations with one substance, the results of this case-control study “suggest that it is important to consider prenatal exposure to multiple substances and the interactions between these substances when counseling women regarding substance use during pregnancy,” wrote Henri M. Garrison-Desany of the Johns Hopkins University, Baltimore, and colleagues.

Using data from children in the prospective Boston Birth Cohort between 1998 and 2019, the researchers did a secondary analysis on the 3,138 children (50.4% of whom were male) with at least 2 years of follow-up, excluding children from multiple-gestation pregnancies, in vitro fertilization pregnancies, and deliveries involving major maternal trauma or major chromosomal anomalies. Mothers answered a questionnaire within 24-72 hours of delivery regarding their demographics, substance use, pregnancy history, and health status. Among the mothers, 58.6% were Black, 22.3% were Hispanic, 7.2% were White, 1.5% were Asian, and 10.4% were other races/ethnicities.

The children’s electronic medical records were used to identify those with ADHD diagnoses. The researchers did not assess prescription opioid exposure during pregnancy, but they based opioid exposure on mothers’ reports of recreationally using heroin or oxycodone, mothers’ reports of receiving methadone treatment, or a newborn diagnosis of neonatal abstinence syndrome or neonatal opioid withdrawal syndrome.

Just under a quarter of the women (24.2%) reported using at least one substance during pregnancy. After tobacco smoking (18.5%), the next most reported substances were alcohol (8.1%), cannabis (3.9%), and opioids (1.9%). With a median 12 years of follow-up, 15.5% of the children had been diagnosed with ADHD, most of whom (71.6%) were male.

Before considering interaction of different substances, children exposed to opioids had a little over twice the risk of ADHD (hazard ratio [HR], 2.19) compared to those with no prenatal substance exposure. Although neither cannabis nor alcohol was independently associated with ADHD, smoking had a 40% increased risk, and researchers found a 21% increase in risk of ADHD with each additional substance mothers used during pregnancy. The researchers had adjusted these findings for maternal age, race/ethnicity, marital status, educational level, annual household income, parity, number of perinatal visits, and general stress during pregnancy, based on a structured interview.

When the researchers considered all the substances together, opioid exposure increased risk of ADHD by 60% (HR, 1.6), opioids with cannabis increased risk by 42%, opioids with alcohol increased risk by 15%, and opioids with smoking increased risk by 17%.

”Our findings suggest opioids may interact with other substances (including cannabis), which may be particularly deleterious,” the researchers reported. “It is not clear whether this interaction is owing to biological or environmental factors, such as whether individuals with illicit polysubstance use are more likely to use more substances or whether they have other characteristics that may impact child development.”

The authors noted that cannabis exposure has been linked to other neurodevelopmental outcomes, including reduced executive and motor function in infants. ”Notably, although we did not find a significant independent association between cannabis exposure and ADHD, children exposed to both cannabis and opioids had a 23% greater risk than expected from either exposure individually,” they reported.

The researchers suggest that their findings provide data for considering harm reduction approaches that reduce use of any single substance during pregnancy. “Focusing on the most obviously harmful exposures may be a useful way to reduce the risk of ADHD,” they wrote. “Further work is needed to directly investigate this hypothesis and examine whether reduction in the use of any substance among those with polysubstance use could be acceptable compared with abstinence.”

In an invited commentary, Angela Lupattelli, PhD, and Nhung T. H. Trinh, PhD, both of the department of pharmacy at the University of Oslo, noted the methodological challenges of assessing exposures and associations from multiple different substances during pregnancy.

“First, how can we disentangle the consequences of individual and/or combined substance exposures during pregnancy from the underlying risks?” they asked. In addition to differences in baseline characteristic between those who use opioids or cannabis, Dr. Lupattelli and Dr. Trinh noted that other important unmeasured factors, such as genetics and family environment, may confound the effect size estimates for ADHD.

They also noted the need to consider intensity, dose, duration, and timing of substance use during pregnancy.

“Understanding the longer-term safety of substance use during pregnancy is paramount to inform prevention policy and shape counseling strategies. Observational studies, despite their limitations, are a necessary piece of the puzzle,” they wrote. “However, the study findings should be interpreted with caution, as the use of advanced analytical methods cannot overcome the unavailability of some important confounding factors and exposure information.”

The research was funded by the U.S. Department of Health and Human Services and the National Institutes of Health. The authors had no industry-related disclosures.

Children prenatally exposed to opioids alone have an increased risk of attention-deficit/hyperactivity disorder (ADHD), but interactions between opioids and both cannabis use and alcohol use were linked to varying levels of ADHD risk as well, according to findings published March 11 in JAMA Network Open.

While many prenatal exposure studies examine associations with one substance, the results of this case-control study “suggest that it is important to consider prenatal exposure to multiple substances and the interactions between these substances when counseling women regarding substance use during pregnancy,” wrote Henri M. Garrison-Desany of the Johns Hopkins University, Baltimore, and colleagues.

Using data from children in the prospective Boston Birth Cohort between 1998 and 2019, the researchers did a secondary analysis on the 3,138 children (50.4% of whom were male) with at least 2 years of follow-up, excluding children from multiple-gestation pregnancies, in vitro fertilization pregnancies, and deliveries involving major maternal trauma or major chromosomal anomalies. Mothers answered a questionnaire within 24-72 hours of delivery regarding their demographics, substance use, pregnancy history, and health status. Among the mothers, 58.6% were Black, 22.3% were Hispanic, 7.2% were White, 1.5% were Asian, and 10.4% were other races/ethnicities.

The children’s electronic medical records were used to identify those with ADHD diagnoses. The researchers did not assess prescription opioid exposure during pregnancy, but they based opioid exposure on mothers’ reports of recreationally using heroin or oxycodone, mothers’ reports of receiving methadone treatment, or a newborn diagnosis of neonatal abstinence syndrome or neonatal opioid withdrawal syndrome.

Just under a quarter of the women (24.2%) reported using at least one substance during pregnancy. After tobacco smoking (18.5%), the next most reported substances were alcohol (8.1%), cannabis (3.9%), and opioids (1.9%). With a median 12 years of follow-up, 15.5% of the children had been diagnosed with ADHD, most of whom (71.6%) were male.

Before considering interaction of different substances, children exposed to opioids had a little over twice the risk of ADHD (hazard ratio [HR], 2.19) compared to those with no prenatal substance exposure. Although neither cannabis nor alcohol was independently associated with ADHD, smoking had a 40% increased risk, and researchers found a 21% increase in risk of ADHD with each additional substance mothers used during pregnancy. The researchers had adjusted these findings for maternal age, race/ethnicity, marital status, educational level, annual household income, parity, number of perinatal visits, and general stress during pregnancy, based on a structured interview.

When the researchers considered all the substances together, opioid exposure increased risk of ADHD by 60% (HR, 1.6), opioids with cannabis increased risk by 42%, opioids with alcohol increased risk by 15%, and opioids with smoking increased risk by 17%.

”Our findings suggest opioids may interact with other substances (including cannabis), which may be particularly deleterious,” the researchers reported. “It is not clear whether this interaction is owing to biological or environmental factors, such as whether individuals with illicit polysubstance use are more likely to use more substances or whether they have other characteristics that may impact child development.”

The authors noted that cannabis exposure has been linked to other neurodevelopmental outcomes, including reduced executive and motor function in infants. ”Notably, although we did not find a significant independent association between cannabis exposure and ADHD, children exposed to both cannabis and opioids had a 23% greater risk than expected from either exposure individually,” they reported.

The researchers suggest that their findings provide data for considering harm reduction approaches that reduce use of any single substance during pregnancy. “Focusing on the most obviously harmful exposures may be a useful way to reduce the risk of ADHD,” they wrote. “Further work is needed to directly investigate this hypothesis and examine whether reduction in the use of any substance among those with polysubstance use could be acceptable compared with abstinence.”

In an invited commentary, Angela Lupattelli, PhD, and Nhung T. H. Trinh, PhD, both of the department of pharmacy at the University of Oslo, noted the methodological challenges of assessing exposures and associations from multiple different substances during pregnancy.

“First, how can we disentangle the consequences of individual and/or combined substance exposures during pregnancy from the underlying risks?” they asked. In addition to differences in baseline characteristic between those who use opioids or cannabis, Dr. Lupattelli and Dr. Trinh noted that other important unmeasured factors, such as genetics and family environment, may confound the effect size estimates for ADHD.

They also noted the need to consider intensity, dose, duration, and timing of substance use during pregnancy.

“Understanding the longer-term safety of substance use during pregnancy is paramount to inform prevention policy and shape counseling strategies. Observational studies, despite their limitations, are a necessary piece of the puzzle,” they wrote. “However, the study findings should be interpreted with caution, as the use of advanced analytical methods cannot overcome the unavailability of some important confounding factors and exposure information.”

The research was funded by the U.S. Department of Health and Human Services and the National Institutes of Health. The authors had no industry-related disclosures.

Breast cancer screening modality has less effect on the probability of false-positive results than screening interval, patient age, and breast density according to a new study comparing digital breast tomosynthesis (DBT) with digital mammography.

Although DBT was associated with a modest improvement in recalls for false-positive results compared with mammography, about half of women in both groups received at least one false-positive result over a 10-year period of annual screening, reported senior author Diana L. Miglioretti, PhD, from the University of California, Davis, and colleagues.

By contrast, the authors reported “substantial reductions” in false-positive recalls with biennial screening. Specifically, while annual mammography and DBT resulted in cumulative 10-year false-positive recall rates of 56.3% and 49.6% respectively, biennial rates were 38.1% and 35.7%.

The comparative effectiveness study, published in JAMA Network Open, included 903,495 women who underwent 10 years of breast cancer screening at 126 radiology facilities in the Breast Cancer Surveillance Consortium. The mean age of participants was 57.6 years, and 46% of them had dense breasts. A total of 2,969,055 screening exams were performed (15% DBT), with each woman receiving a mean of 3.3 exams over 10 years. Most participants (71.8%) had annual exams, while 16.8% had biennial, with the remainder being performed at intervals of 3 years or more.

Investigators looked at the cumulative rate of three kinds of false-positive results over 10 years: false-positive recalls for further imaging, false-positive short-interval follow-up recommendations, and false-positive biopsy recommendations. A result was considered false positive if there was no diagnosis of invasive carcinoma or ductal carcinoma in situ within 1 year of the screening examination and before the next screening examination.

Overall, across all screening intervals, and after adjusting for age and breast density, the percentage of false-positive results was slightly lower for DBT vs. mammography: 7.6% vs. 9.0%, respectively, for false-positive recalls; 1.8% vs. 2.1%, respectively, for false-positive short-interval follow-up recommendations; and 1.1% vs. 1.2% for false-positive biopsy recommendations. “We did not observe consistent clinically meaningful differences in the cumulative probabilities of false-positive short-interval follow-up or biopsy recommendation by screening modality,” they noted, adding that, although DBT provided “modest” reductions in false-positive recalls, compared with mammography (2.4% less for biennial screening and 6.7% less for annual screening), “nonetheless, this percentage equates to many thousands of individuals in absolute numbers, especially for annual screening, which is the dominant practice in the U.S.”

The authors also noted that, regardless of screening modality, all three types of false-positive results were substantially lower for biennial versus annual mammograph, and depended on age and breast density. The highest cumulative rates of false-positive results occurred in women aged 40-49 years (68.0% with annual digital mammography and 60.8% with annual DBT). Women with extremely dense breasts had the highest probability of all three types of false positive, which “may be due to the lack of interspersed fat within dense fibroglandular tissue, with the contrast between the fat and tissue being a requirement for more accurate detection of suspicious features by interpreting radiologists.”

The study findings “offer new information about the potential harms of repeated screening, which may be used to inform screening guidelines and decision-making between individuals and their physicians. However, it is important to weigh these and other potential harms with potential benefits of earlier diagnosis. … Women at high risk of an advanced cancer under biennial screening, including some women with dense breasts, may reduce their risk with annual screening,” they suggested.

Although DBT is now widely used in the United States, amid growing optimism about its superiority over digital mammography, this study reminds clinicians to counsel patients appropriately, according to Lydia E. Pace, MD, from Brigham and Women’s Hospital in Boston. “Unfortunately, the growing availability of DBT does not substantially change the likelihood that women will experience a false-positive result over years of regular mammograms,” she wrote in an invited commentary published with the study. She noted that, although many women tolerate false-positive results, “they are associated with at least transient anxiety as well as time, inconvenience, and expense. More information is needed to understand the association of DBT with overdiagnosis, which is the more clinically important harm of screening.”

The study was funded by the National Cancer Institute. Dr. Miglioretti and Dr. Pace reported no conflicts of interest. One coauthor of the study is an unpaid consultant for Grail, for the STRIVE study, and another coauthor receives personal fees from Grail for work on a data safety monitoring board. No other disclosures were reported.

Breast cancer screening modality has less effect on the probability of false-positive results than screening interval, patient age, and breast density according to a new study comparing digital breast tomosynthesis (DBT) with digital mammography.

Although DBT was associated with a modest improvement in recalls for false-positive results compared with mammography, about half of women in both groups received at least one false-positive result over a 10-year period of annual screening, reported senior author Diana L. Miglioretti, PhD, from the University of California, Davis, and colleagues.

By contrast, the authors reported “substantial reductions” in false-positive recalls with biennial screening. Specifically, while annual mammography and DBT resulted in cumulative 10-year false-positive recall rates of 56.3% and 49.6% respectively, biennial rates were 38.1% and 35.7%.

The comparative effectiveness study, published in JAMA Network Open, included 903,495 women who underwent 10 years of breast cancer screening at 126 radiology facilities in the Breast Cancer Surveillance Consortium. The mean age of participants was 57.6 years, and 46% of them had dense breasts. A total of 2,969,055 screening exams were performed (15% DBT), with each woman receiving a mean of 3.3 exams over 10 years. Most participants (71.8%) had annual exams, while 16.8% had biennial, with the remainder being performed at intervals of 3 years or more.

Investigators looked at the cumulative rate of three kinds of false-positive results over 10 years: false-positive recalls for further imaging, false-positive short-interval follow-up recommendations, and false-positive biopsy recommendations. A result was considered false positive if there was no diagnosis of invasive carcinoma or ductal carcinoma in situ within 1 year of the screening examination and before the next screening examination.

Overall, across all screening intervals, and after adjusting for age and breast density, the percentage of false-positive results was slightly lower for DBT vs. mammography: 7.6% vs. 9.0%, respectively, for false-positive recalls; 1.8% vs. 2.1%, respectively, for false-positive short-interval follow-up recommendations; and 1.1% vs. 1.2% for false-positive biopsy recommendations. “We did not observe consistent clinically meaningful differences in the cumulative probabilities of false-positive short-interval follow-up or biopsy recommendation by screening modality,” they noted, adding that, although DBT provided “modest” reductions in false-positive recalls, compared with mammography (2.4% less for biennial screening and 6.7% less for annual screening), “nonetheless, this percentage equates to many thousands of individuals in absolute numbers, especially for annual screening, which is the dominant practice in the U.S.”

The authors also noted that, regardless of screening modality, all three types of false-positive results were substantially lower for biennial versus annual mammograph, and depended on age and breast density. The highest cumulative rates of false-positive results occurred in women aged 40-49 years (68.0% with annual digital mammography and 60.8% with annual DBT). Women with extremely dense breasts had the highest probability of all three types of false positive, which “may be due to the lack of interspersed fat within dense fibroglandular tissue, with the contrast between the fat and tissue being a requirement for more accurate detection of suspicious features by interpreting radiologists.”

The study findings “offer new information about the potential harms of repeated screening, which may be used to inform screening guidelines and decision-making between individuals and their physicians. However, it is important to weigh these and other potential harms with potential benefits of earlier diagnosis. … Women at high risk of an advanced cancer under biennial screening, including some women with dense breasts, may reduce their risk with annual screening,” they suggested.

Although DBT is now widely used in the United States, amid growing optimism about its superiority over digital mammography, this study reminds clinicians to counsel patients appropriately, according to Lydia E. Pace, MD, from Brigham and Women’s Hospital in Boston. “Unfortunately, the growing availability of DBT does not substantially change the likelihood that women will experience a false-positive result over years of regular mammograms,” she wrote in an invited commentary published with the study. She noted that, although many women tolerate false-positive results, “they are associated with at least transient anxiety as well as time, inconvenience, and expense. More information is needed to understand the association of DBT with overdiagnosis, which is the more clinically important harm of screening.”

The study was funded by the National Cancer Institute. Dr. Miglioretti and Dr. Pace reported no conflicts of interest. One coauthor of the study is an unpaid consultant for Grail, for the STRIVE study, and another coauthor receives personal fees from Grail for work on a data safety monitoring board. No other disclosures were reported.

Breast cancer screening modality has less effect on the probability of false-positive results than screening interval, patient age, and breast density according to a new study comparing digital breast tomosynthesis (DBT) with digital mammography.

Although DBT was associated with a modest improvement in recalls for false-positive results compared with mammography, about half of women in both groups received at least one false-positive result over a 10-year period of annual screening, reported senior author Diana L. Miglioretti, PhD, from the University of California, Davis, and colleagues.

