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Brooks N, Irving SA, Kauffman TL, Vesco KK, Slaughter M, Smith N, Tepper NK, Olson CK, Weintraub ES, Naleway AL. Abnormal uterine bleeding diagnoses and care following COVID-19 vaccination. Am J Obstet Gynecol 2024; 230:540.e1-540.e13. [PMID: 38219855 DOI: 10.1016/j.ajog.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/03/2024] [Accepted: 01/05/2024] [Indexed: 01/16/2024]
Abstract
BACKGROUND There is evidence suggesting that COVID-19 vaccination may be associated with small, transitory effects on uterine bleeding, possibly including menstrual timing, flow, and duration, in some individuals. However, changes in health care seeking, diagnosis, and workup for abnormal uterine bleeding in the COVID-19 vaccine era are less clear. OBJECTIVE This study aimed to assess the impact of COVID-19 vaccination on incident abnormal uterine bleeding diagnosis and diagnostic evaluation in a large integrated health system. STUDY DESIGN Using segmented regression, we assessed whether the availability of COVID-19 vaccines was associated with changes in monthly, population-based rates of incident abnormal uterine bleeding diagnoses relative to the prepandemic period in health system members aged 16 to 44 years who were not menopausal. We also compared clinical and demographic characteristics of patients diagnosed with incident abnormal uterine bleeding between December 2020 and October 13, 2021 by vaccination status (never vaccinated, vaccinated in the 60 days before diagnosis, vaccinated >60 days before diagnosis). Furthermore, we conducted detailed chart review of patients diagnosed with abnormal uterine bleeding within 1 to 60 days of COVID-19 vaccination in the same time period. RESULTS In monthly populations ranging from 79,000 to 85,000 female health system members, incidence of abnormal uterine bleeding diagnosis per 100,000 person-days ranged from 8.97 to 19.19. There was no significant change in the level or trend in the incidence of abnormal uterine bleeding diagnoses between the prepandemic (January 2019-January 2020) and post-COVID-19 vaccine (December 2020-December 2021) periods. A comparison of clinical characteristics of 2717 abnormal uterine bleeding cases by vaccination status suggested that abnormal bleeding among recently vaccinated patients was similar or less severe than abnormal bleeding among patients who had never been vaccinated or those vaccinated >60 days before. There were also significant differences in age and race of patients with incident abnormal uterine bleeding diagnoses by vaccination status (Ps<.02). Never-vaccinated patients were the youngest and those vaccinated >60 days before were the oldest. The proportion of patients who were Black/African American was highest among never-vaccinated patients, and the proportion of Asian patients was higher among vaccinated patients. Chart review of 114 confirmed postvaccination abnormal uterine bleeding cases diagnosed from December 2020 through October 13, 2021 found that the most common symptoms reported were changes in timing, duration, and volume of bleeding. Approximately one-third of cases received no diagnostic workup; 57% had no etiology for the bleeding documented in the electronic health record. In 12% of cases, the patient mentioned or asked about a possible link between their bleeding and their recent COVID-19 vaccine. CONCLUSION The availability of COVID-19 vaccination was not associated with a change in incidence of medically attended abnormal uterine bleeding in our population of over 79,000 female patients of reproductive age. In addition, among 2717 patients with abnormal uterine bleeding diagnoses in the period following COVID-19 vaccine availability, receipt of the vaccine was not associated with greater bleeding severity.
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Affiliation(s)
- Neon Brooks
- Kaiser Permanente Center for Health Research, Portland, OR.
