Childhood vaccine refusal and what to do about it: a systematic review of the ethical literature.

BACKGROUND: Parental refusal of routine childhood vaccination remains an ethically contested area. This systematic review sought to explore and characterise the normative arguments made about parental refusal of routine vaccination, with the aim of providing researchers, practitioners, and policymakers with a synthesis of current normative literature. METHODS: Nine databases covering health and ethics research were searched, and 121 publications identified for the period Jan 1998 to Mar 2022. For articles, source journals were categorised according to Australian Standard Field of Research codes, and normative content was analysed using a framework analytical approach. RESULTS: Most of the articles were published in biomedical journals (34%), bioethics journals (21%), and journals that carry both classifications (20%). Two central questions dominated the literature: (1) Whether vaccine refusal is justifiable (which we labelled 'refusal arguments'); and (2) Whether strategies for dealing with those who reject vaccines are justifiable ('response arguments'). Refusal arguments relied on principlism, religious frameworks, the rights and obligations of parents, the rights of children, the medico-legal best interests of the child standard, and the potential to cause harm to others. Response arguments were broadly divided into arguments about policy, arguments about how individual physicians should practice regarding vaccine rejectors, and both legal precedents and ethical arguments for vaccinating children against a parent's will. Policy arguments considered the normative significance of coercion, non-medical or conscientious objections, and possible reciprocal social efforts to offset vaccine refusal. Individual physician practice arguments covered nudging and coercive practices, patient dismissal, and the ethical and professional obligations of physicians. Most of the legal precedents discussed were from the American setting, with some from the United Kingdom. CONCLUSIONS: This review provides a comprehensive picture of the scope and substance of normative arguments about vaccine refusal and responses to vaccine refusal. It can serve as a platform for future research to extend the current normative literature, better understand the role of cultural context in normative judgements about vaccination, and more comprehensively translate the nuance of ethical arguments into practice and policy.

Dysmenorrhea, Workability, and Absenteeism in Australian Women.

Background: This study determined the prevalence of bothersome menstrual symptoms and their association with workability in naturally menstruating women not using hormonal contraception. Materials and Methods: A representative sample of community-dwelling Australian women aged 18-39 years selected from two large national electronic databases responded to a survey on general health. This study focuses on self-reported dysmenorrhea and menstrual bleeding and their association with workability and absenteeism in working women, assessed by the Workability Index. Results: Of 3,555 women, 1,573 (44.2% [95% CI: 42.6%-45.9%]) reported moderate to severe dysmenorrhea and 774 (21.8% [95% CI: 20.4%-23.2%]) reported heavy to very heavy bleeding. Women with dysmenorrhea were 50% more likely to report poorer work performance and twice as likely to report more days of sick leave in the past year (absenteeism) than other women. Conclusions: Despite the availability of safe and effective management options, Australian working women aged 18-39 years continue to experience bothersome dysmenorrhea and menstrual bleeding. Dysmenorrhea is associated with increased absenteeism and poorer workability. Therefore, awareness needs to be raised among women and health care providers of ways to manage dysmenorrhea and heavy bleeding and the unmet need for intervention in the community, respectively.

The impact of endometriosis on work ability in young Australian women.

BACKGROUND: Whereas symptomatic endometriosis may affect work performance, the impact of endometriosis in the general community is not known. AIMS: The associations between endometriosis and each of sick leave and work ability, were investigated in a large sample of non-healthcare seeking women. MATERIALS AND METHODS: This community-based, cross-sectional study recruited 6986 women, aged 18-39 years, from three eastern states of Australia between 11 November 2016 and 21 July 2017. Women were identified as having endometriosis if they had undergone a pelvic ultrasound and reported a diagnosis of endometriosis. Working women completed the Work Ability Index. RESULTS: Participants were predominantly of European ancestry (73.1%) and 46.8% were overweight or had obesity. The prevalence of endometriosis was 5.4% (95%CI 4.9-6.0%) with the highest prevalence of 7.7% (95%CI 6.5 to 9.1%) for women aged 35-39 years. Among the 4618 working women, those with endometriosis had significantly more sick days from work (33.6% reported ≥10 days vs 13.5%, overall χ2 P < 0.001). Endometriosis was associated with a greater likelihood of poor to moderate work ability, after adjusting for age, body mass index, ethnicity, relationship status, student status, insecure housing, being a carer for another person, parity, ever use of assisted reproductive technologies, and depressed mood (odds ratio 1.90, 95%CI 1.40-2.58, P < 0.001). CONCLUSIONS: This study provides new evidence that the negative impact of endometriosis on work attendance and work ability is not limited to women with prevalent symptoms and severe disease, but appears to encompass women across a broader spectrum of this condition in the community.

