Prevalence studies show that one in five women experience an episode of major depressive disorder during their lifetime. The peripartum period constitutes a prime time for symptom exacerbation and relapse of depressive episodes. It is important for health care providers, specifically those in obstetric care, to be aware of (1) the frequency of depression in pregnant and postpartum women; (2) signs, symptoms, and appropriate screening methods; and (3) the health risks for the mother and growing fetus if depression is undetected or untreated. Because management of depressed peripartum women also includes care of a growing fetus or breastfeeding infant, treatment may be complex and requires input from a multidisciplinary team, including an obstetrician, psychiatrist, and pediatrician, to provide optimal care.
Depression; Peripartum; Obstetric Care; Infant outcomes; Medication; Psychotherapy
Recent guidelines from multiple organizations, including the USPSTF, ACS/ASCCP/ASCP, ACOG and most recently the 2013 Update to the 2006 ASCCP Consensus Guidelines, all stress screening initiation no sooner than the age of 21 years and increased screening intervals for women aged 21 to 29 years. Primary prevention with HPV vaccination has the potential to significantly impact the development of high-grade cervical lesions, including cancer, and will likely affect screening guidelines in the future.
Cervical cancer screening; Adolescents; Young women; Abnormal cytology; HPV testing; HPV vaccination
Despite the histologically identical nature of lesions, multiple complex terminologies and historically meaningful eponyms have been developed to describe this pathologic and clinical spectrum of disease for the purpose of patient management. Based on a growing recognition of a need for unified terminology the American Society for Colposcopy and Cervical Pathology and the College of American Pathologists Pathology and Laboratory Quality Center jointly convened a process to tackle this challenge. The Lower Anogenital Squamous Terminology (LAST) Project was designed to reassess and harmonize the terminology used to describe human papillomavirus-associated squamous lesions of the lower anogenital tract as manifested in a variety of end organs including the cervix, the vagina, the vulva, the perianus, the anus, the penis, and the scrotum. The clear unambiguous distinction between cancer precursors and those without malignant potential inevitably leads to greater consistency in the interpretation of management guidelines, and the therapeutic options offered to patients.
Squamous intraepithelial lesion; human papillomavirus; lower anogenital tract; terminology
The loss of ovarian function during the menopausal transition has a profound impact on female skeletal health. Currently it is estimated that one in every two Caucasian women will experience an osteoporotic fracture during her lifetime,1 contributing to considerable morbidity and an enormous economic burden within the aging female population. However, most studies have been conducted in postmenopausal women, with fewer investigations focusing specifically on perimenopausal bone health. The Study of Women’s Health Across the Nation (SWAN) is the largest prospective cohort to date where changes in bone mineral density and bone turnover have been examined in relation to ovarian aging among women followed across the menopause transition.2–3 As defined by bleeding pattern in SWAN, early perimenopause is characterized by increasing menstrual irregularity but less than 3 months of amenorrhea, late perimenopause by amenorrhea lasting greater than 3 months but less than 1 year, and postmenopause by the absence of menstrual bleeding for twelve consecutive months or more.3–4 A recent multi-study collaboration has further recommended that the early menopause transition be defined by a persistent 7+ day difference in consecutive cycle lengths and the late menopause transition by at least 60 days of amenorrhea.5–6 A serum follicle-stimulating hormone (FSH) level of 40 IU/L or greater has also been found to be an independent marker of the transition that may facilitate predicting the time to the final menstrual period.6–7
osteoporosis; perimenopause; menopause; bone; fractures
Obesity is associated with multiple adverse reproductive outcomes, but the mechanisms involved are largely unknown. Public health scientists studying obesity and its effects on health outcomes have referred to obesity as a “complex system”, defined as a system of heterogeneous parts interacting in nonlinear ways to influence the behavior of the parts as a whole1,22. By this definition, human reproduction is also a complex system which may explain some of the difficulty in identifying the mechanisms linking obesity and adverse reproductive function. Despite the difficulties, research on obesity and reproduction is important as there is an epidemic of obesity among reproductive age women with associated consequences for future generations. In this review we discuss the adverse reproductive outcomes associated with obesity and data from translational studies of the mechanisms involved. We conclude with a brief discussion of public health policy as it relates to the treatment of infertility in obese women.
fertility; obesity; reproduction; public health
Endometriois has been associated with infertility, however the mechanism by which it affects fertility are still not fully understood. This manuscript reviews the proposed mechanisms of endometriosis pathogenesis, it affects on fertility and treatments of endometriosis-associated infertility. Theories on etiology of disease include retrograde menstruation, coelomic metaplasia, altered immunity, stem cells, and genetics. Endometriosis affects gametes and embryos, the fallopian tubes and embryo transport, and the eutopic endometrium; these abnormalities likely all impact fertility. Current treatment options of endometriosis-associated infertility include surgery, superovulation with IUI, and IVF. We also discuss potential future treatments for endometriosis related infertility such as stem cells transplantation and immune therapy.