| | | | - Tia L Kauffman
- Kaiser Permanente Center for Health Research, Portland, OR
| | - Kimberly K Vesco
- Kaiser Permanente Center for Health Research, Portland, OR; Department of Obstetrics and Gynecology, Kaiser Permanente Northwest, Portland, OR
| | | | - Ning Smith
- Kaiser Permanente Center for Health Research, Portland, OR
| | - Naomi K Tepper
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Christine K Olson
- Immunization Safety Office, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Eric S Weintraub
- Immunization Safety Office, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
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van der Woude H, Phan K, Kenwright DN, Goossens L, Hally KE, Currie MJ, Kokkinos J, Sharbeen G, Phillips PA, Henry CE. Development of a long term, ex vivo, patient-derived explant model of endometrial cancer. PLoS One 2024; 19:e0301413. [PMID: 38635728 PMCID: PMC11025966 DOI: 10.1371/journal.pone.0301413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 03/16/2024] [Indexed: 04/20/2024] Open
Abstract
Incidence of endometrial cancer (EC) is rising in the developed world. The current standard of care, hysterectomy, is often infeasible for younger patients and those with high body mass index. There are limited non-surgical treatment options and a lack of biologically relevant research models to investigate novel alternatives to surgery for EC. The aim of the present study was to develop a long-term, patient-derived explant (PDE) model of early-stage EC and demonstrate its use for investigating predictive biomarkers for a current non-surgical treatment option, the levonorgestrel intra-uterine system (LNG-IUS). Fresh tumour specimens were obtained from patients with early-stage endometrioid EC. Tumours were cut into explants, cultured on media-soaked gelatin sponges for up to 21 days and treated with LNG. Formalin-fixed, paraffin embedded (FFPE) blocks were generated for each explant after 21 days in culture. Tumour architecture and integrity were assessed by haematoxylin and eosin (H&E) and immunohistochemistry (IHC). IHC was additionally performed for the expression of five candidate biomarkers of LNG resistance. The developed ex vivo PDE model is capable of culturing explants from early-stage EC tumours long-term (21 Days). This model can complement existing models and may serve as a tool to validate results obtained in higher-throughput in vitro studies. Our study provides the foundation to validate the extent to which EC PDEs reflect patient response in future research.
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Affiliation(s)
- Hannah van der Woude
- Department of Obstetrics, Gynaecology and Women’s Health, University of Otago, Wellington, New Zealand
| | - Khoi Phan
- Department of Obstetrics, Gynaecology and Women’s Health, University of Otago, Wellington, New Zealand
| | - Diane N. Kenwright
- Department of Pathology and Molecular Medicine, University of Otago, Wellington, New Zealand
| | - Louise Goossens
- Medical Photography, Capital, Coast and Hutt Valley, Wellington, New Zealand
| | | | - Margaret Jane Currie
- Department of Pathology and Biomedical Science, University of Otago, Christchurch, New Zealand
| | - John Kokkinos
- Pancreatic Cancer Translational Research Group, School of Biomedical Sciences, Lowy Cancer Research Centre, UNSW Sydney, Sydney, Australia
| | - George Sharbeen
- Pancreatic Cancer Translational Research Group, School of Biomedical Sciences, Lowy Cancer Research Centre, UNSW Sydney, Sydney, Australia
| | - Phoebe A. Phillips
- Pancreatic Cancer Translational Research Group, School of Biomedical Sciences, Lowy Cancer Research Centre, UNSW Sydney, Sydney, Australia
| | - Claire Elizabeth Henry
- Department of Obstetrics, Gynaecology and Women’s Health, University of Otago, Wellington, New Zealand
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Engler J, Filliter C, Montastruc F, Abenhaim H, Rej S, Renoux C. Risk of abnormal uterine bleeding associated with high-affinity compared with low-affinity serotonin and norepinephrine reuptake inhibitors. J Affect Disord 2024; 350:813-821. [PMID: 38246277 DOI: 10.1016/j.jad.2024.01.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/12/2024] [Accepted: 01/15/2024] [Indexed: 01/23/2024]
Abstract
BACKGROUND Concerns have been raised about the potential association between selective serotonin reuptake inhibitors (SSRIs)/serotonin-norepinephrine reuptake inhibitors (SNRIs) and the risk of abnormal uterine bleeding (AUB), which may be influenced by the affinity of SSRIs/SNRIs for serotonin transporter. Thus, we assessed whether SSRIs/SNRIs with high-affinity for serotonin transporter are associated with AUB compared to SSRIs/SNRIs with low-affinity in non-pregnant women. METHODS Using the UK Clinical Practice Research Datalink, we identified a cohort of women aged 15-24 years, newly prescribed a high- or low-affinity SSRI/SNRI between 1990 and 2019. Confounding was addressed using standardized morbidity ratio weighting. We used weighted Cox proportional hazards models to estimate the hazard ratio (HR) and 95 % confidence interval (CI) of AUB associated with high-affinity compared with low-affinity SSRIs/SNRIs. We assessed the risk of anemia as a secondary outcome. RESULTS The cohort included 156,307 users of high-affinity SSRIs/SNRIs and 102,631 users of low-affinity SSRIs/SNRIs. High-affinity SSRIs/SNRIs were not associated with an increased risk of AUB compared with low-affinity SSRIs/SNRIs (incidence rates: 46.3 versus 42.4 per 1000 person-years, respectively; HR 1.01, 95 % CI 0.93-1.09). Duration of use, age, and comorbidities did not modify the risk. However, high-affinity SSRIs/SNRIs were associated with an increased risk of anemia (HR 1.29, 95 % CI 1.04-1.61) compared with low-affinity SSRIs/SNRIs. LIMITATIONS Residual confounding may still be present. CONCLUSIONS The risk of AUB did not differ between high- and low-affinity SSRIs/SNRIs. However, the potential risk of anemia suggests the need for monitoring and further investigation of the risk of AUB with these medications.
