Factors Associated With Resilience or Vulnerability to Hot Flushes and Night Sweats During the Menopausal Transition

Oonagh K. Duffy, PhD, Lisa Iversen, PhD, Lorna Aucott, PhD, Philip C. Hannaford, MD Disclosures
Abstract and Introduction Abstract

Objective. The aim of this study was to explore factors associated with resilience and vulnerability to hot flushes and night sweats. Methods. A total of 4,407 women aged 45 to 54 years who were recruited from family practices in northeast Scotland responded to a postal questionnaire. Among respondents reporting high-frequency hot flushes (n = 628) or night sweats (n = 628), we compared those with low levels of bother ("resilient") with the rest. Similarly, among women reporting lowfrequency hot flushes (n = 459) or night sweats (n = 459), those with high bother ("vulnerable") were compared with the rest. Forward stepwise logistic regression examined social, psychological, and physical factors associated with resilience or vulnerability to each symptom. Results. Women resilient to hot flushes were those who had previously not been bothered by their menstrual periods; were not experiencing somatic symptoms or night sweats; and perceived their symptoms as having low consequences on their lives. Those vulnerable to hot flushes had children; had a high body mass index; reported night sweats; and perceived their symptoms as having high life consequences. Women resilient to night sweats were nonsmokers; were not experiencing sleep difficulties; were not using psychological symptom management strategies; and perceived their menopausal symptoms as having low life consequences. Those vulnerable to night sweats had low educational attainment; had previously been bothered by their menstrual periods; had below-average physical health; reported musculoskeletal symptoms and hot flushes; and perceived their menopausal symptoms as having high life consequences. Conclusions. Factors associated with resilience or vulnerability differ by symptom studied, although relationships with illness perceptions exist in all models. Our results suggest that a single approach to managing these symptoms is likely to be unsuccessful.
Introduction

So far, most research into menopausal symptoms has focused on the frequency of various symptoms experienced by women during each stage of the menopausal transition, associated levels of bother, and use of different symptom management strategies. There is often particular emphasis on those experiencing a high frequency of symptoms or those using particular forms of health care (such as hormone therapy [HT]). There is, however, growing

interest in understanding why some women seem to be untroubled by their symptoms or report having a good quality of life during the menopausal transition.[1] A better understanding of the psychological, physical, and social factors associated with apparent resilience to symptoms may help identify new interventions for women needing help. Resilience is a psychological concept that has been described as "patterns or processes of positive adaptation and development in the context of significant threats to an individual's life or function."[2] Although few would argue that the menopausal transition is a significant threat to a woman's life, it is a time when many women report bothersome symptoms,[3] which persist for a number of years[4] and are associated with health-related quality of life.[5,6] The Study of Women's Health Across the Nation (SWAN) used data from the seventh annual interview of participating women to examine factors associated with discrepancies between reported frequency of, and bother from, hot flushes or night sweats.[7] Women who reported frequent hot flushes and low levels of bother were more likely to be married and less likely to have negative affect than those reporting a similar frequency of hot flushes and high levels of bother. Women who reported a high frequency of night sweats but low levels of bother were more likely to be married, less likely to report sleep difficulties, and less likely to be late perimenopausal than women reporting a high frequency of night sweats and high levels of bother. In contrast, women who reported a low frequency of hot flushes and high levels of bother were more likely to be African American (compared with white women), more likely to report their self-rated health as poor, and more likely to have a lower level of educational attainment. Women reporting a low frequency of night sweats but high levels of bother were also more likely to report poor self-rated health. These results suggest that it may be possible to identify women who are "resilient" or "vulnerable" to the impact of menopausal symptoms. A recent study of Ecuadorian women found that lower scores on the Wagnild and Young Resilience Scale (indicating less resilience) correlated with more severe hot flushes.[8]
What can you do to further your educational goals as a nurse? Log on and learn critical leadership skills needed to enhance your nursing career. Discover how our graduate degree programs can help you meet your educational goals Information from Industry

Rutter[9] pointed out that resilience is likely to reside in the social context as much as within the individual. Thus, social circumstances and support, self-esteem, and self-efficacy are likely to be important determinants of resilience. Other influences among women transitioning through menopause may be attitudes toward menopause[10] and illness perceptions or representations[11] of menopausal symptoms. The aim of this study was to determine factors associated with resilience and vulnerability to menopausal symptoms, using data from a large community-based study of women living in the UK. Our hypothesis was that women who are apparently resilient to menopausal symptoms (ie, those experiencing a high frequency of hot flushes or night sweats but reporting low levels of associated bother) would have positive attitudes toward menopause, low levels of anxiety or depression, high levels of social support, and positive illness perceptions. Conversely, it was hypothesized that apparently vulnerable women (ie, those reporting a low frequency of symptoms but high levels of bother) would have results for these characteristics in the opposite direction.

Methods

Ethical approval for the study was granted by the East of Scotland Research Ethics Service (reference no. 08-S1401-129). The main methods and the prevalence of menopausal symptoms have been reported elsewhere.[3] Briefly, 16 general (family) practices across northeast Scotland each randomly sampled just more than 500 (to allow for exclusions) women aged 45 to 54 years from their list of registered patients. A study pack containing an invitation letter signed by the general practitioner, an information sheet, a consent form, a self-completion questionnaire entitled "Women's Health in Midlife," and a postage prepaid envelope was sent to 8,206 eligible women. Nonrespondents were sent an identical study pack 3 weeks after the initial mailing. The age and socioeconomic status (as determined by the Scottish Index of Multiple Deprivation)[12] of all eligible women were obtained from the practice lists to allow comparison between respondents and nonrespondents. The questionnaire collected data on the following: age; marital status; educational level (none; O grades or equivalent; highers or equivalent; college qualification; degree or professional qualification; postgraduate qualification); employment status; current height and weight (to allow calculation of body mass index [BMI]); menopause status; previous hysterectomy, oophorectomy, or both; other significant medical history; the six-item version of the Multidimensional Scale of Perceived Social Support[13]; the Short Form-12 Health Survey, version 2 (SF-12v2)[14]; the Hospital Anxiety and Depression Scale (HADS)[15]; an Attitude Towards Menopause checklist[16]; a symptom checklist; questions about the frequency of hot flushes and night sweats per day or per week[17]; questions relating to social support; a management strategy for symptoms checklist; and the 14-item version of the Illness Perception QuestionnaireRevised (IPQ-R).[18] The symptom checklist included 23 symptoms commonly experienced around menopause. Respondents were asked to indicate whether they had experienced each symptom in the last month, and, if yes, the level of bother from that symptom and whether they attributed it to menopause.
Statistical Analysis

The data were analyzed using SPSS (version 19). In accordance with the staging system of menses recommended by the Stages of Reproductive Aging Workshop,[19] respondents were classified as premenopausal if they reported that their menstrual periods had not changed in the last few years; perimenopausal if they reported that they were experiencing menstrual cycle irregularities but had not gone 12 months in a row without a period; and postmenopausal if they had not had a period in the last 12 months. Respondents who reported having had hysterectomy, oophorectomy, or both were classified as surgically postmenopausal (had surgical menopause). Women who were using the intrauterine system Mirena, began HT while still menstruating, had endometrial ablation, or had missing data about menstrual periods were regarded as unclassifiable with respect to menopause status. A number of covariates were categorized for analysis to facilitate the interpretation of findings:

Education: no education or O grades; highers or college qualification; degree or postgraduate qualification Employment:not employed; employed part time; self-employed; employed full time

BMI: lower than 25kg/m2; 25 to 30kg/m2; higher than 30 kg/m2 Smoking status: never smokers; current smokers; ex-smokers Alcohol consumption: lower than 7 units/week; 7 to 14 units/week; higher than 14 units/week Frequency of exercise and strenuous exercise: rarely or less than once a week; once or two to three times a week; four to six times a week or every day Self-assessed health: excellent; very good; good; fair or poor (combined) Mental and physical health summary scores for the SF-12v2: median or lower; higher than the median Social support from friends, family, or a significant other: low; moderate; high (based on the distribution of tertile scores from the Multidimensional Scale of Perceived Social Support) Scores of 8 or higher on the anxiety (HADS-A) or depression (HADS-D) subscales of HADS: possible case of anxiety; possible case of depression Attitudes toward menopause: positive; neutral; negative (based on the distribution of tertile scores for the sample, with the highest tertile representing positive attitudes) Scores on the illness perceptions scale (by score tertiles): high; moderate; low Symptom management strategies:
o