Endometriosis; Infertility; Treatment; Pathogenesis; Stem cell; In-Vitro Fertilization
Leiomyoma; Infertility; Assisted Reproductive Technology (ART); Myomectomy; Hysteroscopy; Minimally Invasive Gynecologic Surgeries (MIGS); Magnetic Resonance guided Focused Ultrasound (MRgFUS); Uterine Artery Embolization (UAE)
Primary ovarian insufficiency; Premature ovarian failure; Premature menopause; Infertility; Integrated care
There is a belief that reproductive health is a reflection of whole-body health. It then follows that abnormalities of reproductive milestones may be a manifestation of aberrant or unhealthy aging. In order to assess how menopause per se and the process of the menopause transition may affect future health risks and outcomes, the Study of Women’s Health Across the Nation was begun in 1994. SWAN, now in its 14th follow-up year, has characterized the life experience of a multi-ethnic cohort of mid-life US women in an unprecedented level of detail. Several enduring themes have emerged from SWAN that have associated certain patterns of hormones and symptoms with metabolic status. Moreover, the nature of relationships between hormones, body size, ethnicity, metabolic status and cardiovascular disease symptoms risk vary as women traverse the menopause and ovarian hormone production eventually ceases. This review will describe these cross-cutting themes and their possible meaning for the health of the mid-life woman.
Menopause; menopause transition; metabolic syndrome; hot flashes; estrogen; progesterone
The concept that adrenal androgen production gradually declines with age has changed following the analysis of the longitudinal data collected in the Study of Women’s Health Across the Nation (SWAN). It is now recognized that four adrenal androgens (3-beta hydroxy-5-androsten-17-one or dehydroepiandrosterone--DHEA, its sulfate, dehydroepiandrosterone sulfate--DHEAS; androst-4-ene, 3,17-dione or androstenedione; and androst-5-ene-3-beta, 17-beta diol, also known as androstenediol or Adiol) rise during the menopausal transition in most women. Ethnic and individual differences in sex steroids are more apparent in circulating adrenal steroids than in either estradiol or cyclic ovarian steroid hormone profiles, particularly during the early and late perimenopause. Thus, adrenal steroid production may play a larger role in the occurrence of symptoms and the potential for healthier aging than previously recognized.
menopausal transition; androgens; adrenal
Vasomotor symptoms (VMS), or hot flashes and night sweats, are often considered the cardinal symptoms of menopause. SWAN, one of the largest and most ethnically diverse longitudinal studies of the menopausal transition, has allowed unique insights into VMS. Specifically, SWAN has helped yield important information about the prevalence of, racial/ethnic differences in, risk factors for, and implications of VMS for midlife women’s mental and physical health. Below we review the literature on VMS, emphasizing findings which have emerged from SWAN and new areas of inquiry in the area of VMS.
Hot flashes; hot flushes; vasomotor symptoms; menopause; climacteric symptoms; menopausal symptoms
Perimenopause; menopause; estrogen; follicle stimulating hormone; cognitive function; cardiovascular risk factors; ovariectomy; cognitive function
Is there evidence for a perimenopausal sleep disorder? We address this question in our presentation of the SWAN “sleep story,” in which we summarize and discuss data addressing sleep quality, objective measures of sleep patterns, and sleep disorders that have been published to date by the Study of Women’s Health Across the Nation (SWAN) and the ancillary SWAN Sleep Study. In this review article, we describe what has been learned about sleep during the perimenopause. Analyses exploring racial/ethnic diversity, a hallmark of the SWAN cohort, and the role of hot flashes and mood disturbance in sleep – perimenopause associations are described. Implications for clinical practice are considered.
aging; menopausal transition; perimenopause; psychosocial; reproductive hormones; sleep
Women are twice as likely as men to suffer from depressive symptoms and disorder. Considerable research has focused on the physiological and psychosocial differences between men and women as sources of depression. An important target of study has been the periods of reproductive changes and events that occur at puberty, postpartum and menopause. A controversy has existed regarding the extent to which, if at all, the menopausal transition or postmenopause increases the risk for elevated depressive symptoms and/or disorders. SWAN provided an opportunity to address the issue with the largest, most representative and diverse cohort currently available for study. The current paper presents the findings from analyses conducted on data collected from the larger core SWAN study and an ancillary study on mental health begun in Pittsburgh in 1995. We found, as did four other recent longitudinal studies, that risk for high depressive symptoms and disorder is greater during and possibly after the menopausal transition. Multiple other factors contribute to risk for depression in our SWAN cohort.
menopause; mood; depression; risk factors
The hormonal correlates of reproductive aging and the menopause transition reflect an initial loss of the follicle cohort, while a responsive ovary remains, and an eventual complete loss of follicle response, with persistent hypergonadotropic amenorrhea. The physiology of the process is described, along with key findings of relevant studies, with an emphasis on SWAN, the Study of Women’s Health Across the Nation. A clinical framework is provided to help clinicians forecast the major milestones of the menopausal transition and to predict potential symptoms or disease.