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Affiliation(s)
- Julie Engler
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada; Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
| | - Christopher Filliter
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada
| | - François Montastruc
- Department of Medical and Clinical Pharmacology, Centre of PharmacoVigilance and Pharmacoepidemiology, Toulouse University Hospital (CHU), Faculty of Medicine, Toulouse, France
| | - Haim Abenhaim
- Department of Obstetrics & Gynecology, McGill University, Montreal, Canada
| | - Soham Rej
- Department of Psychiatry, McGill University, Montreal, Canada
| | - Christel Renoux
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada; Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Canada; Department of Medicine, McGill University, Montreal, Canada; Department of Neurology and Neurosurgery, McGill University, Montreal, Canada.
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Wheelwright SJ, Russ S, Mold F, Armes J, Harder H. Symptomatic presentation of cancer in primary care: a scoping review of patients' experiences and needs during the cancer diagnostic pathway. BMJ Open 2024; 14:e076527. [PMID: 38508614 PMCID: PMC10961516 DOI: 10.1136/bmjopen-2023-076527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 02/15/2024] [Indexed: 03/22/2024] Open
Abstract
OBJECTIVES The objective was to map the experiences and needs of patients presenting with symptoms of suspected cancer in the primary care interval (from when they first present to primary care to their first appointment or referral to a secondary or tertiary level healthcare facility). DESIGN This was a scoping review. INCLUSION CRITERIA Studies or reports written in English which included primary data on the primary care interval experiences and/or needs of adult patients presenting with new symptoms of suspected cancer were eligible. Studies which only included patients with secondary or recurring cancer, conference abstracts and reviews were excluded. No date limits were applied. METHODS The Joanna Briggs Institute method for Scoping Reviews guided screening, report selection and data extraction. At least two independent reviewers contributed to each stage. Medline, CINAHL, PsychInfo, Embase and Web of Science were searched and several grey literature resources. Relevant quantitative findings were qualitised and integrated with qualitative findings. A thematic analysis was carried out. RESULTS Of the 4855 records identified in the database search, 18 were included in the review, along with 13 identified from other sources. The 31 included studies were published between 2002 and 2023 and most (n=17) were conducted in the UK. Twenty subthemes across four themes (patient experience, interpersonal, healthcare professional (HCP) skills, organisational) were identified. No studies included patient-reported outcome measures. Patients wanted (1) to feel heard and understood by HCPs, (2) a plan to establish what was causing their symptoms, and (3) information about the next stages of the diagnostic process. CONCLUSIONS Scoping review findings can contribute to service planning as the cancer diagnostic pathway for symptomatic presentation of cancer evolves. The effectiveness of this pathway should be evaluated not only in terms of clinical outcomes, but also patient-reported outcomes and experience, along with the perspectives of primary care HCPs.
