Current women's health reports最新文献

The 20th century model of medical education has focused on a network of urban medical centers serving primarily indigent patients in an unspoken contract of medical services in exchange for student and resident education. The improvement in federal and state reimbursement for indigent care services, along with the decline in reimbursement rates from the private sector, has led to competition for these patients from nonacademic providers. As numbers of patients seeking care at urban teaching centers have steadily declined, concerns about adequate teaching volume and revenue generation have led to very creative problem-solving. Bringing marketing concerns into the indigent care environment is not a straightforward undertaking, but the rewards might far exceed the simple goal of "getting our numbers back up."

New guidelines for when to initiate cervical cancer screening have recently been revised. The American Cancer Society now recommends that screening be initiated within 3 years of the onset of vaginal intercourse but no later than 21 years of age. Natural history studies of human papillomavirus (HPV; the cause of abnormal cytology and cervical cancer) suggest that there is little risk of a significant precancerous lesion going undetected within the first 3 to 5 years after the onset of sexual activity. The new recommendations will assist in the over-referral and overtreatment of adolescents with HPV.

The adolescent years are often characterized by high-risk behaviors. These behaviors carry consequences with them, including pregnancy and abortion. Although the abortion rate for adolescents has been decreasing since 1990, not all groups have seen an equal drop; notably, those adolescents not in school and members of minority groups are experiencing slower rates of decline. Adolescents undergo the same methods of abortion as adults; however, they have unique psychosocial needs, such as parental involvement and the prevention of future unwanted pregnancies, which should be assessed.

Sexually transmitted diseases (STDs) impose a tremendous health burden on women, and adolescent females are the group at the highest risk. Universal annual screening of all women younger than 25 years of age has been a best practice recommendation since 1997. When implemented, such screening leads to a decrease in disease prevalence and of serious sequelae, such as pelvic inflammatory disease (PID). However, STD screening rates in actual clinical practice fail to approach recommendations. In this review, we summarize findings from recent surveys of providers and adolescents, discuss barriers to STD screening, and offer strategies for individual clinicians to improve STD screening rates in practice.

Medical abortion using mifepristone and a prostaglandin analogue is a highly effective option for early abortion. Since the clinical introduction of mifepristone to the world in 1988, millions of women have had the opportunity to have a safe abortion without primary surgical intervention. The standard method of providing medical abortion has evolved through well-done studies to develop regimens that decrease cost and time to abortion. Currently, mifepristone with misoprostol is the most widely used medical abortion regimen. The most effective option available involves mifepristone 200 mg followed at least 24 hours later by misoprostol 800 microg vaginally. Women can self-administer the misoprostol, with complete abortion rates exceeding 95%. Researchers continue to refine the available regimens to improve outcomes and acceptability.

The perimenopause is a time of physiologic, intrapsychic, and social/cultural changes for middle-aged women, who might require assistance to maintain and enhance their sexuality during this transition. Attending to the biologic, psychological, relational, social, and cultural domains, and encouraging perimenopausal women to address these developmental challenges of midlife facilitates the healthy adaptation to this biologic and social transition. Emphasizing the physiologic changes that affect sexual arousal, and educating about enhancing and attending to arousal, might assist middle-aged women to increasingly enjoy their sexuality.

Misoprostol is an important medication for gynecologic practice; however, it is not approved by the US Food and Drug Administration for any gynecologic indication. Evidence-based practice must guide our use of this important drug. Its use for medical abortion in conjunction with mifepristone or methotrexate is supported by a large body of high-quality evidence. There is also a rapidly growing amount of literature on the use of misoprostol for the management of miscarriage; however, more research is needed to optimize use. Solid evidence supports the efficacy of misoprostol for cervical ripening before first-trimester suction curettage abortion, and good evidence supports its use before hysteroscopy in premenopausal women; however, complications are rare with these procedures, making it difficult to assess any impact on complication rates. Most studies have not demonstrated a benefit for using misoprostol as a cervical ripening agent in postmenopausal women.

In this chapter, we address ethical issues in research involving fetuses and pregnant women, with particular attention to the emerging issue of gene-transfer research. Ethical analyses and arguments are based on the concept of the fetus as a patient. The implications of this concept for the ethics of fetal research are identified. The discussion of gene-transfer research extends those implications to address issues concerning informed consent, assessment of potential fetal and neonatal morbidity in study design, prenatal diagnosis after gene transfer, selection criteria based on abortion preference, science by press conference, germline risks, and public oversight.

Graduate medical education continues to deal with multiple stressors. The new work-hour regulations only add to the program directors' and department chairs' difficulty of ensuring adequate educational, didactic, and clinical training for the residents. Appropriately, patient safety has been a concern in the discussion pertaining to resident work hours. Ensuring that the training of our residents is adequate prior to their entering practice will also have a direct impact on patient safety. In this article, areas of concern are identified, and ways of continuing to evaluate and document the adequacy of resident training are proposed.