This Clinical Insights discusses special considerations in recurrent urinary tract infection diagnosis and management in older women.
Bacterial vaginosis is the most common cause of abnormal vaginal discharge, affecting 23%–30% of reproductive-aged people
Bacterial vaginosis is caused by a disrupted vaginal microbiome balance. Symptoms include itch, dysuria, and a thin, grey discharge with a “fishy” odour, particularly after coitus. Risk factors include smoking and unprotected intercourse, including oral sex.
Uterine fibroids are sex–steroid responsive benign tumors primarily composed of smooth muscle cells and extracellular matrix that develop in the wall of the uterus.1 They are one of the most common neoplasms in reproductive-aged women. Lifetime prevalence estimates in premenopausal women range from 40% to 89%, depending on the method of detection, the study population, and the ages of those studied. Fibroids can range in size from less than 1 cm to more than 20 cm. Although not all individuals with fibroids have symptoms, typical symptoms include abnormal uterine bleeding/heavy menstrual bleeding (AUB/HMB), pelvic bulk symptoms (protruding abdomen, pressure on bladder and bowels), pain, and reproductive morbidity (ie, infertility). Due to their high prevalence and associated symptoms, fibroids are the leading cause of hysterectomy in the US and account for up to $34 billion annually in direct and indirect costs.
KEY POINTS
Polycystic ovarian syndrome (PCOS) is a chronic disorder associated with infertility; miscarriage; adverse pregnancy outcomes; and cardiovascular, metabolic, psychological and neoplastic risks.
DIagnosis of PCOS can be made based on the presence of any 2 of menstrual irregularities, clinical or biochemical hyperandrogenism or polycystic ovarian morphology on transvaginal ultrasonography.
Treatment of PCOS may target anovulation, androgen excess, hyperinsulinemia and weight management.
Patients with PCOS should have regular monitoring of their body mass index, blood pressure and metabolic parameters, and should be regularly screened for depression, anxiety and obstructive sleep apnea.
Introduction: Existing guidelines for primary care clinicians (PCCs) on the detection and management of perinatal depression (PD) contain important gaps. This review aims to provide PCCs with a summary of clinically relevant evidence in the field.
Methods: A narrative literature review was conducted by searching PubMed and PsycINFO for articles published between 2010 to 2023. Guidelines, systematic reviews, clinical trials, and/or observational studies were all examined.
Results: Screening with the Edinburgh Postnatal Depression Scale or Patient Health Questionnaire-9 followed by a diagnostic evaluation for major depressive disorder in probable cases can enhance PD detection. At-risk individuals and mild to moderate PD should be referred for cognitive behavioral therapy or interpersonal psychotherapy when available. Selective serotonin reuptake inhibitors should be used for moderate to severe PD, with sertraline, escitalopram, or citalopram being preferred first. Using paroxetine or clomipramine in pregnancy, and fluoxetine or doxepin during lactation is generally not preferred. Gestational antidepressant use is associated with a small increase in risk of reduced gestational age at birth, low birth weight, and lower APGAR scores, though whether these links are causal is unclear. Sertraline and paroxetine have the lowest rate of adverse events during lactation. Consequences of untreated PD can include maternal and offspring mortality, perinatal complications, poor maternal-infant attachment, child morbidity and maltreatment, less breastfeeding, and offspring developmental problems.
Conclusions: These clinically relevant data can support the delivery of high-quality care by PCCs. Risks and benefits of PD treatments and the consequences of untreated PD should be discussed with patients to support informed decision making.
The first question a patient often asks their FP after receiving a diagnosis of breast cancer (BC) is “What will my treatment be?” This article will help FPs answer this complex question by reviewing multimodal therapy for BC, which is contingent on molecular subtype and stage.
Importance: Anxiety disorders are commonly occurring mental health conditions. They are often unrecognized in primary care settings and substantial delays in treatment initiation occur.
Objective: The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for anxiety disorders in asymptomatic adults.
Population: Asymptomatic adults 19 years or older, including pregnant and postpartum persons. Older adults are defined as those 65 years or older.
Evidence assessment: The USPSTF concludes with moderate certainty that screening for anxiety disorders in adults, including pregnant and postpartum persons, has a moderate net benefit. The USPSTF concludes that the evidence is insufficient on screening for anxiety disorders in older adults.
Recommendation: The USPSTF recommends screening for anxiety disorders in adults, including pregnant and postpartum persons. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for anxiety disorders in older adults. (I statement).
