female

A review of relatively common chronic venous abnormalities in the female pelvis that can cause LE varicosities and pelvic pain. James W. Mold, MD, MPH

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Objective: To provide a practical guide to help family physicians recognize, diagnose, and manage patients with pelvic venous disorders (PeVDs), often overlooked as causes of chronic pelvic pain and varicose veins.

Sources of information: This review is based on guidelines from the American Venous Forum, the Society for Vascular Surgery, the American Vein and Lymphatic Society, the Society of Interventional Radiology, and the European Society for Vascular Surgery.

Main message: PeVDs are common, though frequently misdiagnosed, causes of chronic pelvic pain and varicose veins predominantly in female patients. These conditions arise from venous reflux or obstruction, which can cause varicose veins and venous hypertension in the renal hilum, pelvis, perineum, and lower extremities. Family physicians should recognize the clinical signs of PeVDs and use appropriate imaging to confirm diagnoses. Interventional treatments, including embolization and stenting, are effective for symptom management and improving patient outcomes.

Conclusion: Early recognition of patients with PeVDs by family physicians is crucial for timely and effective treatment. By using appropriate diagnostic tools and making timely referrals, physicians can substantially improve patients' quality of life.

Author/s:

Andrew D Brown

Patent Foramen Ovale and Stroke A Review

Hope Smashey — Tue, 29 Jul 2025 17:14:31 +0000

Date Added:

July 29, 2025

Journal/Publication:

JAMA

Publication Date:

July 28, 2025

URL:

Patent Foramen Ovale and Stroke A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2025.10946

Keywords

Congenital Defects

pediatrics

female

PMID (1):

40720119

MeSH

Apparently patent foramen ovale is a lot more common than many of us thought they were and an important cause of embolic strokes. James W. Mold, MD, MPH

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Importance: A patent foramen ovale (PFO), an opening between the right and left atria during normal fetal development that fails to close after birth, is present in approximately 25% of all adults. Paradoxical embolism, a venous thromboembolism that travels to the systemic circulation typically through a PFO, accounts for about 5% of all strokes and 10% of strokes in younger patients.

Observations: Approximately 50% of patients 60 years or younger with an embolic stroke of undetermined source (cryptogenic stroke) have a PFO, compared with 25% of the general population. The Risk of Paradoxical Embolism (RoPE) score incorporates clinical characteristics (age, history of stroke or transient ischemic attack, diabetes, hypertension, smoking, cortical infarct on imaging) to predict the likelihood that embolic stroke of undetermined source was caused by a PFO. Among patients in the lowest RoPE score category (score <3), PFO prevalence was similar to that in the general population (23%), while PFO prevalence was 77% in patients with a RoPE score of 9 or 10. The PFO-Associated Stroke Causal Likelihood (PASCAL) classification system combines the RoPE score and anatomical criteria from echocardiography (large shunt, atrial septal aneurysm) to classify PFO as the “probable,” “possible,” or “unlikely” cause of otherwise cryptogenic stroke. PFO closure reduces recurrent ischemic stroke in patients 60 years or younger with cryptogenic stroke. In a pooled analysis of 6 trials (3740 patients), the annualized incidence of stroke over a median follow-up of 57 months was 0.47% (95% CI, 0.35%-0.65%) with PFO closure vs 1.09% (95% CI, 0.88%-1.36%) with medical therapy (adjusted hazard ratio, 0.41 [95% CI, 0.28-0.60]). However, the benefits and harms of closure were highly heterogeneous across the trial populations. In patients categorized as PASCAL “probable” (ie, younger patients without vascular risk factors and high-risk PFO anatomical features), there was a 90% decreased relative rate of recurrent ischemic stroke after PFO closure at 2 years (hazard ratio, 0.10 [95% CI, 0.03-0.35]; absolute risk reduction, 2.1% [95% CI, 0.9%-3.4%]). PASCAL “unlikely” patients (eg, older patients with vascular risk factors and no high-risk PFO anatomical features) did not have a lower recurrent stroke rate with PFO closure but had higher risk of procedure- and device-related adverse events, such as atrial fibrillation.

