Reproductive Health Among Those with Schizophrenia Spectrum Disorders: An Overview of Considerations Related to the Premenopausal Period, Pregnancy and Postpartum, and the Menopausal Transition, with a Focus on Recent Findings.

PURPOSE OF REVIEW: Schizophrenia spectrum disorders (SSD) impact many aspects of reproductive health for women and non-binary and transgender individuals assigned female at birth. In this narrative review, we highlight considerations and recent research related to (1) the premenopausal period, (2) pregnancy and postpartum, and (3) the menopausal transition. RECENT FINDINGS: Most recent research has focused on pregnancy and the postpartum period, and specifically on elucidating perinatal risk factors, adverse obstetrical and neonatal outcomes (and modifiable contributors such as smoking), long-term child health, and psychotropic medications (with reassuring results related antipsychotic-associated gestational diabetes mellitus and neurodevelopmental outcomes). Much less recent focus has been on menstruation and menopause, although some research has highlighted the relative worsening of illness peri-menstrually and peri-menopausally. Despite the many important reproductive considerations for those with SSD, many aspects including menstruation and menopause have received very little attention. Further research is needed on how to best support women, non-binary, and transgender people assigned female at birth with SSD throughout the lifespan.

Access to symptom screening and severe symptom risk among cancer patients with major mental illness.

INTRODUCTION: Cancer symptom screening has the potential to improve cancer outcomes, including reducing symptom burden among patients with major mental illness (MMI). We determined rates of symptom screening with the Edmonton Symptom Assessment System (ESAS-r) and risk of severe symptoms in cancer patients with MMI. METHODS: This retrospective cohort study used linked administrative health databases of adults diagnosed with cancer between 2007 and 2020. An MMI was measured in the 5 years prior to cancer diagnosis and categorized as inpatient, outpatient, or no MMI. Outcomes were defined as time to first ESAS-r screening and time to first moderate-to-severe symptom score. Cause-specific and Fine and Gray competing events models were used for both outcomes, controlling for age, sex, rural residence, year of diagnosis and cancer site. RESULTS: Of 389,870 cancer patients, 4049 (1.0%) had an inpatient MMI and 9775 (2.5%) had an outpatient MMI. Individuals with inpatient MMI were least likely to complete an ESAS-r (67.5%) compared to those with outpatient MMI (72.3%) and without MMI (74.8%). Compared to those without MMI, individuals with an inpatient or outpatient MMI had a lower incidence of symptom screening records after accounting for the competing risk of death (subdistribution Hazard Ratio 0.77 (95% CI 0.74-0.80) and 0.88 (95% CI 0.86-0.90) respectively). Individuals with inpatient and outpatient MMI status consistently had a significantly higher risk of reporting high symptom scores across all symptoms. CONCLUSIONS: Understanding the disparity in ESAS-r screening and management for cancer patients with MMI is a vital step toward providing equitable cancer care.

Attention-deficit hyperactivity disorder in children born to mothers with infertility: a population-based cohort study.