COVID-19 testing decisions and behaviours in two Australian cities.

ISSUE ADDRESSED: High levels of testing are crucial for minimising the spread of COVID-19. The aim of this study is to investigate what prevents people from getting a COVID-19 test when they are experiencing respiratory symptoms. METHODS: Semi-structured, qualitative interviews were conducted with 14 purposively sampled adults between 20 November 2020 and 3 March 2021 in two capital cities of Australia and analysed thematically. The analysis included people who reported having respiratory symptoms but who did not undergo a COVID-19 test. RESULTS: Participants appraised risks of having COVID-19, of infecting others or being infected whilst attending a testing site. They often weighed these appraisals against practical considerations of knowing where and how to get tested, inconvenience or financial loss. CONCLUSIONS: Clear public health messages communicating the importance of testing, even when symptoms are minor, may improve testing rates. Increasing the accessibility of testing centres, such as having them at transport hubs is important, as is providing adequate information about testing locations and queue lengths. SO WHAT?: The findings of our study suggest that more needs to be done to encourage people to get tested for COVID-19, especially when symptoms are minor. Clear communication about the importance of testing, along with easily accessible testing clinics, and financial support for those concerned about financial impacts may improve testing rates.

'Get your own house in order': Qualitative dialogue groups with nonvaccinating parents on how measles outbreaks in their community should be managed.

OBJECTIVE: Communities with high levels of vaccine rejection present unique challenges to vaccine-preventable disease outbreak management. We sought perspectives of nonvaccinating parents to inform public health responses in such communities. METHODS: Nineteen purposively sampled nonvaccinating Australian parents participated in one of seven online dialogue groups. We asked what they thought parents, school principals and public health professionals should do in a hypothetical school measles outbreak and used a framework approach to data analysis. RESULTS: Parents' views were grounded in strong beliefs in parental responsibility and the belief that vaccines are not effective, thus unvaccinated children do not therefore pose a threat. They then reasoned that the forced exclusion of unvaccinated children from school in a measles outbreak was disproportionate to the risk they pose, and their child's right to education should not be overridden. Nonvaccinating parents judged that all parents should keep sick children at home regardless of disease or vaccination status; that school principals should communicate directly with parents and avoid using social media; that public health professionals should provide information to parents so they can decide for themselves about excluding their children from school; that public health responses should avoid accidental identification of unvaccinated children and that mainstream media should be avoided as a communication tool. CONCLUSION: Nonvaccinating parents do not always agree with current Australian approaches to measles outbreak management. Their perspectives can inform approaches to outbreak responses in communities with high levels of vaccine rejection. PATIENT OR PUBLIC CONTRIBUTION: We sought input from individuals who did and did not vaccinate on study design in its early phases. Individual conversations were used deliberately as we felt the group advisory situation may have felt less safe for nonvaccinating parents, given the divisive and often hostile nature of the topic.

Public health practitioner perspectives on dealing with measles outbreaks if high anti-vaccination sentiment is present.

