Wednesday, October 18, 2017

Does all ovarian cancer originate in fallopian tube? Increasing evidence suggests so!

John Hopkins Medicine

Most-and possibly all ovarian cancer originates not in ovaries, but instead in the distal end of fallopian tubes attached to them, reports the findings of multi-center ovarian cancer genetics study published October 17, 2017 in Journal Nature Communications.

Douglas A. Levine, MD, director of the Division of Gynecologic Oncology at Perlmutter and professor of Obstetrics and Gynecology at NYU School of Medicine said in a news release, "Based on a better understanding of its origins, our study suggests new strategies for the prevention and early detection of ovarian cancer."

Serous tubal intra-epithelial carcinoma (STIC) are identified as precursors in ~50% cases of advanced high-grade serous carcinomas (HGSCs) of the pelvis. STIC have helped us a lot in understanding the origin of ovarian malignancies. It was originally diagnosed in fimbrial part fallopian tube when researchers examined the serial sections of this area in tube samples in cases of women who underwent prophylactic bilateral salpingo-oophorectomy(BSO).

This discovery led researchers to identify many cases of presumed ovarian cancer to be of tubal origin because of presence of a STIC.

The researchers in this study identified a total of 96 bio specimens’ samples, with or without STIC. 

The median age of the women was 59 years, with majority being Caucasians, with nearly 50% of women in FIGO stage IIIC and all women had HGSCs. Presence or absence of STIC did not change the clinical features or median survival.

In depth a morphologic, immunohistochemical, and molecular analysis of the samples failed to identify any difference in genetic profile of cells from HGSCs vs those from STIC in fallopian tube.
"We found no differences in the 20,000 genes that we can identify," says Levine. "This leads us to believe that that these ovarian cancers all originate in the fallopian tubes."

In fact, HGSCs had molecular profiles more similar to normal fallopian tube epithelium than to ovarian surface epithelium or peritoneum.

This study findings have several implications for early diagnosis of ovarian malignancy. If biomarkers can be identified on these tubal cells, then one day we may be able to diagnose ovarian malignancy by blood test. Since the tube is connected to the uterus, direct tissue sampling can also be carried out in future.

If the study finding is confirmed, then only removing the tubes may reduce the women’s risk of ovarian malignancy in patients with BRCA1 and 2 mutations. In fact, the NYU Langone Health center is  currently participating in a study Women Choosing Surgical Prevention or WISP trial, which is comparing the quality of life in women who have undergo only  salpingectomy as compared to salpingo-oophorectomy.

The researchers believe that it may take years before the study findings are confirmed and translate into actual clinical practice. But, at this stage the study holds a lot of meaning for gynecological oncologists and the evidence is sufficient to support incidental salpingectomy in average-risk women.



Tuesday, October 17, 2017

Esaote releases MyLab9 Ultrasound Systems, setting new standards in image clarity and performance



Esaote, the Italian ultrasound manufacturer, today unveiled its brand-new flagship MyLab9 ultrasound system at JFR 2017 (Journées Françaises de la Radiologie - French Imaging Congress) in Paris.

It is designed to provide services at hospitals, clinics and private offices as it can be easily carried from one room to other because of easy to unplug and quick boot-up and stand-by mode.   

It is uniquely designed incorporating non-composite single crystal probe technology for generating images that have a stunning display quality, are clear, have better color contrast, thereby, assisting physicians in wide range of diagnostic procedure.

Its ultra-ergonomics design offers a floating keyboard tablet-like touchscreen and full HD wide format screen. The system hardware has a solid-state hard disk (SSD), latest Intel® Core™ i7 processor, and Windows® 10 that offers unparalleled data security and ease of processing.

Designed according to needs of busy radiology practitioner it’s easyMode, inbuilt software offers ‘one touch’ image optimization technology through intelligent real-time algorithm that adjusts to the illumination of the room. This results in superior image quality along with reducing the use of number of controls by the operator. This increases productivity at the same time reducing the musculoskeletal fatigues experienced often by ultrasound operators.


Massimo Rosa, Esaote Chief Global Marketing Officer said in a news release “Today economic constraints, and the increase in average life expectancy, are opposing forces. The MyLabTM9 eXP provides advanced diagnostic capabilities and clinical efficacy to respond effectively to the most demanding healthcare needs expanding the access to innovative technologies for more customers.”