By contrast, the authors reported “substantial reductions” in false-positive recalls with biennial screening. Specifically, while annual mammography and DBT resulted in cumulative 10-year false-positive recall rates of 56.3% and 49.6% respectively, biennial rates were 38.1% and 35.7%.

The comparative effectiveness study, published in JAMA Network Open, included 903,495 women who underwent 10 years of breast cancer screening at 126 radiology facilities in the Breast Cancer Surveillance Consortium. The mean age of participants was 57.6 years, and 46% of them had dense breasts. A total of 2,969,055 screening exams were performed (15% DBT), with each woman receiving a mean of 3.3 exams over 10 years. Most participants (71.8%) had annual exams, while 16.8% had biennial, with the remainder being performed at intervals of 3 years or more.

Investigators looked at the cumulative rate of three kinds of false-positive results over 10 years: false-positive recalls for further imaging, false-positive short-interval follow-up recommendations, and false-positive biopsy recommendations. A result was considered false positive if there was no diagnosis of invasive carcinoma or ductal carcinoma in situ within 1 year of the screening examination and before the next screening examination.

Overall, across all screening intervals, and after adjusting for age and breast density, the percentage of false-positive results was slightly lower for DBT vs. mammography: 7.6% vs. 9.0%, respectively, for false-positive recalls; 1.8% vs. 2.1%, respectively, for false-positive short-interval follow-up recommendations; and 1.1% vs. 1.2% for false-positive biopsy recommendations. “We did not observe consistent clinically meaningful differences in the cumulative probabilities of false-positive short-interval follow-up or biopsy recommendation by screening modality,” they noted, adding that, although DBT provided “modest” reductions in false-positive recalls, compared with mammography (2.4% less for biennial screening and 6.7% less for annual screening), “nonetheless, this percentage equates to many thousands of individuals in absolute numbers, especially for annual screening, which is the dominant practice in the U.S.”

The authors also noted that, regardless of screening modality, all three types of false-positive results were substantially lower for biennial versus annual mammograph, and depended on age and breast density. The highest cumulative rates of false-positive results occurred in women aged 40-49 years (68.0% with annual digital mammography and 60.8% with annual DBT). Women with extremely dense breasts had the highest probability of all three types of false positive, which “may be due to the lack of interspersed fat within dense fibroglandular tissue, with the contrast between the fat and tissue being a requirement for more accurate detection of suspicious features by interpreting radiologists.”

The study findings “offer new information about the potential harms of repeated screening, which may be used to inform screening guidelines and decision-making between individuals and their physicians. However, it is important to weigh these and other potential harms with potential benefits of earlier diagnosis. … Women at high risk of an advanced cancer under biennial screening, including some women with dense breasts, may reduce their risk with annual screening,” they suggested.

Although DBT is now widely used in the United States, amid growing optimism about its superiority over digital mammography, this study reminds clinicians to counsel patients appropriately, according to Lydia E. Pace, MD, from Brigham and Women’s Hospital in Boston. “Unfortunately, the growing availability of DBT does not substantially change the likelihood that women will experience a false-positive result over years of regular mammograms,” she wrote in an invited commentary published with the study. She noted that, although many women tolerate false-positive results, “they are associated with at least transient anxiety as well as time, inconvenience, and expense. More information is needed to understand the association of DBT with overdiagnosis, which is the more clinically important harm of screening.”

The study was funded by the National Cancer Institute. Dr. Miglioretti and Dr. Pace reported no conflicts of interest. One coauthor of the study is an unpaid consultant for Grail, for the STRIVE study, and another coauthor receives personal fees from Grail for work on a data safety monitoring board. No other disclosures were reported.

Pediatric care centers are a significant point of access for intimate partner violence referrals, according to data from an IPV prevention program embedded in Boston Children’s Hospital.

The pediatric hospital’s embedded Advocacy for Women and Kids in Emergencies (AWAKE) program found an increase in IPV consults and referrals during the COVID-19 pandemic, particularly for emotional abuse. Despite the shift away from in-office consultations, care was effectively delivered remotely by telehealth.

The findings highlight the importance of pediatric primary care as a point of access for IPV survivor support, the authors concluded.

”Programming for survivors (including patients, family members, and staff) of intimate partner violence is critical in the pediatric hospital setting, especially during the COVID-19 pandemic,” Rehana Rahman, MSW, and colleagues wrote in Pediatrics.

Their results align with other research demonstrating an overall increase in violence against women and girls during the pandemic – a phenomenon the World Health Organization has called the “shadow pandemic.”

The challenges of accessing care during the COVID-19 restrictions demonstrate the utility of telehealth as a modality for providing assessment, support, and referrals, the authors stated.

They pointed to certain advantages in supporting IPV survivors virtually, including the ability to speak alone with the survivor, which is often not possible during in-person visits with children in the room.

Other research has documented that health care delivery via telemedicine, especially video teleconferencing, during the pandemic can be as effective as in-office visits. In fact, care providers may be able to pick up on significant visual cues on video that go unnoticed in the immediacy of the office setting.
 

The study

The researchers examined COVID-19–related variations in consultations and referrals in the 11 months before the COVID-19 pandemic (April 1, 2019, to Feb. 29, 2020) and those following its emergence (April 1, 2020, to Feb. 28, 2021).

Face-to-face consults declined from 28% to 2% (P < .001) after COVID-19 emergence, while total consults increased from 240 to 295 (P < .001), primarily for emotional abuse (from 195 to 264, P = .007).

There were no significant changes in the number of consults for other reasons or in the number of reasons recorded for each consult.

Psychoeducation referrals also rose significantly from 199 to 273 (P < .001), while referrals to community resources decreased significantly from 111 to 95 (P < .001).

Primary care was the only practice setting demonstrating significant differences in the overall number of and specific reasons for consultation, as well as associated referral types before and after COVID emergence.

“We hypothesize that this increase may be attributable to the fact that, although many survivors were at home with partners who use abusive behaviors, obligatory pediatric primary care visits may have been a rare opportunity for them to leave their residence and seek support,” the investigators wrote. “Our data support the importance of a domestic violence program in pediatric hospitals and suggest that such support be available as a standard part of care.”

They further suggested that support and assessment may be effective regardless of whether that care is performed face-to-face or via telehealth.
 

Commentary

An accompanying editorial noted that intimate partner violence affects one in five children and has profound health effects on survivors and their children.

“The health, economic, and social ramifications of the COVID-19 pandemic have created unique challenges for families experiencing IPV, by increasing isolation, decreasing available safe and secure services and spaces (e.g., schools), and compounding preexisting inequities, especially for families from marginalized communities,” wrote Maya Ragavan, MD, MS, MPH, and Elizabeth Miller, MD, PhD, of the department of pediatrics at the University of Pittsburgh.

They stressed that pediatric health care providers should be aware of the emotionally coercive control used by abusive partners during the pandemic, including social isolation, manipulating child custody, and taking stimulus money.

Dr. Ragavan and Dr. Miller agreed with the authors that pediatric health care settings can play an important role in supporting families exposed to intimate partner violence, particularly by developing partnerships with IPV aid agencies.

Many pediatric offices may not have access to a comprehensive service like AWAKE, highlighting the importance of developing partnerships with community-based IPV agencies, which have been working innovatively during the pandemic to support families experiencing IPV. “Pediatric health care providers should work to develop formalized partnerships with IPV agencies to assist with staff training, clinical protocols and policies to address IPV, including survivor-centered approaches to care when IPV is disclosed,” they wrote. “Health care settings must recognize that IPV agencies are integral to the pediatric medical home and essential collaborators in the provision of healing-centered care for IPV survivors and their children.”

Among these, Futures Without Violence, a national violence-prevention advocacy and policy organization, offers recommendations on collaboration via the IPV Health Partners website.

Matthew I. Harris, MD, a pediatric emergency physician at Cohen Children’s Medical Center in New York, concurred that the pediatric care setting can be an access point for IPV referrals. “Whether a child comes into our center with an ear infection or an injury, there’s a standard screening process for safety in the home,” he said in an interview. That standard filtering identifies the presence of smoking, alcohol, guns, and potential abusers. “It’s not uncommon that we discover violence or physical, verbal, or sexual abuse not only toward the child but also another family member, including IPV.”

Children’s hospitals are well positioned to identify at-risk families and refer them to appropriate protective services, Dr. Harris said. “Ultimately, we are charged with the responsibility of ensuring children have a safe home environment and that involves minimizing any harmful impact on other family members, including those exposed to IPV.”

The authors received no funding for this study and reported no competing interests. Dr. Ragavan had no relevant conflicts of interest to disclose. Dr. Miller reported royalties for writing content for UpToDate. Dr. Harris disclosed no competing interests.

This article was updated 3/25/22.

Pediatric care centers are a significant point of access for intimate partner violence referrals, according to data from an IPV prevention program embedded in Boston Children’s Hospital.

The pediatric hospital’s embedded Advocacy for Women and Kids in Emergencies (AWAKE) program found an increase in IPV consults and referrals during the COVID-19 pandemic, particularly for emotional abuse. Despite the shift away from in-office consultations, care was effectively delivered remotely by telehealth.

The findings highlight the importance of pediatric primary care as a point of access for IPV survivor support, the authors concluded.

”Programming for survivors (including patients, family members, and staff) of intimate partner violence is critical in the pediatric hospital setting, especially during the COVID-19 pandemic,” Rehana Rahman, MSW, and colleagues wrote in Pediatrics.

Their results align with other research demonstrating an overall increase in violence against women and girls during the pandemic – a phenomenon the World Health Organization has called the “shadow pandemic.”

The challenges of accessing care during the COVID-19 restrictions demonstrate the utility of telehealth as a modality for providing assessment, support, and referrals, the authors stated.

They pointed to certain advantages in supporting IPV survivors virtually, including the ability to speak alone with the survivor, which is often not possible during in-person visits with children in the room.

Other research has documented that health care delivery via telemedicine, especially video teleconferencing, during the pandemic can be as effective as in-office visits. In fact, care providers may be able to pick up on significant visual cues on video that go unnoticed in the immediacy of the office setting.
 

The study

The researchers examined COVID-19–related variations in consultations and referrals in the 11 months before the COVID-19 pandemic (April 1, 2019, to Feb. 29, 2020) and those following its emergence (April 1, 2020, to Feb. 28, 2021).

Face-to-face consults declined from 28% to 2% (P < .001) after COVID-19 emergence, while total consults increased from 240 to 295 (P < .001), primarily for emotional abuse (from 195 to 264, P = .007).

There were no significant changes in the number of consults for other reasons or in the number of reasons recorded for each consult.

Psychoeducation referrals also rose significantly from 199 to 273 (P < .001), while referrals to community resources decreased significantly from 111 to 95 (P < .001).

Primary care was the only practice setting demonstrating significant differences in the overall number of and specific reasons for consultation, as well as associated referral types before and after COVID emergence.

“We hypothesize that this increase may be attributable to the fact that, although many survivors were at home with partners who use abusive behaviors, obligatory pediatric primary care visits may have been a rare opportunity for them to leave their residence and seek support,” the investigators wrote. “Our data support the importance of a domestic violence program in pediatric hospitals and suggest that such support be available as a standard part of care.”

They further suggested that support and assessment may be effective regardless of whether that care is performed face-to-face or via telehealth.
 

Commentary

An accompanying editorial noted that intimate partner violence affects one in five children and has profound health effects on survivors and their children.

“The health, economic, and social ramifications of the COVID-19 pandemic have created unique challenges for families experiencing IPV, by increasing isolation, decreasing available safe and secure services and spaces (e.g., schools), and compounding preexisting inequities, especially for families from marginalized communities,” wrote Maya Ragavan, MD, MS, MPH, and Elizabeth Miller, MD, PhD, of the department of pediatrics at the University of Pittsburgh.

They stressed that pediatric health care providers should be aware of the emotionally coercive control used by abusive partners during the pandemic, including social isolation, manipulating child custody, and taking stimulus money.

Dr. Ragavan and Dr. Miller agreed with the authors that pediatric health care settings can play an important role in supporting families exposed to intimate partner violence, particularly by developing partnerships with IPV aid agencies.

Many pediatric offices may not have access to a comprehensive service like AWAKE, highlighting the importance of developing partnerships with community-based IPV agencies, which have been working innovatively during the pandemic to support families experiencing IPV. “Pediatric health care providers should work to develop formalized partnerships with IPV agencies to assist with staff training, clinical protocols and policies to address IPV, including survivor-centered approaches to care when IPV is disclosed,” they wrote. “Health care settings must recognize that IPV agencies are integral to the pediatric medical home and essential collaborators in the provision of healing-centered care for IPV survivors and their children.”

Among these, Futures Without Violence, a national violence-prevention advocacy and policy organization, offers recommendations on collaboration via the IPV Health Partners website.

Matthew I. Harris, MD, a pediatric emergency physician at Cohen Children’s Medical Center in New York, concurred that the pediatric care setting can be an access point for IPV referrals. “Whether a child comes into our center with an ear infection or an injury, there’s a standard screening process for safety in the home,” he said in an interview. That standard filtering identifies the presence of smoking, alcohol, guns, and potential abusers. “It’s not uncommon that we discover violence or physical, verbal, or sexual abuse not only toward the child but also another family member, including IPV.”

Children’s hospitals are well positioned to identify at-risk families and refer them to appropriate protective services, Dr. Harris said. “Ultimately, we are charged with the responsibility of ensuring children have a safe home environment and that involves minimizing any harmful impact on other family members, including those exposed to IPV.”

The authors received no funding for this study and reported no competing interests. Dr. Ragavan had no relevant conflicts of interest to disclose. Dr. Miller reported royalties for writing content for UpToDate. Dr. Harris disclosed no competing interests.

This article was updated 3/25/22.

Pediatric care centers are a significant point of access for intimate partner violence referrals, according to data from an IPV prevention program embedded in Boston Children’s Hospital.

The pediatric hospital’s embedded Advocacy for Women and Kids in Emergencies (AWAKE) program found an increase in IPV consults and referrals during the COVID-19 pandemic, particularly for emotional abuse. Despite the shift away from in-office consultations, care was effectively delivered remotely by telehealth.

The findings highlight the importance of pediatric primary care as a point of access for IPV survivor support, the authors concluded.

”Programming for survivors (including patients, family members, and staff) of intimate partner violence is critical in the pediatric hospital setting, especially during the COVID-19 pandemic,” Rehana Rahman, MSW, and colleagues wrote in Pediatrics.

Their results align with other research demonstrating an overall increase in violence against women and girls during the pandemic – a phenomenon the World Health Organization has called the “shadow pandemic.”

The challenges of accessing care during the COVID-19 restrictions demonstrate the utility of telehealth as a modality for providing assessment, support, and referrals, the authors stated.

They pointed to certain advantages in supporting IPV survivors virtually, including the ability to speak alone with the survivor, which is often not possible during in-person visits with children in the room.

Other research has documented that health care delivery via telemedicine, especially video teleconferencing, during the pandemic can be as effective as in-office visits. In fact, care providers may be able to pick up on significant visual cues on video that go unnoticed in the immediacy of the office setting.
 

The study

The researchers examined COVID-19–related variations in consultations and referrals in the 11 months before the COVID-19 pandemic (April 1, 2019, to Feb. 29, 2020) and those following its emergence (April 1, 2020, to Feb. 28, 2021).

Face-to-face consults declined from 28% to 2% (P < .001) after COVID-19 emergence, while total consults increased from 240 to 295 (P < .001), primarily for emotional abuse (from 195 to 264, P = .007).

There were no significant changes in the number of consults for other reasons or in the number of reasons recorded for each consult.

Psychoeducation referrals also rose significantly from 199 to 273 (P < .001), while referrals to community resources decreased significantly from 111 to 95 (P < .001).

Primary care was the only practice setting demonstrating significant differences in the overall number of and specific reasons for consultation, as well as associated referral types before and after COVID emergence.

“We hypothesize that this increase may be attributable to the fact that, although many survivors were at home with partners who use abusive behaviors, obligatory pediatric primary care visits may have been a rare opportunity for them to leave their residence and seek support,” the investigators wrote. “Our data support the importance of a domestic violence program in pediatric hospitals and suggest that such support be available as a standard part of care.”

They further suggested that support and assessment may be effective regardless of whether that care is performed face-to-face or via telehealth.
 

Commentary

An accompanying editorial noted that intimate partner violence affects one in five children and has profound health effects on survivors and their children.

“The health, economic, and social ramifications of the COVID-19 pandemic have created unique challenges for families experiencing IPV, by increasing isolation, decreasing available safe and secure services and spaces (e.g., schools), and compounding preexisting inequities, especially for families from marginalized communities,” wrote Maya Ragavan, MD, MS, MPH, and Elizabeth Miller, MD, PhD, of the department of pediatrics at the University of Pittsburgh.

They stressed that pediatric health care providers should be aware of the emotionally coercive control used by abusive partners during the pandemic, including social isolation, manipulating child custody, and taking stimulus money.

Dr. Ragavan and Dr. Miller agreed with the authors that pediatric health care settings can play an important role in supporting families exposed to intimate partner violence, particularly by developing partnerships with IPV aid agencies.