BACKGROUND: Communities with low vaccination rates are at greater risk during outbreaks of vaccine preventable diseases. Most Australian parents support vaccines, but some refuse and are often judged harshly by their community, especially during an outbreak. We sought the perspectives of Australian public health experts on the key issues faced when managing a measles outbreak in an area with high anti-vaccination sentiment. METHODS: A measles outbreak scenario formed the basis of a 3-round modified Delphi process to identify key practitioner concerns in relation to parents/carers who don't follow the recommended vaccination schedule. We surveyed a range of professionals in the field: policymakers, infectious disease experts, immunisation program staff, and others involved in delivering childhood vaccinations, to identify key priorities when responding to an outbreak in a community with low vaccination coverage. RESULTS: Findings indicate that responses to measles outbreaks in communities with high anti-vaccination sentiment are motivated by concerns about the potential for a much larger outbreak event. The highest operational priority is to isolate infected children. The two most highly ranked practical issues are mistrust from non-vaccinating members of the local region and combatting misinformation about vaccines. Trying to change minds of such individuals is not a priority during an outbreak, nor is vaccinating their children. Using media and social media to provide information about the outbreak and measures the public can take to limit the spread of the disease was a focus. CONCLUSIONS: Our findings provide a deeper understanding of the challenges faced during an outbreak and priorities for communicating with communities where there is a high level of anti-vaccination sentiment. In the context of a global pandemic, the results of this study also have implications for managing public health responses to community transmission of SARS-CoV-2, as COVID-19 vaccines becomes widely available.

Longitudinal changes over three years in sex steroid hormone levels in women aged 70 years and over.

OBJECTIVE: Sex steroid levels in women vary with increasing age from the age of 70 years (70+). Whether this reflects change within individuals with age or a survival advantage is not known. This study aimed to determine the stability of circulating sex steroids and SHBG over time in individual women aged 70+. DESIGN: A prospective cohort study. PARTICIPANTS: 400 women, aged 70+ not using any sex steroid, anti-androgen/oestrogen or glucocorticoid therapy. MAIN OUTCOME MEASUREMENTS: Sex steroid concentrations, measured by liquid chromatography-tandem mass spectrometry and sex hormone-binding globulin (SHBG) by immunoassay, in paired blood samples drawn 3 years apart and analysed together. RESULTS: 400 women, median (IQR) age 78.0 (8.6) years, were included in the analysis. Mean testosterone concentrations were statistically significantly higher in follow-up samples compared with baseline. The change was modest (mean change 31 pmol/L, 95% confidence interval (CI) 2.4-59.8; p = .034), and an increase was not observed in all women. There was a statistically significant decline in mean body mass index (mean change -0.4 kg/m2 , 95% CI 0.6 to -0.3; p < .001) and a significant increase in the mean serum SHBG concentration (mean change 4.0 nmol/L, 95% CI 2.7-5.4; p < .001). The change observed in testosterone was not explained by the observed change in SHBG. There was no significant change in the mean oestrone or dehydroepiandrosterone concentration. CONCLUSIONS: Testosterone concentrations in women aged 70+ were more likely to increase than decrease. Whether increasing testosterone concentrations in older women confer a survival advantage needs investigation.

The prevalence of hypoactive sexual desire disorder in Australian and Iranian women at midlife.

OBJECTIVE: This study was undertaken to examine whether the prevalence of low sexual desire, sexually related personal distress, and epidemiological hypoactive sexual desire disorder (eHSDD) differed between midlife Australian and Iranian married women. METHODS: Cross-sectional, community-based studies of women aged 40 to 65 years conducted in Australia (2013-2014, n = 2,020) and Iran (2016-2017, n = 1,520) included 60% and 89% married women, respectively. Participants completed the Female Sexual Function Index and the Female Sexual Distress Scale-Revised. eHSDD was defined as low desire with sexually related personal distress. RESULTS: Restricting the analysis to married women, 76.5% of the 1,210 Australian women, mean age (SD) 52.4 (6.8) years, and 87.8% of the 1,348 Iranian women, mean age 48.5 (6.7) years who were recently sexually active. Low desire was more prevalent in Australian women than Iranian women (68.8%, 95% CI 66.1-71.3 vs 51.3%, 95% CI 48.6-53.9, P < 0.001) as were sexually related personal distress (47.6%, 95% CI 44.8-50.4 vs 17.2%, 95% CI 15.3-19.3, P < 0.001) and eHSDD (39.7%, 95% CI 36.9-42.5 vs 13.9%, 95% CI 12.2-15.9, P < 0.001). Being sexually inactive, versus sexually active, was associated with low desire, sexually related personal distress and eHSDD in Australian women (P < 0.001), but only with low desire in Iranian women (P < 0.001). CONCLUSIONS: The prevalence of eHSDD in married Australian women at midlife was threefold that of Iranian women, primarily due to the higher prevalence of sexually related personal distress. The results were only adjusted for age and sexual activity, and analyses did not account for other observed differences between the study populations. Hence, future studies are warranted to explore if the differences between the two populations are due to variations in demographics such as level of education or employment and/or due to expectations, experiences, or beliefs.

