Update in Women’s Health
Pamela S. Ganschow, MD1, Elizabeth A. Jacobs, MD, MPP1, Jennifer Mackinnon, MD, MM1,
and Pamela Charney, MD, FACP2
1Rush University Medical Center/Stroger Hospital of Cook County, Chicago, IL, USA;2Albert Einstein College of Medicine, Bronx, NY, USA.
INTRODUCTION: The aim of this clinical update is to
summarize articles and guidelines published in the last
year with the potential to change current clinical
practice as it relates to women’s health.
METHODS: We used two independent search strategies
to identify articles relevant to women’s health published
between March 1, 2007 and February 29, 2008. First,
we reviewed the Cochrane Database of Systematic
Reviews and journal indices from the ACP Journal
Club, Annals of Internal Medicine, Archives of Internal
Medicine, British Medical Journal, Circulation, Diabetes,
JAMA, JGIM, Journal of Women’s Health, Lancet, NEJM,
Obstetrics and Gynecology, and Women’s Health Journal
Watch. Second, we performed a MEDLINE search using
the medical subject heading term “sex factors.” The
authors, who all have clinical and/or research experience
in the area of women’s health, reviewed all article titles,
abstracts, and, when indicated, full publications. We
excluded articles relatedto obstetricalaspects of women’s
healthfocusingonthoserelevant to generalinternists.We
had two acceptance criteria, scientific rigor and potential
to impact women’s health. We also identified new and/or
updated women’s health guidelines released during the
same time period.
RESULTS: We identified over 250 publications with
potential relevance to women’s health. Forty-six articles
were selected for presentation as part of the Clinical
Update, and nine were selected for a more detailed
discussion in this paper. Evidence-based women’s
health guidelines are listed in Table 1.
KEY WORDS: women’s health; osteoporosis; preconception counseling;
HPV vaccine; obesity; cardiovascular disease
J Gen Intern Med 24(6):765–70
© Society of General Internal Medicine 2009
GUSTO Vupdate: women experience more bleeding complications
and have a higher mortality after thrombolytic treatment for
Reynolds HR, Farkouh ME, Lincoff AM, Hsu A, Swahn E,
Sadowski ZP, White JA, Popol EJ, Hochman JS . Impact of female
infarction in GUSTO V. Arch Intern Med 2007; 167: 2054–2060.
What do we know? Several studies suggest that the under-
use of reperfusion therapy in women may account for higher
mortality rates after myocardial infarction (MI), compared with
men1,2. While the GUSTO V clinical trial was not designed
specifically to examine this issue, the fact that ALL participants
received some type of reperfusion therapy allows for a post-hoc
analysis to examine whether differences in reperfusion rates
contribute to the disparity in gender-specific mortality.
What does this study add? Retrospective sex analysis was
reported from GUSTO V, a clinical trial that compared two
fibrinolytic regimens for acute ST-elevation myocardial infarction
(MI) in over 16,000 patients at 800 hospitals in 20 countries from
1999 to 2001. The primary endpoint, all-cause mortality at
30 days, was twice as high for women compared with men (9.8
vs. 4.4%; p<0.001), persisted after adjustment for differences in
baseline characteristics (OR 2.00, 95% CI 1.59–2.53), and was
still present at 1 year (HR 1.14, 95% CI 1.01–1.29). Women were
more likely to have post-MI cardiovascular complications, in-
cluding recurrent ischemia and myocardial rupture, as well as
bleeding complications (25.2 vs. 14.4%; p<0.01), including
intracranial hemorrhage (1.2 vs. 0.4%; p<0.01). Consistent with
prior studies, women were referred less frequently for coronary
angiography and had lower rates of percutaneous coronary
intervention. This result is disturbing given the higher rates of
recurrent ischemia, which should have resulted in increased
utilization of percutaneous interventions.
Since all participants received thrombolytics, outcome
differences may be related to differences in care provided to
women and men. Prospective clinical trials powered to examine
gender-specific differences in the harms and benefits of all
interventions for acute myocardial ischemia are needed.