Conclusions and Relevance: Patent foramen ovale is present in approximately 25% of all adults and is a common cause of stroke in young and middle-aged patients. The PASCAL classification system can help guide patient selection for PFO closure. Percutaneous PFO closure substantially reduces the risk of stroke recurrence in well-selected patients younger than 60 years after cryptogenic stroke.

Author/s:

David M. Kent, Andy Y. Wang

Screening for Osteoporosis to Prevent Fractures: US Preventive Services Task Force Recommendation Statement

Alex Haga — Mon, 24 Feb 2025 17:44:58 +0000

Date Added:

February 24, 2025

Journal/Publication:

JAMA

Publication Date:

January 14, 2025

Issue:

Volume:

333

Pages:

498-508

URL:

Screening for Osteoporosis to Prevent Fractures: US Preventive Services Task Force Recommendation Statement

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2024.27154

Keywords

MeSH

osteoporotic fractures

female

USPSTF recommendations regarding screening for osteoporosis in older women. James W. Mold, MD, MPH

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Importance Osteoporotic fractures are associated with psychological distress, subsequent fractures, loss of independence, reduced ability to perform activities of daily living, and death.

Objective The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the evidence on the benefits and harms of screening for osteoporosis to prevent fractures in adults 40 years or older with no known diagnosis of osteoporosis or history of fragility fracture.

Population Adults 40 years or older without known osteoporosis or history of fragility fractures.

Evidence Assessment The USPSTF concludes with moderate certainty that screening for osteoporosis to prevent osteoporotic fractures in women 65 years or older has moderate net benefit. The USPSTF concludes with moderate certainty that screening for osteoporosis to prevent osteoporotic fractures in postmenopausal women younger than 65 years at increased risk has moderate net benefit. The USPSTF concludes that the evidence is insufficient and the balance of benefits and harms for screening for osteoporosis to prevent osteoporotic fractures in men cannot be determined.

Recommendation The USPSTF recommends screening for osteoporosis to prevent osteoporotic fractures in women 65 years or older. (B recommendation) The USPSTF recommends screening for osteoporosis to prevent osteoporotic fractures in postmenopausal women younger than 65 years who are at increased risk for an osteoporotic fracture as estimated by clinical risk assessment. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis to prevent osteoporotic fractures in men. (I statement)

Author/s:

US Preventive Services Task Force

What Should I Know About Recurrent UTIs in Older Women?

Alex Haga — Thu, 13 Jun 2024 21:47:57 +0000

Date Added:

June 13, 2024

Journal/Publication:

JAMA Internal Medicine

Publication Date:

June 10, 2024

URL:

What Should I Know About Recurrent UTIs in Older Women?

Type:

Patient Education Materials

Format:

Article

DOI (1):

10.1001/jamainternmed.2024.1854

Keywords

urinary tract infections

female

PMID (1):

38857042

MeSH

female

Urinary Bladder

Urination

urinary tract infections

Vagina

menopause

Information for older women and their caregivers about diagnosis and treatment of suspected urinary tract infections. James W. Mold, MD, MPH

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This JAMA Internal Medicine Patient Page describes urinary tract infections, their causes, and how to treat them and prevent future episodes.

Author/s:

Sonali D Advani, Kimberly C Claeys, Nazema Y Siddiqui

Stress urinary incontinence and synthetic mesh midurethral slings in women

Rowan Hutchins — Wed, 27 Sep 2023 05:00:00 +0000

Date Added:

September 27, 2023

Journal/Publication:

CMAJ

Publisher:

CMA

Publication Date:

August 21, 2023

Issue:

Volume:

195

URL:

Stress urinary incontinence and synthetic mesh midurethral slings in women

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1503/cmaj.221592

Keywords

female

Surgical treatment

suburethral slings

PMID (1):

37604526

MeSH

urinary incontinence

Stress* / surgery

Surgical Mesh / adverse effects

Suburethral Slings* / adverse effects

A concise review of the management of stress urinary incontinence in women including the use of synthetic mesh. James W. Mold, MD, MPH

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Stress urinary incontinence has a prevalence of 10%–40% and is considered severe in 3%–17% of women worldwide.1 Diagnosis involves demonstrating involuntary urine leakage with increases in intra-abdominal pressure (e.g., exercising, coughing). On history, it is important to differentiate this leakage from symptoms like urgency, frequency and nocturia, as these may indicate mixed urinary incontinence or overactive bladder.

