Compounded Bioidentical Hormones: Myths and Realities.

The spectacular success of compounded bioidentical hormone therapy is a product of the unanticipated negative-to-neutral findings of the Women's Health Initiative hormone trial and the peculiarities of their regulatory status. By not having to provide scientific evidence of safety and efficacy, a requirement for all Food and Drug Administration (FDA)-approved hormone therapy products, the industry's relatively unfettered marketing now accounts for about one third of menopausal hormone therapy prescriptions. Clinicians are often caught in the middle between patient beliefs and a desire to practice evidence-based medicine. Strategies are needed to redirect patients towards truly safe and effective treatment for their menopausal symptoms.

Predictors of Positive Margins at Time of Loop Electrosurgical Excision Procedure.

OBJECTIVE: The aim of the study was to identify factors associated with the presence of high-grade squamous intraepithelial lesion (HSIL) at surgical margins of loop electrosurgical excision procedure (LEEP) pathology specimens. MATERIALS AND METHODS: All women evaluated for lower genital tract disease at a single academic institution were prospectively entered into a database. The database was queried for all women who had a LEEP performed for indications within contemporary American Society of Colposcopy and Cervical Pathology guidelines between April 1, 2013, and April 30, 2015. Factors extracted from the database included demographics, contraception, weight, tobacco use, provider volume, resident participation, history of cervical procedure, and pathology features including preceding Pap test category. A positive margin was defined as HSIL on either the endocervical or ectocervical margin of the LEEP specimen or in endocervical curettage specimen after LEEP. We performed univariable statistics to identify factors associated with positive margins and then logistic regression modeling on significant factors for the outcome of positive margins. RESULTS: Two hundred sixty-nine women were identified. Seventy five (27.8%) of these women had positive margins. Only tobacco use, gravity, parity, and preceding Pap category were significant on univariable analysis. After multivariable analysis, smokers remained more likely to have positive margins (odds ratio = 2.01; CI = 1.12-3.6; p < .01) as did those with preceding HSIL Pap tests (odds ratio = 1.96; CI = 1.13-3.41; p < .01). CONCLUSIONS: In our population, of all the factors assessed, only tobacco use and preceding high-grade Pap tests were associated with positive margins at time of LEEP. This information may be helpful in preprocedural planning to optimize treatment.

Treatment of Acute Abnormal Uterine Bleeding in Adolescents: What Are Providers Doing in Various Specialties?

STUDY OBJECTIVE: The purpose of this study was to assess whether variability exists in the management of acute abnormal uterine bleeding (AUB) in adolescents between pediatric Emergency Department (ED) physicians, pediatric gynecologists, and adolescent medicine specialists. DESIGN: Retrospective chart review. SETTING: Tertiary care medical center ED. PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We included girls aged 9-22 years who presented from July 2008 to June 2014 with the complaint of acute AUB. Patients were identified using the International Classification of Diseases, ninth revision codes for heavy menstrual bleeding, AUB, and irregular menses. Exclusion criteria included pregnancy and current use of hormonal therapy. One hundred fifty patients were included. RESULTS: Among those evaluated, 61% (n = 92) were prescribed hormonal medication to stop their bleeding by providers from the ED, Adolescent Medicine, or Pediatric Gynecology. ED physicians prescribed mostly single-dose and multidose taper combined oral contraceptive pills (85%; n = 24), compared with Adolescent Medicine (54%, n = 7), and Gynecology (28%, n = 13). Pediatric gynecologists were more likely than ED physicians to treat patients with norethindrone acetate, either alone or in combination with a single dose combined oral contraceptive pill (61%, n = 33 vs 7%, n = 2; P < .001). CONCLUSION: Variations in treatment strategies for adolescents who present with acute AUB exist among pediatric specialties, which reflects a lack of standardized care for adolescents. Prospective evaluation of the shortest interval to cessation of bleeding, side effects, and patient satisfaction are valuable next steps.

Cannabinoid hyperemesis syndrome: a cause of refractory nausea and vomiting in pregnancy.

BACKGROUND: Cannabinoid hyperemesis syndrome is a condition present among chronic cannabis users resulting in abdominal pain, intractable nausea and vomiting, and compulsive bathing behaviors. Given the recent legalization of marijuana in certain areas of the United States, the incidence of this condition may increase among pregnant women. CASE: We report the case of a pregnant 28-year-old woman with multiple admissions for episodic nausea and vomiting resulting in Mallory-Weiss esophageal tears, dehydration, and abdominal pain who was noted to be showering compulsively during her hospitalizations. After an extensive workup for the etiology of her intractable nausea and pain, she was diagnosed with cannabinoid hyperemesis syndrome, which is treated simply with abstinence from marijuana use. CONCLUSION: Cannabinoid hyperemesis syndrome should be considered in pregnant women with intractable nausea relieved by frequent hot bathing. By considering this diagnosis, extensive diagnostic testing can be avoided and the correct therapy, abstaining from cannabis use, can be recommended.