How should I change my clinical practice? Women not only
present with different symptoms of MI; they have higher
mortality rates, receive less frequent angiography and expe-
rience higher bleeding rates after thrombolytics than men.
This study highlights the importance of examining gender
differences in the harms and benefits of therapeutic inter-
ventions, but does not answer the question of what interven-
tion is most effective for women with acute MI. Until
additional gender-specific information is available, clinicians
should be aware that women receiving thrombolytics are at a
higher risk of bleeding than men and strive to ensure that
women with acute MI have equivalent access to percutaneous
Use Amiodarone Cautiously in Women with Atrial
Essebag V, Reynolds MR, Hadjis T, et al. Sex differences in
the relationship between amiodarone use and the need for
Received September 12, 2008
Revised December 19, 2008
Accepted December 29, 2008
Published online March 4, 2009
permanent pacing in patients with atrial fibrillation. Arch
Intern Med. 2007;167:1648–1653.
What do we know? Patients with atrial fibrillation who have
been converted to sinus rhythm require maintenance therapy,
most effectively achieved with amiodarone3,4. Prior studies
suggest that women may experience a greater risk of side
effects from this and other antiarryhthmic drugs, including
bradyarrhythmias requiring pacemaker insertion5.
What does this study add? The authors evaluated the
outcomes of 1,005 patients with newly diagnosed atrial
fibrillation or atrial flutter enrolled in a standardized registry
as part of a prospective cohort study involving 17 centers in
the US and Canada. Treatment for atrial arrhythmia was
determined by the local practitioner. Thirty-two patients were
excluded because a pacing device was implanted prior to the
study. Of the 973 participants remaining in the analysis, 40%
were female, the average age was 66 years, and the mean
follow-up was 2 years. The primary outcome was insertion of a
new permanent pacemaker for a bradyarrhythmia. Multivariable
Cox regression models that included time-dependent covariates
accounting for medication exposure and adjusted for age, sex,
atrial flutter, coronary artery disease, heart failure, and hyper-
tension were developed.
Amiodarone use was associated with a two-fold risk of
pacemaker insertion (HR, 2.01; 95% CI, 1.08–3.76), which
was significantly higher in women than in men (HR, 4.69; 95%
CI, 1.99–11.05 versus HR, 1.05; 95% CI, 0.42–2.58, P value for
interaction, 0.02) and persisted after adjusting for amiodarone
dose, weight, BMI, and use of other antiarrhythmic or rate
control drugs. Despite prior studies demonstrating that the
bradycardic effect of amiodarone is dose related, women were
at increased risk for pacemaker insertion whether taking daily
doses above or below 200 mg. Of the 85 patients requiring
pacemaker insertion, the most common reason was bradyar-
rhythmia (n=60), including sick sinus syndrome and AV block.
Older age and atrial flutter were found to be independent risk
factors for increased use of pacemaker insertion. There was no
association between the use of sotalol or class 1 anti-arrhythmic
agents and pacemaker insertion.
The authors hypothesize that the adverse effects of amio-
darone are related to its long half life and to sex-specific
differences in pharmacokinetics and pharmacodynamics. The
main limitations are the lack of randomization and the
absence of tissue and serum concentrations of amiodarone.
How should I change my clinical practice? Rate control has
become the standard of care in atrial fibrillation, decreasing
the need for amiodarone in current therapy. Among patients
who require rhythm control (e.g., those who are cardioverted),
physicians should use amiodarone cautiously in women and
in elderly patients, weighing the risk of pacemaker insertion
with the benefit of maintenance therapy (even at low doses).
Atkins, even more than other diets, is effective with weight
loss and improved BP control among pre-menopausal
women followed for 1 year.
Gardner CD, Kiazand A, Alhassan S, Kim S, Stafford RS,
Balise RR, Kraemer HC, King AC. Comparison of the Atkins,
Zone, Ornish, and LEARN diets for change in weight and
related factors among overweight premenopausal women. The
A TO Z Weight Loss Study: a randomized trial. JAMA 2007;
What do we know? Limited evidence exists about the
efficacy of different dietary programs.