STUDY QUESTION: Is the risk of attention-deficit hyperactivity disorder (ADHD) increased in children born to mothers with infertility, or after receipt of fertility treatment, compared to mothers with unassisted conception? SUMMARY ANSWER: Infertility itself may be associated with ADHD in the offspring, which is not amplified by the use of fertility treatment. WHAT IS KNOWN ALREADY: Infertility, and use of fertility treatment, is common. The long-term neurodevelopmental outcome of a child born to a mother with infertility, including the risk of ADHD, remains unclear. STUDY DESIGN, SIZE, DURATION: This population-based cohort study comprised all singleton and multiple hospital births in Ontario, Canada, 2006-2014. Outcomes were assessed up to June 2020. PARTICIPANTS/MATERIALS, SETTING, METHODS: Linked administrative datasets were used to capture all hospital births in Ontario, maternal health and pregnancy measures, fertility treatment and child outcomes. Included were all children born at ≥24 weeks gestation between 2006 and 2014, and who were alive at age 4 years. The main exposure was mode of conception, namely (i) unassisted conception (reference group), (ii) infertility without fertility treatment (history of an infertility consultation with a physician within 2 years prior to conception but no fertility treatment), (iii) ovulation induction (OI) or intrauterine insemination (IUI) and (iv) IVF or intracytoplasmic sperm injection (ICSI). The main outcome was a diagnosis of ADHD after age 4 years and assessed up to June 2020. Hazard ratios (HRs) were adjusted for maternal age, income quintile, rurality, immigration status, smoking, obesity, parity, any drug or alcohol use, maternal history of mental illness including ADHD, pre-pregnancy diabetes mellitus or chronic hypertension and infant sex. In addition, we performed pre-planned stratified analyses by mode of delivery (vaginal or caesarean delivery), infant sex, multiplicity (singleton or multiple), timing of birth (term or preterm <37 weeks) and neonatal adverse morbidity (absent or present). MAIN RESULTS AND THE ROLE OF CHANCE: The study included 925 488 children born to 663 144 mothers, of whom 805 748 (87%) were from an unassisted conception, 94 206 (10.2%) followed infertility but no fertility treatment, 11 777 (1.3%) followed OI/IUI and 13 757 (1.5%) followed IVF/ICSI. Starting at age 4 years, children were followed for a median (interquartile range) of 6 (4-8) years. ADHD occurred among 7.0% of offspring in the unassisted conception group, 7.5% in the infertility without fertility treatment group, 6.8% in the OI/IUI group and 6.3% in the IVF/ICSI group. The incidence rate (per 1000 person-years) of ADHD was 12.0 among children in the unassisted conception group, 12.8 in the infertility without fertility treatment group, 12.9 in the OI/IUI group and 12.2 in the IVF/ICSI group. Relative to the unassisted conception group, the adjusted HR for ADHD was 1.19 (95% CI 1.16-1.22) in the infertility without fertility treatment group, 1.09 (95% CI 1.01-1.17) in the OI/IUI group and 1.12 (95% CI 1.04-1.20) in the IVF/ICSI group. In the stratified analyses, these patterns of risk for ADHD were largely preserved. An exception was seen in the sex-stratified analyses, wherein females had lower absolute rates of ADHD but relatively higher HRs compared with that seen among males. LIMITATIONS, REASONS FOR CAUTION: Some mothers in the isolated infertility group may have received undocumented OI oral therapy, thereby leading to possible misclassification of their exposure status. Parenting behaviour, schooling and paternal mental health measures were not known, leading to potential residual confounding. WIDER IMPLICATIONS OF THE FINDINGS: Infertility, even without treatment, is a modest risk factor for the development of ADHD in childhood. The reason underlying this finding warrants further study. STUDY FUNDING/COMPETING INTEREST(S): This study was made possible with funding from the Canadian Institutes of Health Research, Grant number PJT 165840. The authors report no conflict of interest. TRIAL REGISTRATION NUMBER: N/A.

Association of Patient-Reported Outcomes With Subsequent Nonfatal Self-injury After a New Cancer Diagnosis.

Importance: Nonfatal self-injury (NFSI) is a patient-centered manifestation of severe distress occurring in 3 out of 1000 patients after cancer diagnosis. How to identify patients at risk for NFSI remains unknown. Objective: To examine the associations between patient-reported outcome measures and subsequent NFSI in patients with cancer. Design, Setting, and Participants: This population-based matched case-control study included adults with a new cancer diagnosis reporting an Edmonton Symptom Assessment System (ESAS) score within 36 months of diagnosis in Ontario, Canada, 2007 to 2019. Data analysis was performed January 2007 to December 2019. Main Outcomes and Measures: Cases included patients with NFSI, and controls were patients without NFSI. Cases and controls were matched 1:4. Multivariable conditional logistic regression assessed the association between moderate to severe ESAS symptom scores and total ESAS (t-ESAS, range 0-90) score with NFSI in the subsequent 180 days. Results: Of 408 858 patients reporting 1 or more ESAS assessments, 425 patients experienced NFSI and reported an ESAS score in the preceding 180 days. Of those, 406 cases were matched to 1624 control patients without an NFSI. Cases reported a higher proportion of moderate to severe symptoms and higher t-ESAS score than controls prior to the event. After adjustment, moderate to severe anxiety (odds ratio [OR], 1.61; 95% CI, 1.14-2.27), depression (OR, 1.66; 95% CI, 1.20-2.31), and shortness of breath (OR, 1.65; 95% CI, 1.18-2.31) and each 10-point increase in t-ESAS score (OR, 1.51; 95% CI, 1.40-1.63) were independently associated with higher odds of subsequent NFSI. Conclusions and Relevance: In this case-control study, reporting moderate to severe anxiety, depression, and shortness of breath and an increasing t-ESAS score after cancer diagnosis were associated with higher odds of NFSI in the following 180 days. These data support the prospective use of routine ESAS screening as a means of identifying patients at higher risk for NFSI to improve supportive care.