MyLab™9, Uncompromised Ease-of-Use







Monday, October 16, 2017

Endometriosis fertility index can accurately predict a women’s chances of conception after laparoscopy


courtesy:Can stock photos

The Endometriosis fertility index can accurately predict the possibility of non-ART conception or the need of ART for achieving pregnancy after surgical resection of moderate-severe (Stage III–IV) endometriosis reports the results of study published in Human Reproduction. The study confirmed that adnexal function is deciding factor in evaluation of fertility prognosis after the surgery.

There is no evidence based guidelines about post-surgery fertility management of women who have undergone surgery for severe endometriosis. Physicians differ in their approach about the length of conservative treatment and that sometimes add years and causes unnecessary delays.

The researchers in this study from Australia, led by Dr. Sarah Maheux-Lacroix of the Royal Hospital for Women in Randwick, looked into data of 279 women who had undergone laparoscopic surgery for stage III-IV and were trying to become pregnant.

Endometriosis fertility index was first published in 2010 and is a robust tool to predict fertility after surgical staging of endometriosis.

https://image.slidesharecdn.com/


The EFI is combines obstetrical and surgical factors to predict a woman’s chance of becoming pregnant. In addition to all the components of the revised-American Society of Reproductive Medicine score, it also includes a detailed evaluation of the fallopian tubes, fimbriae, and ovaries, and accounts for any adnexal dysfunction after surgery.

The researchers calculated EFI for all these women based on detailed operative reports and surgical images plus the obstetric history of women.

The average follow-up was 4 years during which 147 women (63%) gave birth, of which 94 conceived naturally without ART.

None of the women with EFI 0-2 conceived, while 91% women with EFI 9-10 had live births in 5 years period after surgery.

Similarly, women with EFI 0-2 had a success rate of 38% with ART, while those with EFI 9-10 had a success rate of 71%.

So, low EFI was significant in predicting failure to conceive (P = 0.003) in addition to other factors which adversely affected the pregnancy rates like being older than 40 years (P = 0.027), having uterine fibroids (P = 0.037) and history of previous resection (P = 0.019) or incomplete resection (P = 0.028).

The only drawback of the study was its retrospective nature.

The researchers concluded that the tool can be used to predict the fertility prognosis in women after surgery for endometriosis. Depending on the EFI score, the obstetrician can advise patients about timed intercourse or refer the patients  for ART, without wasting precious years.

Friday, October 13, 2017

FDA approves Senhance Surgical Robotic System to facilitate minimally invasive surgery


FDA today approved Senhance Systems, by TransEnterix, Inc., a medical device company that is pioneering the use of robotics to improve minimally invasive surgery.

Robotically-assisted surgical device (RASD) is a type of computer assisted surgical system, which helps surgeon to control, view and move the surgical devices through small ports of minimal invasive surgery in a variety of surgical procedures. It specifically has gynecological and colorectal applications.

The system enables the surgeon to sit in a console or a cockpit of some sort, which provides him or her with a 3D, high-definition view of the surgical field and allows for the control of the system’s 3 robotic arms. At the end of each of the 3 arms are mounted surgical instruments that are based on traditional laparoscopic instrument designs. This increases the surgeon’s comfort and reduces strain.

The system allows the surgeon to “feel” the stiffness of tissue during operation with its force feedback technology. It also features eye-tracking to allow for comparative movement of instruments to standard operations. It facilitates highly efficient operations with minimal additional docking time or change to technique.


 It allows for the visualization and endoscopic manipulation of human tissue, such as grasping, cutting, blunt and sharp dissections, approximation, ligation, electrocautery, suturing, mobilization and retraction in laparoscopic colorectal surgery and laparoscopic gynecological surgery," according to the FDA. 

“Minimally invasive surgery helps reduce pain, scarring and recovery time after surgery,” said Binita Ashar, M.D., director of the Division of Surgical Devices in the FDA’s Center for Devices and Radiological Health. “RASD technology is a specialized innovation in minimally invasive surgery designed to enhance the surgeon’s access and visualization within confined operative sites.” 

The clearance was based on results of a pilot study in which 150 patients underwent various gynecological operations with the Senhance System. The clinical outcomes were compared with outcomes of nearly 8000 surgeries in real world settings using another RASD.

In addition to gynecological surgeries, 45 colorectal sureries were also performed by Senhance system and compared to outcomes of other real-world surgeries.

Based on the study results, real world evidence and simulations, the FDA concluded that the  Senhance System is substantially equivalent to the da Vinci Si IS3000 device for gynecological and colorectal procedures.

