Medscape women's health最新文献

The 3 methods of long-term contraception (LTC) approved for use in the US are intrauterine devices (IUDs), levonorgestrel subdermal implants, and sustained-release medroxyprogesterone acetate injections. Women who use reversible LTC are likely to receive care from clinicians who did not prescribe the method of contraception originally. Fortunately, most concerns arising from the use of reversible LTC can be managed by clinicians regardless of their specialty. Problems associated with an IUD can include a missing string, partial expulsion of the device, change in menstrual pattern, vaginal discharge, or infection. Headaches, weight gain, dermatologic problems, changes in hair growth, and irregularities in menses are among the problems that clinicians may confront while caring for a woman who has had subdermal hormone implants or has been taking depot injections. Besides the problems caused by or complicating specific methods of LTC, a woman may seek clinical care for a variety of general concerns. These include a desire to terminate LTC in order to become pregnant, and physical changes that are suspected to indicate pregnancy or contraceptive failure. In addition, general health conditions such as concurrent medications, hypertension, and endocrine disorders may need special consideration in a woman using LTC. There are few medical indications for discontinuing or changing LTC, even when intercurrent illnesses arise.

Heart disease, breast cancer, and hormone therapy were top clinical concerns in women's health in 1997. One of the major reports on heart disease confirmed that women are no different from men in terms of early infarct-related artery patency rates, reocclusion after thrombolytic therapy, and ventricular functional response to injury/reperfusion; nevertheless, women have 3 times the mortality of men in the first 30 days after an acute myocardial infarction. Research brought only modest gains in the understanding of breast cancer etiology in 1997, but engendered major debate on whether women younger than 50 years should have mammograms every 1 to 2 years. A National Institutes of Health consensus conference said no, but the National Cancer Institute's National Cancer Advisory Board said yes. Evidence of estrogen benefits and risks mounted: One report added to the data suggesting that estrogen may retard age-related memory loss, while another study reported that the risk of breast cancer significantly increased with long-term use of estrogens. The interest in selective estrogen receptor modulators (SERMs), also called "designer estrogens," grew. Efforts to develop pharmacologic treatment for obesity suffered a setback in 1997 when a team reported that 1 in 3 patients who used d-fenfluramine developed abnormal valvular thickening, with the most severe cases needing valve replacement. One of the most promising events in colorectal cancer, the third most common cancer in women, was the set of screening guidelines issued by the Agency for Health Care Policy and Research. The year ended with major ethical debates about multiple gestation and cloning.

The number of primary and secondary syphilis cases in young women rose dramatically in the late 1980s and early 1990s, due to illicit drug use and the exchange of drugs for sex. Of infants born to mothers with primary or secondary syphilis, up to 50% will be premature, stillborn, or die in the neonatal period; further, most of these children are born with congenital disease that may not be apparent for years. While appropriate treatment of the pregnant female can prevent congenital syphilis, the major deterrent has been the inability to effectively identify these women and get them to undergo treatment. In determining a penicillin regimen, the clinician must consider the stage of maternal infection, the length of fetal exposure, and physiologic changes in pregnancy that can affect the pharmacokinetics of antibiotics. Treatment decisions may be further complicated in patients who are allergic to penicillin or infected with HIV. The pathogenesis of congenital syphilis is not completely understood, but placental invasion is the presumed major route. All women should be screened for syphilis with a nontreponemal test (eg, rapid plasma reagin [RPR] or venereal disease research laboratory [VDRL] test) in the first trimester. Those at high risk should be retested at 28 weeks and near delivery. Even with appropriate treatment of syphilis during pregnancy, fetal infection may still occur in up to 14% of cases. Treating syphilis during pregnancy can be difficult due to physiologic changes that can alter drug levels and the risk that drugs will induce uterine contractions or compromise the health of the fetus. While there are added risks and potential complications, treatment regimens parallel those in nonpregnant women.