Psychological strategy: currently talking to family and friends; talking to a health professional; relaxation Prescription medicine: currently using HT, antidepressants, clonidine, estrogen creams Complementary alternative medicine: currently using herbal remedies, vitamins, acupuncture, or reflexology Lifestyle change: avoiding caffeine; wearing cotton clothes; sleeping in a cool room; exercising; using lubricants

For a simplified inclusion of symptoms in the models, factor analysis was used to group the 23 symptoms into six symptom clusters: psychological (depression, tearfulness, mood swings, anxiety), sexual (vaginal dryness, decreased sexual interest), general somatic (breathlessness, passing urine more frequently, headaches/migraine, dizziness, leakage of urine), musculoskeletal (stiff joints, aches and pains), menstrual (irregular periods, heavy periods), and bloating symptoms (increased weight, feeling bloated). The name of each cluster was based on the general characteristics of symptoms included in it. Although hot flushes, night sweats, and sleep difficulties formed a separate symptom cluster, we did not

group these symptoms together in our analyses because we wanted to investigate hot flushes and night sweats separately. Based on the distribution of responses from all respondents reporting hot flushes, women were grouped by frequency of hot flushes per week into 1 to 7 hot flushes/week (low) or 15 or more hot flushes/week (high). Similar to the analysis conducted by SWAN,[7] we did not include in our analyses women with a moderate frequency of hot flushes (8-14 hot flushes/wk), as our hypotheses related only to women with high-frequency and lowfrequency symptoms. Women were grouped by frequency of night sweats per week into 1 to 5 night sweats/week (low) or 6 or more night sweats/week (high). Reported level of bother from each symptom was used to group respondents into not at all/slightly (low) or moderately/quite a bit/extremely bothered (high). Cross-tabulations were constructed from the responses of perimenopausal, postmenopausal, and surgically postmenopausal women who provided information about both the frequency and the level of bother from each symptom to identify respondents deemed "resilient" (ie, reporting high frequency and low levels of bother) or "vulnerable" (ie, reporting low frequency and high levels of bother) to hot flushes or night sweats. Hot flushes and night sweats were reported by some premenopausal women but at a much lower frequency than among perimenopausal, naturally postmenopausal, or surgically postmenopausal women.[3] Fewer premenopausal women were bothered by these symptoms or attributed them to menopause. This suggests a marked difference between the premenopausal group and the other groups in symptom experience and effect and, by implication, in possible factors associated with resilience and vulnerability. These differences led us to exclude premenopausal women from our analyses. Four models comparing resilient or vulnerable women with women experiencing the same frequency of symptom but with opposite level of bother were constructed (Figure 1 and Figure 2). For example, women apparently resilient to hot flushes (high frequency, low bother) were compared with women with a high frequency of hot flushes and high levels of bother. 2 test or Mann-Whitney U test was used to identify statistically significant univariate associations between sociodemographic, psychosocial, and physical variables included in the questionnaire and previously shown to be associated with menopausal symptoms experience (namely, socioeconomic status[6,20,21]; employment[22-24]; BMI[6,21,25,26]; exercise[21-23]; smoking[21-23,27; alcohol consumption[23,28,29]; educational attainment[20,23]; history of hysterectomy, oophorectomy, or both[23,30,31]; health-related quality of life[6,32,33]; marital status[11,21]; medical history[6]; self-rated health[20,29]; attitudes toward menopause[10];social support[28]; and illness perceptions[11])and membership in the resilient or vulnerable group.

(Enlarge Image)

Figure 1.

Summary of factors found in the fully adjusted model to be associated with "resilience" or "vulnerability" to hot flushes. BMI, body mass index.

(Enlarge Image)

Figure 2. Summary of factors found in the fully adjusted model to be associated with "resilience" or "vulnerability" to night sweats.
How do you find time to balance school with a busy nursing career? Our nursing alumni balanced school, work, and family. Find out how our accredited programs fit your schedule Information from Industry

Variables showing significant associations at the P< 0.05 level in any group were entered into forward stepwise logistic regression models to identify the variables independently associated with resilience or vulnerability to hot flushes or night sweats. In addition to including statistically significant variables, management strategies and illness perceptions were forced into the final models even if not statistically significant. This was performed to examine the effects of management strategies and illness perceptions on women who seem to be resilient or vulnerable to hot flushes or night sweats. We wished to look at the use of different management strategies because of comparatively recent changes in clinical guidance regarding the use of HT. We were also interested to see if illness perceptions were associated with menopausal symptoms because this may help identify novel ways for managing symptoms. Interactions between variables with significant independent associations in the multivariate models were tested for.
Results

Ninety-five women did not receive their invitations to participate because their study packs were returned by the mail service undelivered. Removing these women from the denominator, we had a corrected response rate of 55% (4,445/8,111). After exclusions, data were available for 4,407 women. The median age of respondents was 49 years (interquartile range, 47-52 y). Roughly two fifths of the respondents had three or more pregnancies (40%) and two children (43%; Table 1 ). Most of the respondents (78%) were married or cohabiting. Almost a third of respondents

were educated to degree level (29%) or secondary school level (26%). Nearly half of the women were in full-time paid employment (49%). A quarter of the respondents were premenopausal, 28% were perimenopausal, 22% were postmenopausal, 14% were surgically postmenopausal, and 12% were unclassifiable. Hot flushes were experienced by 46.7% (95% CI, 45.2-48.2) of women, and night sweats were experienced by 46.4% (95% CI, 44.9-47.9) of women. Among the 628 women who reported a high frequency of hot flushes, 92 (14.6%) reported low levels of bother (ie, seemed "resilient"; Table 2 ). This subgroup of women was compared in the multivariate models with the remaining 536 (85.4%) who reported high levels of bother. Of the 459 women who reported a low frequency of hot flushes, 217 (47.3%) reported high levels of bother (ie, seemed "vulnerable"; Table 2 ). This subgroup was subsequently compared with the remaining 242 (52.7%) women with low levels of bother from their hot flushes. Among the 794 women who reported a high frequency of night sweats, 145 (18.3%) reported low levels of bother (ie, deemed "resilient"; Table 3 ). This subgroup was compared with the remaining 649 (81.7%) women who reported high levels of bother. Of the 459 women who reported a low frequency of night sweats, 225 (49.0%) women reported high levels of bother (ie, seemed"vulnerable"; Table 3 ). This subgroup was compared with the remaining 234 (51.0%) women with low levels of bother. It is noteworthy that a larger proportion of women seemed to be vulnerable than resilient to either symptom.
Univariate Associations

Several sociodemographic, psychological, and lifestyle variables showed a significant univariate association in at least one of the four models investigating factors associated with being resilient or vulnerable to hot flushes and night sweats.
"Resilience" to Hot Flushes

Significant univariate associations with resilience to hot flushes were found for the following: number of pregnancies; number of children; educational attainment; BMI; smoking status; alcohol consumption; frequency of exercise; perceived severity of previous menstrual periods; anxiety and depression (as assessed by HADS[12]); health-related quality of life (SF12v2 physical and mental health summary scores); reporting psychological symptoms, somatic symptoms, musculoskeletal symptoms, bloating symptoms, night sweats, and sleep difficulties; attitudes toward menopause; current use of complementary alternative medicines, prescription medicines, psychological strategies, and lifestyle changes for symptoms attributed to menopause; and perceived consequences of hot flushes (illness perceptions; data not shown).
"Vulnerability" to Hot Flushes