What does this study add? Three popular diets were
compared with a diet developed based on national guidelines
in a randomized clinical trial to determine their effectiveness
on weight loss and metabolic parameters (e.g., lipid profile,
glucose levels). The Atkins diet (very low carbohydrate, high
protein, high fat), the Zone (low in carbohydrates), and Ornish
Table 1. Important Women’s Health Guidelines in 2007–2008: New or Updated
Updated recommendations and comments
Mammography screening in
ACPIndividualized risk assessment and informed decision making should be used to guide
decisions about mammography screening in this age group.
To aid in the risk assessment, a discussion of the risk factors, which if present
in a woman in her 40s increases her risk to above that of an average 50-year-old
woman, is provided in the guidelines. In addition, available risk prediction models,
such as the NIH Web site calculator (http://www.cancer.gov/bcrisktool/) can also
be used to estimate quantitative breast cancer risk. This model was updated in
2008 with race-specific data for calculating risk in African-American women.18
The harms and benefits of mammography should be discussed and incorporated
along with a woman’s preferences and breast cancer risk profile into the
decision on when to begin screening. If a woman decides to forgo mammography,
the decision should be readdressed every 1 to 2 years.
Routine screening for this infection is now recommended for ALL sexually active
women age 24 and under, based on the recent high prevalence estimates for chlamydia
It is not recommended for women (pregnant or nonpregnant) age 25 and older,
unless they are at increased risk for infection.
Flouroquinolones are NO longer recommended for treatment of N. gonorrhea, due to
increasing resistance (as high as 15% of isolates in 2006).
For uncomplicated infections, treatment of gonorrhea should be initiated with
ceftriaxone 125 mg IM or cefixime 400 mg PO and co-treatment for chlamydia infection
(unless ruled out with testing). Recent estimates demonstrate that almost 50% of persons
with gonorrhea have concomitant chlamydia infection21.
STD screening guidelines19
STD treatment guidelines20
STD = sexually transmitted disease, NIH = National Institutes of Health, ACP = American College of Physicians, USPSTF = United States Prevention
Services Task Force, CDC = Centers for Disease Control
Ganschow et al.: Update in Women’s Health
(very high in carbohydrates) were compared with the LEARN diet
(lifestyle, exercise, attitudes, relationships and nutrition: low in
fat, high in carbohydrates). Subjects included 311 pre-meno-
pausal women aged 25 to 50 years old with a body mass index of
27 to 40 (overweight to obese), whose weight and medications had
been stable for the previous 2 to 3 months. Exclusion criteria in-
cluded women with diabetes or medication use for cardiovascular
risk factors. Participants were randomized, received a book and
8 weekly 1-h educational classes about the program they were
enrolled in, along with $25 to $75 financial incentives for partici-
pation. Serial assessments were performed at baseline, 2, 6, and
12 months and included a 3-day dietary recall, measurements of
height, weight, resting blood pressure, and metabolic laboratory
tests. The primary outcome was weight loss at 12 months.
Class participation, defined as at least 75% class attendance,
was 85–89%. Overall, retention rates were 76–88% with no
significant differences between treatment programs. Total dietary
intake decreased in all the diet treatment programs. Participants
lost more weight at 2, 6, and 12 months than Ornish, LEARN, or
Zone participants (Fig. 1). The Atkins diet also more effectively
elevated HDL and lowered blood pressure and triglycerides.
How should I change my clinical practice? Impressive data were
released this year demonstrating the benefits of bariatric surgery
on sustained weight loss and mortality6. This dietary study de-
monstrates that non-invasive options can also achieve significant
weight loss and other positive metabolic effects. The challenge
remains for patients to commit to the process of change.
Low BMD and Vertebral Fractures Predict New Vertebral
Fractures Within 15 Years.
Cauley JA, Hochberg MC, Lui L. Long-term Risk of Incident
Vertebral Fractures. JAMA 2007;298:2761–2767.