Maternal Schizophrenia, Skin-to-Skin Contact, and Infant Feeding Initiation.

BACKGROUND: The World Health Organization recommends mothers and infants be in direct skin-to-skin contact immediately after birth and initiate breastfeeding as soon as possible. Little is known in women with schizophrenia. METHODS: We conducted a population-based cohort study using administrative health data from Ontario, Canada (2012-2014), comparing women with (n = 471) and without schizophrenia (n = 218 435), and their infants, on the primary outcomes of any skin-to-skin contact and opportunity to initiate breastfeeding within the first 2 h after birth. For dyads with available data, secondary outcomes of intention to breastfeed, breastfeeding support, any breastmilk, and exclusive breastmilk at discharge were assessed. Modified Poisson regression was used to generate relative risks (aRR) and 95% confidence intervals (CI), adjusted for maternal age, parity, neighbourhood income, region of residence, smoking in pregnancy, and maternal medical and non-psychotic psychiatric comorbidity for all outcomes. RESULTS: Maternal schizophrenia was associated with lower likelihood of skin-to-skin contact (65.2% vs 78.1%; aRR 0.88, 95% CI: 0.82-0.94), and breastfeeding initiation post-delivery (38.9% vs 52.6% aRR 0.80, CI: 0.71-0.90) compared to dyads unexposed to maternal schizophrenia. Secondary outcomes followed a similar pattern. The magnitude of the effect was slightly less when restricting the cohort to full-term, vaginal deliveries, not admitted to NICU, and infant not discharged to social services. CONCLUSIONS: Reduced maternal-infant skin-to-skin contact and breastfeeding initiation immediately after birth may significantly impact maternal-child bonding and the establishment breastfeeding in this population. Mothers with schizophrenia may require individualized support to promote these WHO recommended hospital practices in the early post-natal period.

Incidence of and Factors Associated With Nonfatal Self-injury After a Cancer Diagnosis in Ontario, Canada.

Importance: Psychological distress is a key component of patient-centered cancer care. While a greater risk of suicide among patients with cancer has been reported, more frequent consequences of distress, including nonfatal self-injury (NFSI), remain unknown. Objective: To examine the risk of NFSI after a cancer diagnosis. Design, Setting, and Participants: This population-based retrospective cohort study used linked administrative databases to identify adults diagnosed with cancer between 2007 and 2019 in Ontario, Canada. Exposures: Demographic and clinical factors. Main Outcomes and Measures: Cumulative incidence of NFSI, defined as emergency department presentation of self-injury, was computed, accounting for the competing risk of death from all causes. Factors associated with NFSI were assessed using multivariable Fine and Gray models. Results: In total, 806 910 patients met inclusion criteria. The mean (SD) age was 65.7 (14.3) years, and 405 161 patients (50.2%) were men. Overall, 2482 (0.3%) had NFSI and 182 (<0.1%) died by suicide. The 5-year cumulative incidence of NFSI was 0.27% (95% CI, 0.25%-0.28%). After adjusting for key confounders, prior severe psychiatric illness, whether requiring inpatient care (subdistribution hazard ratio [sHR], 12.6; 95% CI, 10.5-15.2) or outpatient care (sHR, 7.5; 95% CI, 6.5-8.8), and prior self-injury (sHR, 6.6; 95% CI, 5.5-8.0) were associated with increased risk of NFSI. Young adults (age 18-39 years) had the highest NFSI rates relative to individuals aged 70 years or older (sHR, 5.4; 95% CI, 4.5-6.5). The magnitude of association between prior inpatient psychiatric illness and NFSI was greatest for young adults (sHR, 17.6; 95% CI, 12.0-25.8). Certain cancer subsites were also associated with increased risk, including head and neck cancer (sHR, 1.5; 95% CI, 1.2-1.9). Conclusions and Relevance: In this study, patients with cancer had a higher incidence of NFSI than suicide after diagnosis. Younger age, history of severe psychiatric illness, and prior self-injury were independently associated with risk of NFSI. These exposures appeared to act synergistically, placing young adults with a prior mental health history at the greatest risk of NFSI. These factors should be used to identify at-risk patients.