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Affiliation(s)
| | - Stephanie Russ
- Brighton & Sussex Medical School, University of Sussex, Brighton, UK
| | - Freda Mold
- Department of Health Care Management & Policy, University of Surrey, Guildford, Surrey, UK
| | - Jo Armes
- School of Health Sciences, University of Surrey, Guildford, Surrey, UK
| | - Helena Harder
- Brighton & Sussex Medical School, University of Sussex, Brighton, UK
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Kanagasabai P, Ormandy J, Filoche S, Henry C, Te Whaiti S, Willink R, Gladman T, Grainger R. Can storytelling of women's lived experience enhance empathy in medical students? A pilot intervention study. MEDICAL TEACHER 2024; 46:219-224. [PMID: 37542361 DOI: 10.1080/0142159x.2023.2243023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/06/2023]
Abstract
PURPOSE This pilot study aimed to investigate the acceptability and efficacy of a patient storytelling intervention (live and recorded) on empathy levels of medical students. MATERIALS AND METHODS Medical students participated in a storytelling intervention that had three components: listening to live or recorded stories from women with abnormal uterine bleeding, reflective writing, and a debriefing session. Empathy scores of students pre- and post-intervention were measured using the Jefferson Scale of Empathy-student version (JSE-S). Students also completed a feedback survey. Descriptive and inferential statistics were used to analyse quantitative data and content analysis was used for text comments. RESULTS Both live and recorded storytelling interventions had positive effects on student's empathy scores post intervention. Overall, students were satisfied with the intervention and reported that it improved their understanding of life experiences of women. Suggestions were made for an in-person storytelling session and interactive discussion after listening to each story. CONCLUSION A storytelling intervention has the potential to improve medical students' empathy and understanding of lived experience of women with health conditions. This could be valuable when student-patient interactions are limited in healthcare settings, or to enable stories of small numbers of patient volunteers to reach students.
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Affiliation(s)
| | - Judy Ormandy
- University of Otago, Wellington, New Zealand
- Te Whatu Ora Health New Zealand Capital, Coast and Hutt Valley, Wellington, New Zealand
| | | | | | - Sarah Te Whaiti
- University of Otago, Wellington, New Zealand
- Te Whatu Ora Health New Zealand Capital, Coast and Hutt Valley, Wellington, New Zealand
| | - Robin Willink
- Biostatistics group, University of Otago, Wellington, New Zealand
| | - Tehmina Gladman
- Education unit, University of Otago, Wellington, New Zealand
| | - Rebecca Grainger
- Te Whatu Ora Health New Zealand Capital, Coast and Hutt Valley, Wellington, New Zealand
- Department of Medicine, University of Otago, Wellington, New Zealand
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Kanagasabai PS, Filoche S, Grainger R, Henry C, Hay-Smith J. Interventions to improve access to care for abnormal uterine bleeding: A systematic scoping review. Int J Gynaecol Obstet 2023; 160:38-48. [PMID: 35429335 PMCID: PMC10084285 DOI: 10.1002/ijgo.14224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/04/2022] [Accepted: 04/11/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Women with abnormal uterine bleeding (AUB) experience barriers to accessing healthcare services. OBJECTIVES To identify and describe the evidence on interventions to improve healthcare access of women with AUB. SEARCH STRATEGY A systematic search of databases including Medline, CINAHL, EMBASE, Scopus, and Cochrane register for clinical trials on February 26, 2021. SELECTION CRITERIA Studies including women with AUB and investigating an intervention to improve access at the levels of individual patient, community, organization, health system, or medical education. DATA COLLECTION AND ANALYSIS Data extraction and descriptive analysis of the country, study design, settings, participant characteristics, intervention, outcome measures, and key findings. MAIN RESULTS We identified 20 studies and most interventions (13 studies) targeted organizational changes. Creating a multidisciplinary team, bringing services together and developing a care pathway improved the availability of services. Management of AUB in an outpatient setting improved the affordability. The use of decision aids improved patient engagement in consultations. There is a lack of interventions at an individual or community level targeting health literacy, health beliefs, social acceptability, and opportunity to reach and pay for services. CONCLUSIONS Community-based culturally-adapted interventions focusing on access to women with different socio-economic and cultural backgrounds should be investigated.