Estrone Is a Strong Predictor of Circulating Estradiol in Women Age 70 Years and Older.

IMPORTANCE: After menopause, estradiol (E2) is predominately an intracrine hormone circulating in very low serum concentrations. OBJECTIVE: The objective of this work is to examine determinants of E2 concentrations in women beyond age 70 years. DESIGN AND SETTING: A cross-sectional, community-based study was conducted. PARTICIPANTS: A total of 5325 women participated, with a mean age of 75.1 years (±â€…4.2 years) and not using any sex steroid, antiandrogen/estrogen, glucocorticoid, or antiglycemic therapy. MAIN OUTCOME MEASURES: Sex steroids were measured by liquid chromatography-tandem mass spectrometry. Values below the limit of detection (LOD; E2 11 pmol/L [3 pg/mL] were assigned a value of LOD/√2 to estimate total E2. RESULTS: E2 and estrone (E1) were below the LOD in 66.1% and 0.9% of women, respectively. The median (interdecile ranges) for E1 and detectable E2 were 181.2 pmol/L (range, 88.7-347.6 pmol/L) and 22.0 pmol/L (range, 11.0-58.7 pmol/L). Women with undetectable E2 vs detectable E2 were older (median age 74.1 years vs 73.8, P = .02), leaner (median body mass index [BMI] 26.8 kg/m2 vs 28.5, P < .001), and had lower E1, testosterone and DHEA concentrations (P < .001). A linear regression model, including age, BMI, E1, and testosterone, explained 20.9% of the variation in total E2, but explained only an additional 1.2% of variation over E1 alone. E1 and testosterone made significant contributions (r2 = 0.162, P < .001) in a model for the subset of women with detectable E2. CONCLUSIONS: Our findings support E1 as a principal circulating estrogen and demonstrate a robust association between E1 and E2 concentrations in postmenopausal women. Taken together with prior evidence for associations between E1 and health outcomes, E1 should be included in studies examining associations between estrogen levels and health outcomes in postmenopausal women.

Underpinning of the sharing knowledge about immunisation (SKAI) communication approach: A qualitative study using recorded observations.

OBJECTIVE: To refine communication strategies to assist clinician conversations with vaccine hesitant and declining parents as part of the Sharing Knowledge About Immunisation (SKAI) package. METHODS: We recorded and analysed consultations held in two Specialist Immunisation Clinics in tertiary hospitals in Australia between consenting clinicians and parents. We undertook content analysis that was both iterative and informed by the Calgary Cambridge Model of health communication and motivational interviewing. RESULTS: We found common strengths and opportunities in clinician's communication styles. Strengths included: rapport building; communicating care for both the parent and child; exhibiting depth of vaccination-specific communication skill and content knowledge. Opportunities for strengthening communication practices included: eliciting parents' concerns to saturation early in the consultation; structuring the consultation to prioritise and address parents' concerns; recognising and responding to parents' motivation to vaccinate; effectively closing consultations. CONCLUSION: This study has synthesised clinical communication strategies from expert vaccination communicators using well-established communication frameworks to advance a unique approach to the challenging task of addressing vaccine hesitancy and refusal. PRACTICE IMPLICATIONS: The clinic observations helped us to create a structured consultation guide that can enhance and provide greater structure to a clinician's existing communication skills.

Testosterone and Estrone Increase From the Age of 70 Years: Findings From the Sex Hormones in Older Women Study.