This report identifies 4 pregnancy-induced dermatoses: (1) pemphigoid gestationis, (2) polymorphic eruption of pregnancy, (3) prurigo of pregnancy, and (4) pruritic folliculitis of pregnancy. According to 1 study of 3192 pregnancies, 0.06% of the women had pemphigoid gestationis (PG), 0.5% had polymorphic eruption of pregnancy (PEP), 0.2% had prurigo of pregnancy (PP), and 0.03% had pruritic folliculitis of pregnancy (PFP). Some reports have suggested an increased risk of fetal morbidity and mortality, as well as an increased risk of premature births, among women with PG. The incidence of fetal morbidity and mortality for the other dermatoses of pregnancy appears to be similar to that in normal pregnancies. Among the drugs used in dermatology, isotretinoin and antineoplastic agents, such as methotrexate, are 2 types that present high risk during pregnancy. Antipruritic medications, such as trimeprazine and doxepin, and some nonsteroidal anti-inflammatory agents, such as indomethacin, also should be avoided during pregnancy and lactation. Analgesics, including acetaminophen, are associated with minimal risk to the fetus or infant. Use of topical corticosteroids is associated with a low risk during pregnancy. Fortunately, many dermatologic disorders allow deferral of treatment or alternate therapeutic methods during pregnancy.

The decrease in the incidence of invasive cervical cancer has been credited to the widespread use of Papanicolaou (Pap) smear screening. Although relatively inexpensive to perform, Pap smears, if positive, often result in further diagnostic work-up (eg, colposcopy, biopsy, endocervical curettage) and associated patient anxiety. Unfortunately, false positives are frequent with Pap smears, and even screened populations of patients continue to have a significant incidence of cervical cancer. Presumably, expanding screening programs to unscreened populations or screening selected, at-risk populations more frequently could further reduce the incidence of invasive cervical cancer. Yet, few rigorous, prospective studies exist to allow for the formulation of cost-effective guidelines that optimize screening resources. To determine just how much screening is cost-effective, the medical community will have to answer several questions regarding the definition of cost-effectiveness itself, the optimal age to begin screening, whether abnormal Pap smears can be better stratified according to risk, the limitations of Pap smear screening, and whether advances in technology can help increase the positive predictive value of current screening strategies.

The clinical presentation of certain dermatologic conditions differs between women and men; this may be especially true when women are perimenstrual or pregnant. Skin diseases that erupt or become aggravated during the perimenstrual period include autoimmune progesterone dermatitis and melasma. Dermatologic conditions that may be exacerbated perimenstrually include acne vulgaris, rosacea, lupus erythematosus, psoriasis, atopic eczema, lichen planus, dermatitis herpetiformis, erythema multiforme, and urticaria. The hormonal effects of increased cutaneous vascularity, seborrhea, and dermal edema during the perimenstrual period may account for the eruption of or increase in severity of these diseases. Clinical presentation, differential diagnoses, and treatment options for select cutaneous conditions are discussed.

Periareolar breast abscess has been an elusive condition, with much debate about its etiology over the last several decades. Presenting symptoms include nipple discharge, mastalgia, and recurrent abscesses with draining fistulas. Many experts disagree about whether this condition develops when inflammation of the duct leads to dilation or whether it begins with dilation that leads to inflammation. Because the frequency of asymptomatic dilated ducts found incidentally in patients during surgery or upon autopsy exceeds that of patients with symptomatic duct dilation or ectasia, we believe that mechanical obstruction with associated retention of secretions is at the core of this disease process. In this article, we term and characterize mammary-duct-associated inflammatory disease as a 3-phase pathologic process that leads to recurrent nonlactational periareolar breast abscess in nonpuerperal women. Effective treatment of abscesses should be based on the disease's pathogenic process and should include excision of all involved ducts. Treated by this method, patients appear to experience minimal sequelae and low recurrence of abscesses.

Through data reported in the US Collaborative Review of Sterilization (CREST) study, we have learned that 10-year cumulative failure rates of sterilization done by tubal occlusion are much higher than originally thought. While the small, earlier studies reported failure rates as low as 3 to 4 per 1000 procedures, they often followed women for only 2 years after the procedure. When pregnancies occurred during this period, the operative assumption was that these failures were due to incomplete occlusion. Most reports have not addressed the possibility of recanalization leading to failures. The CREST findings, however, suggest that failure rates are closer to 18 per 1000, depending on the occlusion method used and characteristics of the patient. This study also shed light on the factors that increase the risk of ectopic pregnancy after sterilization procedures. These new long-term data indicate that all providers should know that pregnancy, including ectopic pregnancy, can occur in women with history of tubal occlusion for sterilization, especially many years after the original procedure.