Author/s:

Kanji, Sarah, Clancy, Aisling A.

Pelvic organ prolapse

Rowan Hutchins — Tue, 26 Sep 2023 05:00:00 +0000

Date Added:

September 26, 2023

Journal/Publication:

CMAJ

Publisher:

CMA

Publication Date:

August 8, 2023

Issue:

Volume:

195

URL:

Pelvic organ prolapse

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

https://doi.org/10.1503/cmaj.230089

Keywords

pelvic organ

female

postmenopause

PMID (1):

37553149

MeSH

Pelvic Organ Prolapse* / surgery

A concise summary of the symptoms, consequences, and management of pelvic organ prolapse in women. James W. Mold, MD, MPH

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Prolapse is found in 41%–50% of adult females, with symptoms of pelvic pressure and vaginal bulge sensation reported by 3%–6% of adult females. Prolapse is diagnosed and staged with physical examination based on the maximum descent of vaginal tissue (anterior, posterior or apex) on Valsalva manoeuvre. Symptoms commonly begin when the bulge reaches within 0.5 cm of the vaginal opening. Imaging is not routinely needed. Risk factors include increasing age, parity, a history of vaginal delivery, obesity, constipation, postmenopausal status and connective tissue disorders.

Author/s:

Lee, Patricia E., Mcleod, Laura

Diagnosis and management of endometriosis

Rowan Hutchins — Sun, 19 Mar 2023 05:00:00 +0000

Date Added:

March 19, 2023

Journal/Publication:

CMAJ

Publisher:

Canadian Medical Association

Publication Date:

March 14, 2023

Issue:

Volume:

195

Pages:

E363-E371

URL:

Diagnosis and management of endometriosis

Type:

Meta-analyses, Reviews, and Guidelines

DOI (1):

10.1503/cmaj.220637

Keywords

PMID (1):

36918177

MeSH

A concise summary of what we know about endometriosis. James W. Mold, MD, MPH

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Endometriosis is a chronic condition defined by the presence of endometrial-like tissue outside of the uterus, which can lead to estrogen-driven inflammation. The extent of disease can be highly variable, ranging from minimal peritoneal deposits to deep disease that can invade into the bowel, bladder and ureter and, more rarely, spread to extrapelvic (e.g., cutaneous, thoracic) sites. Endometriosis is a complex disease that has considerable impact on the quality of life of those affected and that has no cure. It remains poorly understood. We review the epidemiology, pathophysiology, diagnosis and management of endometriosis, based on the best available evidence and clinical guidelines

Author/s:

Allaire, Catherine, Bedaiwy, Mohamed, Yong, Paul

A challenging diagnosis: hereditary angioedema presenting during pregnancy

Aubrey Delammermore — Sat, 01 Oct 2022 05:00:00 +0000

Date Added:

October 1, 2022

Journal/Publication:

CMAJ

Publisher:

CMA Impact

Publication Date:

September 26, 2022

Issue:

Volume:

194

Pages:

E1283-E1287

URL:

A challenging diagnosis: hereditary angioedema presenting during pregnancy

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1503/cmaj.220604

Keywords

abdominal pain

Morbidity

diagnosis, differential

Hereditary angioedema (HAE)

female

PMID (1):

36162836

MeSH

pregnancy

Angioedema, hereditary

delayed diagnosis

Postpartum period

Diagnostic Errors

A concise review of the diagnosis and management of hereditary angioedema. James W. Mold, MD, MPH