CONTEXT: There is a lack of understanding of what is normal in terms of sex steroid levels in older women. OBJECTIVE: To determine whether sex steroid levels vary with age in and establish reference ranges for women >70 years of age. DESIGN AND SETTING: Cross-sectional, community-based study. PARTICIPANTS: Included 6392 women ≥70 years of age. MAIN OUTCOME MEASURES: Sex steroids measured by liquid chromatography-tandem mass spectrometry. A reference group, to establish sex steroid age-specific reference ranges, excluded women using systemic or topical sex steroid, antiandrogen or glucocorticoid therapy, or an antiglycemic agent. RESULTS: The reference group of 5326 women had a mean age of 75.1 (±4.2) years, range of 70 to 94.7 years. Median values (range) were 181.2 pmol/L (3.7 to 5768.9) for estrone (E1), 0.38 nmol/L (0.035 to 8.56) for testosterone (T), 2.60 nmol/L (0.07 to 46.85) for dehydroepiandrosterone (DHEA), and 41.6 nmol/L (2.4 to 176.6) for SHBG. Estradiol and DHT were below method sensitivity in 66.1% and 72.7% of the samples, respectively. Compared with women aged 70 to 74 years, women aged ≥85 years had higher median levels of E1 (11.7%, P = 0.01), T (11.3%, P = 0.02), and SHBG (22.7%, P < 0.001) and lower DHEA (30% less, P < 0.001). Women with overweight and obesity had higher E1 (P < 0.001) and T (P < 0.03) and lower SHBG (P < 0.001) than did women with normal body mass index. Smokers had 17.2% higher median T levels (P = 0.005). CONCLUSION: From the age of 70 years, T and E1 increase with age, despite a steady decline in DHEA. Whether E1 and T are biomarkers for longevity or contribute to healthy aging merits investigation.

Exogenous Testosterone Does Not Influence 11-Oxygenated C19 Steroid Concentrations in Healthy Postmenopausal Women.

CONTEXT: 11ß-Hydroxyandrostenedione (11OHA4), 11ß-hydroxytestosterone (11OHT), and their respective peripheral derivatives, 11-ketoandrostenedione (11KA4) and 11-ketotesosterone (11KT), have been implicated in androgen-related physiopathology. Little is known of these steroids in postmenopausal women or whether exogenous testosterone therapy influences their levels. OBJECTIVE: The impact of exogenous testosterone on serum levels of 11-oxygenated steroids was determined in healthy postmenopausal women. PARTICIPANTS AND METHODS: Levels of 19-carbon (C19) steroids were measured by liquid chromatography-tandem mass spectrometry in serum obtained at baseline and at 12 and 26 weeks from 73 healthy postmenopausal women, aged 55 to 65 years, who participated in a randomized, double-blind, placebo-controlled clinical trial assessing the effects of transdermal testosterone on cognitive performance. RESULTS: Of the 11-oxygenated androgens, 11OHA4 was the most abundant (median, 6.46 nmol/L; range, 1.51 to 23.82 nmol/L), with concentrations several fold greater than its precursor androstenedione (median, 1.38 nmol/L; range, 0.52 to 2.92 nmol/L). Baseline median (range) testosterone and 11KT levels were similar [0.56 (0.23 to 1.48) nmol/L; 0.85 (0.25 to 2.86) nmol/L, respectively). 11OHT was closely correlated with 11KT (Spearman rank correlation coefficient, 0.79; P < 0.001) and 11OHA4 correlated with 11KA4 (Spearman rank correlation coefficient, 0.73; P < 0.001). Testosterone therapy resulted in an increase in serum testosterone level, whereas all 11-oxygenated androgens remained unchanged throughout the 26 weeks of treatment. CONCLUSION: After menopause, the adrenal production of 11-oxygenated derivatives of androstenedione and testosterone contributes importantly to the total circulating androgen pool. Exogenous testosterone does not influence the circulating levels 11-oxygenated C19 steroids.

Intravaginal Testosterone Improves Sexual Satisfaction and Vaginal Symptoms Associated With Aromatase Inhibitors.

