Impact of a 12-minute educational video prior to initial consultation in a Mature Women's Health and Menopause Clinic.

OBJECTIVES: Assess acceptability of a 12-minute educational video before menopause clinic consultation and evaluate its impact on knowledge and treatment certainty. METHODS: This was a pre-post intervention study among new patients with vasomotor symptoms (VMS) referred to a menopause clinic in Toronto, Canada. Participants completed electronic questionnaires before and after viewing a 12-minute online video covering menopause facts and VMS treatments. Participants' demographic information and referring provider type were recorded. A 19-item true/false knowledge quiz and validated Decision Conflict Scale (DCS) were administered before and after viewing the video along with a validated Acceptability questionnaire after the video. Demographic information and acceptability were summarized descriptively and independent samples t tests compared knowledge and DCS total and subscores before and after viewing the education module. Multivariable analysis was used to identify factors associated with achieving treatment certainty. RESULTS: Seventy-one participants completed pre- and postintervention questionnaires. Mean age was 51.4 ± 6.0 years and most were White (58/71, 81.7%), had a university degree (24/71, 63.3%) and household income >$90,000 (53/71, 74.6%). After the video, there was significant increase in knowledge score (12.7 ± 2.1 vs. 16.9 ± 1.8, P < 0.001) and decrease in all DCS scores (total and five subscores) compared with preintervention scores (P < 0.001). Acceptability was high with 62/71 (87.3%) respondents indicating the tool was useful. Findings were independent of level of education, household income, and referring physician type. CONCLUSION: In a study of predominantly university-educated White women, a 12-minute education module on menopause and VMS treatment was acceptable, there was improved knowledge and decision certainty about VMS treatment.

Guideline No. 422e: Menopause and Cardiovascular Disease.

OBJECTIVE: Provide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence. TARGET POPULATION: Perimenopausal and postmenopausal women. BENEFITS, HARMS, AND COSTS: Target population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment. EVIDENCE: Databases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002-2020, and MeSH search terms were specific for each topic developed through the 7 chapters. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: physicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population. SUMMARY STATEMENTS: RECOMMENDATIONS.

Directive clinique no 422e : Ménopause et maladies cardiovasculaires.

OBJECTIF: Proposer des stratégies pour améliorer les soins aux femmes en périménopause ou ménopausées d'après les plus récentes données probantes publiées. POPULATION CIBLE: Femmes en périménopause ou ménopausées. BéNéFICES, RISQUES ET COûTS: La population cible bénéficiera des plus récentes données scientifiques publiées que leur communiqueront les fournisseurs de soins de santé. Aucun coût ni préjudice ne sont associés à cette information, car les femmes seront libres de choisir parmi les différentes options thérapeutiques, y compris le statu quo, pour la prise en charge des symptômes et morbidités associés à la ménopause. DONNéES PROBANTES: Les auteurs ont interrogé les bases de données PubMed, Medline et Cochrane Library pour extraire des articles publiés entre 2002 et 2020 en utilisant des termes MeSH spécifiques à chacun des sujets abordés dans les 7 chapitres. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique d'évaluation, de développement et d'évaluation (GRADE). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: médecins, y compris gynécologues, obstétriciens, médecins de famille, internistes, urgentologues; infirmières, y compris infirmières autorisées et infirmières praticiennes; pharmaciens; stagiaires, y compris étudiants en médecine, résidents, moniteurs cliniques; et autres fournisseurs de soins auprès de la population cible. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Quality and readability of online health information on menopausal hormone therapy in Canada: what are our patients reading?

OBJECTIVE: To assess the quality and readability of 24 of the most accessed menopause hormone therapy (MHT) websites by Canadian women. METHODS: The top 24 websites from Google, Bing, and Yahoo were identified using the search term "hormone replacement therapy." Five menopause specialists assessed website content quality using the DISCERN Instrument, Journal of the American Medical Association (JAMA) benchmarks, and Abbott's Scale. Two reviewers assessed website credibility using the Health on the Net Foundation Code of Conduct certification, and website readability using the Simple Measure of Gobbledygook, Flesch-Kincaid Grade Level, and Flesch-Kincaid Read Ease formulae. RESULTS: Scores for quality of information varied. The mean JAMA score was low at 2.3 ±â€Š1.1 (out of 4). Only one website met all benchmarks. Fourteen websites (58%) had a good/excellent DISCERN score, while four (17%) had a poor/very poor score. For Abbott's Scale, both the mean authorship score at 2.2 ±â€Š1.0 (out of 4) and mean content score at 45.9 ±â€Š9.8 (out of 100) were low. Inter-rater reliability was high for all tools. Fifteen websites (63%) were Health on the Net Foundation Code of Conduct certified. The mean Flesch-Kincaid Read Ease was 42.7 ±â€Š10.3, mean Flesch-Kincaid Grade Level was 12.3 ±â€Š1.9, and mean Simple Measure of Gobbledygook grade level was 11.3 ±â€Š1.5. Only one website presented content at a reading level recommended for the public. Websites meeting more JAMA benchmarks were significantly less readable (P < 0.05). CONCLUSION: Although good quality MHT information exists online, several resources are inaccurate or incomplete. Overall, these resources are not considered comprehensible by the public. There is a need to disseminate accurate, comprehensive, and understandable MHT information online.