Overestimation of Postpartum Depression Prevalence Based on a 5-item Version of the EPDS: Systematic Review and Individual Participant Data Meta-analysis.

OBJECTIVE: The Maternal Mental Health in Canada, 2018/2019, survey reported that 18% of 7,085 mothers who recently gave birth reported "feelings consistent with postpartum depression" based on scores ≥7 on a 5-item version of the Edinburgh Postpartum Depression Scale (EPDS-5). The EPDS-5 was designed as a screening questionnaire, not to classify disorders or estimate prevalence; the extent to which EPDS-5 results reflect depression prevalence is unknown. We investigated EPDS-5 ≥7 performance relative to major depression prevalence based on a validated diagnostic interview, the Structured Clinical Interview for DSM (SCID). METHODS: We searched Medline, Medline In-Process & Other Non-Indexed Citations, PsycINFO, and the Web of Science Core Collection through June 2016 for studies with data sets with item response data to calculate EPDS-5 scores and that used the SCID to ascertain depression status. We conducted an individual participant data meta-analysis to estimate pooled percentage of EPDS-5 ≥7, pooled SCID major depression prevalence, and the pooled difference in prevalence. RESULTS: A total of 3,958 participants from 19 primary studies were included. Pooled prevalence of SCID major depression was 9.2% (95% confidence interval [CI] 6.0% to 13.7%), pooled percentage of participants with EPDS-5 ≥7 was 16.2% (95% CI 10.7% to 23.8%), and pooled difference was 8.0% (95% CI 2.9% to 13.2%). In the 19 included studies, mean and median ratios of EPDS-5 to SCID prevalence were 2.1 and 1.4 times. CONCLUSIONS: Prevalence estimated based on EPDS-5 ≥7 appears to be substantially higher than the prevalence of major depression. Validated diagnostic interviews should be used to establish prevalence.

Maternal schizophrenia and adverse birth outcomes: what mediates the risk?

PURPOSE: Maternal schizophrenia is associated with adverse birth outcomes, but the reasons for this remain unclear. In a population-based cohort of infants born to women with schizophrenia, we determined the occurrence of key perinatal outcomes and explored whether factors identifiable in our datasets explained any elevated risk. METHODS: Using population-level health administrative data linked to clinical birth-registry data in Ontario, Canada (2006-2011), we examined the relative risk (RR) of preterm birth (< 37 weeks), small for gestational age (SGA), and Apgar scores < 8 in infants of women with schizophrenia (n = 4279) versus infants of unaffected women (n = 286,147). Generalized estimating equations determined whether reproductive history, maternal health conditions, pregnancy exposures, and complications explained elevated RRs. RESULTS: Among infants of women with schizophrenia, risk was higher for prematurity (11.4% vs. 6.9%, aRR 1.64, 95% CI 1.51-1.79), SGA (3.5% vs. 2.5%, aRR 1.40, 95% CI 1.20-1.64), and Apgar score < 8 at 1 (19.0% vs. 12.8%, aRR 1.49, 95% CI 1.40-1.59) and 5 min (5.6% vs. 3.0%, aRR 1.90, 95% CI 1.68-2.16). Smoking, fourfold more common among women with schizophrenia, was the variable that explained the greatest proportion of the elevated aRR for prematurity (9.9%), SGA (28.7%), and Apgar < 8 at 1 and 5 min (9.8%, 5.6%). Illicit substance use, certain reproductive history variables, and pregnancy complications also contributed to the elevated aRR for preterm birth. CONCLUSIONS: Elevated risks of preterm birth, SGA, and low Apgar scores in infants of women with schizophrenia are partly explained by potentially modifiable factors such as smoking and illicit drug use, suggesting opportunities for targeted intervention.