Many pediatric offices may not have access to a comprehensive service like AWAKE, highlighting the importance of developing partnerships with community-based IPV agencies, which have been working innovatively during the pandemic to support families experiencing IPV. “Pediatric health care providers should work to develop formalized partnerships with IPV agencies to assist with staff training, clinical protocols and policies to address IPV, including survivor-centered approaches to care when IPV is disclosed,” they wrote. “Health care settings must recognize that IPV agencies are integral to the pediatric medical home and essential collaborators in the provision of healing-centered care for IPV survivors and their children.”

Among these, Futures Without Violence, a national violence-prevention advocacy and policy organization, offers recommendations on collaboration via the IPV Health Partners website.

Matthew I. Harris, MD, a pediatric emergency physician at Cohen Children’s Medical Center in New York, concurred that the pediatric care setting can be an access point for IPV referrals. “Whether a child comes into our center with an ear infection or an injury, there’s a standard screening process for safety in the home,” he said in an interview. That standard filtering identifies the presence of smoking, alcohol, guns, and potential abusers. “It’s not uncommon that we discover violence or physical, verbal, or sexual abuse not only toward the child but also another family member, including IPV.”

Children’s hospitals are well positioned to identify at-risk families and refer them to appropriate protective services, Dr. Harris said. “Ultimately, we are charged with the responsibility of ensuring children have a safe home environment and that involves minimizing any harmful impact on other family members, including those exposed to IPV.”

The authors received no funding for this study and reported no competing interests. Dr. Ragavan had no relevant conflicts of interest to disclose. Dr. Miller reported royalties for writing content for UpToDate. Dr. Harris disclosed no competing interests.

This article was updated 3/25/22.

A French research team has developed a microRNA (miRNA) signature for diagnosing endometriosis through a simple saliva test. Its validation in a larger cohort could soon allow doctors to have a cheap, noninvasive, and accurate tool to use in diagnosing a disease that, for the time being, is difficult to identify with any certainty. The researchers suggest that their methodology could be used as a blueprint to investigate other pathologies, both benign and malignant.

ENDO-miRNA study

miRNAs regulate as much as 60% of gene expression at the posttranscriptional level. In the setting of endometriosis, several authors have evaluated the relevance of a blood-based miRNA signature, but the results are discordant because of methodological and control group issues. Other researchers have also sought to develop a miRNA saliva test. A French team wanted to determine whether it was possible to define a saliva-based diagnostic miRNome signature that would allow patients with and without endometriosis to be differentiated and, from there, develop the first specific diagnostic test for the disease.

The prospective ENDO-miRNA study included saliva samples obtained from women with chronic pelvic pain suggestive of endometriosis. Exploratory procedures were performed to look for lesions. All the patients underwent either a laparoscopic procedure (therapeutic or diagnostic laparoscopy) and/or MRI imaging. For the patients who underwent laparoscopy, diagnosis was confirmed by histology. For the patients diagnosed with endometriosis without laparoscopic evaluation, all had MRI imaging with features of deep endometriosis.

One part of the study involved the identification of a biomarker based on genomewide miRNA expression profiling by small RNA sequencing using next-generation sequencing. The second part involved the development of a saliva-based miRNA diagnostic signature according to expression and accuracy profiling using a random forest algorithm.
 

High sensitivity, specificity

Among the 200 patients (mean age, 31 years) enrolled in the study, 76.5% (n = 153) were diagnosed with endometriosis. On average, their pain was statistically more severe than that of the women in the control group. The Visual Analogue Scale (VAS) scores were, respectively: dysmenorrhea 6 versus 5.0 (P < .001), dyspareunia 5.28 versus 4.95 (P < .001), and urinary pain during menstruation 4.35 versus 2.84 (P < .001).

Next-generation sequencing identified an average of 2,561 expressed miRNAs in the saliva samples. The feature selection method generated a subset of 109 miRNAs composing the endometriosis diagnostic signature. Among those miRNAs, 29 were associated with the main signaling pathways of endometriosis: PI3K/AKT, PTEN, Wnt/beta-catenin, HIF1-alpha/NF kappa B, and YAP/TAZ/EGFR.

The accuracy and reproducibility of the signature were tested on several data sets randomly composed of the same proportion of controls and patients with endometriosis. The respective sensitivity, specificity, and area under the curve for the diagnostic miRNA signature were 96.7%, 100%, and 98.3%, respectively.

The study’s results support the use of a saliva-based miRNA signature for diagnosing whether a patient is discordant/complex (chronic pelvic pain suggestive of endometriosis and both negative clinical examination and imaging findings) or has early-stage or advanced-stage endometriosis.

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

A French research team has developed a microRNA (miRNA) signature for diagnosing endometriosis through a simple saliva test. Its validation in a larger cohort could soon allow doctors to have a cheap, noninvasive, and accurate tool to use in diagnosing a disease that, for the time being, is difficult to identify with any certainty. The researchers suggest that their methodology could be used as a blueprint to investigate other pathologies, both benign and malignant.

ENDO-miRNA study

miRNAs regulate as much as 60% of gene expression at the posttranscriptional level. In the setting of endometriosis, several authors have evaluated the relevance of a blood-based miRNA signature, but the results are discordant because of methodological and control group issues. Other researchers have also sought to develop a miRNA saliva test. A French team wanted to determine whether it was possible to define a saliva-based diagnostic miRNome signature that would allow patients with and without endometriosis to be differentiated and, from there, develop the first specific diagnostic test for the disease.

The prospective ENDO-miRNA study included saliva samples obtained from women with chronic pelvic pain suggestive of endometriosis. Exploratory procedures were performed to look for lesions. All the patients underwent either a laparoscopic procedure (therapeutic or diagnostic laparoscopy) and/or MRI imaging. For the patients who underwent laparoscopy, diagnosis was confirmed by histology. For the patients diagnosed with endometriosis without laparoscopic evaluation, all had MRI imaging with features of deep endometriosis.

One part of the study involved the identification of a biomarker based on genomewide miRNA expression profiling by small RNA sequencing using next-generation sequencing. The second part involved the development of a saliva-based miRNA diagnostic signature according to expression and accuracy profiling using a random forest algorithm.
 

High sensitivity, specificity

Among the 200 patients (mean age, 31 years) enrolled in the study, 76.5% (n = 153) were diagnosed with endometriosis. On average, their pain was statistically more severe than that of the women in the control group. The Visual Analogue Scale (VAS) scores were, respectively: dysmenorrhea 6 versus 5.0 (P < .001), dyspareunia 5.28 versus 4.95 (P < .001), and urinary pain during menstruation 4.35 versus 2.84 (P < .001).

Next-generation sequencing identified an average of 2,561 expressed miRNAs in the saliva samples. The feature selection method generated a subset of 109 miRNAs composing the endometriosis diagnostic signature. Among those miRNAs, 29 were associated with the main signaling pathways of endometriosis: PI3K/AKT, PTEN, Wnt/beta-catenin, HIF1-alpha/NF kappa B, and YAP/TAZ/EGFR.

The accuracy and reproducibility of the signature were tested on several data sets randomly composed of the same proportion of controls and patients with endometriosis. The respective sensitivity, specificity, and area under the curve for the diagnostic miRNA signature were 96.7%, 100%, and 98.3%, respectively.

The study’s results support the use of a saliva-based miRNA signature for diagnosing whether a patient is discordant/complex (chronic pelvic pain suggestive of endometriosis and both negative clinical examination and imaging findings) or has early-stage or advanced-stage endometriosis.

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

A French research team has developed a microRNA (miRNA) signature for diagnosing endometriosis through a simple saliva test. Its validation in a larger cohort could soon allow doctors to have a cheap, noninvasive, and accurate tool to use in diagnosing a disease that, for the time being, is difficult to identify with any certainty. The researchers suggest that their methodology could be used as a blueprint to investigate other pathologies, both benign and malignant.

ENDO-miRNA study

miRNAs regulate as much as 60% of gene expression at the posttranscriptional level. In the setting of endometriosis, several authors have evaluated the relevance of a blood-based miRNA signature, but the results are discordant because of methodological and control group issues. Other researchers have also sought to develop a miRNA saliva test. A French team wanted to determine whether it was possible to define a saliva-based diagnostic miRNome signature that would allow patients with and without endometriosis to be differentiated and, from there, develop the first specific diagnostic test for the disease.

The prospective ENDO-miRNA study included saliva samples obtained from women with chronic pelvic pain suggestive of endometriosis. Exploratory procedures were performed to look for lesions. All the patients underwent either a laparoscopic procedure (therapeutic or diagnostic laparoscopy) and/or MRI imaging. For the patients who underwent laparoscopy, diagnosis was confirmed by histology. For the patients diagnosed with endometriosis without laparoscopic evaluation, all had MRI imaging with features of deep endometriosis.

One part of the study involved the identification of a biomarker based on genomewide miRNA expression profiling by small RNA sequencing using next-generation sequencing. The second part involved the development of a saliva-based miRNA diagnostic signature according to expression and accuracy profiling using a random forest algorithm.
 

High sensitivity, specificity

Among the 200 patients (mean age, 31 years) enrolled in the study, 76.5% (n = 153) were diagnosed with endometriosis. On average, their pain was statistically more severe than that of the women in the control group. The Visual Analogue Scale (VAS) scores were, respectively: dysmenorrhea 6 versus 5.0 (P < .001), dyspareunia 5.28 versus 4.95 (P < .001), and urinary pain during menstruation 4.35 versus 2.84 (P < .001).

Next-generation sequencing identified an average of 2,561 expressed miRNAs in the saliva samples. The feature selection method generated a subset of 109 miRNAs composing the endometriosis diagnostic signature. Among those miRNAs, 29 were associated with the main signaling pathways of endometriosis: PI3K/AKT, PTEN, Wnt/beta-catenin, HIF1-alpha/NF kappa B, and YAP/TAZ/EGFR.

The accuracy and reproducibility of the signature were tested on several data sets randomly composed of the same proportion of controls and patients with endometriosis. The respective sensitivity, specificity, and area under the curve for the diagnostic miRNA signature were 96.7%, 100%, and 98.3%, respectively.

The study’s results support the use of a saliva-based miRNA signature for diagnosing whether a patient is discordant/complex (chronic pelvic pain suggestive of endometriosis and both negative clinical examination and imaging findings) or has early-stage or advanced-stage endometriosis.

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

A small, and likely decreasing, number of health care providers in the United States perform abortions, and there is a risk that the count will be shrinking in the face of legislative attacks on the service, researchers have found.

Until now, producing an accurate count of abortion service providers in the United States has been difficult, leaving researchers to rely on indirect assessments of abortion clinics rather than counts of physicians who perform the procedure.

But the authors of a research letter published in JAMA Internal Medicine have come up with a number: Roughly 3,550 clinicians provide procedural and medication abortions, while 22,001 manage pregnancy loss with the same procedures and medications. More than half of all abortions in the United States now are achieved by medication.

The small number of providers is a cause for concern as a growing number of states move to restrict access to abortions, experts say.

“Abortions are only available if clinicians provide them,” said Julia Strasser, DrPH, MPH, senior research scientist at the George Washington University Milken Institute School of Public Health, Washington, D.C., who led the research. “This study finds that a variety of clinician types provide abortion care. But the number of abortion providers is low, and increasing restrictions will only make this worse.”

For their census, Dr. Strasser and her colleagues evaluated medical claims covering a full year from a private data company. They focused on two sets of services: medications (misoprostol and mifepristone) used in abortion care and pregnancy loss and procedures such as dilation and curettage and dilation and evacuation. Services were categorized as induced abortion or management by pregnancy loss on the basis of medical coding.

The researchers found that there were 3,550 abortion providers and 22,001 clinicians who managed pregnancy loss. Of those who induced abortions, 88% were physicians and 12% were advanced practice clinicians.

The clinicians who most frequently provided induced abortions were ob/gyns (72%), followed by family physicians (9%), advanced practice registered nurses (8%), and nurse midwives (3%). Several other specialists performed about 1% of abortions each.

Dr. Strasser said that 3,550 is an undercount because many providers do offer abortions but cannot or do not bill for them. Even so, the number likely will fall because fewer medical students are being trained for abortion procedures, according to Kaiser Health News.

Despite recommendations from the American College of Obstetricians and Gynecologists for standardized training on abortion care during medical residency, the number of programs that prohibit that training has surged in recent years, the report notes.
 

Restrictions looming

Compounding the problem, the researchers say, is the recent spate of state-level legislation regarding access to abortion. The U.S. Supreme Court is due to rule soon on a Mississippi law banning all abortions over 15 weeks’ gestational age, except in medical emergencies and in the case of severe fetal abnormalities.

Last May, Texas passed a law outlawing termination of pregnancy after 6 weeks of gestation – before many women know they’re pregnant. The law created a bounty system that permits essentially anyone in the United States to sue a woman in the state who seeks an abortion outside the law or anyone who assists her – including health care professionals. The Supreme Court in December refused to overturn the law – which reportedly has triggered a surge in women seeking abortion services in neighboring Oklahoma.

The legal environment is greatly increasing the risk that more clinicians will drop out of the workforce, Dr. Strasser told this news organization.

“As this happens, abortion care will undoubtedly become harder to access, especially for vulnerable populations,” she said. “Patients will have to travel farther, pay more money, or forgo necessary care.”

Another major variable is insurance coverage, the researchers found. Abortion coverage is highly restricted under private insurance and Medicaid, they note. Beyond increasingly restrictive payment issues, policies seen as punitive toward clinicians may cause many to stop offering medication and procedural services, Dr. Strasser said.

“The national political climate will likely see more barriers and less access to care in the coming months and years,” she told this news organization. “However, some states are taking concrete steps to protect abortion access for their residents and for others out of state. In supportive environments like these, enhanced training, expanded scope of practice, and improved reimbursement policies can increase access.”

If the Supreme Court overturns Roe v. Wade, Kaiser Health News reported, 26 states would likely ban abortion, triggering a flood of patients to states where the procedure remains more widely available.

According to the Center for Reproductive Rights, states that have expanded access are Washington, Oregon, California, New York, Vermont, Connecticut, and New Jersey. Another 12 states offer protected access, in which abortion is likely to remain legal even if Roe v. Wade is overturned, since in many of them, abortion is protected under their state constitutions.
 

Pivot to telehealth?

Another study, published in the same issue of JAMA Internal Medicine, evaluated health outcomes for 3,779 women. That study found that eligibility screening for medical abortions by history alone, without pelvic examination or ultrasonography, was safe and effective. That study found that medications were either dispensed in person or through the mail.

Taken together, the two studies suggest that more abortion services may shift toward telehealth, which could expand the number of health care professionals performing such services. Providers could include nurse practitioners, midwives, and physician assistants, said Melissa Grant, chief operating officer of carafem, a reproductive health and abortion service provider.

The service, which has offices in Atlanta, Chicago, Nashville, and Washington, D.C., has found that many patients prefer online appointments, especially if they live in rural areas, Ms. Grant said. The pandemic created a push toward online services.

“Even before the current breadth of restrictive legislation, we were seeing in increase because of COVID,” she said. “Most likely, abortion providers will continue to be pushed out of the profession, so having an option that’s widely available no matter where you live is essential. The United States is moving toward a system where the ZIP code you live in will foretell what care you get. That’s chilling.”

Those who currently provide abortion care have two advantages over what was available previously, Ms. Grant said. First, medical abortion is much more common, and data show that it is safe and effective for most pregnant people, as long as they undergo a health screening. Second, the boom in telehealth during the pandemic means providers are much more experienced in this type of service than before.

As more services such as carafem crop up, costs will drop, since a telehealth clinic – even one that uses health care professionals – has fewer expenses, such as for rent and equipment, than a physical facility.

“Because of the stigma around abortion, this is not likely to prompt a big rush of start-ups, but I do think we’re going to see a shake-up in the way services are being offered, and both patients and providers will likely turn toward technology,” Ms. Grant said. “An environment like this will require flexibility, innovation, and some real grit. We may take some time to get there, but it’s possible this moment is a pivot point in how abortion care is provided.”

Some of the researchers received grants from the Susan T. Buffett Foundation.

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

A small, and likely decreasing, number of health care providers in the United States perform abortions, and there is a risk that the count will be shrinking in the face of legislative attacks on the service, researchers have found.

Until now, producing an accurate count of abortion service providers in the United States has been difficult, leaving researchers to rely on indirect assessments of abortion clinics rather than counts of physicians who perform the procedure.

But the authors of a research letter published in JAMA Internal Medicine have come up with a number: Roughly 3,550 clinicians provide procedural and medication abortions, while 22,001 manage pregnancy loss with the same procedures and medications. More than half of all abortions in the United States now are achieved by medication.

The small number of providers is a cause for concern as a growing number of states move to restrict access to abortions, experts say.

“Abortions are only available if clinicians provide them,” said Julia Strasser, DrPH, MPH, senior research scientist at the George Washington University Milken Institute School of Public Health, Washington, D.C., who led the research. “This study finds that a variety of clinician types provide abortion care. But the number of abortion providers is low, and increasing restrictions will only make this worse.”