The effect of menopause on metabolic syndrome: cross-sectional results from the Canadian Longitudinal Study on Aging.

OBJECTIVES: Data were examined from women surveyed in the Canadian Longitudinal Study on Aging to evaluate whether menopause is an independent risk factor for the development of metabolic syndrome (MetS) or its components, including hypertension, central obesity, dyslipidemia, or elevated glycated hemoglobin. METHODS: We conducted a cross-sectional analysis of women aged 45-85 years old that participated in the baseline data of the Canadian Longitudinal Study on Aging Comprehensive Cohort collected from 2012 to 2015. Modified Poisson regression with robust error variance was used to estimate the crude and adjusted relative risks (aRRs) of MetS in postmenopausal women compared to premenopausal women. RESULTS: Among 12,611 women analyzed, 10,035 (79.6%) had undergone menopause and 2,576 (20.4%) were premenopausal. Postmenopausal women were more likely to meet criteria for MetS compared to premenopausal women (32.6% vs 20.5%, P < 0.001). Using the MetS criteria with a lower waist circumference threshold, the prevalence of MetS was higher at 38.2% among postmenopausal women and 23.2% among premenopausal women (P < 0.001). After adjusting for age, body mass index, and other covariates, the occurrence of menopause was not associated with a significantly higher relative risk of MetS, using the unified criteria for MetS (aRR 1.09 [95% CI: 0.99-1.19]). Women with menopause had a significantly higher relative risk of MetS when using criteria with a lower waist circumference (aRR 1.10 [95% CI: 1.01-1.19]). Menopause was also associated with a higher risk of impaired glucose tolerance (aRR 1.42 [95% CI: 1.26-1.59]), elevated blood pressure (aRR 1.12 [95% CI: 1.03-1.21]), and elevated triglycerides (aRR 1.17 [95% CI: 1.08-1.26]). CONCLUSION: Menopause is associated with an increased risk of MetS, independent of age. Lifestyle interventions targeted at women with MetS are known to prevent type 2 diabetes mellitus and cardiovascular risk. Perimenopause may be an important preventative care opportunity to assess metabolic risk factors and improve health and longevity of Canadian women.

A critical appraisal of vasomotor symptom assessment tools used in clinical trials evaluating hormone therapy compared to placebo.

OBJECTIVE: Vasomotor symptoms (VMS) have been consistently reported as the leading predictor of health-related quality of life (HRQOL) among menopausal women, and the strongest indication for treatment. The North American Menopause Society endorses the use of oral estrogen for the treatment of VMS based on a Cochrane meta-analysis. The Cochrane review concludes that oral hormone therapy reduces the frequency and severity of VMS. The objective of this review is to critically appraise the outcome measures used in these clinical trials to evaluate whether there is adequate evidence that oral hormone therapy improves HRQOL. METHODS: Each trial in the 2004 Cochrane review of oral hormone therapy for the management of VMS was evaluated with respect to study design, outcome measures, and method of analysis. RESULTS: Twenty-four randomized, double-blind, placebo-controlled clinical trials were appraised. Six trials were excluded from the Cochrane meta-analysis due to inadequate reporting of outcome measures. Of the remaining trials, 15 trials assessed only symptom frequency and/or severity. One trial used a subscale of the General Health Questionnaire. Two trials used the Greene Climacteric Scale, a validated outcome measure in menopausal women, to directly assess the impact of hormone therapy on HRQOL. Both studies showed an improvement in HRQOL in the hormone-treated group, although the sample size was small (n = 118) and the effect was modest. CONCLUSION: Although oral hormone therapy improves VMS scores, there is a paucity of evidence on whether it improves HRQOL in menopausal women. Future studies using validated, patient-reported outcome measures that directly assess HRQOL are needed.

Brachial Plexus Birth Injury in Elective Versus Emergent Caesarean Section: A Cohort Study.