Factors significantly associated with vulnerability to hot flushes were as follows: number of pregnancies; number of children; educational attainment; BMI; smoking status; alcohol consumption; perceived severity of menstrual periods; frequency of exercise; anxiety and depression; health-related quality of life; reporting somatic symptoms, psychological symptoms, musculoskeletal symptoms, bloating symptoms, night sweats, and sleep difficulties; attitudes toward menopause; current use of complementary alternative medicines,

prescription medicines, psychological strategies, and lifestyle changes for symptoms attributed to menopause; and perceived consequences of hot flushes (illness perceptions).
"Resilience" to Night Sweats

Factors significantly associated with resilience to night sweats on univariate analysis were as follows: number of pregnancies; number of children; educational attainment; BMI; smoking status; alcohol consumption; frequency of exercise; perceived severity of menstrual periods; anxiety and depression; health-related quality of life; reporting somatic symptoms, psychological symptoms, musculoskeletal symptoms, bloating symptoms, hot flushes, and sleep difficulties; attitudes toward menopause; current use of complementary alternative medicines, prescription medicines, lifestyle changes, and psychological strategies for symptoms attributed to menopause; and perceived consequences of night sweats (illness perceptions).
"Vulnerability" to Night Sweats

Before adjustment, factors significantly associated with vulnerability to night sweats were as follows: number of pregnancies; number of children; educational attainment; BMI; smoking status; alcohol consumption; frequency of exercise; perceived severity of previous menstrual periods; anxiety and depression; health-related quality of life; reporting somatic symptoms, musculoskeletal symptoms, psychological symptoms, bloating symptoms, hot flushes, and sleep difficulties; attitudes toward menopause; current use of complementary alternative medicines, prescription medicines, psychological strategies, and lifestyle changes for symptoms attributed to menopause; and perceived consequences of night sweats (illness perceptions).
Multivariate Models

Factors Independently Associated With "Resilience" to Hot Flushes. On multivariate analysis, women who reported being previously bothered by their menstrual periods were significantly less likely to be in the "resilient"-to-hot-flushes group than their reference counterparts, as were those who reported experiencing one, two, or three somatic symptoms; those reporting night sweats; and those who perceived their menopausal symptoms to be having high consequences on their lives ( Table 4 ). Forcing the inclusion of management strategies and illness representations into the final model did not tend to change the odds ratios in this model or in the other models. Factors Independently Associated with "Vulnerability" to Hot Flushes. Women who reported having one or more children were significantly more likely to be in the "vulnerable"to-hot flushes group than those in the reference group, as were women with a BMI of 30 kg/m2 or higher; those also reporting night sweats; and those who perceived their menopausal symptoms to be having moderate or high consequences on their lives ( Table 5 ). Factors Independently Associated with "Resilience" to Night Sweats. Table 6 shows that women who reported being a current smoker were significantly less likely to be in the "resilient"-to-night-sweats group than those in the reference group, as were those reporting sleep difficulties; those using psychological strategies to manage their menopausal symptoms; and those who perceived their menopausal symptoms to be having moderate or high consequences on their lives.

At the University of Phoenix College of Nursing, we have the cure for the common curriculum Our coursework focuses on key critical thinking and leadership skills. Learn how we are putting nurses to work Information from Industry

Factors Independently Associated with "Vulnerability" to Night Sweats. Women who reported being bothered by menstrual periods in the past were more likely to be in the"vulnerable"-to-night-sweats group than those in the corresponding reference group, as were those with a below-median SF-12v2 physical health summary score; those also reporting hot flushes; those with one or two musculoskeletal symptoms; and those who perceived their menopausal symptoms to be having high consequences on their lives ( Table 7 ). In contrast, women who had a degree or postgraduate level of education were significantly less likely to be in the "Vulnerable"-to-night-sweats group. No significant interactions were found for factors independently associated with resilience or vulnerability to hot flushes or night sweats. Figures 1 and 2 summarize the factors found to be independently associated with resilience or vulnerability to hot flushes and night sweats, respectively.
Discussion

We wished to identify the characteristics of women who seemed to be resilient or vulnerable to the effects of hot flushes or night sweats. We were able to include a wide range of personal biopsychosocial characteristics in our analyses. Factors independently associated with different group memberships included the following: having had children, smoking, education, self-reported poor physical health, history of menstrual problems, different symptoms (somatic symptoms, night sweats, hot flushes, sleep difficulties, and musculoskeletal symptoms), and perceived consequences of menopausal symptoms. The characteristics of women differed in each multivariate model, except for "perceived consequences," which emerged as an independent factor in each model. Some factors including social support and marital statuswere notable for their absence in the final models. However, it should be noted that almost 80% of women in our study were married, and so we lacked power to examine the effect of marital status on resilience and vulnerability to hot flushes and night sweats. There has been only one other community-based study, conducted in North America, that looked at this issue with similar depth.[7] In contrast to that study, marital status and menopause status were not found in our study to be independently associated with resilience to hot flushes or night sweats, and poor self-rated health was not independently associated with vulnerability to either symptom. On the other hand, as in SWAN,[7] women resilient to night sweats in our study were less likely to report sleep difficulties. Educational attainment was associated with vulnerability to hot flushes in SWAN, whereas this variable was associated with vulnerability to night sweats in our study. Differences between studies may be attributed to how educational attainment and self-rated health were assessed or to the influences of these factors in different countries. Further studies are needed to build the

evidence base for factors associated with resilience or vulnerability to these and other menopausal symptoms. A common factor in all models was the respondents' perceptions about the consequences of their symptom on their lives (one aspect of illness representations). Women who perceived their menopausal symptoms as having little consequence on their lives were more likely to be in the "resilient" group of either symptom, whereas those with perceptions of moderate or high consequences were more likely to be in the "vulnerable" group. The relationship between perceptions about the consequences of symptoms and vasomotor symptom experience has not been reported before. However, Women's perceptions about the consequences of their menopausal symptoms have been linked to help-seeking behavior; women reporting negative consequences have been found to be more likely to have visited their doctor recently than women with less negative illness perceptions.[34] Our results suggest that illness representations may influence the impact of menopausal symptoms. Illness representations can be changed,[35,36] suggesting a novel way for helping some women manage their menopausal symptoms, perhaps by designing psychoeducational programs for menopause management[36] or by challenging negative perceptions about symptoms through group cognitive-behavioral therapy.[37,38] Future studies of the menopausal transition should include measures of illness perceptions.
Methodological Strengths and Weaknesses

One of the main strengths of our study was its community base. Results from this study are more likely to be representative of women living in the community than those from studies using samples from healthcare settings such as gynecological clinics.[39-41] The analyses assume that frequency of symptoms and reported associated level of bother correctly differentiated women into those who, if asked directly, perceive themselves as "resilient" or "vulnerable" to the effects of these menopausal symptoms. A strength of our approach is that it moves away from groupings based on help-seeking behavior for symptoms.[42] Consulting a healthcare professional may not always identify women who are resilient or vulnerable to their symptoms because a proportion of women bothered by their symptoms do not consult their doctor.[43] Indeed, in our study, only one of the five different types of management strategies examined emerged as an independent variable in one of our multivariate models (not currently using psychological strategies and "resilience" to night sweats). This indicates, at best, only a weak relationship between help-seeking behavior and resilience or vulnerability to symptoms. Although work is needed to ascertain whether our assumptions about our ability to accurately allocate women to appropriate groups are correct, we believe that our study provides an important addition to the paucity of information about resilience and vulnerability during the menopausal transition. The inclusion of information about illness perceptions was novel. We adapted the IPQ-R in our study after consulting with one of the individuals (Professor John Weinman) who devised the original measure. The adapted questionnaire included two items for each domain to restrict the size of the questionnaire and referred to menopausal symptoms, rather than illness, throughout because many women are unlikely to regard menopause as an illness. Although perceived consequences of menopausal symptoms emerged as a significant factor in all four models, none of the other psychological elements emerged as important due to the fact that we only included two items per domain in our version of the IPQ-R. Although further work is needed to test the validity of our IPQ-R, our observations show that

psychological factors probably have an important role in symptom experience and thus should be measured. Like others,[44,45] we separately categorized women who had a hysterectomy as surgically postmenopausal. We did this even though women who had had the operation without concomitant bilateral oophorectomy will not have had an immediate cessation of ovarian function. In our study, among women with hysterectomy, roughly two thirds (65.4%) reported having had hysterectomy without bilateral oophorectomy. We have previously shown that women classified as surgically postmenopausal in this way had a similar frequency of hot flushes and night sweats and a similar level of associated bother as women postmenopausal from natural causes.[3] This pattern occurred even though more surgically postmenopausal women were current users of HT than naturally postmenopausal women (21% vs 8%, respectively). It is probable, therefore, that a high proportion of women classified in our study as surgically postmenopausal had cessation of ovarian function. This concurs with other research reporting that hysterectomy with ovarian conservation in premenopausal women is associated with loss of ovarian function almost 4 years earlier than women without hysterectomy.[46] Differences in the use of HT or other medications were allowed for in the statistical models and thus cannot explain our findings.
How do you find time to balance school with a busy nursing career? Our nursing alumni balanced school, work, and family. Find out how our accredited programs fit your schedule Information from Industry