Inflammatory bowel disease and new-onset psychiatric disorders in pregnancy and post partum: a population-based cohort study.

OBJECTIVE: Patients with inflammatory bowel disease (IBD) have an elevated risk of mental illness. We determined the incidence and correlates of new-onset mental illness associated with IBD during pregnancy and post partum. DESIGN: This cohort study using population-based health administrative data included all women with a singleton live birth in Ontario, Canada (2002-2014). The incidence of new-onset mental illness from conception to 1-year post partum was compared between 3721 women with and 798 908 without IBD, generating adjusted HRs (aHR). Logistic regression was used to identify correlates of new-onset mental illness in the IBD group. RESULTS: About 22.7% of women with IBD had new-onset mental illness versus 20.4% without, corresponding to incidence rates of 150.2 and 132.8 per 1000 patient-years (aHR 1.12, 95% CI 1.05 to 1.20), or one extra case of new-onset mental illness per 43 pregnant women with IBD. The risk was elevated in the post partum (aHR 1.20, 95% CI 1.09 to 1.31), but not during pregnancy, and for Crohn's disease (aHR 1.12, 95% CI 1.02 to 1.23), but not ulcerative colitis. The risk was specifically elevated for a new-onset mood or anxiety disorder (aHR 1.14, 95% CI 1.04 to 1.26) and alcohol or substance use disorders (aHR 2.73, 95% CI 1.42 to 5.26). Predictors of a mental illness diagnosis were maternal age, delivery year, medical comorbidity, number of prenatal visits, family physician obstetrical care and infant mortality. CONCLUSION: Women with IBD were at an increased risk of new-onset psychiatric diagnosis in the postpartum period, but not during pregnancy. Providers should look to increase opportunities for prevention, early identification and treatment accordingly.

Long-term Risk of a Seizure Disorder After Eclampsia.

OBJECTIVE: To evaluate the incidence rate and relative risk of a seizure disorder after eclampsia. METHODS: We evaluated 1,565,733 births in a retrospective data linkage cohort study in Ontario, Canada, from April 1, 2002, to March 31, 2014. We included females aged 15-50 years and excluded patients with epilepsy, conditions predisposing to seizure, and those who died within 30 days of the delivery discharge date. The exposure was defined as a hypertensive disorder of pregnancy, namely 1) eclampsia, 2) preeclampsia, or 3) gestational hypertension. The referent was an unaffected pregnancy. The primary outcome was the risk of seizure disorder starting 31 days after a hospital birth discharge. Risk was expressed as an incidence rate and a hazard ratio (HR) with 95% CI. The predefined study hypothesis was that women with eclampsia would have an increased risk of future seizure disorder. RESULTS: There were 1,615 (0.10%) pregnancies exclusively affected by eclampsia, 17,264 (1.1%) with preeclampsia, 60,863 (3.9%) with gestational hypertension, and 1,485,991 (94.9%) unaffected. A future seizure disorder was significantly more likely after a pregnancy with eclampsia (4.58/10,000 person-years) than a pregnancy without a hypertensive disorder of pregnancy (0.72/10,000 person-years; crude HR 6.09, 95% CI 2.73-13.60). The adjusted HR was minimally attenuated from 6.09 to 5.42 (95% CI 2.42-12.12) after multivariable adjustment for confounders at the index birth as well as adjusting for traumatic brain injury, stroke, cerebral tumor, aneurysm or hemorrhage, and multiple sclerosis. The risk of seizure disorder was doubled in pregnancies affected by preeclampsia (adjusted HR 1.96, 95% CI 1.21-3.17), but not by gestational hypertension (adjusted HR 1.01, 95% CI 0.71-1.43). CONCLUSION: Women with eclampsia should be reassured that, although the relative risk of a seizure disorder is higher than unaffected women, the absolute risk is extremely low (approximately one seizure/2,200 person-years).