For their census, Dr. Strasser and her colleagues evaluated medical claims covering a full year from a private data company. They focused on two sets of services: medications (misoprostol and mifepristone) used in abortion care and pregnancy loss and procedures such as dilation and curettage and dilation and evacuation. Services were categorized as induced abortion or management by pregnancy loss on the basis of medical coding.

The researchers found that there were 3,550 abortion providers and 22,001 clinicians who managed pregnancy loss. Of those who induced abortions, 88% were physicians and 12% were advanced practice clinicians.

The clinicians who most frequently provided induced abortions were ob/gyns (72%), followed by family physicians (9%), advanced practice registered nurses (8%), and nurse midwives (3%). Several other specialists performed about 1% of abortions each.

Dr. Strasser said that 3,550 is an undercount because many providers do offer abortions but cannot or do not bill for them. Even so, the number likely will fall because fewer medical students are being trained for abortion procedures, according to Kaiser Health News.

Despite recommendations from the American College of Obstetricians and Gynecologists for standardized training on abortion care during medical residency, the number of programs that prohibit that training has surged in recent years, the report notes.
 

Restrictions looming

Compounding the problem, the researchers say, is the recent spate of state-level legislation regarding access to abortion. The U.S. Supreme Court is due to rule soon on a Mississippi law banning all abortions over 15 weeks’ gestational age, except in medical emergencies and in the case of severe fetal abnormalities.

Last May, Texas passed a law outlawing termination of pregnancy after 6 weeks of gestation – before many women know they’re pregnant. The law created a bounty system that permits essentially anyone in the United States to sue a woman in the state who seeks an abortion outside the law or anyone who assists her – including health care professionals. The Supreme Court in December refused to overturn the law – which reportedly has triggered a surge in women seeking abortion services in neighboring Oklahoma.

The legal environment is greatly increasing the risk that more clinicians will drop out of the workforce, Dr. Strasser told this news organization.

“As this happens, abortion care will undoubtedly become harder to access, especially for vulnerable populations,” she said. “Patients will have to travel farther, pay more money, or forgo necessary care.”

Another major variable is insurance coverage, the researchers found. Abortion coverage is highly restricted under private insurance and Medicaid, they note. Beyond increasingly restrictive payment issues, policies seen as punitive toward clinicians may cause many to stop offering medication and procedural services, Dr. Strasser said.

“The national political climate will likely see more barriers and less access to care in the coming months and years,” she told this news organization. “However, some states are taking concrete steps to protect abortion access for their residents and for others out of state. In supportive environments like these, enhanced training, expanded scope of practice, and improved reimbursement policies can increase access.”

If the Supreme Court overturns Roe v. Wade, Kaiser Health News reported, 26 states would likely ban abortion, triggering a flood of patients to states where the procedure remains more widely available.

According to the Center for Reproductive Rights, states that have expanded access are Washington, Oregon, California, New York, Vermont, Connecticut, and New Jersey. Another 12 states offer protected access, in which abortion is likely to remain legal even if Roe v. Wade is overturned, since in many of them, abortion is protected under their state constitutions.
 

Pivot to telehealth?

Another study, published in the same issue of JAMA Internal Medicine, evaluated health outcomes for 3,779 women. That study found that eligibility screening for medical abortions by history alone, without pelvic examination or ultrasonography, was safe and effective. That study found that medications were either dispensed in person or through the mail.

Taken together, the two studies suggest that more abortion services may shift toward telehealth, which could expand the number of health care professionals performing such services. Providers could include nurse practitioners, midwives, and physician assistants, said Melissa Grant, chief operating officer of carafem, a reproductive health and abortion service provider.

The service, which has offices in Atlanta, Chicago, Nashville, and Washington, D.C., has found that many patients prefer online appointments, especially if they live in rural areas, Ms. Grant said. The pandemic created a push toward online services.

“Even before the current breadth of restrictive legislation, we were seeing in increase because of COVID,” she said. “Most likely, abortion providers will continue to be pushed out of the profession, so having an option that’s widely available no matter where you live is essential. The United States is moving toward a system where the ZIP code you live in will foretell what care you get. That’s chilling.”

Those who currently provide abortion care have two advantages over what was available previously, Ms. Grant said. First, medical abortion is much more common, and data show that it is safe and effective for most pregnant people, as long as they undergo a health screening. Second, the boom in telehealth during the pandemic means providers are much more experienced in this type of service than before.

As more services such as carafem crop up, costs will drop, since a telehealth clinic – even one that uses health care professionals – has fewer expenses, such as for rent and equipment, than a physical facility.

“Because of the stigma around abortion, this is not likely to prompt a big rush of start-ups, but I do think we’re going to see a shake-up in the way services are being offered, and both patients and providers will likely turn toward technology,” Ms. Grant said. “An environment like this will require flexibility, innovation, and some real grit. We may take some time to get there, but it’s possible this moment is a pivot point in how abortion care is provided.”

Some of the researchers received grants from the Susan T. Buffett Foundation.

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

A small, and likely decreasing, number of health care providers in the United States perform abortions, and there is a risk that the count will be shrinking in the face of legislative attacks on the service, researchers have found.

Until now, producing an accurate count of abortion service providers in the United States has been difficult, leaving researchers to rely on indirect assessments of abortion clinics rather than counts of physicians who perform the procedure.

But the authors of a research letter published in JAMA Internal Medicine have come up with a number: Roughly 3,550 clinicians provide procedural and medication abortions, while 22,001 manage pregnancy loss with the same procedures and medications. More than half of all abortions in the United States now are achieved by medication.

The small number of providers is a cause for concern as a growing number of states move to restrict access to abortions, experts say.

“Abortions are only available if clinicians provide them,” said Julia Strasser, DrPH, MPH, senior research scientist at the George Washington University Milken Institute School of Public Health, Washington, D.C., who led the research. “This study finds that a variety of clinician types provide abortion care. But the number of abortion providers is low, and increasing restrictions will only make this worse.”

For their census, Dr. Strasser and her colleagues evaluated medical claims covering a full year from a private data company. They focused on two sets of services: medications (misoprostol and mifepristone) used in abortion care and pregnancy loss and procedures such as dilation and curettage and dilation and evacuation. Services were categorized as induced abortion or management by pregnancy loss on the basis of medical coding.

The researchers found that there were 3,550 abortion providers and 22,001 clinicians who managed pregnancy loss. Of those who induced abortions, 88% were physicians and 12% were advanced practice clinicians.

The clinicians who most frequently provided induced abortions were ob/gyns (72%), followed by family physicians (9%), advanced practice registered nurses (8%), and nurse midwives (3%). Several other specialists performed about 1% of abortions each.

Dr. Strasser said that 3,550 is an undercount because many providers do offer abortions but cannot or do not bill for them. Even so, the number likely will fall because fewer medical students are being trained for abortion procedures, according to Kaiser Health News.

Despite recommendations from the American College of Obstetricians and Gynecologists for standardized training on abortion care during medical residency, the number of programs that prohibit that training has surged in recent years, the report notes.
 

Restrictions looming

Compounding the problem, the researchers say, is the recent spate of state-level legislation regarding access to abortion. The U.S. Supreme Court is due to rule soon on a Mississippi law banning all abortions over 15 weeks’ gestational age, except in medical emergencies and in the case of severe fetal abnormalities.

Last May, Texas passed a law outlawing termination of pregnancy after 6 weeks of gestation – before many women know they’re pregnant. The law created a bounty system that permits essentially anyone in the United States to sue a woman in the state who seeks an abortion outside the law or anyone who assists her – including health care professionals. The Supreme Court in December refused to overturn the law – which reportedly has triggered a surge in women seeking abortion services in neighboring Oklahoma.

The legal environment is greatly increasing the risk that more clinicians will drop out of the workforce, Dr. Strasser told this news organization.

“As this happens, abortion care will undoubtedly become harder to access, especially for vulnerable populations,” she said. “Patients will have to travel farther, pay more money, or forgo necessary care.”

Another major variable is insurance coverage, the researchers found. Abortion coverage is highly restricted under private insurance and Medicaid, they note. Beyond increasingly restrictive payment issues, policies seen as punitive toward clinicians may cause many to stop offering medication and procedural services, Dr. Strasser said.

“The national political climate will likely see more barriers and less access to care in the coming months and years,” she told this news organization. “However, some states are taking concrete steps to protect abortion access for their residents and for others out of state. In supportive environments like these, enhanced training, expanded scope of practice, and improved reimbursement policies can increase access.”

If the Supreme Court overturns Roe v. Wade, Kaiser Health News reported, 26 states would likely ban abortion, triggering a flood of patients to states where the procedure remains more widely available.

According to the Center for Reproductive Rights, states that have expanded access are Washington, Oregon, California, New York, Vermont, Connecticut, and New Jersey. Another 12 states offer protected access, in which abortion is likely to remain legal even if Roe v. Wade is overturned, since in many of them, abortion is protected under their state constitutions.
 

Pivot to telehealth?

Another study, published in the same issue of JAMA Internal Medicine, evaluated health outcomes for 3,779 women. That study found that eligibility screening for medical abortions by history alone, without pelvic examination or ultrasonography, was safe and effective. That study found that medications were either dispensed in person or through the mail.

Taken together, the two studies suggest that more abortion services may shift toward telehealth, which could expand the number of health care professionals performing such services. Providers could include nurse practitioners, midwives, and physician assistants, said Melissa Grant, chief operating officer of carafem, a reproductive health and abortion service provider.

The service, which has offices in Atlanta, Chicago, Nashville, and Washington, D.C., has found that many patients prefer online appointments, especially if they live in rural areas, Ms. Grant said. The pandemic created a push toward online services.

“Even before the current breadth of restrictive legislation, we were seeing in increase because of COVID,” she said. “Most likely, abortion providers will continue to be pushed out of the profession, so having an option that’s widely available no matter where you live is essential. The United States is moving toward a system where the ZIP code you live in will foretell what care you get. That’s chilling.”

Those who currently provide abortion care have two advantages over what was available previously, Ms. Grant said. First, medical abortion is much more common, and data show that it is safe and effective for most pregnant people, as long as they undergo a health screening. Second, the boom in telehealth during the pandemic means providers are much more experienced in this type of service than before.

As more services such as carafem crop up, costs will drop, since a telehealth clinic – even one that uses health care professionals – has fewer expenses, such as for rent and equipment, than a physical facility.

“Because of the stigma around abortion, this is not likely to prompt a big rush of start-ups, but I do think we’re going to see a shake-up in the way services are being offered, and both patients and providers will likely turn toward technology,” Ms. Grant said. “An environment like this will require flexibility, innovation, and some real grit. We may take some time to get there, but it’s possible this moment is a pivot point in how abortion care is provided.”

Some of the researchers received grants from the Susan T. Buffett Foundation.

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

As family medicine physicians it is our duty to help facilitate patients’ health care based on what is in patients’ best interests and aligns with the goals they have for their lives.

I am aware of how intersecting social, economic, familial, and environmental factors influence what is best for patient’s lives, and I consider having this awareness to be part of being a family medicine physician.

People being able to make choices about their reproductive health and their reproductive futures without unnecessary and harmful barriers is a part of a person’s overall health that family medicine physicians should recognize and prioritize. Helping people achieve their reproductive health care goals includes helping patients access abortion care if that is the care that they decide that they need.

According to the Guttmacher Institute, 2021 was “the worst year for abortion rights in almost half a century” as 108 abortion restrictions were enacted throughout the country. The most damaging restriction was introduced in Texas in the fall of 2021 called SB8, which has virtually stopped all abortion care in person for any person with a pregnancy greater than 6 weeks’ gestation. Now, in 2022 we are seeing several other states, including Idaho and Oklahoma, set to pass similar laws that will essentially halt most abortion care in the clinical setting in those states.

Abortion access had already been a problem in much of the country prior to 2021 because of burdensome and not medically necessary restrictions. Based on current political trends we are getting to a place where it is not hard to imagine that up to half of the states in this country will not allow their communities to access abortion care in the clinical setting at all in the very near future. This is not reproductive freedom, and I am outraged that people are being forced to travel hundreds of miles for their abortion care, forced to continue pregnancies that they don’t want, or forced to find other ways to obtain medication abortion pills.

While obtaining medication abortion pills online and managing the abortion process at home is safe and recognized as safe by the World Health Organization, no one should be forced to utilize a certain type of care based on their state of residence, in my opinion.

Providing evidence-based medicine to patients is ‘my duty’

Abortion care is health care and is primary care. One in four women will have an abortion by the age of 45, and we know that transgender, nonbinary, and gender-expansive people also have abortions. That means on any given day as family medicine physicians we are likely taking care of more than one person who has had an abortion, will have an abortion, and/or is considering an abortion. Therefore, all family medicine physicians need to be prepared to counsel patients about all of their pregnancy options, answer questions about pregnancy and abortion, and help people get the compassionate care that they deserve.

Our patients turn to us as trusted sources of information. When they reach out to us, I consider providing evidence-based medicine to patients – that includes factual information about abortion care if and when our patients need it – to be my duty as a family medicine physician.
 

Resources on abortion care for family medicine physicians

For family medicine physicians who did not have adequate exposure to abortion care during residency, there are many evidence-based resources to review in order to become more knowledgeable in abortion care.

In many areas of medicine, we have to continue to learn and seek out references, and abortion care is no different. One could argue that understanding abortion care and providing patients with factual information about their options and abortion care is even more important because of stigma surrounding abortion care and the rampant lies about abortion care that are easily accessible and that even other medical professionals and politicians spread. There are even fake clinics, often called “crisis pregnancy centers”, that intimidate, lie about abortion, and coerce patients to make decisions that are against their desires. Thus, being that trusted source of factual information about abortion care is even more important in the face of so many lies.

There are several organizations that are dedicated to education surrounding abortion care, in particular within the primary care setting. The Reproductive Health Access Project (RHAP), Reproductive Health Education in Family Medicine (RHEDI), and Training in Early Abortion for Comprehensive Healthcare (TEACH) all provide free resources on abortion care, how to incorporate abortion care into primary care, and how to teach medical students and residents about abortion care.

In addition, the National Network of Abortion Funds connects people to community-led organizations that provide assistance related to direct financial and logistical support for obtaining abortion care. I believe it is critical that we familiarize ourselves with our local abortion funds and share what we learn about these resources with our patients.

As abortion access continues to be further stripped away from many people that we take care of, I think standing up for what is right and what is our duty as physicians becomes more important. That duty is to provide our patients with evidence-based medicine and compassionate care so that our communities can obtain reproductive health outcomes and freedom that are best for their lives.
 

Dr. Lockley is a family physician currently living in Harlem, N.Y., and a member of the editorial advisory board of Family Practice News. She currently works for Public Health Solutions’ Sexual and Reproductive Health Centers in Brooklyn, providing primary care and reproductive health care services there, and as an abortion provider throughout the New York region. She completed both medical school and residency in Philadelphia and then did a fellowship in reproductive health care and advocacy through the Family Health Center of Harlem and the Reproductive Health Access Project. She can be reached at [email protected].

As family medicine physicians it is our duty to help facilitate patients’ health care based on what is in patients’ best interests and aligns with the goals they have for their lives.

I am aware of how intersecting social, economic, familial, and environmental factors influence what is best for patient’s lives, and I consider having this awareness to be part of being a family medicine physician.

People being able to make choices about their reproductive health and their reproductive futures without unnecessary and harmful barriers is a part of a person’s overall health that family medicine physicians should recognize and prioritize. Helping people achieve their reproductive health care goals includes helping patients access abortion care if that is the care that they decide that they need.

According to the Guttmacher Institute, 2021 was “the worst year for abortion rights in almost half a century” as 108 abortion restrictions were enacted throughout the country. The most damaging restriction was introduced in Texas in the fall of 2021 called SB8, which has virtually stopped all abortion care in person for any person with a pregnancy greater than 6 weeks’ gestation. Now, in 2022 we are seeing several other states, including Idaho and Oklahoma, set to pass similar laws that will essentially halt most abortion care in the clinical setting in those states.

Abortion access had already been a problem in much of the country prior to 2021 because of burdensome and not medically necessary restrictions. Based on current political trends we are getting to a place where it is not hard to imagine that up to half of the states in this country will not allow their communities to access abortion care in the clinical setting at all in the very near future. This is not reproductive freedom, and I am outraged that people are being forced to travel hundreds of miles for their abortion care, forced to continue pregnancies that they don’t want, or forced to find other ways to obtain medication abortion pills.

While obtaining medication abortion pills online and managing the abortion process at home is safe and recognized as safe by the World Health Organization, no one should be forced to utilize a certain type of care based on their state of residence, in my opinion.

Providing evidence-based medicine to patients is ‘my duty’

Abortion care is health care and is primary care. One in four women will have an abortion by the age of 45, and we know that transgender, nonbinary, and gender-expansive people also have abortions. That means on any given day as family medicine physicians we are likely taking care of more than one person who has had an abortion, will have an abortion, and/or is considering an abortion. Therefore, all family medicine physicians need to be prepared to counsel patients about all of their pregnancy options, answer questions about pregnancy and abortion, and help people get the compassionate care that they deserve.