Here is a  video of Senhance Surgical Systems. 


Senhance Surgical Robotic System - Functional Overview from TransEnterix, Inc on Vimeo.



ACOG updates guidance on postpartum hemorrhage- calls for standard, coordinated, protocol based intervention


The American College of Obstetricians and Gynecologists (ACOG) recently released expanded guidelines for management of postpartum hemorrhage (PPH)—the leading cause of maternal mortality worldwide.

PPH is defined as total blood loss of 1000 ml or more along with signs or symptoms of hypovolemia within 24 hours after the labor, but can occur up to 12 weeks postpartum. Although Maternal Mortality Rates(MMR) have decreased worldwide in last 4 decades, it still accounts for 10% of all pregnancy related mortality.

Incidence varies, but 1-5% is reasonable estimate, with uterine atony accounting for 70-80% of cases PPH.

This practice bulletin discusses the risk factors along with evaluation, prevention, and management of maternal hemorrhage.

It also calls upon all obstetricians and other obstetric care providers to formulate standard protocols for recognizing, evaluating and management of maternal hemorrhage by multidisciplinary approach and implement it in every center.

Multidisciplinary teams, including physicians, nurses and midwives, should be trained to implement key elements in four categories, including readiness to respond; recognition and prevention measures; multidisciplinary response; and data reporting and systematic learning, including drills like simulation-based training.

ACOG also has partnered with multiple organization to implement the care bundle suggested by  Alliance for Innovation on Maternal Health (AIM), which many states have are already adapted.

It also lays emphasis on identifying the patients at risk of developing PPH, prenatally, during admission and during labor. It includes patients with vaginal lacerations, retained placenta, abnormally adherent placenta with previous cesarean section. All Ob-gyn should be aware of high risk of PPH in placenta previa with previous uterine scar.

Uterotonic agents should be the first line of treatment in case of atonic PPH, choice of a specific agent is at the discretion of the provider as none is identified as superior over other. Active management of third stage of labor should be implemented.

All hospitals, especially those in rural areas should be able to escalate the efforts quickly, and have a specific plan to go to next level of treatment or quickly refer patient to a specialty hospital.

Tranexamic acid can be given when primary line of therapy fails, it is especially found effective if given within 3 hours of birth.

Surgical approach includes Intrauterine balloon tamponade, but less invasive methods should always be used first. 

All hospitals should have functioning massive transfusion protocols and ‘hemorrhage carts’, with all the necessary medication in place.

The Practice Bulletin #183, "Postpartum Hemorrhage" is published in October issue of Obstetrics and Gynecology.




Thursday, October 12, 2017

News from NAMS 2017: “Bisphosphonate drug holiday” not mandatory



A presentation at the North American Menopause Society (NAMS) Annual Meeting in Philadelphia October 11-14, will  present new evidence regarding long term safety and effectiveness of Bisphosphonates and denosumab in treating postmenopausal osteoporosis.

According to International Osteoporosis Foundation, Osteoporosis is estimated to affect 200 million women worldwide - approximately one-tenth of women aged 60, one-fifth of women aged 70, two-fifths of women aged 80 and two-thirds of women aged 90.

Bisphosphonates and denosumab are the most commonly prescribed treatments for osteoporosis. There is no cure for osteoporosis and the effects of these drugs wear-off as treatment ceases, hence prevention is the best bet.

As Bisphosphonates therapy is started, protection from osteoporosis is gained in first few months and persists as long as treatment is continued.

If Bisphosphonate treatment is continued beyond 3 years, increasing risk of unusual or “atypical” fractures of the femur (thigh bone) is observed. The risk increases gradually as patient continue to take the drug beyond 3 years: the risk is 20/100,000 patients at 5 years and 1/1,000 patients at 8-10 years.

If the drug is stopped, protection from fractures is lost gradually in 3-5 years.

This combination of increased risk of atypical fractures on continued treatment and decline in protection from fractures as treatment is stopped led to the confusing concept of a “bisphosphonate holiday.”

The American Society for Bone and Mineral Research (ASBMR) has recently provided clear recommendations about “bisphosphonate holidays.”

ASBMR recommends that, after 3-5 years of treatment with bisphosphonates, a patient risk of fracture should be evaluated. If the patient remains at ‘high risk’ for fracture because of low BMD, previous history of hip, spine, or multiple other fractures, the treatment should not be stopped.