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• Hereditary angioedema (HAE) is a rare autosomal dominant
disorder characterized by recurrent episodes of painful (and
usually asymmetric) swelling without urticaria that leads to
substantial morbidity and even mortality (in the case of
laryngeal involvement) if left untreated.
• Delayed diagnosis and misdiagnosis of HAE are common,
particularly during pregnancy and the postpartum period.
• Hereditary angioedema should be considered in the differential
diagnosis of any patient presenting with unexplained
abdominal pain and recurrent episodes of angioedema
(particularly if asymmetric in nature) without urticaria.
• Tests to confirm the diagnosis of HAE include measurement of
C4 and C1 inhibitor (INH) antigen and function.
• Successful pregnancy and delivery are possible in HAE with
proper medical management, which includes plasma-derived
C1-INH and collaboration with HAE specialists.

Author/s:

Chair, I., Lacuesta, G., Nash, C. M., Cook, V.

Screening for Syphilis Infection in Nonpregnant Adolescents and Adults: US Preventive Services Task Force Reaffirmation Recommendation Statement

Aubrey Delammermore — Sat, 01 Oct 2022 05:00:00 +0000

Date Added:

October 1, 2022

Journal/Publication:

JAMA

Publisher:

JAMA

Publication Date:

September 27, 2022

Issue:

Volume:

328

Pages:

1243-1249

URL:

Screening for Syphilis Infection in Nonpregnant Adolescents and Adults: US Preventive Services Task Force Reaffirmation Recommendation Statement

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2022.15322

Keywords

PMID (1):

36166020

MeSH

preventative health services

Sexually Transmitted Diseases* / etiology

Syphilis* / diagnosis

Mass Screening / adverse effects

Humans

Updated recommendation from USPSTF on screening for syphilis. James W. Mold, MD, MPH

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Importance: Syphilis is a sexually transmitted infection that can progress through different stages (primary, secondary, latent, and tertiary) and cause serious health problems if left untreated. Reported cases of primary and secondary syphilis in the US increased from a record low of 2.1 cases per 100 000 population in 2000 and 2001 to 11.9 cases per 100 000 population in 2019. Men account for the majority of cases (83% of primary and secondary syphilis cases in 2019), and rates among women nearly tripled from 2015 to 2019.

Objective: To reaffirm its 2016 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a reaffirmation evidence update focusing on targeted key questions evaluating the performance of risk assessment tools and the benefits and harms of screening for syphilis in nonpregnant adolescents and adults.

Population: Asymptomatic, nonpregnant adolescents and adults who have ever been sexually active and are at increased risk for syphilis infection.

Evidence assessment: Using a reaffirmation process, the USPSTF concludes with high certainty that there is a substantial net benefit of screening for syphilis infection in nonpregnant persons who are at increased risk for infection.

Recommendation: The USPSTF recommends screening for syphilis infection in persons who are at increased risk for infection. (A recommendation).

Author/s:

US Preventative Services task Force, Mangione, C. M., Barry, M. J., Nicholson, W. K., Cabana, M., Chelmow, D., Coker, T. R., Davis, E. M., Donahue, K. E., Jaén, C. R., Kubik, M., Li, L., Ogedegbe, G., Pbert, L., Ruiz, J. M., Stevermer, J., Wong, B. J.

Diagnosis and treatment of adenomyosis

Devin Evans — Wed, 24 Feb 2021 06:00:00 +0000

Date Added:

February 24, 2021

Journal/Publication:

Canadian Medical Association Journal

Publication Date:

February 16, 2021

Issue:

Volume:

193

URL:

Diagnosis and treatment of adenomyosis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

https://doi.org/10.1503/cmaj.201607

Keywords

MeSH

A concise one-page summary of adenomyosis cause, diagnosis, and treatment. James W. Mold, MD, MPH

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Adenomyosis is a benign gynecological disorder characterized by aberrant development of endometrial glands and stroma within the myometrium, causing inflammation and neuroangiogenesis. Adenomyosis often coexists with other gynecological conditions and may cloud the clinical presentation.