Our questionnaire response rate of 55% was less than desired but higher than those achieved by others in recent UK-based lifestyle surveys.[47] Respondents were significantly more affluent than nonrespondents.[3] Response bias, therefore, may have occurred. Some studies have found that women from lower socioeconomic groups report more menopausal symptoms than those from higher socioeconomic groups.[6,20,21] Alternatively, women experiencing menopausal symptoms may have been more likely to complete the questionnaire than asymptomatic recipients. Although response bias might have influenced our estimates of the prevalence of hot flushes and night sweats, it is unclear how this might have affected our comparisons of resilience and vulnerability. A further limitation of our work was its cross-sectional nature. Although it was possible to investigate different patterns of associations, temporal sequences of cause and effect could not be established. Furthermore, although a wide range of sociodemographic, physical, and psychological variables were assessed in the questionnaire, others, such as diet, were not assessed to avoid response fatigue. Some of the associations, therefore, may be attributed to confounding. A further limitation was the investigation of numerous variables, making the study potentially prone to type I errors. On the other hand, some of the comparisons were based on a small number of women with the outcome of interest, so some factors related to resilience or vulnerability may not have been detected.
Conclusions Our nursing degree programs are designed for working nurses like you Learn how our accredited nursing degree programs make higher education more accessible.

Explore our flexible learning options Information from Industry

Although our results should be interpreted with caution, they suggest that factors associated with resilience or vulnerability to the classic menopausal symptoms of hot flushes and night sweats differ depending on the symptom studied. Only one factor was common to all models examinedrespondents' perceptions of the consequences of their symptoms. Future studies of menopause should consider the role of participants' illness perceptions because these may play a role in how women experience and manage menopausal symptoms.

Gynecologic Care of Women With HIV Management Overview

WIHS and HERS Studies
As the human immunodeficiency virus (HIV) epidemic progressed and women represented an increasing proportion of cases, concerns arose about possible clinically significant gynecologic manifestations of HIV infection and acquired immunodeficiency syndrome (AIDS). To address those concerns, the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC) funded 2 large, multisite, prospective cohort studies, respectively: the Women's Interagency HIV Study (WIHS)[1] and the HIV Epidemiology Research Study (HERS).[2] WIHS and HERS have contributed greatly to the understanding of HIV infection in women. Findings from these and other studies indicate that there are subtle differences between HIV disease in men and women, although these differences are less pronounced than originally predicted. WIHS, which began in 1994 and is ongoing, was established to follow the natural history of HIV infection and related health conditions among 2,058 women with HIV and 568 women without HIV.[1] In HERS, 871 women with HIV and 439 women without infection who were at-risk, aged 1655, were enrolled at 4 US sites between 1993 and 1995 and were followed prospectively until 2000 to evaluate medical and psychosocial events associated with the clinical course of HIV infection.[2]

Epidemiologic Data
As therapies continue to improve, women with HIV can expect to live longer. Consequently, health care providers must be aware of the special needs of women with HIV/AIDS. The American College of Obstetricians and Gynecologists has released clinical management guidelines for practitioners who care for women infected with HIV.[3] Globally, nearly half of all adults living with AIDS are women. In the United States, women account for more than one quarter of HIV/AIDS cases. Black and Hispanic women account

for more than 80% of AIDS cases among women in the United States, although they represent less than 25% of all US women; these disparities remain poorly explained.[4] Approximately 20% of new HIV infections in women are related to injection drug use.[5, 6] Overwhelmingly, women who contract HIV infection are diagnosed during their reproductive years, and most (80%) become infected through high-risk heterosexual contact: sex with multiple partners, bisexual males, male injection drug users, or males with unidentified risk factors.[5] Disparities in survival by race and sex have been identified in studies: blacks and women have poorer outcomes compared with whites and men.[7] Although mortality from HIV disease has not been among the 15 leading causes of death in the US since 1997, in 2005, HIV/AIDS was the fifth leading cause of death among US women aged 3544 and the sixth leading cause of death among women aged 2534. Among black women in the United States, HIV/AIDS was the leading cause of death among women aged 25-34 and the third leading cause of death among women aged 3544 in 2005. Among Hispanic women, HIV/AIDS was the fourth leading cause of death.[5] Findings from several studies indicate that differential use of highly active antiretroviral therapy (HAART) explains much of the disparity.[7] Lemly et al found that black patients presented with more advanced stages of HIV, were slower to initiate HAART, and were less likely to receive HAART while in care.[8] Studies have clearly demonstrated sex and race differences in HAART prescription and use among patients with access to therapy. Other studies have demonstrated higher rates of discontinuation and virologic failure among blacks and other minorities.[9] Women have been found to be less likely to use HAART, but even after correction for HAART use, women still have poorer outcomes.[8] The reasons for differential use of HAART are unclear. Substance abuse, mental illness, gaps in public insurance coverage (ie, Medicaid), and psychosocial stressors may be contributing factors. For other discussions on of HIV infection, see HIV Disease, Pediatric HIV Infection, and Antiretroviral Therapy for HIV Infection, as well as HIV in Pregnancy.

Menstrual Abnormalities
Menstrual dysfunction is relatively common in the general population of reproductive-aged women. Studies have not established a consistent association between HIV infection and menstrual abnormalities. Additionally, no clear relationship has been established between menstrual dysfunction (particularly amenorrhea) and the use of highly active antiretroviral therapy (HAART). The few studies that have evaluated menstrual disorders or complaints in women with or without HIV have not found significant differences in amenorrhea, menstrual cycle length, or variability by HIV serostatus, unless advanced immunodeficiency (eg, CD4+ lymphocyte count < 200 cells/mL) is present.[10] Women with HIV should receive the same workup and

treatment for menstrual disorders (including evaluation of risk factors) as women without HIV.