What do we know? Approximately 30–50% of women
develop vertebral fractures7, which are associated with a
decrease in survival and predict future osteoporotic frac-
tures8-10. Whether this future fracture risk is independent of
BMD and whether the risk persists over 5 years is unclear.
What does this study add? This study examined the
absolute risk of subsequent vertebral fracture as predicted by
BMD and prevalent vertebral fracture. Investigators used a
sub-group from the Study of Osteoporotic Fractures (SOF), a
longitudinal cohort study, involving 9,704 women, aged
>65 years. Baseline BMD and vertebral X-ray films were
performed on 2,680 white women who completed a 15-year
follow-up visit. Incident vertebral fractures were defined as a
decrease of 20% or more and at least 4 mm in length in any of
the vertebral height measurements.
Eighteen percent of women (487/2,680) had an incident
vertebral fracture. Rates of incident vertebral fractures were
41.4% and 14.2% among women with and without a prevalent
vertebral fracture at baseline, respectively (OR, 4.21, 95% CI
3.33–5.34). This increase was independent of BMD and other
risk factors. Low BMD at every site was also independently
associated with increased risk. Together, low BMD and prev-
alent vertebral fracture were associated with a high risk for
incident vertebral fracture. The absolute risk of vertebral
fracture ranged from 56% among women who had both a total
hip BMD T score of −2.5 or less and a prevalent vertebral
fracture, to 9% for women with normal BMD and no prevalent
This study is limited by: (1) it only included white women, and
(2) women who returned for a follow-up visit at 15 years were
much healthier at baseline than those who did not, leading to a
potential underestimation of the risk for vertebral fracture.
How should I change my clinical practice? Vertebral fractures
and should be incorporated into risk models.
Any fracture in older women should raise suspicion for
Mackey DC, Lui L, Cawthon PM, et al. High-trauma
fractures and low bone mineral density in older women and
men. JAMA 2007;298:2381–2388.
What do we know? Low trauma fractures and falls from
standing height or less are categorized as osteoporotic because
they are related to low bone mineral density (BMD) and future
fracture risk11. High trauma fractures (e.g., those resulting
from motor vehicle crashes and falls from greater than
standing height) may have a similar correlation to BMD and
future fracture risk12,13and deserve further study.
What does this study add? This study used data from two
cohorts, 8,022 women (Study of Osteoporotic Fractures, SOF,
1988–2006) followed for an average of 9.1 years and 5,995 men
(Osteoporotic Fractures in Men Study Group, MrOS, 2000–
2007) followed for an average of 5.1 years. The participants
were community-dwelling adults throughout the US aged
65 years or older. Hip and spine BMD were assessed by dual-
energy X-ray absorptiometry. Participants were contacted
Figure 1. Weight change relative to baseline. Legend: Baseline
values were carried forward for any missing values. The overall diet
group × time interaction was significant (P<0.001). The analysis of
variance test for differences among diet groups in weight change
from baseline was significant at 2 and 6 months (P<0.001) and at
12 months (P=0.01). Analyses of all pairwise differences by the
Tukey standardized range test (<0.05) indicate that the Atkins diet
group was significantly different than all other diet groups at 2 and
6 months and that the Atkins diet group was significantly different
than the Zone diet group at 12 months. There were no significant
differences among the Zone, LEARN, or Ornish diet groups at any
time point. Error bars indicate standard error of the mean. Source:
Gardner CD, Kiazand A, Alhassan S. Comparison of Atkins, Zone,
Ornish, and LEARN Diets for Change in Weight and Related Risk
Factors Among Overweight Premenopausal Women. JAMA. 2007;
297: 969–77. Permission for reproduction granted.