Rates of Mental Illness and Addiction among High-Cost Users of Medical Services in Ontario.

OBJECTIVE: To quantify the burden of mental illness and addiction among high-costing users of medical services (HCUs) using population-level data from Ontario, and compare to a referent group of nonusers. METHOD: We conducted a population-level cohort study using health administrative data from fiscal year 2011-2012 for all Ontarians with valid health insurance as of April 1, 2011 (N = 10,909,351). Individuals were grouped based on medical costs for hospital, emergency, home, complex continuing, and rehabilitation care in 2011-2012: top 1%, top 2% to 5%, top 6% to 50%, bottom 50%, and a zero-cost nonuser group. The rate of diagnosed psychotic, major mood, and substance use disorders in each group was compared to the zero-cost referent group with adjusted odds ratios (AORs) for age, sex, and socioeconomic status. A sensitivity analysis included anxiety and other disorders. RESULTS: Mental illness and addiction rates increased across cost groups affecting 17.0% of the top 1% of users versus 5.7% of the zero-cost group (AOR, 3.70; 95% confidence interval [CI], 3.59 to 3.81). This finding was most pronounced for psychotic disorders (3.7% vs. 0.7%; AOR, 5.07; 95% CI, 4.77 to 5.38) and persisted for mood disorders (10.0% vs. 3.3%; AOR, 3.52; 95% CI, 3.39 to 3.66) and substance use disorders (7.0% vs. 2.3%; AOR, 3.82; 95% CI, 3.66 to 3.99). When anxiety and other disorders were included, the rate of mental illness was 39.3% in the top 1% compared to 21.3% (AOR, 2.39; 95% CI, 2.34 to 2.45). CONCLUSIONS: A high burden of mental illness and addiction among HCUs warrants its consideration in the design and delivery of services targeting HCUs.

Systematic review of gamma-aminobutyric-acid inhibitory deficits across the reproductive life cycle.

Deficiencies in the inhibitory functioning of gamma-aminobutyric acid (GABA) have been implicated in the pathophysiology of depressive disorders. Reproductive life cycle events, including menstruation, pregnancy, and menopause, are consistently associated with increased psychopathology, in particular mood disorders. Given that GABA-inhibitory activity may be modulated directly or indirectly by estrogen, progesterone, and their metabolites receptors, it has been hypothesized that GABA deficits may be evident during these reproductive periods. We aimed to compare GABA function among women during these "high-risk" reproductive periods to GABA function among women at other time periods. We conducted a systematic review of studies comparing women during reproductive life stages associated with depressive disorder risk (luteal phase of the menstrual cycle, perinatal period, and menopausal transition) to women at other time periods. The study outcome was GABA function. The review included 11 studies, 9 focused on the menstrual cycle, and 2 focused on the perinatal period. GABA-inhibitory function fluctuated across the menstrual cycle, with differing patterns in women with and without depressive disorders. GABA-inhibitory function was reduced in pregnancy and early postpartum compared to the nonpregnant state. Key limitations were the absence of studies evaluating the menopausal transition, and the heterogeneity of GABA outcome measures. GABA-inhibitory function fluctuates across the menstrual cycle and is reduced perinatally. This has potential implications for a role of GABAergically mediated interventions in the prevention and treatment of menstrual cycle-related and perinatal depressive disorders.

Depressive symptoms as a determinant of breast and cervical cancer screening in women: a population-based study in Ontario, Canada.