Sexually Transmitted Infections

The HIV Epidemiology Research Study (HERS)[2] and other studies have not found significant differences in the prevalence of chlamydial infection, gonorrhea, trichomoniasis, or syphilis in women by HIV serostatus.[11, 12] However, the presence of new or recurrent sexually transmitted infections (STIs) indicates high-risk behavior and warrants further counseling. Because the presence of STIs increases HIV shedding (which may increase the risk of HIV transmission to partners)[13] , STIs should be treated aggressively in women with HIV. Many STIs are asymptomatic; therefore, sexually active women with HIV should be screened at least annually for curable STIs (eg, syphilis, trichomoniasis, gonorrhea, chlamydia).[14, 15] More frequent STI screening may be indicated based on symptoms and risk behaviors. The diagnosis and treatment of gonorrhea, chlamydial infection, and trichomoniasis are the same diagnosed and treated in HIV-positive women as in HIV-negative women. However, closer monitoring after treatment for syphilis is warranted for HIV-infected women.[14, 15]
Genital ulcer disease from herpes simplex virus type 2

Herpes simplex virus type 2 (HSV2) is the most common cause of genital ulcer disease worldwide. While the prevalence of HSV2 varies by geographic location, it is consistently present in high percentages (5090%) among persons infected with HIV. Among those coinfected with HIV and HSV2, more shedding of HSV2 and HIV in the genital tract occurs than in those infected with HIV or HSV2 alone.[16] Co-infection with HSV increases the risk of HIV acquisition by nearly twofold. Women with HIV may have recurrent problems with herpetic outbreaks and may benefit from episodic or suppressive therapy. highly active antiretroviral therapy (HAART) may decrease HSV shedding, although the data are inconsistent. The CDCs Sexually Transmitted Diseases Treatment Guidelines provide recommendations for both episodic and suppressive HSV therapy in women with HIV.[14]
Vulvovaginal candidiasis

Vulvovaginal candidiasis (VVC) is a common cause of vaginitis among women. In both women with and without HIV, the most common cause of VVC is Candida albicans. Studies have consistently found that both vaginal colonization and VVC are more frequent among women with HIV infection.[17, 18] The clinical spectrum of signs and symptoms and the severity of disease, however, do not appear to differ between those infected and those uninfected with HIV. The frequency of vaginal yeast colonization is inversely related to CD4+ counts, which may predispose the subgroup of women with HIV and low CD4+ counts to more frequent or severe infections.[19] Since the clinical and microbiological spectrum of VVC appears similar for women with and without HIV, the treatment decision should be based on the clinical

indications.[14, 19, 20] VVC is associated with increased HIV cervicovaginal shedding; in women with HIV, however, the effect of treatment for VVC on HIV transmission is unknown.
Bacterial vaginosis

Bacterial vaginosis (BV) is the most common cause of vaginal discharge among women of reproductive age. Several clinical studies have found that the prevalence of BV in women with HIV is similar to that among women without HIV.[21, 22] However, evaluation of HERS concluded that BV is more prevalent among women with HIV, primarily because of more persistent infections rather than more incident (ie, frequent) infections.[21] Women who are immunocompromised (CD4+ T-cell count < 200 cells/mL) have a higher prevalence of BV than women with HIV with higher CD4+ counts. Women with HIV may require longer or more frequent treatment. Otherwise, the treatment regimens for BV in women with HIV infection are the same as for those not infected.
Pelvic inflammatory disease

Few data suggest that the course of pelvic inflammatory disease (PID) in women with HIV is worse than that in women without HIV. Thus, women should be managed according to the standard treatment criteria. Tubo-ovarian abscesses may be more common in women infected with HIV, but these appear to respond equally as well as uninfected women to standard IV and oral antibiotic therapies.[14]
Human papillomavirus infection and cervical disease

Human papillomavirus (HPV) causes cervical cytologic abnormalities (such as atypical squamous cells of undetermined significance [ASCUS] and squamous intraepithelial neoplasia [SIL]) and cervical cancer. More than 40 types of HPV cause genital infection; the types are typically grouped as low-risk (eg, 6, 11) or high-risk (eg, 16, 18) for development of cervical cancer. Persistent infection with a high-risk HPV type is necessary for progression to high-grade SIL and invasive cervical cancer, while both low-risk and high-risk HPV types can cause ASCUS and low-grade SIL. Nearly 70% of invasive cervical cancer is caused by HPV types 16 and 18. HPV infections are common, frequent, and generally transient and asymptomatic in the general population of sexually active young women. Approximately 70% of new HPV infections in young women without HIV clear spontaneously within 1 year, and up to 91% clear within 2 years.[23] Among women with HIV, HPV infection is more prevalent and persistent, the distribution of high-risk types is different, and cytologic abnormalities are more prevalent. High-risk HPV types have been found to have lower clearance rates than low-risk types, but there does not appear to be a difference by HIV serostatus.[24] The degree of immunosuppression correlates inversely with the frequency and severity of cytologic abnormalities. The relationship between HIV infection and invasive cervical cancer is less clear. Some studies have reported that although HIV infection increases the risk of abnormal cervical cytology, most abnormalities are low-grade. High-grade lesions and invasive cancers are rare (ie, similar to that among women without HIV)[25, 26] ; however, it appears that women with

HIV and invasive cervical cancer have a greater degree of immunosuppression than women with HIV who are immunocompetent.[27] Highly active antiretroviral therapy (HAART) has improved the length and quality of life among women with HIV infection. Consequently, researchers have hypothesized that HAART could reduce the risk of cervical dysplasia and progression to invasive cervical cancer by decreasing HIV replication, but this hypothesis has not been proven. A 2009 HERS publication reported that HAART was associated with enhanced HPV clearance but not with Papanicolaou test abnormality regression.[28]

HIV Testing
More than 20% of people who are infected with HIV in the United States are estimated to be unaware of their HIV status. The CDC recommends HIV screening in health care settings for all patients aged 13-64 years.[29] Because they often provide primary health care for women, obstetrician-gynecologists are well positioned to encourage HIV screening for women.

Management Overview
After initial diagnosis, women with HIV should provide a complete history of previous cervical disease, and they should receive a comprehensive gynecologic examination.[14, 15]
Papanicolaou testing

A Papanicolaou test should be performed twice during the first year. If the results of both tests are normal, subsequent Papanicolaou tests should be performed annually. Otherwise, subsequent care should be administered according to the American Society of Colposcopy and Cervical Pathology (ASCCP) 2006 Consensus Guidelines for Management of Abnormal Cervical Cytology.[30]
Management for cytologic abnormalities

Women infected with HIV who have cytologic abnormalities, regardless of CD4+ count or antiretroviral treatment status, should undergo colposcopy and directed biopsy. Conversely, women with HIV with normal cervical cytology should not receive colposcopy and biopsy. Because of the increased prevalence of abnormal cervical cytology, more women with HIV may undergo hysterectomy for high-grade squamous intraepithelial neoplasia (SIL) or carcinoma in situ. HERS found that 63% of women with HIV with evidence of cervical intraepithelial neoplasia (CIN) before or at hysterectomy experienced SIL vaginal cytology during follow-up, a level that is significantly higher than in women in the general population. [31] Low CD4+ counts and high viral load appear to also be predictors of SIL during follow-up. Women with HIV have higher rates of intraepithelial neoplasia of the vulvar, vaginal, and anal regions than women without HIV, and these lesions may be present in the absence of squamous intraepithelial lesions of the cervix. Risk factors for development of vulvar,

vaginal, and anal intraepithelial neoplasia include CD4+ counts less than 200 cells/mL, HPV positivity, and high-risk HPV positivity. When women with HIV receive routine pelvic examinations, the vulva, vagina, and anus should be carefully examined. When colposcopy is indicated, the entire lower genital tract should be evaluated, including biopsies as needed.[32]

Preconception Counseling
The CDC, the American Congress of Obstetricians and Gynecologists (ACOG), and several other national organizations recommend preconception counseling for all women of childbearing age. The goals of preconception care are to provide education and counseling targeted to the individual's needs, identify risk factors for adverse maternal or fetal outcomes, and initiate interventions to optimize outcomes.[33] Most women with HIV infection are of reproductive age, and 70-80% are sexually active. With highly active antiretroviral therapy (HAART), women with HIV are living longer, healthier lives; consequently more women with HIV may desire their own biologic children. By suppressing viral load, HAART significantly decreases mother-to-child transmission. To maximize outcomes and minimize risk, physicians should encourage women to plan their pregnancies, to use an effective form of contraception until they are ready to conceive, and to reduce risky behaviors (ie, smoking, substance use) and use folic acid. In addition, physicians should counsel women regarding the risk of transmitting infection through unprotected intercourse with an uninfected male partner. Intravaginal or intrauterine insemination may be feasible to reduce the risk of HIV transmission to an uninfected male partner.
Contraception

Nearly 50% of all pregnancies in the United States are unintended. Women with HIV should be counseled regarding the need to avoid unintended pregnancy as well as the need to protect themselves against sexually transmitted infections (STIs) and to protect their uninfected male partner(s) from infection. Highly effective contraceptive methods (eg, hormonal methods, intrauterine devices [IUDs]) should be recommended when appropriate. Depomedroxyprogesterone acetate (DMPA) is considered safe and effective in women with HIV without known interactions with antiretroviral therapy.[34, 35] Combined oral contraceptives (COCs) are not recommended for women with HIV on certain HAART regimens because of potential alterations in safety and effectiveness of both the hormonal contraceptive and the antiretroviral drug.[36, 37] Specifically, for women taking ritonavir-boosted protease inhibitors, COCs are generally not recommended.[37] Women on HAART who are interested in using COCs should consistently use condoms (ie, dual method). IUDs are considered safe and effective for women with HIV,[38] but IUD insertion is not recommended for women with AIDS unless they are clinically stable on antiretroviral

therapy.[37] Although data on surgical sterilization of women with HIV are scant, no specific recommendations or concerns different from those regarding women without HIV have been described. Correct, consistent condom use is essential for protection of an uninfected male partner and for protection of the woman from STIs, which can increase viral shedding. Studies have reported decreased condom use among women with HIV on HAART[39] , and among women without HIV whose partners have HIV[40] .