Ganschow et al.: Update in Women’s Health
every 4 months to determine if (and how) they had sustained a
fracture. Fractures were assessed as low or high trauma,
without knowledge of BMD. Multivariate Cox hazards regression
conditions, smoking history, fractures since age 50, fall in the
past year, use of hormone replacement therapy, and functional
Forty percent of women in the SOF (n=3,211) sustained low
trauma fractures and 3% (n=264) high trauma fractures. Each
1-standard deviation reduction in total hip BMD correlated
with increased risk of both low (RH, 1.49; 95% CI, 1.42–1.57)
and high trauma fracture (RH, 1.45; 95% CI, 1.42–1.57). This
relationship held for men as well. Women with high-trauma
fracture had lower body weight, lower body mass index, and
were more likely to report a fracture since age 50 years and a
fall in the previous year, compared to those without fractures.
The subsequent fracture risk was similar between high and
low trauma fracture (high: 34% 95% CI, 7%–67% vs. low: 31%,
95% CI, 20–43%) in women.
The main limitations of this study are that fractures were
self-reported, vertebral fractures were not included, and there
was no information about bisphosphonate use. In addition,
subjects were older, predominantly Caucasian and healthy
volunteers, limiting the applicability of these findings to a
younger and more general population.
How should I change my clinical practice? A thorough
evaluation for underlying osteoporosis and efforts to reduce
future fractures should be offered to all older patients regardless
of gender and type of non-spine fracture.
CANCER RISK AND PREVENTION
Limit CT scan use in younger patients and women to
reduce future cancer risks.
Einstein AJ, Henzlova MJ, Rajagopalan S. Estimating risk of
cancer associated with radiation exposure from 64-slice
computed tomography coronary angiography. JAMA 2007;298
What do we know? Very little is known about the riskof cancer
from computed tomography (CT), despite higher doses of radia-
tionfromCTscansandincreaseduse. Thelargest increases inCT
use are seen in pediatric populations and adult screening14.
What does this study add? This study estimated the organ-
specific and whole body lifetime attributable risks (LAR) of
cancer associated with radiation exposure from a computed
tomography coronary angiography (CTCA) study. The influence
of age, sex, and scan protocol on cancer risk was also
assessed. The investigators used current data available on
the health risks from radiation, obtained from the National
Academies’ Biological Effects of Ionizing Radiation (BEIR) VII
Phase 2 report. This report, presented to Congress in 2005,
contains risk estimates for cancer from low level exposure to
ionizing radiation and is based on data from epidemiological
models, atomic bomb survivor studies, and medical and
occupational radiation studies.
This study demonstrated that LARs of cancer were in-
creased and associated with: female gender, younger age, and
scan/tube protocol. The risk of cancer was higher among
women in all age groups (Fig. 2), particularly for women
exposed in their 20s (LAR: 1 in 143 for women versus 1 in
686 for men). This risk declined with age (1 in 1,338 for an 80-
year-old woman). The major differences between women and
men were (1) increased radiosensitivity among women and (2)
the cancer risk attributable to exposure of the breast in the
field of irradiation. Combined protocols with extended fields
(e.g., through the aortic arch), such as the common “triple
rule-out” scan, which evaluates for CAD, aortic dissection, and
pulmonary embolism, were associated with increased risk of
cancer. Tube current reduction lowered risk.
How should I change my clinical practice? Until empirical
data become available, use CT scans cautiously, especially in
young women. Consider alternative diagnostic modalities,
such as MRI and ultrasound.
Use HPV vaccine early and continue to screen regularly
with conventional pap smears.
The Future II Study Group. Effect of prophylactic human
papillomavirus L1 virus like particle vaccine on risk of cervical
intraepithelial neoplasia grade, grade 3, and adenocarcinoma
in situ: a combined analysis of four randomized clinical trials.
What do we know? Cervical cancer is common15and
potentially preventable since the etiology of 100% of cervical
cancer and its obligate precursors appears to be due to
infection with the HPV virus. Vaccines directed against two of
the most common oncogenic strains (HPV 16 and HPV 18
Figure 2. Organ contributions to lifetime attributable risk of cancer incidence from a single standard computed tomography coronary
angiography (CTCA) scan. Source for Figure 2: Einstein AJ, Henzlova MJ, Rajagopalan S. Estimating Risk of Cancer Associated with Radiation
Exposure From 64-Slice Computed Tomography Coronary Angiography. JAMA. 2007; 298: 317–23. Permission for reproduction granted.