Our patients turn to us as trusted sources of information. When they reach out to us, I consider providing evidence-based medicine to patients – that includes factual information about abortion care if and when our patients need it – to be my duty as a family medicine physician.
 

Resources on abortion care for family medicine physicians

For family medicine physicians who did not have adequate exposure to abortion care during residency, there are many evidence-based resources to review in order to become more knowledgeable in abortion care.

In many areas of medicine, we have to continue to learn and seek out references, and abortion care is no different. One could argue that understanding abortion care and providing patients with factual information about their options and abortion care is even more important because of stigma surrounding abortion care and the rampant lies about abortion care that are easily accessible and that even other medical professionals and politicians spread. There are even fake clinics, often called “crisis pregnancy centers”, that intimidate, lie about abortion, and coerce patients to make decisions that are against their desires. Thus, being that trusted source of factual information about abortion care is even more important in the face of so many lies.

There are several organizations that are dedicated to education surrounding abortion care, in particular within the primary care setting. The Reproductive Health Access Project (RHAP), Reproductive Health Education in Family Medicine (RHEDI), and Training in Early Abortion for Comprehensive Healthcare (TEACH) all provide free resources on abortion care, how to incorporate abortion care into primary care, and how to teach medical students and residents about abortion care.

In addition, the National Network of Abortion Funds connects people to community-led organizations that provide assistance related to direct financial and logistical support for obtaining abortion care. I believe it is critical that we familiarize ourselves with our local abortion funds and share what we learn about these resources with our patients.

As abortion access continues to be further stripped away from many people that we take care of, I think standing up for what is right and what is our duty as physicians becomes more important. That duty is to provide our patients with evidence-based medicine and compassionate care so that our communities can obtain reproductive health outcomes and freedom that are best for their lives.
 

Dr. Lockley is a family physician currently living in Harlem, N.Y., and a member of the editorial advisory board of Family Practice News. She currently works for Public Health Solutions’ Sexual and Reproductive Health Centers in Brooklyn, providing primary care and reproductive health care services there, and as an abortion provider throughout the New York region. She completed both medical school and residency in Philadelphia and then did a fellowship in reproductive health care and advocacy through the Family Health Center of Harlem and the Reproductive Health Access Project. She can be reached at [email protected].

As family medicine physicians it is our duty to help facilitate patients’ health care based on what is in patients’ best interests and aligns with the goals they have for their lives.

I am aware of how intersecting social, economic, familial, and environmental factors influence what is best for patient’s lives, and I consider having this awareness to be part of being a family medicine physician.

People being able to make choices about their reproductive health and their reproductive futures without unnecessary and harmful barriers is a part of a person’s overall health that family medicine physicians should recognize and prioritize. Helping people achieve their reproductive health care goals includes helping patients access abortion care if that is the care that they decide that they need.

According to the Guttmacher Institute, 2021 was “the worst year for abortion rights in almost half a century” as 108 abortion restrictions were enacted throughout the country. The most damaging restriction was introduced in Texas in the fall of 2021 called SB8, which has virtually stopped all abortion care in person for any person with a pregnancy greater than 6 weeks’ gestation. Now, in 2022 we are seeing several other states, including Idaho and Oklahoma, set to pass similar laws that will essentially halt most abortion care in the clinical setting in those states.

Abortion access had already been a problem in much of the country prior to 2021 because of burdensome and not medically necessary restrictions. Based on current political trends we are getting to a place where it is not hard to imagine that up to half of the states in this country will not allow their communities to access abortion care in the clinical setting at all in the very near future. This is not reproductive freedom, and I am outraged that people are being forced to travel hundreds of miles for their abortion care, forced to continue pregnancies that they don’t want, or forced to find other ways to obtain medication abortion pills.

While obtaining medication abortion pills online and managing the abortion process at home is safe and recognized as safe by the World Health Organization, no one should be forced to utilize a certain type of care based on their state of residence, in my opinion.

Providing evidence-based medicine to patients is ‘my duty’

Abortion care is health care and is primary care. One in four women will have an abortion by the age of 45, and we know that transgender, nonbinary, and gender-expansive people also have abortions. That means on any given day as family medicine physicians we are likely taking care of more than one person who has had an abortion, will have an abortion, and/or is considering an abortion. Therefore, all family medicine physicians need to be prepared to counsel patients about all of their pregnancy options, answer questions about pregnancy and abortion, and help people get the compassionate care that they deserve.

Our patients turn to us as trusted sources of information. When they reach out to us, I consider providing evidence-based medicine to patients – that includes factual information about abortion care if and when our patients need it – to be my duty as a family medicine physician.
 

Resources on abortion care for family medicine physicians

For family medicine physicians who did not have adequate exposure to abortion care during residency, there are many evidence-based resources to review in order to become more knowledgeable in abortion care.

In many areas of medicine, we have to continue to learn and seek out references, and abortion care is no different. One could argue that understanding abortion care and providing patients with factual information about their options and abortion care is even more important because of stigma surrounding abortion care and the rampant lies about abortion care that are easily accessible and that even other medical professionals and politicians spread. There are even fake clinics, often called “crisis pregnancy centers”, that intimidate, lie about abortion, and coerce patients to make decisions that are against their desires. Thus, being that trusted source of factual information about abortion care is even more important in the face of so many lies.

There are several organizations that are dedicated to education surrounding abortion care, in particular within the primary care setting. The Reproductive Health Access Project (RHAP), Reproductive Health Education in Family Medicine (RHEDI), and Training in Early Abortion for Comprehensive Healthcare (TEACH) all provide free resources on abortion care, how to incorporate abortion care into primary care, and how to teach medical students and residents about abortion care.

In addition, the National Network of Abortion Funds connects people to community-led organizations that provide assistance related to direct financial and logistical support for obtaining abortion care. I believe it is critical that we familiarize ourselves with our local abortion funds and share what we learn about these resources with our patients.

As abortion access continues to be further stripped away from many people that we take care of, I think standing up for what is right and what is our duty as physicians becomes more important. That duty is to provide our patients with evidence-based medicine and compassionate care so that our communities can obtain reproductive health outcomes and freedom that are best for their lives.
 

Dr. Lockley is a family physician currently living in Harlem, N.Y., and a member of the editorial advisory board of Family Practice News. She currently works for Public Health Solutions’ Sexual and Reproductive Health Centers in Brooklyn, providing primary care and reproductive health care services there, and as an abortion provider throughout the New York region. She completed both medical school and residency in Philadelphia and then did a fellowship in reproductive health care and advocacy through the Family Health Center of Harlem and the Reproductive Health Access Project. She can be reached at [email protected].

Note: In this article, “women” refers to ciswomen – those who identify as women and were assigned female sex at birth. Menopause also affects transmen and nonbinary people, but published research on the menopause experience has included only ciswomen participants.

Gina Brown was boarding an early morning flight in 2016 when suddenly she started to overheat. “As soon as I stepped on the plane, I immediately was drenched in sweat,” she said. Not knowing what to do, she stood still until a fellow female passenger noticed her alarm and asked a flight attendant to grab her a cup of ice. “Is this the first time this has happened to you?” the woman asked, and Ms. Brown nodded. “It’s called a hot flash,” the woman continued, “and you’re going to be okay.”

As soon as Ms. Brown returned from her trip, she visited her doctor for blood work and learned that her hormone levels were decreasing. “I knew something was going on, but [my provider and I] didn’t have a conversation about menopause,” she said. Ms. Brown, who is 56 years old, has been living with HIV for nearly 28 years, and is part of a growing group of women with HIV now entering menopause.

In 1996, a person diagnosed with HIV at 20 years of age could expect to live only to age 39. Because of antiretroviral therapy (ART), an HIV diagnosis is not nearly so dire. Now, someone with HIV who adheres to the ART regimen is estimated to have a lifespan close to that of the general population.

For women with HIV, this means going through menopause. Though this transition can be challenging for any woman, experiencing menopause with HIV adds another level of complication. On top of adhering to daily ART regimens, the woman must also deal with the hormonal changes of menopause and the symptoms that come with it. And the limited research in this area suggests that women with HIV and their clinicians may not be prepared.

“Those of us long-term survivors who have been around for a while never expected to be here, and I don’t think providers or the health care system expected us to be here,” said Vickie A. Lynn, PhD, 56, who has been living with HIV for 37 years and received an AIDS diagnosis in 1991. Her work focuses on health care interventions for people with HIV. “So now that we’re here, I don’t know that we have enough information or research to inform some of our treatment options.” Instead, these women are met with a series of unknowns due to limited studies and conflicting findings.
 

Earlier menopause?

The onset of menopause can be difficult to determine in women living with HIV, said Sara Looby, PhD, ANP-BC, a researcher at Massachusetts General Hospital and assistant professor of medicine at Harvard Medical School, both in Boston. Her research focuses on metabolic disorders, including bone loss, cardiovascular disease risk, and menopause in women living with HIV. This population is at an increased risk for amenorrhea, due to both behavioral and clinical factors, and sometimes this amenorrhea is mistakenly assumed to be menopause, she explained. A history of smoking, low weight, methadone use, or use of other psychotropic medications are common in women with HIV and can lead to missed periods. Some factors specific to HIV – including a low CD4 count and a history of an AIDS diagnosis – have also been linked to amenorrhea.

This is likely why research studies on the age of onset of menopause with women with HIV can reach conflicting conclusions. Some studies suggest that women with HIV tend to go through menopause 3-5 years earlier than women without HIV. Other studies suggest no difference in the age of onset in menopause between women living with and without HIV. But how menopause status has been accessed can vary from study to study, Dr. Looby said. Future research needs to consider participants’ complete menstrual and reproductive history, as well as relevant medical, social, and behavioral factors, she added, so that the findings are reliably capturing the age of onset of menopause rather than amenorrhea from other causes.

If menopause does occur earlier in women with HIV, there could be additional health implications. Estrogen regulates bone mass, and some research suggests the hormone may be cardioprotective. Estrogen is also thought to increase production of the neurotransmitter serotonin, which could affect mood and cognition. Women with HIV are already at higher risk for bone loss, cardiovascular disease, and depressed mood compared to women without HIV, Dr. Looby said, and as estrogen levels fall during menopause, these conditions may be deleteriously affected.

“If it is determined that women with HIV experience menopause at an earlier age, maybe early to mid-40s instead of 51 and older, they may be at increased risk for cardiovascular and bone conditions as well as mood symptoms associated with estrogen loss at an earlier age than women without HIV, which could be highly detrimental to their physical and mental health,” Dr. Looby said.
 

More frequent and severe menopausal symptoms?

Women with HIV may not only go through menopause earlier than women without HIV, but their symptoms may also be more frequent and more severe. In a 2017 study of both HIV-positive and HIV-negative Nigerian women, participants with HIV had more menopause symptoms overall and were three times as likely to report severe symptoms compared to women without HIV. A 2005 study conducted in New York found HIV-positive women were 24% more likely to report menopause symptoms compared to HIV-negative women in the study.

Looby’s own research has also found a similar pattern. In a study comparing 33 women with HIV to 33 women without HIV – all were close to menopause and matched for age, race, body mass index, and menstrual patterns – women with HIV reported more severe hot flashes and more days with hot flashes. These women also reported that their hot flashes interfered to a much greater degree with daily activities and quality of life compared to participants without HIV.

But studies of women with HIV who are entering menopause are rare, and most include only small numbers of women. As a result, many women with HIV do not know what to expect entering menopause. “I always say, I wish somebody would do some real research on HIV and menopause, because I want to know if it is worse for us or if it is the same,” said Ms. Brown, who works as the director of strategic partnership and community engagement at the Southern Aids Coalition in Powder Springs, Ga. “I would think it’s worse for me.”

More frequent and severe symptoms can have downstream effects, with some evidence suggesting that women with HIV who experience severe menopause symptoms are less likely to stick to their ART regimen. “There’s a clear picture emerging that menopausal symptoms in this group really matter,” said Shema Tariq, PhD, FRCP, an HIV physician-scientist at the University College London Institute for Global Health in England. “They really impact women’s well-being, as well as impacting their ability to look after their long-term condition.”
 

Providers wary of treating menopause symptoms in women with HIV

The little research we do have about women with HIV experiencing menopause suggests that this population could greatly benefit from treatment prescribed in women without HIV for menopause symptoms and conditions, including hormone replacement therapy (HRT). Women with HIV regularly experience night sweats and hot flashes during the menopause transition and may have more severe symptoms than women not living with the virus. If women with HIV also frequently enter early menopause (entering menopause before the age of 45), then this group meets two indications for hormone replacement therapy.

Despite the potential benefits of HRT in this population, some studies suggest this intervention is underutilized. In Dr. Tariq’s Positive Transitions through Menopause (PRIME) study, which explores how menopause affects more than 800 women living with HIV, only 8% of respondents reported using HRT. In a Canadian study that has not yet gone through peer review, 11.8% of perimenopausal and postmenopausal women reported ever using HRT, about half the rate of women in North America without HIV.

Provider discomfort with managing menopause-related care in women with HIV is one reason for such low HRT use in this population, Dr. Tariq said. In a survey of 88 general practitioners in the United Kingdom, nearly all (> 95%) respondents said they were comfortable managing menopause in a general population, but just 46% said they felt comfortable managing menopause in women with HIV. Their top concerns included the potential for drug-to-drug interactions between ART and HRT, missing an HIV-related diagnosis, and risks of menopausal hormone therapy in HIV. Nearly half of respondents (46%) said only specialists should be providing menopause-related care for women with HIV.

But specialists may also feel conflicted about managing menopause-related care in women with HIV, said Dr. Tariq. “If you’re looking at people who manage HIV, you’re looking primarily at infectious disease physicians and HIV physicians. We’re not trained as gynecologists. We’re not used to prescribing HRT,” she said. “And the problem is gynecologists aren’t used to managing HIV. They get nervous about prescribing anything when they see antiretroviral medication because all that people think of is a drug-drug interaction.”

This leaves women with HIV seeking care and treatment for menopause in a difficult situation, where they are “just being ping-ponged around between different health care providers,” said Susan Cole-Haley, 53, an HIV-activist in London who has been living with the virus for 23 years. “So many women with HIV have multiple health conditions and multiple health care providers, which can just make it really problematic and really exhausting in terms of getting help.”
 

Many unknowns

Providers may also be uncomfortable with prescribing hormone therapy because of alarming research in the early 2000s, which found that hormone replacement therapy increased the risk of breast cancer and cardiovascular disease. Later analyses have found no increased cardiovascular disease risk in women who were younger than 60 or were less than 10 years beyond the onset of menopause. Still, the “media frenzy” around the initial findings “has put off a whole load of patients and a whole load of clinicians from even thinking of HRT,” Dr. Tariq said.

Providers may be even more hesitant because people with HIV already have a higher risk for heart disease, due to behaviors such as smoking and HIV-specific factors. (Research has yet to tease out whether these cardiovascular effects are a result of the virus, a result of the antiretroviral therapy, or a result of both factors.) In addition, there have been no prospective studies looking directly at the efficacy and safety of hormone replacement therapy in women with HIV, so providers generally rely on the guidelines for the use of menopausal hormone therapy for women without HIV. While researchers from Canada and the United Kingdom have compiled recommendations for HRT in women with HIV, there is great need for a large-scale clinical trial to establish consistent guidelines for the use of HRT for women with HIV globally, Dr. Looby said.

There are also hormonal preparations and drug-to-drug interactions to consider, though none of the interactions identified so far rise to the level of contraindications. Because of how the liver metabolizes ART and HRT, hormone doses may need to be adjusted, or perhaps administered transdermally via a patch versus a pill form. (Estrogen delivered via skin patch may have reduced cardiovascular disease risk compared to other methods of delivery, some studies in women without HIV suggest.) These expected interactions are based on data from contraceptives, noted Elizabeth King, MD, whose research at the Women’s Health Research Institute at BC Women’s Hospital in Vancouver, B.C., focuses on menopause and HIV. Studies have not been done on drug-drug interactions between ART and HRT specifically, she said, and formulations for HRT are a bit different from contraceptives.

While these unknowns do need to be discussed in shared decision-making around starting HRT in women with HIV, they should not dissuade providers from considering the treatment, Dr. King said. “If women are having extremely troublesome symptoms, then withholding therapy that is potentially beneficial because of worries about some of the things we do not know – I don’t know if that is any better,” she said.

Many women with HIV may not want to start HRT – as was the case for Dr. Lynn. “I’ve taken a lot of medication in my time, and I really try to avoid it as much as possible,” she said. Uncertainties around drug interactions were the main concern for Dawn Averitt, 53, founder of the Well Project, an HIV nonprofit focused on women and girls. Ms. Averitt has lived with HIV for 34 years. “What if some of the things that I’m dealing with could be managed by HRT?” she said. “Or what if taking it exacerbates problems in a way that nobody knows to look for?” In this case, providers may work with patients to discuss nonhormonal treatment options for menopause symptom management.

While some women with HIV may not want HRT, “It’s important that women have that option, and from what we are seeing right now, not a lot of women are even being offered the therapy,” Dr. King said.