Context: Intravaginal testosterone (IVT) is a potential treatment of vulvovaginal atrophy (VVA) associated with aromatase inhibitor (AI) use. Objective: To investigate the effects of IVT on sexual satisfaction, vaginal symptoms, and urinary incontinence (UI) associated with AI use. Design: Double-blind, randomized, placebo-controlled trial. Setting: Academic clinical research center. Participants: Postmenopausal women taking an AI with VVA symptoms. Intervention: IVT cream (300 µg per dose) or identical placebo, self-administered daily for 2 weeks and then thrice weekly for 24 weeks. Main Outcomes and Measures: The primary outcome was the change in the sexual satisfaction score on the Female Sexual Function Index (FSFI). Secondary outcomes included vaginal symptoms and responses to the Profile of Female Sexual Function, the Female Sexual Distress Scale-Revised (FSDS-R), and the Questionnaire for UI Diagnosis. Serum sex steroids were measured. Results: A total of 44 women were randomly assigned and 37 provided evaluable data, (mean age 56.4 years, SD 8.8 years). At 26 weeks, the mean between-group difference in the baseline-adjusted change in FSFI satisfaction scores was significantly greater for the IVT group than the placebo group (mean difference 0.73 units; 95% CI, 0.02 to 1.43; P = 0.043). IVT cream resulted in significant improvements, compared with placebo, in FSDS-R scores (P = 0.02), sexual concerns (P < 0.001), sexual responsiveness (P < 0.001), vaginal dryness (P = 0.009), and dyspareunia (P = 0.014). Serum sex steroid levels did not change. Few women had UI symptoms, with no treatment effect. Conclusion: IVT significantly improved sexual satisfaction and reduced dyspareunia in postmenopausal women on AI therapy. The low reporting of UI among women on AI therapy merits further investigation.

The benefits of adding metformin to tamoxifen to protect the endometrium-A randomized placebo-controlled trial.

BACKGROUND: We investigated whether metformin prevents tamoxifen-induced endometrial changes and insulin resistance (IR) after a diagnosis of breast cancer. METHODS: This was a single-centre, randomized, double-blind, placebo-controlled, parallel group trial. Postmenopausal women with hormone receptor-positive breast cancer taking tamoxifen were randomly allocated to metformin 850 mg or identical placebo, twice daily, for 52 weeks. Outcome measures included double endometrial thickness (ET) measured by transvaginal ultrasound, fasting insulin, glucose and IR estimated by the homeostasis model of assessment (HOMA-IR). RESULTS: A total of 112 women were screened and 102 randomized. Results are presented as median (range). The 101 women who took at least one dose of medication were aged 56 (43-72) years, with 5(0.5-28) years postmenopause, and had taken tamoxifen for 28.9 (0-367.4) weeks. The baseline ET was 2.9 mm (1.4-21.9) for the placebo group (n = 52) and 2.5 mm (1.3-14.8) for the metformin group (n = 50). At 52 weeks, the median ET was statistically significantly lower for the metformin (n = 36) than for the placebo group (n = 45) (2.3 mm (1.4-7.8) vs 3.0 (1.2-11.3); P = 0.05). 13.3% allocated to placebo had an ET greater than 4 mm vs 5.7% for metformin (P = 0.26). There was no endometrial atypia or cancer. Compared with placebo, metformin resulted in significantly greater baseline-adjusted reductions in weight (P < 0.001), waist circumference (0.03) and HOMA-IR (P < 0.001). CONCLUSIONS: Metformin appears to inhibit tamoxifen-induced endometrial changes and has favourable metabolic effects. Further research into the adjuvant use of metformin after breast cancer and to prevent EH and cancer is warranted.

Sharing knowledge about immunisation (SKAI): An exploration of parents' communication needs to inform development of a clinical communication support intervention.

INTRODUCTION: The SKAI (Sharing Knowledge About Immunisation) project aims to develop effective communication tools to support primary health care providers' consultations with parents who may be hesitant about vaccinating their children. AIM: This study explored parents' communication needs using a qualitative design. METHODS: Parents of at least one child less than five years old were recruited from two major cities and a regional town known for high prevalence of vaccine objection. Focus groups of parents who held similar vaccination attitudes and intentions were convened to discuss experiences of vaccination consultations and explore their communication needs, including preferences. Draft written communication support tools were used to stimulate discussion and gauge acceptability of the tools. RESULTS: Important differences in communication needs between group types emerged. The least hesitant parent groups reported feeling reassured upon reading resources designed to address commonly observed concerns about vaccination. As hesitancy of the group members increased, so did their accounts of the volume and detail of information they required. Trust appeared to be related to apparent or perceived transparency. More hesitant groups displayed increased sensitivity and resistance to persuasive language forms.