Gynecologic Surgery
There is little published information on gynecologic surgery in women with HIV; most information is from studies of postoperative complications after cesarean section. The limited available data on gynecologic surgery suggest that no differences in the clinical management of women with HIV undergoing routine gynecologic procedures are required. Two limited studies found no significant differences in postoperative complications between immunocompetent women with HIV and women without HIV.[41, 42] A larger, retrospective study concluded that women with HIV who undergo abdominal surgery or uterine curettage appear to be at risk for increased infectious morbidity such as postoperative fever (either transient or fever requiring antibiotic therapy).[43] Complications are more likely in women with HIV who are immunocompromised.[43, 42]

Menopause
Because of improved antiretroviral therapies, women with HIV are living longer, healthier lives. In addition, the HIV/AIDS epidemic is maturing in the United States. As a result, increasing numbers of women with HIV are reaching menopause. However, data on menopause in women with HIV are very limited. Menopause in the general US population occurs at a median age of 51.4 years; a few studies have found that menopause occurs 2-3 years earlier in women with HIV. Menopause has also been found to occur earlier among African-American women, cigarette smokers, and drug users; and each of these groups is overrepresented among women with HIV. A prospective study of the natural history of menopause among 302 women with HIV and 269 high-risk women without HIV found an average age of menopause of 46 and 47 years, respectively. In addition, this study found that HIV infection, use of cocaine or opioids, and physical inactivity were independently associated with age-adjusted onset of menopause.[44] The degree to which a women with HIV experiences menopausal symptoms may relate to her immune status.[45] While hormone replacement therapy (HRT) has been studied extensively among the general population, it has not been studied in women with HIV.

Infants Often Introduced to Solid Food Too Early

Early introduction to solid foods for infants under 4 months old is highly prevalent in the United States, even though recommendations call for solid food introduction between 4 and 6 months of age, according to an article published online March 25 in Pediatrics. The early introduction may leave affected infants vulnerable to higher risk for chronic diseases, such as diabetes and obesity, researchers note. Heather B. Clayton, PhD, MPH, from the Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, and colleagues analyzed the responses of 1334 mothers who participated in the Infant Feeding Practices Study II between 2005 and 2007. The study group included women who returned completed questionnaires during the months after birth and indicated when they introduced solid foods to their infants and why. Overall, 40.4% of mothers introduced solid foods before their infants were 4 months old (P < .05), and some did so earlier than 4 weeks of age. Mothers were more likely to do so if they were younger, were unmarried, had less education, earned less, and participated in the Women, Infants, and Children program. When the researchers accounted for the type of milk feeding of infants, they found that 52.7% of mothers who formula-fed started solid feeding before 4 months, compared with 50.2% of mothers who reported mixed feeding and 24.3% of mothers who breast-fed. Most mothers (88.9%) gave their reason as "My baby was old enough to begin eating solid food," and many others (71.4%) said, "My baby seemed hungry a lot of the time." Using logistic regression analysis adjusting for age, marital status, education, and other variables, the researchers found that mothers who breast-fed were less likely to cite the reason as "I wanted to feed my baby something in addition to breast milk or formula" compared with women who formula-fed (adjusted odds ratio [aOR], 0.62; 95% confidence interval [CI], 0.39 - 0.99). Mothers who formula-fed were almost twice as likely as mothers who breast-fed to give the reason "A doctor or other health care professional said my baby should begin eating solid food" (aOR 1.79; 95% CI, 1.15 - 2.80). At the time of the surveys, the American Academy of Pediatrics recommendation for solid food introduction was 4 months. However, in 2012 the AAP changed that to 4 to 6 months, which would equate to a rate of early introduction of 92.9%, the researchers note. Limitations of the study include the fact that most mothers were white and had moderate incomes. The researchers note that because mothers of lower socioeconomic status are at higher risk for early introduction of solid food, the study results may underestimate the true prevalence. How does an online nursing degree work? University of Phoenix College of Nursing offers accredited nursing degree programs that fit your busy life. Learn how you can attend school on your own schedule Information from Industry The researchers conclude, "Our study provides key information on why mothers introduced solid food earlier than recommended and how the commonly cited reasons varied by milk feeding type. This information can be used by health professionals to develop targeted

interventions to improve adherence with infant feeding recommendations, with the goal of reducing any morbidity associated with early introduction of solid foods." The research was supported by the US Food and Drug Administration, Centers for Disease Control and Prevention, Office of Women's Health, National Institutes of Health, and the Maternal and Child Health Bureau in the US Department of Health and Human Services. The authors have disclosed no relevant financial relationships.

Designer Genitalia: Fad, Benefit, or Mutilation?

An Expert Interview With Cheryl B. Iglesia, MD

Editor's Note: "Vaginal rejuvenation" -- or female genital cosmetic procedures, such as "designer vaginoplasty," "revirgination," and "G-spot amplification" -- are currently experiencing an increase in demand among women seeking to modify genital appearance, reclaim a more youthful vulva, or enhance sexual response. A news article published on Medscape reported that "More than 2,140 U.S. women underwent 'vaginal rejuvenation' last year, according to the American Society for Aesthetic Plastic Surgery. The International Society of Aesthetic Plastic Surgeons put the U.S. total at nearly 5,200 in 2010. Experts note such figures do not include the many procedures done by gynecologists." However, this growing trend is troubling to some medical organizations and healthcare professionals that are concerned about the safety, effectiveness, and ethics of these procedures. Medscape explores this issue further with Dr. Cheryl B. Iglesia, a leading expert in urogynecology. Dr. Iglesia is Section Director of Female Pelvic Medicine and Reconstructive Surgery at MedStar Washington Hospital Center and is an Associate Professor of Obstetrics, Gynecology, and Urology at Georgetown University in Washington, DC.