Patient can continue the same treatment or change to some other drugs like denosumab.

Those patients who are at ‘low risk’ for fracture, the treatment can be stopped for 3-4 years, but it is not mandatory.

The concept of ‘drug holiday’ only holds good for Bisphosphonates only, and not for other drugs like raloxifene, teriparatide, and denosumab because beneficial effects of these drugs are lost as soon as they are stopped.

Dr. Michael McClung of the Oregon Osteoporosis Center in Portland, Oregon, who will be presenting his recommendations on long-term osteoporosis therapy at the NAMS Annual Meeting said, “Because protection from fractures disappears quickly if denosumab treatment is stopped, and since there are no currently known safety issues that limit the duration of denosumab therapy, there is no justification for a drug holiday with this treatment.”

“Just as we do not recommend stopping treatment for high blood pressure or diabetes, it is necessary to have a long-term treatment plan for postmenopausal women with osteoporosis if the benefits of our therapies are to be realized,” he further added.

Dr. JoAnn Pinkerton, NAMS executive director said, “Prevention of osteoporosis should be a goal for those treating menopausal women, as up to 20% of bone loss occurs within the first five years of menopause. Once diagnosed with osteoporosis, the goal becomes lowering the risk of fractures as fractures can be life changing or life limiting. This presentation will offer valuable insights about the need for long-term treatment and will change the way health care providers approach long-term osteoporosis management.”


Wednesday, October 11, 2017

NAMS updates position statement about Hormone Therapy at the 2017 annual meeting

courtesy: dailytimes.com
The North American Menopause Society(NAMS) executive director, JoAnn Pinkerton, MD, from the University of Virginia in Charlottesville, issued the updated Hormone Therapy(HT) Position statement at the ongoing annual meeting at Philadelphia October 11-14, 2017.

This update’s the 2012 statement from NAMS, and includes special needs population like women who had early menopause or breast cancer.

The recent findings from Women’s Health Initiative(WHI) follow-up study, published recently reinforced the development of this position statement. The results of follow-up study showed no increase in all-cause or disease specific mortality in women taking hormone therapy.

The advisory panel reviewed WHI data along with 13 years of follow -up, plus newer randomized trial and other observational data and studied the effect of HT on a wide range of diseases.

Recommendations:

NAMS urges the health practitioners to assess each individual woman based on her unique health risk and co-morbidities, and make a shared, informed decision about staring the HT. The women should be revaluated and her risk reassessed periodically.

The practitioners should choose the best dose, combination, route and duration of therapy for each individual patient.

HT is most effective in treating hot flashes, night sweats, and sleep disruption caused by menopause in addition to preventing bone loss and fractures.

Risk of HT differ according to the duration, timing of starting the therapy, type and route of administration and formulation. Risks vary according to the addition of progesterone.

Always use the lowest and safest dose that brings about relief of symptoms.

HT is safe for most menopausal women age less than 60 years or when started within 10 years of menopause.

The benefits of starting HT decreases and the risk increases (Increased benefit/risk ratio) if started 10-20 years after menopause or after the age of 60 years. In these women low dose vaginal estrogen is recommended for relief of Genitourinary syndrome(GSM).

Special populations:

Breast cancer: The WHI study data analysis did not show any increased risks with conjugated estrogen alone during the study period (7 years), but some studies have suggested increased risk after 15-20 years. The rare risk of <1/1000 for breast cancer appears to be due to combination of estrogen and progesterone or extended duration of estrogen alone.

CVD: HT reduces the risk of CHD when started at younger age or within 10 years of menopause and no effect of risk reduction was observed when it was initiated 10-20 years after menopause or after the age of 60 years.

Early menopause: Unless contraindicated, women who have had premature ovarian failure or surgically induced menopause should receive HT till median age of 52 years as benefits outweigh the risks. (Level II).

Family history of breast cancer: Evidence shows that HT does not alter the risk of breast cancer in women with FH of the disease, however she should undergo counselling about it. (Level II).

BRCA-positive women without breast cancer: These group of women are at high risk of primarily estrogen-receptor negative breast cancer. To mitigate the health risk caused by oophorectomy, systematic HT can be started after shared decision making until the median age of natural menopause. (Level II).

Extended use of HT: The recent data does not support the routine discontinuation of HT after the age of 65 years as per Beers criteria. Each woman should be individually assessed to continue HT beyond the age of 60 years. Her risk should be reassessed and close follow-up is needed. (Level III).