Ganschow et al.: Update in Women’s Health
serotypes) have been developed, but there are limited data as
to their efficacy in preventing cervical cancer.
What does this study add? This is an analysis of initial data
from the first four large randomized controlled trials examining
the effect of a prophylactic quadrivalent HPV 6/11/16/18
vaccine on the incidence of HPV-related cervical lesions. The
four trials included over 20,000 women aged 16–26, from the
Americas, Europe and Asia-Pacific. Vaccine or placebo was
administered at day 1 and at months 2 and 6, and the mean
follow-up was 3 years after the first dose. At enrollment,
women underwent serum sampling for antibodies to HPV 6/
11/16/18, and a pelvic exam was performed with cervicova-
ginal specimens collected for Pap testing and HPV DNA testing.
The trials did not exclude women with serological evidence of
prior or ongoing HPV infection. Periodic Pap tests and HPV
testing were performed at 6–12-month intervals throughout
the study. The primary endpoint was the combined incidence
of HPV 16/18 related cervical intraepithelial neoplasia (CIN)
2/3, adenocarcinoma in situ, or cervical cancer.
These studies demonstrated that HPV vaccination is effective
(99%, 95% CI 93–100) at decreasing HPV 16/18-related high-
grade CIN and carcinoma in situ among HPV naïve individuals.
Importantly, the vaccine was less effective (44%) among those
already exposed to the HPV strains, suggesting that vaccination
should be given to women younger than 16. In addition, the
vaccine had little effectiveness (18%, 95% CI 7–29) in decreasing
the rate of cervical disease resulting from any HPV type. These
may be caused by other HPV strains and highlights the impor-
tance of continued screening with Pap smears in vaccinated
Limitations include the fact that cervical dysplasia, rather
than cervical cancer, was used as an efficacy endpoint and the
lack of data on the duration of vaccine effectiveness.
How should I change my clinical practice? Vaccination
should optimally be administered before HPV exposure from
sexual activity, and providers should continue regular cervical
cancer screening for vaccinated patients. However, longer term
data are needed before widespread vaccination programs are
SSRI use in pregnancy safe overall, with the exception of
a few individual SSRIs that confer increased risk for
some rare defects.
Louik C, Lin AE, Werler MM, Hernandez-Diaz S, Mitchell AA.
First-Trimester Use of Selective Serotonin-Reuptake Inhibitors
and the Risk of Birth Defects. NEJM. 2007;356:2675–83.
What do we know? Up to 10% of women experience
depression during pregnancy16. Selective serotonin-reuptake
inhibitors (SSRIs) have been increasingly used in pregnant
women. Recently, some SSRIs have been implicated in the
development of birth defects.
What does this study add? This study assessed the
association between a woman’s first-trimester use of SSRIs
and the risk of birth defects. The authors used retrospective
data from the Sloan Epidemiology Center Birth Defects Study,
which identifies infants with a wide range of malformations in
five study centers. Mothers of these infants who agreed to
participate comprised the study group. A control group was
obtained from mothers of non-malformed infants from study
centers and within a random population sample from Massa-
chusetts. Approximately 60% of women in both groups
participated, and surveys were administered within 6 months
ofdeliverytoassess self reportofspecific SSRI use. Exposurewas
defined as the use of any SSRI from 28 days before the last
menstrual period through 112 days after the last menstrual
A total of 9,849 infants with malformations and 5,860 control
infants were included. There was no significant increase in the
risk of craniosynostosis or omphalocele associated with SSRIs as
a group or individually. There was no significant increase in the
overall risk of congenital heart defects with SSRIs, but there were
associations between specific heart defects and specific SSRIs.
Sertraline increased the risk of septal defects (OR 2.0; 95% CI
1.2–4.0), and paroxetine increased the risk of right ventricular
outflowtractobstruction(OR3.3; 95% CI1.3–8.8).Inexploratory
analyses, several other significant associations between specific
SSRI use and birth defects were identified: sertraline with anal
atresia and limb-reduction defects, and paroxetine with neural-
tube defects and clubfoot.
