Cardiovascular health and the menopause: the gynecologist as the patients' interface

The large decrease in estrogen following menopause appears to explain the dramatic increase in cardiovascular disease (CVD) in postmenopausal women. Gynecologists are well placed to play a primary role in the diagnosis, prevention and management of CVD in these patients; this role may include advice on lifestyle changes, and, if appropriate, prescribing preventative treatments such as hormone replacement therapy (HRT) and lipid-lowering drugs. The use of estrogen replacement therapy (ERT) to prevent CVD is supported by a number of observational studies. However, recently, large, randomized trials gave unexpected, conflicting data on the cardiovascular benefits of HRT, leading to confusion, and influencing both patient and clinical perceptions regarding the role of HRT postmenopause. These different outcomes may be due to differences in the HRT regimens, mean age and mean time from menopause at enrollment, duration of therapy, and patient selection bias in observational studies. A 'unified hypothesis' consistent with findings from all studies has now been developed: HRT initiated at the time of the menopause prevents CVD, whereas HRT initiated years after the menopause seems to increase CHD events. This knowledge is essential for gynecologists making clinical decisions regarding HRT use.

Ductal lavage for detection of cellular atypia in women at high risk for breast cancer

BACKGROUND

Breast cancer originates in breast epithelium and is associated with progressive molecular and morphologic changes. Women with atypical breast ductal epithelial cells have an increased relative risk of breast cancer. In this study, ductal lavage, a new procedure for collecting ductal cells with a microcatheter, was compared with nipple aspiration with regard to safety, tolerability, and the ability to detect abnormal breast epithelial cells.

METHODS

Women at high risk for breast cancer who had nonsuspicious mammograms and clinical breast examinations underwent nipple aspiration followed by lavage of fluid-yielding ducts. All statistical tests were two-sided.

RESULTS

The 507 women enrolled included 291 (57%) with a history of breast cancer and 199 (39%) with a 5-year Gail risk for breast cancer of 1.7% or more. Nipple aspirate fluid (NAF) samples were evaluated cytologically for 417 women, and ductal lavage samples were evaluated for 383 women. Adequate samples for diagnosis were collected from 111 (27%) and 299 (78%) women, respectively. A median of 13,500 epithelial cells per duct (range, 43-492,000 cells) was collected by ductal lavage compared with a median of 120 epithelial cells per breast (range, 10-74,300) collected by nipple aspiration. For ductal lavage, 92 (24%) subjects had abnormal cells that were mildly (17%) or markedly (6%) atypical or malignant (<1%). For NAF, corresponding percentages were 6%, 3%, and fewer than 1%. Ductal lavage detected abnormal intraductal breast cells 3.2 times more often than nipple aspiration (79 versus 25 breasts; McNemar's test, P<.001). No serious procedure-related adverse events were reported.

CONCLUSIONS

Large numbers of ductal cells can be collected by ductal lavage to detect atypical cellular changes within the breast. Ductal lavage is a safe and well-tolerated procedure and is a more sensitive method of detecting cellular atypia than nipple aspiration.

Lack of utility in clinical practice of cytologic examination of nonbloody cyst fluid from palpable breast cysts

OBJECTIVE

This study was undertaken to answer the following question: Does cytologic evaluation of nonbloody fluid aspirated from breast cysts contribute to appropriate clinical management?

STUDY DESIGN

A retrospective review of palpable breast cyst fluid cytologic reports and associated medical records was undertaken to determine whether the cytologic findings affected patient management. Breast cyst size, fluid volume, fluid color, and patient age were abstracted from 689 medical records (1988-1999) of women whose palpable cysts had been aspirated at the Breast Diagnostic Center, Women's and Children's Hospital, Los Angeles. These observations were correlated with the fluid cytologic reports.

RESULTS

Except for frankly bloody fluid, all breast fluid cytologic reports listed the results as acellular, inadequate for cytologic diagnosis, or no malignant cells identified.

CONCLUSION

In clinical practice only frankly bloody fluid should be submitted for cytologic analysis. All other cyst fluid should be discarded.

A breast clinic in a department of obstetrics and gynecology

In 1988, the Department of Obstetrics and Gynecology of the University of Southern California School of Medicine; created its own Breast Diagnostic Center for training resident physicians and providing breast care for outpatients and inpatients of Women's and Children's Hospital, Los Angeles, California. The structure and function of the Breast Diagnostic Center allow residents to be directly involved in and responsible for evaluation and care of benign breast problems and allow comprehensive breast-care education and integration of referral breast services for residents and patients. Direct faculty supervision, uniform history and physical records on printed forms, fine-needle aspirations and breast biopsies, and staff assistance with follow-up and patient tracking maximize resident physician education and experience. This departmental approach to resident physician training in breast care can be adapted to the resources and logistics of any department of obstetrics and gynecology.