There are other nonhormonal treatments available for managing menopause symptoms, including selective serotonin reuptake inhibitors (SSRIs) as well as nonmedicinal interventions such as cognitive behavioral therapy, but these also have not been studied specifically in women with HIV.
 

The path forward

Dr. Tariq and Dr. Looby agreed the next step in expanding our knowledge around HIV and menopause should be to better engage women with HIV in research and clinical care around their experience with menopause. This includes studies on the symptoms they regularly experience and how these symptoms affect their quality of life, including their physical, psychological, cognitive, and social health. These studies could also help researchers and clinicians understand what these women with HIV want for their menopause care, whether that be medication, psychotherapy, and/or peer support groups. These interventions, whether pharmaceutical based or not, can then be assessed based on outcomes in women with HIV, Dr. Tariq noted.

Another important factor is increasing education, on both the patient and provider side, Dr. Looby said. Many women may not know what menopause is, what symptoms look like, and how these hormonal changes can affect their health. If providers keep an open dialogue with female patients around menopause throughout their adult care, that can better prepare women for the menopause transition and alert them to common symptoms they may experience. There also is a great need for provider education, Dr. Looby added. Infectious disease specialists may need further education on menopause management, while women’s health specialists may need additional training for managing care for patients with HIV. Ideally, this information could be shared among a team of providers, including infectious disease, primary care, and women’s health specialists, so that clinicians can collaborate in prescribing treatment for women with HIV, Dr. Looby said.

Lastly, there needs to be more research funding allocated toward answering questions related to menopause and HIV, including the age of onset of menopause in women with HIV, the severity of symptoms, how HIV may influence the menopause transition and vice versa, and regarding the effectiveness of treatment – pharmaceutical and nonpharmaceutical – for women with HIV going through the menopause transition. “If we don’t have funding for these studies, then we won’t have answers to establish clinical care guidelines necessary to support the health, well-being, and quality of life of women with HIV,” Dr. Looby said.

And the number of women living with HIV entering menopause is expected to keep growing, Dr. King added. “It was only a couple of decades ago when women were being told they wouldn’t even live to experience menopause, and now we are at a point where this is the highest proportion of menopausal women ever that we have seen in our HIV clinics,” she said. “It speaks to the success of antiretrovirals,” Dr. King acknowledged, but that also means identifying new challenges and addressing recognized gaps in care.

“We are charting a new course, in some ways,” she added. “There is a lot of work to be done.”

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

Note: In this article, “women” refers to ciswomen – those who identify as women and were assigned female sex at birth. Menopause also affects transmen and nonbinary people, but published research on the menopause experience has included only ciswomen participants.

Gina Brown was boarding an early morning flight in 2016 when suddenly she started to overheat. “As soon as I stepped on the plane, I immediately was drenched in sweat,” she said. Not knowing what to do, she stood still until a fellow female passenger noticed her alarm and asked a flight attendant to grab her a cup of ice. “Is this the first time this has happened to you?” the woman asked, and Ms. Brown nodded. “It’s called a hot flash,” the woman continued, “and you’re going to be okay.”

As soon as Ms. Brown returned from her trip, she visited her doctor for blood work and learned that her hormone levels were decreasing. “I knew something was going on, but [my provider and I] didn’t have a conversation about menopause,” she said. Ms. Brown, who is 56 years old, has been living with HIV for nearly 28 years, and is part of a growing group of women with HIV now entering menopause.

In 1996, a person diagnosed with HIV at 20 years of age could expect to live only to age 39. Because of antiretroviral therapy (ART), an HIV diagnosis is not nearly so dire. Now, someone with HIV who adheres to the ART regimen is estimated to have a lifespan close to that of the general population.

For women with HIV, this means going through menopause. Though this transition can be challenging for any woman, experiencing menopause with HIV adds another level of complication. On top of adhering to daily ART regimens, the woman must also deal with the hormonal changes of menopause and the symptoms that come with it. And the limited research in this area suggests that women with HIV and their clinicians may not be prepared.

“Those of us long-term survivors who have been around for a while never expected to be here, and I don’t think providers or the health care system expected us to be here,” said Vickie A. Lynn, PhD, 56, who has been living with HIV for 37 years and received an AIDS diagnosis in 1991. Her work focuses on health care interventions for people with HIV. “So now that we’re here, I don’t know that we have enough information or research to inform some of our treatment options.” Instead, these women are met with a series of unknowns due to limited studies and conflicting findings.
 

Earlier menopause?

The onset of menopause can be difficult to determine in women living with HIV, said Sara Looby, PhD, ANP-BC, a researcher at Massachusetts General Hospital and assistant professor of medicine at Harvard Medical School, both in Boston. Her research focuses on metabolic disorders, including bone loss, cardiovascular disease risk, and menopause in women living with HIV. This population is at an increased risk for amenorrhea, due to both behavioral and clinical factors, and sometimes this amenorrhea is mistakenly assumed to be menopause, she explained. A history of smoking, low weight, methadone use, or use of other psychotropic medications are common in women with HIV and can lead to missed periods. Some factors specific to HIV – including a low CD4 count and a history of an AIDS diagnosis – have also been linked to amenorrhea.

This is likely why research studies on the age of onset of menopause with women with HIV can reach conflicting conclusions. Some studies suggest that women with HIV tend to go through menopause 3-5 years earlier than women without HIV. Other studies suggest no difference in the age of onset in menopause between women living with and without HIV. But how menopause status has been accessed can vary from study to study, Dr. Looby said. Future research needs to consider participants’ complete menstrual and reproductive history, as well as relevant medical, social, and behavioral factors, she added, so that the findings are reliably capturing the age of onset of menopause rather than amenorrhea from other causes.

If menopause does occur earlier in women with HIV, there could be additional health implications. Estrogen regulates bone mass, and some research suggests the hormone may be cardioprotective. Estrogen is also thought to increase production of the neurotransmitter serotonin, which could affect mood and cognition. Women with HIV are already at higher risk for bone loss, cardiovascular disease, and depressed mood compared to women without HIV, Dr. Looby said, and as estrogen levels fall during menopause, these conditions may be deleteriously affected.

“If it is determined that women with HIV experience menopause at an earlier age, maybe early to mid-40s instead of 51 and older, they may be at increased risk for cardiovascular and bone conditions as well as mood symptoms associated with estrogen loss at an earlier age than women without HIV, which could be highly detrimental to their physical and mental health,” Dr. Looby said.
 

More frequent and severe menopausal symptoms?

Women with HIV may not only go through menopause earlier than women without HIV, but their symptoms may also be more frequent and more severe. In a 2017 study of both HIV-positive and HIV-negative Nigerian women, participants with HIV had more menopause symptoms overall and were three times as likely to report severe symptoms compared to women without HIV. A 2005 study conducted in New York found HIV-positive women were 24% more likely to report menopause symptoms compared to HIV-negative women in the study.

Looby’s own research has also found a similar pattern. In a study comparing 33 women with HIV to 33 women without HIV – all were close to menopause and matched for age, race, body mass index, and menstrual patterns – women with HIV reported more severe hot flashes and more days with hot flashes. These women also reported that their hot flashes interfered to a much greater degree with daily activities and quality of life compared to participants without HIV.

But studies of women with HIV who are entering menopause are rare, and most include only small numbers of women. As a result, many women with HIV do not know what to expect entering menopause. “I always say, I wish somebody would do some real research on HIV and menopause, because I want to know if it is worse for us or if it is the same,” said Ms. Brown, who works as the director of strategic partnership and community engagement at the Southern Aids Coalition in Powder Springs, Ga. “I would think it’s worse for me.”

More frequent and severe symptoms can have downstream effects, with some evidence suggesting that women with HIV who experience severe menopause symptoms are less likely to stick to their ART regimen. “There’s a clear picture emerging that menopausal symptoms in this group really matter,” said Shema Tariq, PhD, FRCP, an HIV physician-scientist at the University College London Institute for Global Health in England. “They really impact women’s well-being, as well as impacting their ability to look after their long-term condition.”
 

Providers wary of treating menopause symptoms in women with HIV

The little research we do have about women with HIV experiencing menopause suggests that this population could greatly benefit from treatment prescribed in women without HIV for menopause symptoms and conditions, including hormone replacement therapy (HRT). Women with HIV regularly experience night sweats and hot flashes during the menopause transition and may have more severe symptoms than women not living with the virus. If women with HIV also frequently enter early menopause (entering menopause before the age of 45), then this group meets two indications for hormone replacement therapy.

Despite the potential benefits of HRT in this population, some studies suggest this intervention is underutilized. In Dr. Tariq’s Positive Transitions through Menopause (PRIME) study, which explores how menopause affects more than 800 women living with HIV, only 8% of respondents reported using HRT. In a Canadian study that has not yet gone through peer review, 11.8% of perimenopausal and postmenopausal women reported ever using HRT, about half the rate of women in North America without HIV.

Provider discomfort with managing menopause-related care in women with HIV is one reason for such low HRT use in this population, Dr. Tariq said. In a survey of 88 general practitioners in the United Kingdom, nearly all (> 95%) respondents said they were comfortable managing menopause in a general population, but just 46% said they felt comfortable managing menopause in women with HIV. Their top concerns included the potential for drug-to-drug interactions between ART and HRT, missing an HIV-related diagnosis, and risks of menopausal hormone therapy in HIV. Nearly half of respondents (46%) said only specialists should be providing menopause-related care for women with HIV.

But specialists may also feel conflicted about managing menopause-related care in women with HIV, said Dr. Tariq. “If you’re looking at people who manage HIV, you’re looking primarily at infectious disease physicians and HIV physicians. We’re not trained as gynecologists. We’re not used to prescribing HRT,” she said. “And the problem is gynecologists aren’t used to managing HIV. They get nervous about prescribing anything when they see antiretroviral medication because all that people think of is a drug-drug interaction.”

This leaves women with HIV seeking care and treatment for menopause in a difficult situation, where they are “just being ping-ponged around between different health care providers,” said Susan Cole-Haley, 53, an HIV-activist in London who has been living with the virus for 23 years. “So many women with HIV have multiple health conditions and multiple health care providers, which can just make it really problematic and really exhausting in terms of getting help.”
 

Many unknowns

Providers may also be uncomfortable with prescribing hormone therapy because of alarming research in the early 2000s, which found that hormone replacement therapy increased the risk of breast cancer and cardiovascular disease. Later analyses have found no increased cardiovascular disease risk in women who were younger than 60 or were less than 10 years beyond the onset of menopause. Still, the “media frenzy” around the initial findings “has put off a whole load of patients and a whole load of clinicians from even thinking of HRT,” Dr. Tariq said.

Providers may be even more hesitant because people with HIV already have a higher risk for heart disease, due to behaviors such as smoking and HIV-specific factors. (Research has yet to tease out whether these cardiovascular effects are a result of the virus, a result of the antiretroviral therapy, or a result of both factors.) In addition, there have been no prospective studies looking directly at the efficacy and safety of hormone replacement therapy in women with HIV, so providers generally rely on the guidelines for the use of menopausal hormone therapy for women without HIV. While researchers from Canada and the United Kingdom have compiled recommendations for HRT in women with HIV, there is great need for a large-scale clinical trial to establish consistent guidelines for the use of HRT for women with HIV globally, Dr. Looby said.

There are also hormonal preparations and drug-to-drug interactions to consider, though none of the interactions identified so far rise to the level of contraindications. Because of how the liver metabolizes ART and HRT, hormone doses may need to be adjusted, or perhaps administered transdermally via a patch versus a pill form. (Estrogen delivered via skin patch may have reduced cardiovascular disease risk compared to other methods of delivery, some studies in women without HIV suggest.) These expected interactions are based on data from contraceptives, noted Elizabeth King, MD, whose research at the Women’s Health Research Institute at BC Women’s Hospital in Vancouver, B.C., focuses on menopause and HIV. Studies have not been done on drug-drug interactions between ART and HRT specifically, she said, and formulations for HRT are a bit different from contraceptives.

While these unknowns do need to be discussed in shared decision-making around starting HRT in women with HIV, they should not dissuade providers from considering the treatment, Dr. King said. “If women are having extremely troublesome symptoms, then withholding therapy that is potentially beneficial because of worries about some of the things we do not know – I don’t know if that is any better,” she said.

Many women with HIV may not want to start HRT – as was the case for Dr. Lynn. “I’ve taken a lot of medication in my time, and I really try to avoid it as much as possible,” she said. Uncertainties around drug interactions were the main concern for Dawn Averitt, 53, founder of the Well Project, an HIV nonprofit focused on women and girls. Ms. Averitt has lived with HIV for 34 years. “What if some of the things that I’m dealing with could be managed by HRT?” she said. “Or what if taking it exacerbates problems in a way that nobody knows to look for?” In this case, providers may work with patients to discuss nonhormonal treatment options for menopause symptom management.

While some women with HIV may not want HRT, “It’s important that women have that option, and from what we are seeing right now, not a lot of women are even being offered the therapy,” Dr. King said.

There are other nonhormonal treatments available for managing menopause symptoms, including selective serotonin reuptake inhibitors (SSRIs) as well as nonmedicinal interventions such as cognitive behavioral therapy, but these also have not been studied specifically in women with HIV.
 

The path forward

Dr. Tariq and Dr. Looby agreed the next step in expanding our knowledge around HIV and menopause should be to better engage women with HIV in research and clinical care around their experience with menopause. This includes studies on the symptoms they regularly experience and how these symptoms affect their quality of life, including their physical, psychological, cognitive, and social health. These studies could also help researchers and clinicians understand what these women with HIV want for their menopause care, whether that be medication, psychotherapy, and/or peer support groups. These interventions, whether pharmaceutical based or not, can then be assessed based on outcomes in women with HIV, Dr. Tariq noted.

Another important factor is increasing education, on both the patient and provider side, Dr. Looby said. Many women may not know what menopause is, what symptoms look like, and how these hormonal changes can affect their health. If providers keep an open dialogue with female patients around menopause throughout their adult care, that can better prepare women for the menopause transition and alert them to common symptoms they may experience. There also is a great need for provider education, Dr. Looby added. Infectious disease specialists may need further education on menopause management, while women’s health specialists may need additional training for managing care for patients with HIV. Ideally, this information could be shared among a team of providers, including infectious disease, primary care, and women’s health specialists, so that clinicians can collaborate in prescribing treatment for women with HIV, Dr. Looby said.

Lastly, there needs to be more research funding allocated toward answering questions related to menopause and HIV, including the age of onset of menopause in women with HIV, the severity of symptoms, how HIV may influence the menopause transition and vice versa, and regarding the effectiveness of treatment – pharmaceutical and nonpharmaceutical – for women with HIV going through the menopause transition. “If we don’t have funding for these studies, then we won’t have answers to establish clinical care guidelines necessary to support the health, well-being, and quality of life of women with HIV,” Dr. Looby said.

And the number of women living with HIV entering menopause is expected to keep growing, Dr. King added. “It was only a couple of decades ago when women were being told they wouldn’t even live to experience menopause, and now we are at a point where this is the highest proportion of menopausal women ever that we have seen in our HIV clinics,” she said. “It speaks to the success of antiretrovirals,” Dr. King acknowledged, but that also means identifying new challenges and addressing recognized gaps in care.

“We are charting a new course, in some ways,” she added. “There is a lot of work to be done.”

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

Note: In this article, “women” refers to ciswomen – those who identify as women and were assigned female sex at birth. Menopause also affects transmen and nonbinary people, but published research on the menopause experience has included only ciswomen participants.

Gina Brown was boarding an early morning flight in 2016 when suddenly she started to overheat. “As soon as I stepped on the plane, I immediately was drenched in sweat,” she said. Not knowing what to do, she stood still until a fellow female passenger noticed her alarm and asked a flight attendant to grab her a cup of ice. “Is this the first time this has happened to you?” the woman asked, and Ms. Brown nodded. “It’s called a hot flash,” the woman continued, “and you’re going to be okay.”

As soon as Ms. Brown returned from her trip, she visited her doctor for blood work and learned that her hormone levels were decreasing. “I knew something was going on, but [my provider and I] didn’t have a conversation about menopause,” she said. Ms. Brown, who is 56 years old, has been living with HIV for nearly 28 years, and is part of a growing group of women with HIV now entering menopause.

In 1996, a person diagnosed with HIV at 20 years of age could expect to live only to age 39. Because of antiretroviral therapy (ART), an HIV diagnosis is not nearly so dire. Now, someone with HIV who adheres to the ART regimen is estimated to have a lifespan close to that of the general population.

For women with HIV, this means going through menopause. Though this transition can be challenging for any woman, experiencing menopause with HIV adds another level of complication. On top of adhering to daily ART regimens, the woman must also deal with the hormonal changes of menopause and the symptoms that come with it. And the limited research in this area suggests that women with HIV and their clinicians may not be prepared.

“Those of us long-term survivors who have been around for a while never expected to be here, and I don’t think providers or the health care system expected us to be here,” said Vickie A. Lynn, PhD, 56, who has been living with HIV for 37 years and received an AIDS diagnosis in 1991. Her work focuses on health care interventions for people with HIV. “So now that we’re here, I don’t know that we have enough information or research to inform some of our treatment options.” Instead, these women are met with a series of unknowns due to limited studies and conflicting findings.
 