As the authors note, these findings should be interpreted
with caution. Multiple comparisons were performed, increasing
the study, congenital malformations are so rare it is hard to
distinguish true risk from random variation.
How should I change clinical practice? This study suggests
that many SSRIs are safe to use in the first trimester of
pregnancy, but that specific SSRIs may increase the risk of
specific birth defects and should be avoided. However, it must
be kept in mind that the occurrence of these defects is so rare
that the absolute increase in risk is small.
Women of childbearing age frequently fill prescriptions
for potentially teratogenic medications without documen-
tation of contraceptive counseling.
Schwarz DB, Postlethwaite DA, Hung Y, Armstrong MA.
Documentation of Contraception and Pregnancy When Pre-
scribing Potentially Teratogenic Medications for Reproductive-
Age Women. Ann Int Med. 2007; 147: 370–376.
What do we know? Very little is known about how often
contraception or contraception counseling is provided to
women of reproductive age when prescribed potentially tera-
What does this study add? This study was designed to
assess pregnancy rates and the frequency of contraceptive
counseling documented for women of reproductive age who
filled prescriptions for class D or X drugs. The authors
conducted a retrospective cohort study of 488,175 women
between the ages of 15–44 years of age who had continuous
pharmacy and member benefits from Kaiser Permanente
Northern California during 2001. They abstracted data from
the Pharmacy Information Data Management System related
to Class A, B, D, X, and contraceptive medications filled.
Information on insertion of IUDs, placement of a contraceptive
implant, diaphragm, or cervical cap fitting, and sterilization
were abstracted from the Outpatient Services Clinical Record
System. In addition to documentation of use of any of these
methods of contraception, women were considered to have
received contraceptive counseling if there was documentation
of contraceptive counseling, oral contraceptive management,
or family planning counseling. Data on pregnancy tests
Ganschow et al.: Update in Women’s Health
performed within 3 months of a woman filling a prescription Download full-text
for the classes of drugs studied were also abstracted from the
A class D or X medication was prescribed for 1 in 6 women
of reproductive age, 48% by internists and family practitioners.
Almost half had no contraceptive method dispensed, had not
been sterilized, and had no documentation of contraceptive
counseling in the 2 years before filling one of these prescriptions.
B prescriptions. Statin prescriptions were the least likely to have
documentation of contraceptive use, sterilization, or counseling.
Women who filled class D or X prescriptions were only slightly
less likely than women who filled a class A or B prescription to
have a positive pregnancy test (1.0% vs. 1.4% of prescriptions).
How should I change clinical practice? Physicians should be
aware of the teratogenic risk class of drugs they prescribe and
provide contraception or counseling on pregnancy prevention to
reproductive-age women taking these medications.
Conflict of Interest: None disclosed.
Corresponding Author: Pamela S. Ganschow, MD; Breast and
Cervical Cancer Screening Program, Stroger Hospital of Cook
County, Rush University Medical Center, 1900 W. Polk St. Room
910, Chicago, IL 60612, USA (e-mail: Pamela_Ganschow@rush.
1. Barron HV, Bowlby LJ, Breen T, et al. Use of reperfusion therapy for
acute myocardial infarction in the United States: data from the National
Registry of Myocardial Infarction 2. Circulation. 1998; 9712: 1150–56.
2. Maynard C, Litwin PE, Martin JS, Weaver WD. Gender differences in
the treatment and outcome of acute myocardial infarction: results from
the Myocardial Infarction Triage and Intervention Registry. Arch Intern
Med. 1992; 1525: 972–76.
3. Letelier LM, Udol K, Ena J, Weaver B, Guyatt GH. Effectiveness of
amiodarone for conversion of atrial fibrillation to sinus rhythm: a meta-
analysis. Arch Intern Med. 2003; 1637: 777–85.