OBJECTIVE: Although Caesarean section (CS) is protective for brachial plexus birth injury (BPBI), the incidence is not zero. A trial of labour with unfavourable intrauterine positioning is hypothesized to result in excessive force on the brachial plexus. The purpose of this study was to determine the risk of BPBI in emergent CS versus elective CS. METHODS: This was a retrospective cohort study. The authors used a nationwide demographic sample of all infants born in Canada from 2004 to 2012. BPBI diagnoses, risk factors, and national incidence data were obtained from the Canadian Institute for Health Information Discharge Abstract Database and Hospital Morbidity Database. The primary outcome was risk of BPBI in emergent CS versus elective CS. RESULTS: BPBI incidence was 1.24 per 1000 live births. Known biases may have underestimated the incidence. CS (elective and emergent) was protective for BPBI as compared with vaginal delivery (odds ratio [OR] 0.15; 95% confidence interval [CI] 0.13-0.18, P < 0.0001). Emergent CS was a moderately strong risk factor for BPBI versus elective CS (OR 3.14; 95% CI 1.79-5.10, P = 0.0001). CONCLUSION: Emergent CS is a moderate risk factor for BPBI compared with elective CS. Intrauterine positioning with a trial of labour may provide an antenatal etiology in these distinct cases.

Survey of Canadian PGY-4 and PGY-5 Obstetrics and Gynaecology Residents on Knowledge of and Exposure to Premature Ovarian Insufficiency.

OBJECTIVES: (1) To determine exposure to and general knowledge on premature ovarian insufficiency (POI) among Canadian senior obstetrics and gynaecology residents. (2) To identify opportunity to improve trainee exposure to POI. METHODS: Canadian PGY-4 and PGY-5 obstetrics and gynaecology residents were approached to complete an electronic survey. The questions in the survey included the basic POI knowledge, previous exposure to POI, and comfort level in managing POI patients. Data from the survey was summarized descriptively and compared between two trainee groups (PGY-4 and PGY-5) using chi-square or Fisher exact tests. RESULTS: Responses were received from trainees in all Canadian residency programs with an overall response rate of 45% (95/210 residents). Most respondents (79%, 75/95 residents) identified correct age for POI diagnosis, and 65% (62/95 residents) recognized the most common aetiology. A majority (99%, 92/93 residents) would prescribe hormone therapy for POI patients. Most trainees (62%, 59/95 residents) lack access to a POI clinic at their centre and 63% (59/94 residents) have seen less than six POI patients during residency training. Most feel somewhat comfortable managing POI patients (67%, 64/95 residents), but 22% (21/95 residents) feel totally uncomfortable with a majority of respondents (83%, 78/94 residents), indicating they would benefit from additional training. Compared with PGY-4 residents, the proportion of trainees who could identify the correct age for diagnosis of POI was significantly higher in PGY-5 residents (89% vs. 70%, P = 0.024). CONCLUSION: Many senior obstetrics and gynaecology residents in Canada lack knowledge around POI, and most indicate need for further exposure to POI during residency training. We identified an opportunity for improved POI curricula.

Aromatase Inhibitors Are Associated With Low Sexual Desire Causing Distress and Fecal Incontinence in Women: An Observational Study.

BACKGROUND: Little is known of the impact of aromatase inhibitor (AI) therapy on sexual and pelvic floor function. AIM: To document the prevalence of, and factors associated with, low desire, sexually related personal distress, hypoactive sexual desire dysfunction (HSDD), and pelvic floor dysfunction in women 10 years after breast cancer diagnosis. METHODS: This was a prospective, observational, community-based cohort study of Australian women with invasive breast cancer recruited within 12 months of diagnosis. 1,053 of the 1,305 who completed the initial 5 years of study follow-up agreed to be re-contacted, and 992 of these women alive 10 years after diagnosis were sent the study questionnaire. OUTCOMES: The main outcome measure was HSDD determined by a score no higher than 5.0 on the desire domain of the Female Sexual Function Index (FSFI) plus a score of at least 11.0 on the Female Sexual Distress Scale-Revised (FSDS-R). Pelvic floor disorders, including urinary incontinence, fecal incontinence, and pelvic organ prolapse, were assessed using validated questionnaires. Multivariable logistic regression was used to assess factors associated with low desire, personal distress, and HSDD. RESULTS: 625 completed questionnaires were returned. The respondents' median age was 65.1 years (range = 36.4-95.5). Current AI use was reported by 10% and tamoxifen use was reported by 3.4%. 521 of the 608 women (85.7%; 95% CI = 82.9-88.5) who competed the FSFI desire domain had low sexual desire, and 246 of the 563 women (43.7%; 95% CI = 39.6-47.8%) who completed the FSDS-R had sexually related personal distress. 221 of the 559 women (39.5%; 95% CI = 35.5-43.6%) who completed the 2 questionnaires had HSDD. Current AI users were more likely to have HSDD than non-users (55.2% [95% CI = 42.2-68.1] vs 37.8% [95% CI = 33.5-42.0]; P = .01). HSDD was more prevalent in sexually active, current AI users (66.7%; 95% CI = 49.4-83.9) vs current non-users (43.6%; 95% CI = 37.0-50.2; P = .02). In a logistic regression model, HSDD was significantly associated with current AI use and inversely associated with age. Fecal incontinence was more prevalent in AI users than in current non-users (29.8% [95% CI = 17.8-41.8] vs 16.4% [95% CI = 13.2-19.6], respectively; P = .01). CLINICAL IMPLICATIONS: It is important to address women's sexual health even many years after their breast cancer diagnosis. STRENGTHS AND LIMITATIONS: Strengths include a representative sample, use of validated questionnaires, and few missing data. Limitations include sexual activity being a 4-week recall. CONCLUSIONS: AI use is associated with HSDD and fecal incontinence in women who are 10 years after breast cancer diagnosis. Robinson PJ, Bell RJ, Christakis MK, et al. Aromatase Inhibitors Are Associated With Low Sexual Desire Causing Distress and Fecal Incontinence in Women: An Observational Study. J Sex Med 2017;14:1566-1574.