Tuesday, October 10, 2017

Finally, an oral drug found effective in treatment of Uterine Fibroids following successful phase-3 trial


Relugolix successfully reduced heavy menstrual blood loss among Japanese women in a Multicenter, Randomized, Double-Blind, Parallel-Group, Phase 3 Study to Evaluate the Efficacy and Safety of Oral relugolix 40 mg as compared with injectable leuprolide  in the Treatment of Uterine Fibroids.

Relugolix is an oral, once-daily, small molecule GnRH receptor antagonist that has been evaluated in almost 1,600 study participants in Phase 1, Phase 2 and Phase 3 clinical trials. In these trials, it has shown to suppress estrogen and progesterone levels in women and testosterone levels in men. (It is also being evaluated in advanced prostate cancer via ongoing phase-3 HERO study).

The drug is being developed by Switzerland’s Myovant Sciences along with Japan’s Takeda. They said that these results will support the other ongoing global trials evaluating the drug in endometriosis and uterine fibroid patients.

"The positive results of decreased menstrual bleeding from Takeda's Phase 3 study of relugolix in Japanese women with uterine fibroids provides strong support for Myovant's ongoing Phase 3 studies with relugolix in North America, Europeand other regions," stated Lynn Seely, M.D., President and Chief Executive Officer of Myovant Sciences in a press release

"Uterine fibroids result in debilitating heavy menstrual bleeding and anemia in millions of women throughout the world, oftentimes requiring a hysterectomy to control the bleeding.  Myovant is working to develop relugolix, an oral, once-daily medication that can potentially provide women with an alternative option to major surgery for the treatment of uterine fibroids."

The study recruited 288 women with heavy menstrual bleeding associated with uterine fibroids. They were randomized to receive either relugolix 40 mg, administered orally once daily, or leuprolide acetate, an injectable GnRH agonist, administered by subcutaneous injection every four weeks, at a dose of 1.88 mg or 3.75 mg, for 24 weeks. 

The amount of blood loss was assessed by Pictorial Blood Loss Assessment Chart, or PBAC self-reported by patient themselves. At entry into study all patient had PBAC ≥ 120.

In the study, relugolix successfully demonstrated that it was as good as leuprolide acetate with 82.2% of patients achieving a score of less than 10 on the PBAC, compared with 83.1% of patients treated with leuprolide acetate (p = 0.0013).

The incidence of adverse effects was nearly similar and varied according to the drug. Another phase 3 trial with relugolix is currently ongoing in Japan with 70 patients who also complained of pain because of fibroids.

Two more trials (LIBERTY 1 and LIBERTY 2) are ongoing and were initiated by Myovant in January 2017.  These trials are looking at reducing heavy menstrual blood loss by relugolix alone followed by leuprolide  as monotherapy, relugolix combined with low dose leuprolide  or placebo for 24 weeks. 

These two trials are looking at reduction in blood loss by at least 50%, decrease in pain and size of fibroid and safety of the drug, as evident by bone -mineral density.

Myovant is solely responsible for obtaining Food and Drug Administration (FDA) approval for relugolix in the United States and the results of Takeda study will definitely reinforce its application. 

The drug is also currently tested by two phase-3 ongoing trials for relieving endometriosis associated pain, named as SPIRIT 1 and SPIRIT 2. These two trials are still recruiting patients and will run through 2020. The trials will evaluate relugolix with and without low-dose hormonal add-back therapy, to avoid the iatrogenic menopausal side effects.



Monday, October 9, 2017

Twelve important risk factors for Uterine Fibroid identified: A systematic review


First and only systematic review conducted so far to know the prevalence and risk factors for developing Uterine Fibroid (UF), identified race and ovarian hormone exposure as the most important determinants of fibroid development. The review was published recently in BJOG.

Uterine fibroids are most common benign neoplasm in women and nearly affect 2/3 of women before menopause, but largely remain undetected as only 25% cause symptoms that warrant treatment.

They are also the number one cause of gynecological hospital admissions and also an important indication for hysterectomy.

A literature search identified 60 studies that were eligible to be included in the review. There was considerable variations in type of studies, some reported single center experience while mostly were registry based studies. Studies included cohort and case control studies with international or local population with women from different race and ethnicity.

Fibroids were diagnosed by pelvic examination, Ultrasound or at the time of surgery.

There was a wide range in incidence of UF, and varied between 217–3745 cases per 100 000 women-years while the prevalence was between 4.5% to 68.6%.