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Affiliation(s)
| | - Sara Filoche
- Department of Obstetrics, Gynaecology and Women's Health, University of Otago Wellington, Wellington, New Zealand
| | - Rebecca Grainger
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
| | - Claire Henry
- Department of Obstetrics, Gynaecology and Women's Health, University of Otago Wellington, Wellington, New Zealand
| | - Jean Hay-Smith
- Rehabilitation Teaching and Research Institute, University of Otago Wellington, Wellington, New Zealand
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Fakas S, Lu AMR, Shahani D, Blitz MJ, Rodriguez-Ayala G. Social Vulnerability Index and Surgical Management of Abnormal Uterine Bleeding in Reproductive-Age Women. J Minim Invasive Gynecol 2022; 29:1104-1109. [PMID: 35691547 DOI: 10.1016/j.jmig.2022.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/30/2022] [Accepted: 06/01/2022] [Indexed: 10/18/2022]
Abstract
STUDY OBJECTIVE To determine whether surgical management of abnormal uterine bleeding (AUB) is associated with Social Vulnerability Index (SVI). DESIGN Retrospective cohort. SETTING Seven hospitals and four ambulatory surgery centers within large New York health system. PATIENTS All patients 15-45 years of age who underwent either a hysterectomy or myomectomy for AUB between January 2019 and October 2021. INTERVENTIONS None. Home addresses were linked to Census tracts and SVI scores. SVI is composed of 4 themes that potentially influence a community's vulnerability to health stressors: socioeconomic status, household composition and disability, minority status and language, and housing type and transportation. Multiple logistic regression analyses were performed to evaluate the association between SVI and surgical procedure/approach, adjusting for: age, race and ethnicity, marital status, insurance, language, body mass index, and prior abdominal surgery. MEASUREMENTS AND MAIN RESULTS A total of 1,628 patients were included. On regression analysis between SVI quarters and type of surgery, the odds of laparotomy for the hysterectomy group were not impacted by SVI composite score both before and after adjusting for alternative factors (OR and aOR). Amongst those who had a myomectomy, individuals in SVI Q3 had 1.86 (95% CI: 1.27 to 2.72) higher odds of having a laparotomy versus those in SVI Q1. Individuals in SVI Q4 had 1.74 (95% CI: 1.15 to 2.62) higher odds of having a laparotomy versus those in SVI Q1. While some unadjusted odds ratios were statistically significant in the myomectomy group, when adjusted for social, demographic and economic factors the results were not statistically significant. CONCLUSION Patients living in more vulnerable communities are less likely to have minimally invasive hysterectomy or myomectomy for management of AUB. Neighborhood characteristics are independently associated with surgical procedure and approach.
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Affiliation(s)
- Steliana Fakas
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Anjanique Mariquit Rosete Lu
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Disha Shahani
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Matthew J Blitz
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA; Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Gianni Rodriguez-Ayala
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA.
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Evaluation of frozen section biopsy for fast track diagnosis of endometrial pathology in high-risk women with abnormal uterine bleeding. Eur J Obstet Gynecol Reprod Biol 2021; 264:97-102. [PMID: 34298451 DOI: 10.1016/j.ejogrb.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/20/2021] [Accepted: 07/06/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To study the accuracy of frozen section biopsy for endometrial pathology in high-risk women with abnormal uterine bleeding (AUB). STUDY DESIGN A case-control study was conducted between November 2017 to April 2019, a total of 150 women with postmenopausal bleeding, perimenopausal AUB, and high-risk women of age < 40 years with AUB were recruited. All women underwent transvaginal sonography and Doppler, based on age-appropriate endometrial thickness cut-offs 80 women then underwent hysteroscopy. Based on hysteroscopy, women suspicious of malignancy were taken as cases (n = 40) and those with benign findings as controls (n = 40). All cases and controls underwent dilatation and curettage (D & C) with frozen section (FS) and routine histopathology. RESULTS The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR), negative LR, and overall test accuracy of FS were 90.9%, 93.19%, 83.33%, 96.19%, 13.8, 0.1 and 86.25% respectively for diagnosing endometrial hyperplasia and cancer taking histopathology as the gold standard. Correlation between frozen section biopsy and histopathology was highly significant (p < 0.001) on D & C specimens and the level of agreement was good (K = 0.778). CONCLUSION In women suspicious of malignancy on hysteroscopy, frozen section has high accuracy on D&C specimen and can be used to diagnose endometrial hyperplasia and cancer in an effort to fast-track investigations and work-up for definitive treatment while awaiting final histopathology.
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