Earlier menopause?

The onset of menopause can be difficult to determine in women living with HIV, said Sara Looby, PhD, ANP-BC, a researcher at Massachusetts General Hospital and assistant professor of medicine at Harvard Medical School, both in Boston. Her research focuses on metabolic disorders, including bone loss, cardiovascular disease risk, and menopause in women living with HIV. This population is at an increased risk for amenorrhea, due to both behavioral and clinical factors, and sometimes this amenorrhea is mistakenly assumed to be menopause, she explained. A history of smoking, low weight, methadone use, or use of other psychotropic medications are common in women with HIV and can lead to missed periods. Some factors specific to HIV – including a low CD4 count and a history of an AIDS diagnosis – have also been linked to amenorrhea.

This is likely why research studies on the age of onset of menopause with women with HIV can reach conflicting conclusions. Some studies suggest that women with HIV tend to go through menopause 3-5 years earlier than women without HIV. Other studies suggest no difference in the age of onset in menopause between women living with and without HIV. But how menopause status has been accessed can vary from study to study, Dr. Looby said. Future research needs to consider participants’ complete menstrual and reproductive history, as well as relevant medical, social, and behavioral factors, she added, so that the findings are reliably capturing the age of onset of menopause rather than amenorrhea from other causes.

If menopause does occur earlier in women with HIV, there could be additional health implications. Estrogen regulates bone mass, and some research suggests the hormone may be cardioprotective. Estrogen is also thought to increase production of the neurotransmitter serotonin, which could affect mood and cognition. Women with HIV are already at higher risk for bone loss, cardiovascular disease, and depressed mood compared to women without HIV, Dr. Looby said, and as estrogen levels fall during menopause, these conditions may be deleteriously affected.

“If it is determined that women with HIV experience menopause at an earlier age, maybe early to mid-40s instead of 51 and older, they may be at increased risk for cardiovascular and bone conditions as well as mood symptoms associated with estrogen loss at an earlier age than women without HIV, which could be highly detrimental to their physical and mental health,” Dr. Looby said.
 

More frequent and severe menopausal symptoms?

Women with HIV may not only go through menopause earlier than women without HIV, but their symptoms may also be more frequent and more severe. In a 2017 study of both HIV-positive and HIV-negative Nigerian women, participants with HIV had more menopause symptoms overall and were three times as likely to report severe symptoms compared to women without HIV. A 2005 study conducted in New York found HIV-positive women were 24% more likely to report menopause symptoms compared to HIV-negative women in the study.

Looby’s own research has also found a similar pattern. In a study comparing 33 women with HIV to 33 women without HIV – all were close to menopause and matched for age, race, body mass index, and menstrual patterns – women with HIV reported more severe hot flashes and more days with hot flashes. These women also reported that their hot flashes interfered to a much greater degree with daily activities and quality of life compared to participants without HIV.

But studies of women with HIV who are entering menopause are rare, and most include only small numbers of women. As a result, many women with HIV do not know what to expect entering menopause. “I always say, I wish somebody would do some real research on HIV and menopause, because I want to know if it is worse for us or if it is the same,” said Ms. Brown, who works as the director of strategic partnership and community engagement at the Southern Aids Coalition in Powder Springs, Ga. “I would think it’s worse for me.”

More frequent and severe symptoms can have downstream effects, with some evidence suggesting that women with HIV who experience severe menopause symptoms are less likely to stick to their ART regimen. “There’s a clear picture emerging that menopausal symptoms in this group really matter,” said Shema Tariq, PhD, FRCP, an HIV physician-scientist at the University College London Institute for Global Health in England. “They really impact women’s well-being, as well as impacting their ability to look after their long-term condition.”
 

Providers wary of treating menopause symptoms in women with HIV

The little research we do have about women with HIV experiencing menopause suggests that this population could greatly benefit from treatment prescribed in women without HIV for menopause symptoms and conditions, including hormone replacement therapy (HRT). Women with HIV regularly experience night sweats and hot flashes during the menopause transition and may have more severe symptoms than women not living with the virus. If women with HIV also frequently enter early menopause (entering menopause before the age of 45), then this group meets two indications for hormone replacement therapy.

Despite the potential benefits of HRT in this population, some studies suggest this intervention is underutilized. In Dr. Tariq’s Positive Transitions through Menopause (PRIME) study, which explores how menopause affects more than 800 women living with HIV, only 8% of respondents reported using HRT. In a Canadian study that has not yet gone through peer review, 11.8% of perimenopausal and postmenopausal women reported ever using HRT, about half the rate of women in North America without HIV.

Provider discomfort with managing menopause-related care in women with HIV is one reason for such low HRT use in this population, Dr. Tariq said. In a survey of 88 general practitioners in the United Kingdom, nearly all (> 95%) respondents said they were comfortable managing menopause in a general population, but just 46% said they felt comfortable managing menopause in women with HIV. Their top concerns included the potential for drug-to-drug interactions between ART and HRT, missing an HIV-related diagnosis, and risks of menopausal hormone therapy in HIV. Nearly half of respondents (46%) said only specialists should be providing menopause-related care for women with HIV.

But specialists may also feel conflicted about managing menopause-related care in women with HIV, said Dr. Tariq. “If you’re looking at people who manage HIV, you’re looking primarily at infectious disease physicians and HIV physicians. We’re not trained as gynecologists. We’re not used to prescribing HRT,” she said. “And the problem is gynecologists aren’t used to managing HIV. They get nervous about prescribing anything when they see antiretroviral medication because all that people think of is a drug-drug interaction.”

This leaves women with HIV seeking care and treatment for menopause in a difficult situation, where they are “just being ping-ponged around between different health care providers,” said Susan Cole-Haley, 53, an HIV-activist in London who has been living with the virus for 23 years. “So many women with HIV have multiple health conditions and multiple health care providers, which can just make it really problematic and really exhausting in terms of getting help.”
 

Many unknowns

Providers may also be uncomfortable with prescribing hormone therapy because of alarming research in the early 2000s, which found that hormone replacement therapy increased the risk of breast cancer and cardiovascular disease. Later analyses have found no increased cardiovascular disease risk in women who were younger than 60 or were less than 10 years beyond the onset of menopause. Still, the “media frenzy” around the initial findings “has put off a whole load of patients and a whole load of clinicians from even thinking of HRT,” Dr. Tariq said.

Providers may be even more hesitant because people with HIV already have a higher risk for heart disease, due to behaviors such as smoking and HIV-specific factors. (Research has yet to tease out whether these cardiovascular effects are a result of the virus, a result of the antiretroviral therapy, or a result of both factors.) In addition, there have been no prospective studies looking directly at the efficacy and safety of hormone replacement therapy in women with HIV, so providers generally rely on the guidelines for the use of menopausal hormone therapy for women without HIV. While researchers from Canada and the United Kingdom have compiled recommendations for HRT in women with HIV, there is great need for a large-scale clinical trial to establish consistent guidelines for the use of HRT for women with HIV globally, Dr. Looby said.

There are also hormonal preparations and drug-to-drug interactions to consider, though none of the interactions identified so far rise to the level of contraindications. Because of how the liver metabolizes ART and HRT, hormone doses may need to be adjusted, or perhaps administered transdermally via a patch versus a pill form. (Estrogen delivered via skin patch may have reduced cardiovascular disease risk compared to other methods of delivery, some studies in women without HIV suggest.) These expected interactions are based on data from contraceptives, noted Elizabeth King, MD, whose research at the Women’s Health Research Institute at BC Women’s Hospital in Vancouver, B.C., focuses on menopause and HIV. Studies have not been done on drug-drug interactions between ART and HRT specifically, she said, and formulations for HRT are a bit different from contraceptives.

While these unknowns do need to be discussed in shared decision-making around starting HRT in women with HIV, they should not dissuade providers from considering the treatment, Dr. King said. “If women are having extremely troublesome symptoms, then withholding therapy that is potentially beneficial because of worries about some of the things we do not know – I don’t know if that is any better,” she said.

Many women with HIV may not want to start HRT – as was the case for Dr. Lynn. “I’ve taken a lot of medication in my time, and I really try to avoid it as much as possible,” she said. Uncertainties around drug interactions were the main concern for Dawn Averitt, 53, founder of the Well Project, an HIV nonprofit focused on women and girls. Ms. Averitt has lived with HIV for 34 years. “What if some of the things that I’m dealing with could be managed by HRT?” she said. “Or what if taking it exacerbates problems in a way that nobody knows to look for?” In this case, providers may work with patients to discuss nonhormonal treatment options for menopause symptom management.

While some women with HIV may not want HRT, “It’s important that women have that option, and from what we are seeing right now, not a lot of women are even being offered the therapy,” Dr. King said.

There are other nonhormonal treatments available for managing menopause symptoms, including selective serotonin reuptake inhibitors (SSRIs) as well as nonmedicinal interventions such as cognitive behavioral therapy, but these also have not been studied specifically in women with HIV.
 

The path forward

Dr. Tariq and Dr. Looby agreed the next step in expanding our knowledge around HIV and menopause should be to better engage women with HIV in research and clinical care around their experience with menopause. This includes studies on the symptoms they regularly experience and how these symptoms affect their quality of life, including their physical, psychological, cognitive, and social health. These studies could also help researchers and clinicians understand what these women with HIV want for their menopause care, whether that be medication, psychotherapy, and/or peer support groups. These interventions, whether pharmaceutical based or not, can then be assessed based on outcomes in women with HIV, Dr. Tariq noted.

Another important factor is increasing education, on both the patient and provider side, Dr. Looby said. Many women may not know what menopause is, what symptoms look like, and how these hormonal changes can affect their health. If providers keep an open dialogue with female patients around menopause throughout their adult care, that can better prepare women for the menopause transition and alert them to common symptoms they may experience. There also is a great need for provider education, Dr. Looby added. Infectious disease specialists may need further education on menopause management, while women’s health specialists may need additional training for managing care for patients with HIV. Ideally, this information could be shared among a team of providers, including infectious disease, primary care, and women’s health specialists, so that clinicians can collaborate in prescribing treatment for women with HIV, Dr. Looby said.

Lastly, there needs to be more research funding allocated toward answering questions related to menopause and HIV, including the age of onset of menopause in women with HIV, the severity of symptoms, how HIV may influence the menopause transition and vice versa, and regarding the effectiveness of treatment – pharmaceutical and nonpharmaceutical – for women with HIV going through the menopause transition. “If we don’t have funding for these studies, then we won’t have answers to establish clinical care guidelines necessary to support the health, well-being, and quality of life of women with HIV,” Dr. Looby said.

And the number of women living with HIV entering menopause is expected to keep growing, Dr. King added. “It was only a couple of decades ago when women were being told they wouldn’t even live to experience menopause, and now we are at a point where this is the highest proportion of menopausal women ever that we have seen in our HIV clinics,” she said. “It speaks to the success of antiretrovirals,” Dr. King acknowledged, but that also means identifying new challenges and addressing recognized gaps in care.

“We are charting a new course, in some ways,” she added. “There is a lot of work to be done.”

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

The infants of obese pregnant women had a 55% higher adjusted perinatal death rate, compared with those of normal-weight pregnant women, but lower gestational age had a mediating effect, based on data from nearly 400,000 women-infant pairs.

“While some obesity-related causes of fetal death are known, the exact pathophysiology behind the effects of obesity on perinatal death are not completely understood,” Jeffrey N. Bone, MD, of the University of British Columbia, Vancouver, and colleagues wrote. Higher body mass index prior to pregnancy also is associated with preterm delivery, but the effect of gestational age on the association between BMI and infant mortality has not been well explored.

In a study published in PLOS ONE, the researchers reviewed data from nearly 400,000 women obtained through the British Columbia Perinatal Database Registry, which collects obstetric and neonatal data from hospital charts and from delivery records of home births. Births at less than 20 weeks’ gestation and late pregnancy terminations were excluded.

BMI was based on self-reported prepregnancy height and weight; of the 392,820 included women, 12.8% were classified as obese, 20.6% were overweight, 60.6% were normal weight, and 6.0% were underweight. Infants of women with higher BMI had a lower gestational age at delivery. Perinatal mortality occurred in 1,834 pregnancies (0.5%). In adjusted analysis, infant perinatal death was significantly more likely for obese women (adjusted odds ratio, 1.55) and overweight women (aOR, 1.22).

However, 63.1% of this association in obese women was mediated by gestational age of the infant at delivery, with aORs of 1.32 and 1.18 for natural indirect and natural direct effects, respectively, compared with that of normal-weight women. Similar, but lesser effects were noted for overweight women, with aORs of 1.11 and 1.10, respectively. “Direct effects were higher, and mediation was lower for stillbirth than for neonatal death, where the total effect was entirely indirect,” but the confidence intervals remained consistent with the primary analyses, the researchers noted.

The increased perinatal death rates of infants of obese and overweight women reflect data from previous studies, but the current study’s use of mediation analysis offers new insight on the mechanism by which perinatal death rates increase with higher maternal BMI, the researchers wrote.

The study findings were limited by several factors including the need to consider potential common risk factors for both perinatal death and early delivery that would be affected by maternal obesity, the researchers noted. Other limitations included the use of gestational age at stillbirth, which represents an approximation of fetal death in some cases, and the use of self-reports for prepregnancy maternal BMI.

However, the results were strengthened by the large, population-based design and information on potential confounding variables, and suggest that early gestational age at delivery may play a role in maternal obesity-related perinatal death risk.

“To better inform the pregnancy management in obese women, further studies should continue to disentangle the causal pathways under which obesity increases the risk of perinatal death, including, for example, gestational diabetes and other obesity-related pregnancy complications,” they concluded.
 

More testing and counseling are needed

The current study is important because obesity rates continue to increase in the reproductive-age population, Marissa Platner, MD, of Emory University, Atlanta, said in an interview. “Obesity has become a known risk factor for adverse pregnancy outcomes, specifically the risk of stillbirth and perinatal death. However, the authors correctly point out that the underlying cause of these perinatal deaths in women with obesity is unclear. Additionally, ACOG recently updated their clinical guidelines to recommend routine antenatal testing for women with obesity due to these increased rates of stillbirth.

“I was not surprised by these findings; similar to previous literature, the risks of perinatal death seem to have a dose-response relationship with increasing BMI. We know that women with prepregnancy obesity are also at higher risk of perinatal complications in the preterm period, which would increase the risk of perinatal death,” Dr. Platner said

“I think the take-home message for clinicians is twofold,” Dr. Platner said. First, “we need to take the updated antenatal testing guidelines from ACOG very seriously and implement these in our practices.” Second, “in the preconception or early antepartum period, these patients should be thoroughly counseled on the associated risks of pregnancy and discuss appropriate gestational weight gain guidelines and lifestyle modifications.”

However, “additional research is needed in a U.S. population with higher rates of obesity to determine the true effects of obesity on perinatal deaths and to further elucidate the underlying pathophysiology and disease processes that may lead to increased risk of both stillbirth and perinatal deaths,” Dr. Platner emphasized.

*This story was updated on March 23, 2022.

The study was supported by the Sick Kids Foundation and the Canadian Institute of Health Research. The researchers had no financial conflicts to disclose. Dr. Platner had no financial conflicts to disclose.

The infants of obese pregnant women had a 55% higher adjusted perinatal death rate, compared with those of normal-weight pregnant women, but lower gestational age had a mediating effect, based on data from nearly 400,000 women-infant pairs.

“While some obesity-related causes of fetal death are known, the exact pathophysiology behind the effects of obesity on perinatal death are not completely understood,” Jeffrey N. Bone, MD, of the University of British Columbia, Vancouver, and colleagues wrote. Higher body mass index prior to pregnancy also is associated with preterm delivery, but the effect of gestational age on the association between BMI and infant mortality has not been well explored.

In a study published in PLOS ONE, the researchers reviewed data from nearly 400,000 women obtained through the British Columbia Perinatal Database Registry, which collects obstetric and neonatal data from hospital charts and from delivery records of home births. Births at less than 20 weeks’ gestation and late pregnancy terminations were excluded.

BMI was based on self-reported prepregnancy height and weight; of the 392,820 included women, 12.8% were classified as obese, 20.6% were overweight, 60.6% were normal weight, and 6.0% were underweight. Infants of women with higher BMI had a lower gestational age at delivery. Perinatal mortality occurred in 1,834 pregnancies (0.5%). In adjusted analysis, infant perinatal death was significantly more likely for obese women (adjusted odds ratio, 1.55) and overweight women (aOR, 1.22).

However, 63.1% of this association in obese women was mediated by gestational age of the infant at delivery, with aORs of 1.32 and 1.18 for natural indirect and natural direct effects, respectively, compared with that of normal-weight women. Similar, but lesser effects were noted for overweight women, with aORs of 1.11 and 1.10, respectively. “Direct effects were higher, and mediation was lower for stillbirth than for neonatal death, where the total effect was entirely indirect,” but the confidence intervals remained consistent with the primary analyses, the researchers noted.