4. Vorperian VR, Havighurst TC, Miller S, January CT. Adverse effects of
low dose amiodarone: a meta-analysis. J Am Coll Cardiol. 1997; 303:
5. Essebag V, Hadjis T, Platt RW, Pilote L. Amiodarone and the risk of
bradyarrhythmia requiring permanent pacemaker in elderly patients
with atrial fibrillation and prior myocardial infarction. J Am Coll Cardiol.
2003; 412: 249–54.
6. Sjöström L, Narbro K, Sjostrom D, et al. Effects of bariatric surgery on
mortality in Swedish obese subjects. N Engl J Med. 2007; 357: 741–52.
7. Melton LJ III, Kan SH, Freye MA, Wahner HW, O’Fallon WM, Riggs
BL. Epidemiology of vertebral fractures in women. Am J Epidemiol.
1989; 1295: 1000–11.
8. Hasserius R, Karlsson MK, Nilsson BE, et al. Prevalent vertebral
deformities predict increased mortality and increased fracture rate in
both men and women: a 10-year population-based study of 598
individuals from the Swedish cohort in the European Vertebral Osteo-
porosis Study. Osteoporosis Int. 2003; 141: 61–68.
9. Kado DM, Duong T, Stone KL, et al. Incident vertebral fractures and
mortality in older women: a prospective study. Osteoporosis Int. 2003;
10. Lindsay R, Pack S, Li Z. Longitudinal progression of fracture prevalence
through a population of postmenopausal women with osteoporosis.
Osteoporosis Int. 2005; 163: 306–12.
11. Melton LJ III, Thamer M, Ray NF, et al. Fractures attributable to
osteoporosis: report from the National Osteoporosis foundation. J Bone
Miner Res. 1997; 121: 16–23.
12. Sanders KM, Pasco JA, Ugoni AM, et al. The exclusion of high trauma
fractures may underestimate the prevalence of bone fragility fractures in
the community: the Geelong Osteoporosis Study. J Bone Miner Res.
1998; 138: 1337–42.
13. Karlsson MK, Hasserius R, Obrant KJ. Individuals who sustain
nonosteoporotic fractures continue to also sustain fragility fractures.
Calcif Tissue INt. 1993; 534: 229–31.
14. Brenner DJ, Hall EJ. Computed tomography-an increasing source of
radiation exposure. New Engl J Med. 2007; 35722: 2277–84.
15. Ferlay J, Bray F, Pisani P, Parkin DM. GLOBOCAN 2002: cancer
incidence, mortality and prevalence worldwide. IARC CancerBase No.5,
version 2.0. Lyon, France: IARC Press 2004. http://www-dep.iarc.fr/.
Accessed January 13, 2009.
16. Bennett HA, Einarson A, Taddio A, Koren G, Einarson TR. Prevalence
of depression during pregnancy: systematic review. Obstet Gynecol.
2004; 1034: 698–709.
17. Qaseem A, Snow V, Sherif K, Aronson M, Weiss KB, Owens DK.
Screening mammography for women 40 to 49 years of age: a clinical
practice guideline from the American College of Physicians. Ann Intern
Med. 2007; 146: 511–15.
18. Gail MH, Constantino JP, Pee D, et al. Projecting individualized
absolute invasive breast cancer risk in African American women. J Natl
Cancer Inst. 2007; 99: 1782–92.
19. U.S. Preventive Services Task Force. Screening for Chlamydial Infection:
US Preventive Services Task Force Recommendation Statement. Ann Intern
20. Centers for Disease Control and Prevention. Update to CDC’s Sexually
Transmitted Diseases Treatment Guidelines, 2006: Fluoroquinolones No
Longer Recommended for Treatment of Gonococcal Infections. MMWR
Morb Mortal Wkly Rep. 2007;56:332–36.
21. Datta SD, Sternberg M, Johnson RE, et al. Gonorrhea and chlamydia
in the United States among persons 14 to 39 years of Age, 1999 to 2002.
Ann Intern Med. 2007; 147: 89–96.
Ganschow et al.: Update in Women’s Health