Cheryl B. Iglesia, MD Medscape: Which cosmetic procedures in particular are more likely to be requested? Dr. Iglesia: Most likely to be requested are labiaplasties -- lip reductions, more commonly of the labia minora but sometimes also of the labia majora. Some surgeons are performing

clitoral hood reductions, supposedly to reduce the frenulum -- the skin or prepuce overlying the clitoris -- so that the clitoris is more exposed. I'm concerned about scarring and denervation injury affecting engorgement and a woman's ability to orgasm. Vaginal rejuvenation, generally speaking, encompasses traditional reconstructive procedures, such as anterior and posterior repair, where you dissect certain tissue planes, push back the dropped organs, tighten the connective tissue, trim, and then close. Cosmetic surgeons are doing similar tightening using sutures; however, they also tout the use of a laser, which has not been shown to have significant benefits over traditional scalpel or electrosurgery. And they charge high rates that are not covered by insurance. The bona fide surgical procedures would be covered by insurance if women were evaluated properly and were educated about normal and abnormal vulvar anatomy and pelvic support. Medscape: What reasons might explain why more women now than in the past are considering or choosing to have these procedures? Dr. Iglesia: Mostly it involves 2 things: marketing and media. I also feel that the trend toward pubic hair removal gives people a clearer view of the genital area. Many of the images in the media, and certainly on the Internet and in pornography, feature no pubic hair, and the external genitalia appear to be uniform, almost Barbie-like. We published a study in the November 2012 issue of the American Journal of Obstetrics and Gynecology [1] in which we surveyed approximately 400 women. We divided them into 2 age groups: millennials/Generation X vs baby boomers and older women. Among those who were in their 30s and younger, 84% did some type of waxing, pubic hair grooming, shaving, or laser removal vs only 36% in the older group. In the first Sex and the City movie, one of the women was wearing her bathing suit and her pubic hair was showing. Another character said that she would never be caught dead or in jail looking like that. So I feel that this is a trend or a fad, and certainly many people are getting their information -- or misinformation -- from the many images available in the media. By the way, an increasing trend has also been reported from the National Health Service in England. It's hard to believe the numbers, but they went from 500 cosmetic genital procedures in 2001 to over 2000 procedures in 2010.[2] Medscape: Why is the increasing trend in these procedures a cause for concern, both for healthcare professionals and patients? Dr. Iglesia: It is a cause for concern if women are having these procedures because of feelings of self-consciousness or that they have to adhere to a certain standard. It is also concerning if women feel bad about normal anatomy because of the opinions of others. Women are experiencing downsides of having these procedures, and I have seen some of the complications associated with labiaplasty and vaginal rejuvenation surgeries. Complication rates range anywhere from 4% to 18%. People need to understand that these rates are not small. Complications include pain with sex, bleeding, scarring, and improper healing.

The scarring can be substantial. I had a patient who had a vaginal rejuvenation and labia minora plasty procedure for her lover. She thought it would be a great surprise for him to make her vagina tighter and lips smaller. And now every time they have sex, the posterior vagina rips and causes severe dyspareunia. She has a lot of regret. Most women don't realize that this intimate part is highly innervated and vascularized. In older women, as estrogen levels decline, the labia thin out -- similar to how their lips thin. We don't know the long-term effects for some of these surgeries that are designed to tighten the vagina and can cause scarring. The complications could also be very difficult to repair. Medscape: The fact that these procedures are being done in prepubescent girls is very concerning. Dr. Iglesia: These procedures are marketed heavily, and some of the requests for the procedures are being done for prepubescent adolescents. A study by Crouch and colleagues[3] found labiaplasties being requested for girls as young as 11 years of age. I remember being interviewed by a reporter from Cosmopolitan who said she was at a conference where a doctor was saying that a mother brought in her 16- and 11-year-old daughters and wanted them both done. I was appalled. Yes, this trend is concerning, especially among adolescents. Such children have not even finished puberty. So it's a cause for concern that 11- to 14-year-olds are already so selfconscious about their intimate parts. An image is already being set that something is wrong with them, when it's highly likely that they're completely normal. The overall expectation for labiaplasty procedures is to improve the appearance of the labia minora (the inner lips), mostly for aesthetic reasons but sometimes for functional reasons -ie, the labia are getting in the way of exercise and causing chafing, or obstruction or urination is an issue. How will the changing future of nursing affect your career? Nurses with graduate degrees are needed to take on leadership roles in management, education, and community health. Learn how you can benefit from a BSN or MSN degree Information from Industry The mean labial measurement in one study[4] was 2.6 cm, and the range is anywhere from 7 mm to 5 cm. People don't realize that this wide range is normal. The images in today's media make it look as if the labia minora should be small and not protrude outside of the labia majora, the outer lips. This is just not true. In the majority of women, the labia minora do protrude past the labia majora. Pediatricians, obstetrician-gynecologists, and other clinicians who see adolescent patients need to get the word out that there is a wide range of normal. These girls have not finished developing completely. Providing images of the variety of vulvas may be useful (a good reference is the book Petals [5]). On a side note, some providers, particularly in Australia and New Zealand, want these procedures banned because they consider them akin to female genital mutilation, particularly when the surgery includes clitoral hood reduction.

The Distinction Between Traditional vs Cosmetic

Medscape: How do female genital cosmetic procedures differ from traditional or corrective gynecologic surgeries? Dr. Iglesia: We need to make a big point of this. I am a female pelvic medicine and reconstructive surgeon. "Reconstructive" means that we're putting things back to normal: eg, when the bladder or uterus has dropped, when there is urine leakage, or a woman suffers from bowel control issues. Bona fide vaginal repair surgeries and anti-incontinence operations can treat these conditions, and level-1 evidence is available for them. What cosmetic gynecologists are suggesting is that they don't need to have a medical indication because they are operating on women who are healthy -- nothing is wrong with them. The women just don't like the appearance of their genitals, akin to a woman who doesn't like the appearance of her nose or her breasts. I can respect a woman's right to undergo cosmetic procedures solely for aesthetic reasons. However, many cosmetic gynecologists' Websites have misinformation and false claims about outcomes of these procedures, with either no or very low-quality data to support the marketing claims. For example, these surgeries are being promoted in some cases to improve urinary incontinence or bladder control issues, but there are absolutely no data to support this. Claiming that tightening procedures are going to improve one's sex life also has little supporting evidence. Many components go along with satisfaction from sex, and the emotional, psychological, and physical aspects of sex are much more complex than just making a woman's vagina feel tighter for her partner. In addition, cosmetic procedures cost an average of $4500 and are usually not covered by insurance. Bona fide pelvic reconstructive surgeries have documented evidence for safety and effectiveness and can be performed by urogynecologists or pelvic reconstructive surgeons, gynecologists, or urologists. These procedures are medically indicated and covered by insurance. Furthermore, I'm not 100% certain that women are getting full disclosure about what is normal or about some of the potential risks and adverse events associated with these procedures, not to mention the potential for conflicts of interest for some cosmetic surgeons performing these procedures. Medscape: What is the American College of Obstetricians and Gynecologists' (ACOG's) position on female genital cosmetic procedures?
How will the changing future of nursing affect your career? Nurses with graduate degrees are needed to take on leadership roles in management, education, and community health. Learn how you can benefit from a BSN or MSN degree Information from Industry

Dr. Iglesia: The committee opinion was originally published in 2007.[6] Essentially, ACOG is against procedures that are not medically indicated or do not have significant safety and effectiveness data to support them. Female genital cosmetic procedures fall into this category. The medically indicated surgeries would include repair of genital mutilation or genital cutting; treatment of labial hypertrophy or asymmetry, where one lip is larger than the other; or treatment of congenital conditions or exposure to extra androgen that causes certain organs to grow excessively, such as congenital adrenal hyperplasia, where one has too much testosterone. ACOG feels that it is deceptive to give the impression that vaginal rejuvenation, revirgination, and G-spot amplification are acceptable and routine. The reality is that they're marketed as such, and no evidence-based data have been published to support these procedures. ACOG also is concerned that some kinds of procedures have been "franchised." You have to take a weekend course where you pay tens of thousands of dollars. You're supposed to use a particular laser, and then you can't share any information about these "trademarked" procedures. Such a business model that controls the dissemination of scientific knowledge is troubling, because in medicine, we're not supposed to be secretive. We're supposed to share best practices if they are in the best interests of the patient.
Advising Patients

Medscape: What should clinicians know about female genital cosmetic procedures? Dr. Iglesia: Gynecologists and other clinicians who treat women and girls need to know that these procedures are marketed and that we do not have sufficient data to support them. Although some procedures may be indicated for functional reasons, possible problems that can occur include development of pain, pain with intercourse, scarring, nonhealing, and sexual dysfunction. They also need to know that the sexual response is complex and that body dysmorphic disorders may coexist in the population of patients seeking cosmetic surgery. Taking a good history, asking your patients about what their expectations are and why they're interested in doing this, and trying to rule out an underlying pelvic support disorder or sexual disorder are very important. We need to address a lot of the emotional components as well. A thorough history and physical examination are necessary in order to develop a treatment plan that is going to be acceptable to both the clinician and the patient. But what needs to happen first is that women need to be educated on the anatomy of the vulva and the vagina, and about the wide range of normal anatomy -- in particular, labial variation. Medscape: How should clinicians advise patients who consult them about these cosmetic procedures? Dr. Iglesia: They need to ask open-ended questions about the patient's concerns and understand the reasons why she wants surgery. Find out whether she is in a relationship, and ask whether there are any issues with her partner or whether any domestic violence or sexual abuse is present.