The increased perinatal death rates of infants of obese and overweight women reflect data from previous studies, but the current study’s use of mediation analysis offers new insight on the mechanism by which perinatal death rates increase with higher maternal BMI, the researchers wrote.

The study findings were limited by several factors including the need to consider potential common risk factors for both perinatal death and early delivery that would be affected by maternal obesity, the researchers noted. Other limitations included the use of gestational age at stillbirth, which represents an approximation of fetal death in some cases, and the use of self-reports for prepregnancy maternal BMI.

However, the results were strengthened by the large, population-based design and information on potential confounding variables, and suggest that early gestational age at delivery may play a role in maternal obesity-related perinatal death risk.

“To better inform the pregnancy management in obese women, further studies should continue to disentangle the causal pathways under which obesity increases the risk of perinatal death, including, for example, gestational diabetes and other obesity-related pregnancy complications,” they concluded.
 

More testing and counseling are needed

The current study is important because obesity rates continue to increase in the reproductive-age population, Marissa Platner, MD, of Emory University, Atlanta, said in an interview. “Obesity has become a known risk factor for adverse pregnancy outcomes, specifically the risk of stillbirth and perinatal death. However, the authors correctly point out that the underlying cause of these perinatal deaths in women with obesity is unclear. Additionally, ACOG recently updated their clinical guidelines to recommend routine antenatal testing for women with obesity due to these increased rates of stillbirth.

“I was not surprised by these findings; similar to previous literature, the risks of perinatal death seem to have a dose-response relationship with increasing BMI. We know that women with prepregnancy obesity are also at higher risk of perinatal complications in the preterm period, which would increase the risk of perinatal death,” Dr. Platner said

“I think the take-home message for clinicians is twofold,” Dr. Platner said. First, “we need to take the updated antenatal testing guidelines from ACOG very seriously and implement these in our practices.” Second, “in the preconception or early antepartum period, these patients should be thoroughly counseled on the associated risks of pregnancy and discuss appropriate gestational weight gain guidelines and lifestyle modifications.”

However, “additional research is needed in a U.S. population with higher rates of obesity to determine the true effects of obesity on perinatal deaths and to further elucidate the underlying pathophysiology and disease processes that may lead to increased risk of both stillbirth and perinatal deaths,” Dr. Platner emphasized.

*This story was updated on March 23, 2022.

The study was supported by the Sick Kids Foundation and the Canadian Institute of Health Research. The researchers had no financial conflicts to disclose. Dr. Platner had no financial conflicts to disclose.

The infants of obese pregnant women had a 55% higher adjusted perinatal death rate, compared with those of normal-weight pregnant women, but lower gestational age had a mediating effect, based on data from nearly 400,000 women-infant pairs.

“While some obesity-related causes of fetal death are known, the exact pathophysiology behind the effects of obesity on perinatal death are not completely understood,” Jeffrey N. Bone, MD, of the University of British Columbia, Vancouver, and colleagues wrote. Higher body mass index prior to pregnancy also is associated with preterm delivery, but the effect of gestational age on the association between BMI and infant mortality has not been well explored.

In a study published in PLOS ONE, the researchers reviewed data from nearly 400,000 women obtained through the British Columbia Perinatal Database Registry, which collects obstetric and neonatal data from hospital charts and from delivery records of home births. Births at less than 20 weeks’ gestation and late pregnancy terminations were excluded.

BMI was based on self-reported prepregnancy height and weight; of the 392,820 included women, 12.8% were classified as obese, 20.6% were overweight, 60.6% were normal weight, and 6.0% were underweight. Infants of women with higher BMI had a lower gestational age at delivery. Perinatal mortality occurred in 1,834 pregnancies (0.5%). In adjusted analysis, infant perinatal death was significantly more likely for obese women (adjusted odds ratio, 1.55) and overweight women (aOR, 1.22).

However, 63.1% of this association in obese women was mediated by gestational age of the infant at delivery, with aORs of 1.32 and 1.18 for natural indirect and natural direct effects, respectively, compared with that of normal-weight women. Similar, but lesser effects were noted for overweight women, with aORs of 1.11 and 1.10, respectively. “Direct effects were higher, and mediation was lower for stillbirth than for neonatal death, where the total effect was entirely indirect,” but the confidence intervals remained consistent with the primary analyses, the researchers noted.

The increased perinatal death rates of infants of obese and overweight women reflect data from previous studies, but the current study’s use of mediation analysis offers new insight on the mechanism by which perinatal death rates increase with higher maternal BMI, the researchers wrote.

The study findings were limited by several factors including the need to consider potential common risk factors for both perinatal death and early delivery that would be affected by maternal obesity, the researchers noted. Other limitations included the use of gestational age at stillbirth, which represents an approximation of fetal death in some cases, and the use of self-reports for prepregnancy maternal BMI.

However, the results were strengthened by the large, population-based design and information on potential confounding variables, and suggest that early gestational age at delivery may play a role in maternal obesity-related perinatal death risk.

“To better inform the pregnancy management in obese women, further studies should continue to disentangle the causal pathways under which obesity increases the risk of perinatal death, including, for example, gestational diabetes and other obesity-related pregnancy complications,” they concluded.
 

More testing and counseling are needed

The current study is important because obesity rates continue to increase in the reproductive-age population, Marissa Platner, MD, of Emory University, Atlanta, said in an interview. “Obesity has become a known risk factor for adverse pregnancy outcomes, specifically the risk of stillbirth and perinatal death. However, the authors correctly point out that the underlying cause of these perinatal deaths in women with obesity is unclear. Additionally, ACOG recently updated their clinical guidelines to recommend routine antenatal testing for women with obesity due to these increased rates of stillbirth.

“I was not surprised by these findings; similar to previous literature, the risks of perinatal death seem to have a dose-response relationship with increasing BMI. We know that women with prepregnancy obesity are also at higher risk of perinatal complications in the preterm period, which would increase the risk of perinatal death,” Dr. Platner said

“I think the take-home message for clinicians is twofold,” Dr. Platner said. First, “we need to take the updated antenatal testing guidelines from ACOG very seriously and implement these in our practices.” Second, “in the preconception or early antepartum period, these patients should be thoroughly counseled on the associated risks of pregnancy and discuss appropriate gestational weight gain guidelines and lifestyle modifications.”

However, “additional research is needed in a U.S. population with higher rates of obesity to determine the true effects of obesity on perinatal deaths and to further elucidate the underlying pathophysiology and disease processes that may lead to increased risk of both stillbirth and perinatal deaths,” Dr. Platner emphasized.

*This story was updated on March 23, 2022.

The study was supported by the Sick Kids Foundation and the Canadian Institute of Health Research. The researchers had no financial conflicts to disclose. Dr. Platner had no financial conflicts to disclose.

There is insufficient evidence to weigh the balance of benefits and harms of screening for eating disorders in adolescents and adults, the U.S. Preventive Services Task Force says in their first-ever statement on the topic.

Eating disorders (binge eating disorder, bulimia nervosa, and anorexia nervosa) can cause “serious harms to physical and psychosocial health and take a tremendous toll on individuals and families,” task force member Lori Pbert, PhD, told this news organization.

“Screening for eating disorders has the potential to improve health by leading to early detection and effective treatment,” said Dr. Pbert, with the department of population and quantitative health sciences, University of Massachusetts, Worcester.

However, a “deep dive” into the available literature failed to turn up adequate evidence to recommend for or against routine screening for eating disorders for children and adolescents aged 10 years and older and for adults who have no signs or symptoms of an eating disorder or concerns about their eating and who have not previously been diagnosed with an eating disorder, Dr. Pbert said.

The task force, therefore, issued an “I” statement (insufficient evidence), meaning it cannot at this time recommend for or against screening for eating disorders.

An “I” statement is “fundamentally a call for more research,” Dr. Pbert noted.

Adolescents and adults who have signs and symptoms of an eating disorder – which include rapid weight loss; weight gain or pronounced deviation from growth trajectory; pubertal delay; bradycardia; oligomenorrhea; and amenorrhea – are not included in this recommendation.

The USPSTF recommendation statement and accompanying evidence report were published online March 15 in JAMA.
 

Clinical judgment key

In the absence of evidence, clinicians should use their judgment when determining whether or not to screen an individual patient for an eating disorder, Dr. Pbert advised.

One thing to consider is whether the patient is in a group at higher risk for eating disorders, such as athletes, females, young adults aged 18-29, and transgender individuals.

Another is whether the patient reports engaging in unhealthy weight control behaviors, such as fasting or skipping meals, Dr. Pbert said.

Importantly, any patient who has signs or symptoms of an eating disorder or is expressing concerns about their eating should be assessed and referred for appropriate care, Dr. Pbert said.

“The good news is that eating disorders can be treated,” she said.

Several organizations currently recommend screening in the context of monitoring changes in weight and other vital signs or signs and symptoms to determine whether a patient might have an eating disorder.

Dr. Pbert said it’s important to recognize that the USPSTF statement “doesn’t really conflict” with the recommendations of other organizations. “We all agree that patients who present with signs or symptoms of an eating disorder should be assessed further.”
 

Evidence gaps

The authors of an invited commentary in JAMA) say the task force has identified several “notable deficiencies” in the available data on screening for eating disorders.

“Directing attention to rigorous research to close this evidence gap will be important to find optimal approaches to identify patients with these complex disorders and improve their health outcomes,” write Evelyn Attia, MD, with Weill Cornell Medicine in New York, and Angela Guarda, MD, with Johns Hopkins University, Baltimore.

This “I” statement, they say, “highlights the need to prioritize research aimed at closing the evidence gap identified by USPSTF in a timely manner and underscores the need for new studies that address screening for eating disorders, treatment trials that enroll screen-detected populations from primary care settings, and screening in specific populations.

“Research on screening in primary care also should be paired with development and assessment of early brief intervention strategies for those individuals who screen positive, especially adolescents,” Dr. Attia and Dr. Guarda say.

Members of the USPSTF have disclosed no relevant financial relationships. Dr. Attia has received research support from the National Institute of Mental Health and the Hilda & Preston David Foundation; royalties from UpToDate; and has served as a clinical advisor to Equip Health. Dr. Guarda has received support from the Stephen and Jean Robinson Fund and research funding from the Klarman Family Foundation.

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

There is insufficient evidence to weigh the balance of benefits and harms of screening for eating disorders in adolescents and adults, the U.S. Preventive Services Task Force says in their first-ever statement on the topic.

Eating disorders (binge eating disorder, bulimia nervosa, and anorexia nervosa) can cause “serious harms to physical and psychosocial health and take a tremendous toll on individuals and families,” task force member Lori Pbert, PhD, told this news organization.

“Screening for eating disorders has the potential to improve health by leading to early detection and effective treatment,” said Dr. Pbert, with the department of population and quantitative health sciences, University of Massachusetts, Worcester.

However, a “deep dive” into the available literature failed to turn up adequate evidence to recommend for or against routine screening for eating disorders for children and adolescents aged 10 years and older and for adults who have no signs or symptoms of an eating disorder or concerns about their eating and who have not previously been diagnosed with an eating disorder, Dr. Pbert said.

The task force, therefore, issued an “I” statement (insufficient evidence), meaning it cannot at this time recommend for or against screening for eating disorders.

An “I” statement is “fundamentally a call for more research,” Dr. Pbert noted.

Adolescents and adults who have signs and symptoms of an eating disorder – which include rapid weight loss; weight gain or pronounced deviation from growth trajectory; pubertal delay; bradycardia; oligomenorrhea; and amenorrhea – are not included in this recommendation.

The USPSTF recommendation statement and accompanying evidence report were published online March 15 in JAMA.
 

Clinical judgment key

In the absence of evidence, clinicians should use their judgment when determining whether or not to screen an individual patient for an eating disorder, Dr. Pbert advised.

One thing to consider is whether the patient is in a group at higher risk for eating disorders, such as athletes, females, young adults aged 18-29, and transgender individuals.

Another is whether the patient reports engaging in unhealthy weight control behaviors, such as fasting or skipping meals, Dr. Pbert said.

Importantly, any patient who has signs or symptoms of an eating disorder or is expressing concerns about their eating should be assessed and referred for appropriate care, Dr. Pbert said.

“The good news is that eating disorders can be treated,” she said.

Several organizations currently recommend screening in the context of monitoring changes in weight and other vital signs or signs and symptoms to determine whether a patient might have an eating disorder.

Dr. Pbert said it’s important to recognize that the USPSTF statement “doesn’t really conflict” with the recommendations of other organizations. “We all agree that patients who present with signs or symptoms of an eating disorder should be assessed further.”
 

Evidence gaps

The authors of an invited commentary in JAMA) say the task force has identified several “notable deficiencies” in the available data on screening for eating disorders.

“Directing attention to rigorous research to close this evidence gap will be important to find optimal approaches to identify patients with these complex disorders and improve their health outcomes,” write Evelyn Attia, MD, with Weill Cornell Medicine in New York, and Angela Guarda, MD, with Johns Hopkins University, Baltimore.

This “I” statement, they say, “highlights the need to prioritize research aimed at closing the evidence gap identified by USPSTF in a timely manner and underscores the need for new studies that address screening for eating disorders, treatment trials that enroll screen-detected populations from primary care settings, and screening in specific populations.

“Research on screening in primary care also should be paired with development and assessment of early brief intervention strategies for those individuals who screen positive, especially adolescents,” Dr. Attia and Dr. Guarda say.

Members of the USPSTF have disclosed no relevant financial relationships. Dr. Attia has received research support from the National Institute of Mental Health and the Hilda & Preston David Foundation; royalties from UpToDate; and has served as a clinical advisor to Equip Health. Dr. Guarda has received support from the Stephen and Jean Robinson Fund and research funding from the Klarman Family Foundation.

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

There is insufficient evidence to weigh the balance of benefits and harms of screening for eating disorders in adolescents and adults, the U.S. Preventive Services Task Force says in their first-ever statement on the topic.

Eating disorders (binge eating disorder, bulimia nervosa, and anorexia nervosa) can cause “serious harms to physical and psychosocial health and take a tremendous toll on individuals and families,” task force member Lori Pbert, PhD, told this news organization.

“Screening for eating disorders has the potential to improve health by leading to early detection and effective treatment,” said Dr. Pbert, with the department of population and quantitative health sciences, University of Massachusetts, Worcester.

However, a “deep dive” into the available literature failed to turn up adequate evidence to recommend for or against routine screening for eating disorders for children and adolescents aged 10 years and older and for adults who have no signs or symptoms of an eating disorder or concerns about their eating and who have not previously been diagnosed with an eating disorder, Dr. Pbert said.

The task force, therefore, issued an “I” statement (insufficient evidence), meaning it cannot at this time recommend for or against screening for eating disorders.

An “I” statement is “fundamentally a call for more research,” Dr. Pbert noted.

Adolescents and adults who have signs and symptoms of an eating disorder – which include rapid weight loss; weight gain or pronounced deviation from growth trajectory; pubertal delay; bradycardia; oligomenorrhea; and amenorrhea – are not included in this recommendation.

The USPSTF recommendation statement and accompanying evidence report were published online March 15 in JAMA.
 

Clinical judgment key

In the absence of evidence, clinicians should use their judgment when determining whether or not to screen an individual patient for an eating disorder, Dr. Pbert advised.

One thing to consider is whether the patient is in a group at higher risk for eating disorders, such as athletes, females, young adults aged 18-29, and transgender individuals.

Another is whether the patient reports engaging in unhealthy weight control behaviors, such as fasting or skipping meals, Dr. Pbert said.

Importantly, any patient who has signs or symptoms of an eating disorder or is expressing concerns about their eating should be assessed and referred for appropriate care, Dr. Pbert said.

“The good news is that eating disorders can be treated,” she said.

Several organizations currently recommend screening in the context of monitoring changes in weight and other vital signs or signs and symptoms to determine whether a patient might have an eating disorder.

Dr. Pbert said it’s important to recognize that the USPSTF statement “doesn’t really conflict” with the recommendations of other organizations. “We all agree that patients who present with signs or symptoms of an eating disorder should be assessed further.”
 

Evidence gaps

The authors of an invited commentary in JAMA) say the task force has identified several “notable deficiencies” in the available data on screening for eating disorders.

“Directing attention to rigorous research to close this evidence gap will be important to find optimal approaches to identify patients with these complex disorders and improve their health outcomes,” write Evelyn Attia, MD, with Weill Cornell Medicine in New York, and Angela Guarda, MD, with Johns Hopkins University, Baltimore.

This “I” statement, they say, “highlights the need to prioritize research aimed at closing the evidence gap identified by USPSTF in a timely manner and underscores the need for new studies that address screening for eating disorders, treatment trials that enroll screen-detected populations from primary care settings, and screening in specific populations.

“Research on screening in primary care also should be paired with development and assessment of early brief intervention strategies for those individuals who screen positive, especially adolescents,” Dr. Attia and Dr. Guarda say.

Members of the USPSTF have disclosed no relevant financial relationships. Dr. Attia has received research support from the National Institute of Mental Health and the Hilda & Preston David Foundation; royalties from UpToDate; and has served as a clinical advisor to Equip Health. Dr. Guarda has received support from the Stephen and Jean Robinson Fund and research funding from the Klarman Family Foundation.

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