Menopause; menopause transition; inhibin; AMH; LH; FSH; estrogen; progesterone
This paper characterizes changes in menstrual bleeding during perimenopause, including bleeding changes that represent markers of the menopausal transition. Recent results from the Study of Women’s Health Across the Nation (SWAN), a multiethnic cohort study of midlife women, as well as data from other cohort studies of women in the midlife are reviewed. Emerging data describing subpopulation differences in the transition experience is highlighted . Early transition, defined as a persistent difference in consecutive menstrual cycle length of seven or more days, begins on average 6-8 years before the FMP. Late transition, defined by an episode of 60 or more days of amenorrhea, begins on average two years before the FMP. When treating women in the midlife, clinicians should pay careful attention to medical factors, including both conditions and treatments, that may increase menstrual blood loss or alter menstrual cycle characteristics sufficiently to obscure the onset of the menopausal transition or the FMP.
menstruation; menstrual cycle; menopause; perimenopause
Physical activity; Menopause; Symptoms; Weight gain; Bone loss
Menopause; Smoking; Parity; Race/ethnicity; Socioeconomic status; Age; Genetics; Family history; Diet
The popularity of natural or “alternative” remedies to treat medical and psychiatric disorders has accelerated dramatically over the past decade, in the United States and worldwide. This article reviews the evidence for clinical efficacy, active ingredients, mechanisms of action, recommended dosages, and toxicities of the three best-studied putative natural antidepressants, St. John's Wort (hypericum), S-adenosyl methionine, and the omega-3 fatty acids eicosapentaenoic acid and docosahexaenoic acid. Despite growing evidence for efficacy and safety, more comprehensive studies are required before these remedies can be recommended as safe and effective alternatives or adjuncts to conventional psychotropic agents. There are limited data regarding safety in pregnancy and during lactation, and caution is therefore recommended in women who are pregnant or breastfeeding.
Omega-3; EPA; DHA; St. John's Wort; hypericum; S-adenosyl methionine; SAMe; eicosapentanoic; docosahexanoic; depression
Pregnancy; Postpartum period; Puerperium; Gestational weight gain; Obesity; Parity; Epidemiology; Women
Adolescents have been shown to have the highest rates of HPV infection. The cause of this is likely a combination of sexual risk behavior and biologic vulnerability. Not surprisingly, the frequent nature of HPV in this age group also results in frequent abnormal cytology. Most HPV and its associated abnormal cytology are transient with frequent clearance of HPV and the lesion. These findings have resulted in new strategies for adolescents with abnormal cytology, which include observation. For cytologic atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesions (LSIL), adolescents should be followed with cytology at one-year intervals up to two years before referral for colposcopy is necessary. For biopsy proven cervical intraepithelial neoplasia (CIN 1), management is similar with yearly cytology indefinitely or until high (H)SIL or CIN 2/3 develops. CIN 2/3 in compliant adolescents can be managed with 6-month cytology and colposcopy.
Adolescence; human papillomavirus; low grade and high-grade squamous intra-epithelial lesions; cervical intra-epithelial neoplasia I, II and III
We review studies published in the past 10 years that examine the prevalence and trends in the prevalence of gestational diabetes mellitus (GDM). The prevalence of GDM in a population is reflective of the prevalence of type 2 diabetes in that population. In low-risk populations, such as those found in Sweden, the prevalence in population-based studies is lower than 2% even when universal testing is offered, while studies in high-risk populations, such as the Native American Cree, Northern Californian Hispanics and Northern Californian Asians, reported prevalence rates ranging from 4.9% to 12.8%. Prevalence rates for GDM obtained from hospital-based studies similarly reflect the risk of type 2 diabetes in a population with a single hospital-based study in Australia reporting prevalences ranging from 3.0% in Anglo-Celtic women to 17.0% in Indian women. Finally, of the eight studies published that report on trends in the prevalence of GDM, 6 studies report an increase in the prevalence of GDM across most racial/ethnic groups studied. In summary, diabetes during pregnancy is a common and increasing complication of pregnancy.
gestational diabetes mellitus; prevalence; trends; diagnostic criteria