After analysis of data, broadly 30 factors were identified that increased a woman’s risk of developing UF, of which  12 were of considerable magnitude.

Risk Factors:

Demographically, black race is important risk  factor and increases the risk by 2-3-fold as compared to  whites, followed  by age. 

Age increases the risk by nearly 10 folds,  for women between age the  40 -60 years as compared to women in their 20s. 

A positive family history also predisposes the women to higher risk for UF.

More than 5 years since child birth puts you at higher risk as compared to woman who has recently given birth.

Premenopausal women have 3-5 times increased risk as compared to postmenopausal women.

Women who are diagnosed with hypertension are 5 times the risk as compared to their normotensive counterparts.

Consuming food with additives and Soyabean increases the risk by 2.5times.

Protective Factors:

Increased parity (more than 3 children) is protective against UF and lowers the risk by 80% as compared to Nulliparous woman.

Smoking was found to be protective, but only in women with low BMI

Oral and injectable contraceptives protect against UF and reduces the risk by nearly 20-50%.

This study supports the view that genetic and ovarian hormones are two important risk factors for development of UF. The genetic aspect cannot be modified, but life style and hormonal modification can reduce the risk of fibroid development.

In an accompanying commentary, Vercellini P and Frattaruolo MP stress the importance of therapies using selective progesterone receptor modulators (SPRMs) as an alternative to invasive treatments for fibroid associated menorrhagia and volume symptoms.

This study has identified important risk factors that can be used by physicians in clinical settings and researchers for further drug and treatment development.






Sunday, October 8, 2017

The Future of Breast Cancer Detection is Already Here | Kevin Kelly | TEDx Talk


October is Breast Cancer Awareness month. Dr. Kelly is one of this country’s leading authorities on using ultrasound to detect cancers in women with dense breast tissue and/or implants. Nearly 20 plus years of research have provided sufficient evidence to link dense breast tissue and increased risk of missing cancer diagnosis by screening mammography. As the breast density increases, the reliability of mammogram as a screening tool for picking up breast malignancy decreases.

In his TEDx Talk, Dr Kelly is calling all women with dense breasts or implants to know that  small, curable cancers are often missed by mammography. Following Dr. Papanicolaou’s 30-year struggle to gain acceptance of the Pap smear for detection of cervical cancer, Dr. Kelly is working to do the same for an automated ultrasound technology that finds cancers when they are very small and very curable.

Dr. Kevin Kelly is passionate and dedicated to the early detection of breast cancer. His goal is to educate women about the importance of understanding their breast type so they can make informed decisions about their screening options. Kevin is the Medical Director of The Breast Ultrasound Center in Pasadena, CA, and has been in private practice as a diagnostic radiologist for 34 years.

Related Links on early detection of cancer in dense breast:

Here is the TEDx talk: 







Friday, October 6, 2017

Easing the menopause transition by latest technology- upcoming North American Menopause Society (NAMS) 2017 Annual Meeting.


The upcoming NAMS 2017 annual meeting that will be held at Philadelphia October 11-14 is sure to be an academic feast. The scientific session will bring in all the latest and comprehensive updates from world renowned speakers with focus on the technological advances that can help women in seemingly smooth transition through the menopausal years.

The meeting is going to kick start with a pre-meeting symposium about Musculoskeletal Health in Postmenopausal Women: Assessment and Management of Fracture Risk by Co-Chair, Michael R. McClung, MD.  This symposium will cover assessment of postmenopausal osteoporosis; including dual-energy x-ray absorptiometry(DXA) best practices and new imaging modalities. It will also cover the new pharmacological therapies for osteoporosis and ways to improve the muscle functions.

This will be followed by President’s Reception and other CME activities. The topics that are expected to be covered include: Vaginal Health and Pelvic Pain, Hormone Therapy, Uterine Bleeding and Adnexal Masses, Lesbian Health and Sexuality, Cardiovascular Disease Risk Factors, Migraines and Mood Disorders in Midlife Women, Advances in Breast Imaging, Musculoskeletal Health Concerns, Social Media and Technology: Driving the Direction of Women’s Health and Update on MsFLASH Trials.

The NAMS updated position statement on Hormone therapy will be presented by JoAnn Pinkerton, MD, from the University of Virginia in Charlottesville, who is executive director of NAMS.
The findings of WHI follow -up study published in JAMA, played a key role in supporting some of the recommendations.