Also, some women might not feel anything during sex because of laxity of connective tissue and weak pelvic floor muscles. We need to figure out whether there is real prolapse and medical indications for reconstructive surgery. A woman may not have to pay the $4500 for the procedure if it's covered by insurance and performed by a good reconstructive pelvic surgeon, general gynecologist, or urologist. There are also concerns about other specialists, such as plastic surgeons, doing these types of procedures because they may not have adequate training in reconstructive pelvic surgery. Medscape: If, after evaluation and counseling, the patient still decides to go forward with one of these procedures, how should the gynecologist or other primary clinician manage the care of this patient?
We can help you achieve your nursing educational goals For more than 27 years, University of Phoenix College of Nursing has been educating nurses. Learn how you can become a nurse leader in your community Information from Industry

Dr. Iglesia: We need to do all of the work-up for sexual dysfunction and conduct a thorough medical examination, both in the sitting and standing positions, to find out whether there's a bona fide prolapse or any functional issues with the bladder or bowel (urinary or fecal incontinence). If the woman is menopausal, she may need vaginal estrogen or lubricant. I always like to advocate for exercise. We also need to evaluate the pelvic floor muscles or connective tissues and ask whether the woman is doing Kegel exercises. Women who have increased body mass index can have more problems with the pelvic floor, particularly bladder control. Weight loss can significantly improve some of those issues. If a patient decides to have this procedure, I would refer her to a reconstructive pelvic surgeon or someone who definitely knows the anatomy down there. And I'd be very wary of physicians who just take weekend courses and then call themselves cosmetic gynecologists. I'd check their credentials.
Importance of Education and Advocacy

Medscape: What could the healthcare community do to support women's relationships with their bodies and help to reverse this trend? Dr. Iglesia: We need to educate women that vulvas are unique and that not everybody has to look like a Barbie doll. Women's health specialists should create campaigns aimed particularly at teens, so that these young women can understand what's normal down there. Displaying contrasting images of normal vulvar anatomy would be useful. The marketing for these procedures has much power over people's perceptions. That women are willing to alter normal anatomy or have these procedures for sexual enhancement is very

disturbing. Even worse, what sells right now in such publications as Playboy and Penthouse and in Internet pornography are prepubescent images. I hope that larger labia and pubic hair return as fads.
2.7 million BSN-prepared RNs will be needed by 2020 There's never been a better time to take advantage of accredited nursing degree programs designed to fit your busy schedule. Prepare for the future now Information from Industry

It's our ethical obligation to listen to our patients and to educate them. Many women are really bothered because they think that they are supposed to look a certain way. And they may have partners who are also telling them that they need to look a certain way. So it's not just about educating women; it's also about educating both men and women. Certainly, "vaginal rejuvenation" sounds sexier than an "anterior repair," but the procedures are essentially identical, and much more evidence is available on the pros and cons of anterior repairs. Shoot, I'd pick "vaginal rejuvenation," but I would vaginally rejuvenate with some bona fide procedures. Resources for Patients The Great Wall of Vagina. Artwork by Jamie McCartney Petals . Nick Karras (Crystal River, 2003) Femalia. Joani Blank, ed. (Last Gasp, 2011)
Cancer and Contraception: Release Date May 2012 SFP Guideline #20121

olonsky M Contraception. 2012;86:191-198

Cancer Treatment and Contraception

Malignant diseases typically are diagnosed later in life. Certain types of cancers, however, are more prevalent in children and young adults. Moreover, some of the cancers that usually are diagnosed in the older population can be detected in young adults as well.[1] Cancer therapy has improved significantly in the past decades. With better understanding of the pathomechanism of most cancers, more effective screening tools have been developed. These tests allow identification of cancer at an early stage, when conservative treatment can be offered and improved survival can be achieved. Therapy for more advanced-stage disease has improved as well. Radiation therapy can be limited to the organ or tumor involved, and damage to otherwise healthy tissue can be

minimized. Chemotherapy is now associated with fewer side effects, and surgical treatments have become more conservative. These developments have resulted in improved survival, and as a result, the number of cancer survivors is increasing. Persons who receive cancer treatment in their reproductive years could remain fertile afterward and will then have to make decisions about birth control or family planning. Chemotherapy and radiation therapy are known to have teratogenic effects. Therefore, contraception must be used during treatment and for at least 6 months after its completion. Many contraceptive methods are available, all of which have different adverse effect profiles. These adverse effects have to be taken into consideration in light of the special needs of the patient with cancer.
Contraceptive Guidelines for Women With Cancer

The Society of Family Planning has issued guidelines about the contraceptive choices of women diagnosed with cancer. The society points out that although chemotherapy and radiation therapy can compromise fertility, many women remain fertile. Antimllerian hormone testing is the best available tool to assess the size of the remaining follicle pool, but pregnancy cannot be ruled out, even with patients with a severely compromised ovarian reserve. The type of cancer and the specific risks posed to the patient will affect her contraceptive options. Hormones are known to play a role in the development of breast cancer; therefore, the use of combined contraceptive pills or progestin-only pills is not recommended in women undergoing treatment for breast cancer. In these women, the copper intrauterine device (IUD) seems to be the best choice. For women who receive tamoxifen as part of their cancer treatment, the intrauterine system (IUS) seems to offer the most benefit. Its use will counteract the proliferative effects of tamoxifen on the endometrium while concurrently providing effective contraception. Cancer increases the risk for thromboembolism. Therefore, estrogen/progestin combined contraception is not recommended during cancer treatment. Current data on progestin-only pills are insufficient to make firm recommendations about its effect on thromboembolism risk. Anemic patients, however, may benefit from the use of combined contraceptive pills because they reduce blood loss at menstruation. The same holds true for the levonorgestrelreleasing IUS. Depot medroxyprogesterone acetate is not recommended for patients with osteoporosis; instead, an estrogen-containing method could benefit such patients. Although not contraindicated, care must be taken with the use of an IUD in immunosuppressed patients. It is equally important to determine whether contraception is associated with an increased risk for cancer. Combined contraceptive pills have been found to be associated with an increased risk for breast cancer, but newer reports have not confirmed this finding.[2,3] Progestin-only pills were not found to be linked to breast cancer. The use of combined contraceptive pills is associated with a reduction in the risks for ovarian and endometrial cancers. The levonorgestrel-releasing IUS also is associated with a lower risk for endometrial cancer.

Viewpoint 2.7 million BSN-prepared RNs will be needed by 2020 There's never been a better time to take advantage of accredited nursing degree programs designed to fit your busy schedule. Prepare for the future now Information from Industry

Improvements in the diagnosis and management of cancer have increased quality of life for patients with cancer both during and after treatment. Many cancer patients are in relationships where sexual activity is part of their lives. Unprotected intercourse can result in pregnancy even when the chance of fertility is considered minimal. Pregnancy may be undesired because of the potential teratogenic effects of cancer treatments, or fear that the pregnancy will negatively affect the course of the cancer. Women undergoing cancer treatment and female cancer survivors are more likely to terminate pregnancy, an action that has psychological and emotional consequences. As a result, it is important to provide appropriate counseling about contraception to these women. Many contraceptive options are available to female cancer patients and survivors, and the choice can be individualized to the patient's circumstances. The type of cancer, the age of the patient, her ovarian reserve, comorbid conditions, and potential noncontraceptive benefits all must be taken into account with this decision. It also should be considered that some of the contraceptive options offer protection against certain types of cancer. With the use of effective and appropriate contraception, women who are undergoing cancer treatment or who have survived cancer can maintain as normal an everyday life as possible without the fear of an undesired pregnancy or of harming their health. Abstract