The objective of this study was to investigate the relationship between depression and screening for breast and cervical cancer. The study sample included Ontario female respondents to the Canadian Community Health Survey Cycle 1.2, Mental Health and Well Being component (2002). Women with Major Depressive Disorder (MDD) were identified based on the World Mental Health Composite International Diagnostic Interview and women with clinically significant depressive symptoms were identified using the Kessler 6-item Distress Scale (K6 ≥ 8). Respondents eligible for screening (N = 4,042 for cervical cancer and N = 1,403 for breast cancer) were linked to Ontario administrative data to prospectively ascertain screening outcomes. Both women with MDD and K6 ≥ 8 were less likely to receive breast cancer screening than their non-depressed counterparts (46.1% vs. 61.5% for MDD, Χ(2) = 5.47, p = 0.02; 49.9% vs. 61.9% for K6, Χ(2) = 6.61, p = 0.01). Adjusted analyses revealed persistence of the association between K6 ≥ 8 and breast cancer screening (adjusted odds ratio (AOR) 0.63, 95% CI 0.40-0.97). Neither MDD nor K6 ≥ 8 were found to be associated with cervical cancer screening in the full sample. A sub-group analysis by age revealed that women over age 40 years with K6 ≥ 8 were less likely to receive cervical cancer screening than their non-depressed counterparts (49.9% vs. 64.5%, X(2) = 6.47, p = 0.01). This association approached statistical significance in adjusted analysis (AOR = 0.65, 95% CI 0.41-1.04). This study's findings suggest that attention to the uptake of preventive services in women with depressive symptoms is warranted.

Management of abnormal uterine bleeding by northern, rural and isolated primary care physicians: PART II: What do we need?

BACKGROUND: Abnormal uterine bleeding (AUB) is a common problem that affects one in five women during the pre-menopausal years. It is frequently managed by family physicians, especially in northern, rural and isolated areas where severe shortages of gynecologists exist. METHODS: We surveyed 194 family physicians in northern, rural and isolated areas of Ontario, Canada to determine their educational and resource needs for the management of AUB, with a specific focus on the relevance and feasibility of using clinical practice guidelines (CPGs). RESULTS: Most physicians surveyed did not use CPGs for the management of AUB because they did not know that such guidelines existed. The majority were interested in further education on the management of AUB through mailed CPGs and locally held training courses. A major theme among respondents was the need for more timely and effective gynecological referrals. CONCLUSION: A one-page diagnostic and treatment algorithm for AUB would be easy to use and would place minimal restrictions on physician autonomy. As the majority of physicians had Internet access, we recommend emailing and web posting in addition to mailing this algorithm. Local, hands-on courses including options for endometrial biopsy training would also be helpful for northern, rural and isolated physicians, many of whom cannot readily take time away from their practices.

Management of abnormal uterine bleeding by northern, rural and isolated primary care physicians: PART I - How are we doing?

BACKGROUND: Canadian hysterectomy rates have declined in recent years. However, hysterectomy rates for discretionary indications, principally abnormal uterine bleeding (AUB), remain high in some regions. In northern Ontario, hysterectomy rates for women aged 34-45 are almost triple the rates in southern, urban areas. Primary care physicians (family doctors) usually manage AUB initially in these northern areas where a severe shortage of gynecologists exists. METHODS: We surveyed 194 family physicians in northern Ontario with a case scenario of a pre-menopausal woman with heavy vaginal bleeding to characterize management and to gain physicians' perspectives on the factors that affect it. RESULTS: To investigate her heavy vaginal bleeding, only 17% of physicians recommended a pelvic examination for the woman in our case scenario. Most physicians advocated a course of medical therapy before referral to a gynecologist, for whom the average waiting time was seven weeks. However, most physicians recommended referral after only one failed trial of medical treatment. Physicians felt that major deterrents to medical treatments were patient desires for immediate relief and/or permanent solutions, poor patient compliance and the high cost of medication. Only 25% of respondents indicated that they would perform an endometrial biopsy prior to referral. CONCLUSIONS: Family physicians would benefit from further education on appropriate investigations for AUB, primarily training in pelvic examination and endometrial biopsy techniques, as well as appropriate treatment algorithms. Further research into patient perspectives on treatment options is needed.