Technological advances, especially mobile health technology and its role in improving patient’s engagement and health will also be focused upon.

In all, the meeting will engage a diverse, multiracial, multiethnic and multispecialty group of people with varied interests, but there will be something for everyone.

Looking forward seeing latest updates and good clinical research abstracts from the meeting.

Related Links




North American Menopause Society (NAMS) video series about important midlife health topics: common cognitive complaints

The North American Menopause Society (NAMS) has started comprehensive video series for clinicians about important midlife health topics. All the interviews in the series are hosted by NAMS Board of Trustees Member and President Dr. Marla Shapiro, a Canadian physician, who led this exciting initiative.

In this latest video, Common Cognitive Complaints, Dr. Shapiro interviews Dr. Victor Henderson, NAMS Past President, Professor of Health Research and Policy and Neurology and Neurological Sciences at Stanford University and Director of the Alzheimer's Disease Research Center in Stanford, California. Dr. Henderson explains cognitive complaints as it relates to aging and decline in estrogen as well as the cardiovascular connection. He also provides advice for when advanced testing is required.   

Here is the video about Common Cognitive Complaints around perimenopausal and menopausal years. 



Thursday, October 5, 2017

Latest facts and figures about Breast Cancer from American Cancer Society


October is breast cancer awareness month. Here are some facts and figures to know from American Cancer Society (ACS).

Increasing awareness among women, increased screening and better techniques for early cancer detection has decreased a woman’s risk of dying from breast cancer by 38% between late 1980s and 2014, translating into 297,300 fewer cancer death during that period.

However, much is needed to be done as breast cancer is still second leading cause of cancer death in women, being exceeded by lung cancer which kills more women peryear.

A woman chances of dying from breast cancer is about 1 in 37 (about 2.7 percent).

ACS estimates for breast cancer for the year 2017 are:

Currently, there are more than 3.1 million people with breast cancer in USA, which includes persons undergoing treatment and also persons who have already completed the treatment.

It is expected that about 40,610 women will die from breast cancer in the year 2017.

About 63,410 new cases of carcinoma in situ (CIS) and 252,710 new cases of invasive breast cancer will be diagnosed in 2017

Although the incidence of breast cancer is nearly same in black and white women, black women are more likely to die from breast cancer.

Some latest research related to risk factors shows that:

Long term and heavy smoking increases a woman’s risk of breast cancer particularly if it started before her first pregnancy.

An obese postmenopausal woman faces 1.5 times increased risk of cancer, if she is overweight and 2 times the risk if she is obese women as compared to lean women.

Evidence is accumulating that regular physically activity lower your chances of breast cancer by 10-25%, more so in postmenopausal than premenopausal women.

Each alcoholic drink/day increases the chances of getting breast cancer by 7-10% on an average and women who regularly consume 2-3 drinks have 20% higher chances as compared to non-drinkers.

New lower dose formulation of estradiol vaginal cream 0.003% relieves vulvovaginal atrophy.

getty images

Low dose estradiol vaginal cream 0.003% helps in relieving symptoms of vulvovaginal atrophy (VVA) in postmenopausal women says the results of phase 3 trial published September 18, in Journal Menopause.

This randomized, double blind, placebo control trial recruited a total of 550 sexually active postmenopausal women who were bothered by moderate to severe dyspareunia. The average age was 58 years. These women also had vaginal pH > 5.0 and cytology revealed only 5% superficial cells.

The women were randomized to receive either placebo or the 0.003% estradiol cream applied daily for two weeks, followed by three applications per week for 10 weeks. The women were assessed in terms of relief from dyspareunia, improvement in superficial cell cytology and decrease in pH.

After completing the treatment, women receiving estradiol cream reduced dyspareunia by 1.5 points vs 1.2 points in women with placebo. Estradiol also improved superficial cells by 10.1% vs 1.4% in placebo, vaginal pH reduced by 1.36 versus 0.53 for placebo.

Estradiol cream also relieved irritation, itching, dryness more effectively as compared to placebo (P < 0.01).

Mycotic fungal infections were significantly more common in estradiol group.

“Lower-dose estradiol vaginal cream (0.003%) dosed three applications/week is an effective and well-tolerated treatment for VVA-related dyspareunia,” the authors concluded.

The study was sponsored by Allergan, which is developing the new low dose 0.003% cream, the company’s other cream Estrace, which have 0.01% estradiol is already approved by the U.S. Food and Drug Administration for treating postmenopausal VVA.