Obstetrical brachial plexus injury (OBPI): Canada's national clinical practice guideline.

OBJECTIVE: The objective of this study was to establish an evidence-based clinical practice guideline for the primary management of obstetrical brachial plexus injury (OBPI). This clinical practice guideline addresses 4 existing gaps: (1) historic poor use of evidence, (2) timing of referral to multidisciplinary care, (3) Indications and timing of operative nerve repair and (4) distribution of expertise. SETTING: The guideline is intended for all healthcare providers treating infants and children, and all specialists treating upper extremity injuries. PARTICIPANTS: The evidence interpretation and recommendation consensus team (Canadian OBPI Working Group) was composed of clinicians representing each of Canada's 10 multidisciplinary centres. OUTCOME MEASURES: An electronic modified Delphi approach was used for consensus, with agreement criteria defined a priori. Quality indicators for referral to a multidisciplinary centre were established by consensus. An original meta-analysis of primary nerve repair and review of Canadian epidemiology and burden were previously completed. RESULTS: 7 recommendations address clinical gaps and guide identification, referral, treatment and outcome assessment: (1) physically examine for OBPI in newborns with arm asymmetry or risk factors; (2) refer newborns with OBPI to a multidisciplinary centre by 1 month; (3) provide pregnancy/birth history and physical examination findings at birth; (4) multidisciplinary centres should include a therapist and peripheral nerve surgeon experienced with OBPI; (5) physical therapy should be advised by a multidisciplinary team; (6) microsurgical nerve repair is indicated in root avulsion and other OBPI meeting centre operative criteria; (7) the common data set includes the Narakas classification, limb length, Active Movement Scale (AMS) and Brachial Plexus Outcome Measure (BPOM) 2 years after birth/surgery. CONCLUSIONS: The process established a new network of opinion leaders and researchers for further guideline development and multicentre research. A structured referral form is available for primary care, including referral recommendations.

Female Pelvic Medicine and Reconstructive Surgery in Canada: A Survey of Obstetrician-Gynecologists and Urologists.

OBJECTIVE: The aim of this study was to assess the current status of female pelvic medicine and reconstructive surgery (FPMRS) in Canada, including level of training, practice patterns, barriers to practice and opinions among obstetrician-gynecologists (OB/GYNs) and urologists. METHODS: Electronic surveys were distributed to 737 OB/GYNs through the Society of Obstetricians and Gynaecologists of Canada and to 489 urologists through the Canadian Urological Association. RESULTS: Complete responses were collected from 301 (41%) OB/GYNs and 39 (8%) urologists. Of the OB/GYN respondents, 57% were generalists (GEN), and 22% completed FPMRS fellowship training (FPMRS-GYN). OB/GYN GENs were less likely than FPMRS-GYNs to report comfort with pelvic organ prolapse quantification assessment, urodynamic testing, cystoscopy, treatment of mesh complications, and management of overactive bladder. Urologists were less likely than FPMRS-GYNs to report comfort completing a pelvic organ prolapse quantification assessment, fitting pessaries, and treating mesh complications but more likely to report comfort managing overactive bladder. FPMRS-GYNs were more likely than other providers to report high volumes (>20 cases in the past year) of vaginal hysterectomy, as well as incontinence and prolapse procedures. OB/GYN GENs and urologists frequently cited lack of formal training in residency as a barrier to performing FPMRS procedures, whereas FPMRS-GYNs reported a lack of operating room facilities and support personnel. Overall, 76% of the respondents were of the opinion that FPMRS should be a credentialed Canadian subspecialty (92% FPMRS-GYN, 69% OB/GYN GEN, 59% urologists). CONCLUSIONS: OB/GYN GENs reported low case volumes and cited inadequate training in residency as a barrier to surgically managing pelvic floor disorders. Most respondents felt that FPMRS should be a credentialed subspecialty.