Menopause is defined as 1 year of amenorrhea caused by
declining ovarian reserve or as the onset of vasomotor
symptoms in people with iatrogenic amenorrhea. It is preceded
by perimenopause or the menopause transition, which can last
for as long as 10 years. Although many treatments exist for
menopausal symptoms, fears around the risks of menopausal
hormone therapy and lack of knowledge regarding treatment
options often impede patients from receiving treatment. In this
review, we summarize the evidence for treating menopausal
symptoms and discuss their risks and benefits to help guide
clinicians to evaluate and treat patients during the menopausal
transition (Box 1).
• Menopausal symptoms can occur for as long as 10 years before
the last menstrual period and are associated with substantial
morbidity and negative impacts on quality of life.
• Menopausal hormone therapy is indicated as first-line
treatment of vasomotor symptoms, and is a safe treatment
option for patients with no contraindications.
• Though less effective, nonhormonal treatments also exist to
treat vasomotor symptoms and sleep disturbances.
• It is critical that clinicians inquire about symptoms during the
menopause transition and discuss treatment options with
their patients.
Importance: Menopause is defined as the cessation of a person's menstrual cycle. It is defined retrospectively, 12 months after the final menstrual period. Perimenopause, or the menopausal transition, is the few-year time period preceding a person's final menstrual period and is characterized by increasing menstrual cycle length variability and periods of amenorrhea, and often symptoms such as vasomotor dysfunction. The prevalence and incidence of most chronic diseases (eg, cardiovascular disease, cancer, osteoporosis, and fracture) increase with age, and US persons who reach menopause are expected on average to live more than another 30 years.
Objective: To update its 2017 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of systemic (ie, oral or transdermal) hormone therapy for the prevention of chronic conditions in postmenopausal persons and whether outcomes vary by age or by timing of intervention after menopause.
Population: Asymptomatic postmenopausal persons who are considering hormone therapy for the primary prevention of chronic medical conditions.
Evidence assessment: The USPSTF concludes with moderate certainty that the use of combined estrogen and progestin for the primary prevention of chronic conditions in postmenopausal persons with an intact uterus has no net benefit. The USPSTF concludes with moderate certainty that the use of estrogen alone for the primary prevention of chronic conditions in postmenopausal persons who have had a hysterectomy has no net benefit.
Recommendation: The USPSTF recommends against the use of combined estrogen and progestin for the primary prevention of chronic conditions in postmenopausal persons. (D recommendation) The USPSTF recommends against the use of estrogen alone for the primary prevention of chronic conditions in postmenopausal persons who have had a hysterectomy. (D recommendation).
BACKGROUND
Neurogenic lower urinary tract dysfunction (NLUTD) is a highly prevalent and disabling condition; nevertheless, standard treatments often remain unsatisfactory. Sacral neuromodulation (SNM) is a well-established therapy for non-NLUTD, but there is a lack of randomized controlled trials to show benefit in patients with NLUTD.
METHODS
For this sham-controlled, double-blind, multicenter trial, patients with refractory NLUTD (and intended SNM) were recruited at four Swiss SNM referral centers. After lead placement into the sacral foramina S3 (rarely, S4), all participants underwent SNM testing. If successful (≥50% improvement in key bladder diary variables), the neurostimulator was implanted for permanent stimulation. For 2 months, neuromodulation was optimized using subsensory stimulation with individually adjusted parameters. Thereafter, the neurostimulator remained on or was switched off (1:1 random allocation to group SNM ON or SNM OFF, respectively) for 2 months, followed by a neurourologic reevaluation. The primary outcome was success, as defined above, of SNM compared with baseline.
RESULTS
Of 124 patients undergoing SNM testing, 65 (52%) had successfully improved lower urinary tract function. Of these, 60 patients (median age, 49.5 years; 43 women) were randomly assigned to the intervention. After 2 months of intervention, the SNM ON group demonstrated a success rate of 76%. In the SNM OFF group, 42% of patients showed sustained SNM effects despite their neurostimulator being switched off during the last 2 months (odds ratio, 4.35; 95% confidence interval, 1.43 to 13.21; P=0.009). During the entire study period, there were 11 adverse events (6 dropouts; no dropouts during the intervention phase).
CONCLUSIONS
SNM effectively corrected refractory NLUTD in the short term in well-selected neurologic patients. (Funded by the Swiss National Science Foundation, Vontobel–Stiftung, Gottfried und Julia Bangerter–Rhyner Stiftung, Dr. Urs Mühlebach, and the Swiss Continence Foundation; ClinicalTrials.gov number, NCT02165774.)