More updates on vulvovaginal  syndrome of menopause:

Tuesday, October 3, 2017

Revolutionary technique prints pure medications on any surface, in combination to accelerate drug delivery and new drug development.

Condensed drug films

University of Michigan have developed a way to print pure medication, without any solvent, in various combination which could one day result into pharmacies printing drugs to fill prescription onsite, as per individual requirement.

The technique was developed at University of Michigan and the research paper published September 27, 2017 in Journal of Nature Communications.

There is a huge unmet need of developing, alternative drug delivery systems that are precise, quick and deliver the drugs directly to the site. In this paper, the researchers make use of solvent-free organic vapor jet printing to deposit micronized and nano-structured thin film of drugs on skin and buccal patches or ingestible strips or any other structure.

This technique improves the dissolution kinetics of active pharmaceutical ingredients (APIs),which increases the efficacy and bioavailability. The new method uses organic vapor jet printing (OVJP), in which the compound is thermally evaporated to mix with inert gas ( Nitrogen) followed by condensing the gas mixture onto cooled substrate, where the organic material condenses.

The process is controlled so that the shape, thickness and morphology of resulting film can be regulated.

The process does not change the chemical properties or stability of the drug. They have experimented with 6 common drugs caffeine, paracetamol, ibuprofen, tamoxifen, BAY 11-7082 and fluorescein.

It was shown that the pure, printed tamoxifen destroyed cultured breast and ovarian cancer cells in vitro as effectively as medication delivered by traditional means. The advantage was the new system did not use any solvent or other compounds that pharma company use to lend stability to the drug.

 Max Shtein, professor of materials science and engineering said, “A doctor or pharmacist can choose any number of medications, which the machine would combine into a single dose. The machine could be sitting in the back of the pharmacy or even in a clinic.”

"Pharma companies have libraries of millions of compounds to evaluate, and one of the first tests is solubility," Shtein said. "About half of new compounds fail this test and are ruled out. Organic vapor jet printing could make some of them more soluble, putting them back into the pipeline."

While printing drugs for mass market might be years away, the immediate use of this technique can be in drug testing, drug developing and evaluating the drugs for human use.



Watch a video about the technique 


In case you missed it: Here are the top 5 posts this month


September was a very busy month with lots of good research papers and systematic reviews published on various topics. We also saw many guidelines and recommendations updates from ACOG, ASRM and USPSTF. Here are the top 5 most read posts for the month of September.

USPSTF simplifies cervical cancer screening recommendations: Dual testing no longer advised
The US Preventive Services Task Force (USPSTF) has issued new draft recommendations for cervical cancer screening with a major change that it recommends either cervical cytology (CC) or high-risk HPV (hrHPV) test as a screening procedure every 3 years for women aged 30-65 years, and not both ( Grade A)  

ACOG issues clinical practice guidelines for Gestational Diabetes Mellitus
The American College of Obstetricians and Gynecologists (ACOG) has issued clinical practice guidelines for the diagnosis and treatment of gestational diabetes mellitus (GDM).
Although prevalence of GDM is directly proportional to prevalence of type 2 DM in a given population, it is estimated that GDM accounts for 90% of cases diabetes in pregnancy. The prevalence of DM in pregnancy is around 6-9%.

ASRM guidelines update: Metformin alone is not the first line of treatment for ovulation induction in women with PCOS
Practice Committee of the American Society for Reproductive Medicine does not recommend Metformin alone for ovulation induction as a first line therapy in women with PCOS. The guidelines were published in Journal Fertility and Sterility Epub ahead of print.
Metformin is a biguanide used as an oral insulin lowering agent in type2 diabetes, but also used enthusiastically in women with PCOS because of shared pathophysiology of insulin resistance in both.

Oral Nifedipine parallels IV hydralazine in lowering down BP in acute hypertensive emergency in pregnancy
Intravenous hydralazine and oral nifedipine both exhibit the same efficacy in lowering the blood pressure in acute hypertensive emergency of pregnancy reports the results of small randomized trial published online in journal American Journal of Obstetrics and Gynecology.


Oral diclofenac potassium plus cervical lidocaine cream eases the pain during hysterosalpingography
Oral diclofenac potassium tab 30 minutes before hysterosalpingography (HSG) and cervical lidocaine cream 5% significantly relieves pain and eases patient anxiety during the procedure and for half an hour after reports the results of a randomized trial published in September issue of journal Fertility and Sterility.