Identification of the Gender-Specific Health Needs of Women Following Lung Transplantation.

BACKGROUND: Little is known of the prevalence and severity of menstrual dysfunction, climacteric symptoms, pelvic floor disorders, sexual problems, and psychological wellbeing after lung transplantation in women. MATERIALS AND METHODS: Adult female lung transplant recipients, attending the Alfred Hospital Lung Transplant Service in Melbourne, Australia participated in a women's health, cross-sectional questionnaire-based study. RESULTS: The 123 of 149 potential participants were recruited between September 2014 and July 2015. Their median age was 53.5 years, and 44 were premenopausal, 3 perimenopausal, and 76 postmenopausal. Moderate-severe menstrual and premenstrual symptoms were common, and 43% of partnered premenopausal women were not using contraception. Vasomotor symptoms (VMS) were common in postmenopausal women <55 years (80.0%), and the use of menopausal hormone therapy was low (8.9%). The estimated prevalence of low sexual desire associated with distress was 24.4%. Low wellbeing was significantly and independently associated with being aged 50 ≤ 60 years, moderate-severe VMS, impaired forced expiratory volume in 1 second, and psychotropic medication use. CONCLUSIONS: Our findings demonstrate that premenopausal lung transplant recipients need to be asked about bothersome menstrual symptoms, and contraceptive compliance needs regular review. Transplant recipients at midlife have substantially lower wellbeing than women of other ages and this needs attention, including assessment and management of menopausal symptoms.

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.

Moderate-Severe Vasomotor Symptoms Are Associated with Moderate-Severe Depressive Symptoms.

BACKGROUND: The association between menopausal vasomotor symptoms (VMS) and depressive symptoms remains controversial. We aimed to examine the associations between moderate-severe VMS and moderate-severe depressive symptoms. METHODS: Nationally representative cross-sectional survey of 2,020 noninstitutionalized Australian women aged 40-65 randomly recruited between October 2013 and March 2014. Symptoms were assessed by the Menopause-Specific Quality of Life Questionnaire, the Beck Depression Inventory-II, with score ≥20 defined as moderate-severe depressive symptoms. Cigarette, alcohol, and psychotropic medication use was also assessed. Binge drinking was defined as four standard drinks on one occasion. RESULTS: VMS were classified as moderate-severe for 267 of the 2,020 women (13.3%). After adjusting for multiple factors, including age, partnership status, paid employment, housing insecurity, and body mass index, when compared to women with no or mild VMS, women with moderate-severe VMS were more likely to have moderate-severe depressive symptoms (odds ratio [OR] 2.80, confidence interval [95% CI], 2.01-3.88, p < 0.001). Having moderate-severe depressive symptoms was associated with a greater likelihood of use of psychotropic medications (48.9%, 95% CI, 43.1-54.8 vs. 20.1%, 95% CI, 18.2-22.1, p < 0.001), smoking (25.9%, 95% CI, 20.8-30.9 vs. 12.2%, 95% CI, 10.6-13.7, p < 0.001), and binge drinking at least weekly (15.1%, 95% CI, 11.0-19.2 vs. 10.3% 95% CI, 8.8-11.7, p = 0.015). CONCLUSION: Moderate-severe VMS are independently and significantly associated with moderate-severe depressive symptoms.

Clinical audit of estradiol implant therapy: Long duration of action and implications in non-hysterectomised women.

We audited the files of 114 postmenopausal women who had been treated with subcutaneous Estrapel (50mg oestradiol implants). Of the 92 women who received more than one implant, the median number of days between implants was 223.5 (range 49-875), with an estimated median time to return to baseline of 311days (range 108-1228). Although oestradiol implants can provide an excellent non-oral treatment option, their prolonged action makes patient selection important, as the implants cannot easily be removed. In women with an intact uterus, the continuation of progestin therapy after cessation of implant therapy is imperative.