Author/s:

Dason, Ebernella Shirin, Chan, Crystal, Sobel, Mara

Use of anastrozole for breast cancer prevention (IBIS-II): long-term results of a randomised controlled trial

John Bayhi — Fri, 10 Jan 2020 16:02:17 +0000

Date Added:

January 10, 2020

Journal/Publication:

Lancet

Publisher:

Elsevier Ltd.

Publication Date:

January 11, 2020

Issue:

10218

Volume:

395

Pages:

117-122

URL:

Use of anastrozole for breast cancer prevention (IBIS-II): long-term results of a randomised controlled trial

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1016/S0140-6736(19)32955-1

Keywords

breast cancer

anastrozole

female

PMID (1):

31839281

MeSH

cardiovascular diseases

Anastrozole (Arimidex) reduced the long term risk of breast cancer by 50% in women at risk with no major adverse side effects. Menopausal symptoms were increased, primarily during the first year of treatment. James W. Mold, MD, MPH.

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BACKGROUND:

Two large clinical trials have shown a reduced rate of breast cancer development in high-risk women in the initial 5 years of follow-up after use of aromatase inhibitors (MAP.3 and International Breast Cancer Intervention Study II [IBIS-II]). Here, we report blinded long-term follow-up results for the IBIS-II trial, which compared anastrozole with placebo, with the objective of determining the efficacy of anastrozole for preventing breast cancer (both invasive and ductal carcinoma in situ) in the post-treatment period.

METHODS:

IBIS-II is an international, randomised, double-blind, placebo-controlled trial. Postmenopausal women at increased risk of developing breast cancer were recruited and were randomly assigned (1:1) to either anastrozole (1 mg per day, oral) or matching placebo daily for 5 years. After treatment completion, women were followed on a yearly basis to collect data on breast cancer incidence, death, other cancers, and major adverse events (cardiovascular events and fractures). The primary outcome was all breast cancer.

FINDINGS:

3864 women were recruited between Feb 2, 2003, and Jan 31, 2012. 1920 women were randomly assigned to 5 years anastrozole and 1944 to placebo. After a median follow-up of 131 months (IQR 105-156), a 49% reduction in breast cancer was observed for anastrozole (85 vs 165 cases, hazard ratio [HR] 0·51, 95% CI 0·39-0·66, p<0·0001). The reduction was larger in the first 5 years (35 vs 89, 0·39, 0·27-0·58, p<0·0001), but still significant after 5 years (50 vs 76 new cases, 0·64, 0·45-0·91, p=0·014), and not significantly different from the first 5 years (p=0·087). Invasive oestrogen receptor-positive breast cancer was reduced by 54% (HR 0·46, 95% CI 0·33-0·65, p<0·0001), with a continued significant effect in the period after treatment. A 59% reduction in ductal carcinoma in situ was observed (0·41, 0·22-0·79, p=0·0081), especially in participants known to be oestrogen receptor-positive (0·22, 0·78-0·65, p<0·0001). No significant difference in deaths was observed overall (69 vs 70, HR 0·96, 95% CI 0·69-1·34, p=0·82) or for breast cancer (two anastrozole vs three placebo). A significant decrease in non-breast cancers was observed for anastrozole (147 vs 200, odds ratio 0·72, 95% CI 0·57-0·91, p=0·0042), owing primarily to non-melanoma skin cancer. No excess of fractures or cardiovascular disease was observed.

INTERPRETATION:

This analysis has identified a significant continuing reduction in breast cancer with anastrozole in the post-treatment follow-up period, with no evidence of new late side-effects. Further follow-up is needed to assess the effect on breast cancer mortality.

FUNDING:

Cancer Research UK, the National Health and Medical Research Council Australia, Breast Cancer Research Foundation, Sanofi Aventis, and AstraZeneca.

Author/s:

Cuzick, J, Sestak, I, Forbes, JF, Dowsett, M, Cawthorn, S, Mansel, RE, Loibl, S, Bonanni, B, Evans, DG, Howell, A, IBIS-II Investigators