T o p 10ish Wo me n s He a lth o r to pic s in the ne ws Mo stly - - PDF document

T

• p 10ish Wo me n’ s He a lth

Artic le s o f 2015-16

Re b e c c a Ja c kso n, MD Ob ste tric s, Gyne c o lo g y a nd Re pro duc tive Sc ie nc e s UCSF

Pre vie w Artic le s tha t mig ht c ha ng e pra c tic e

• r to pic s in the ne ws

Mo stly g yn, a little o b Bre a d a nd b utte r: me no pa use , dyspla sia , c o ntra c e ptio n, misc a rria g e Me no pa use : 3 studie s

in the subg roup of young e r wome n… .

MHT (a ka HRT ) a nd CVD in yo ung e r me no pa usa l wo me n

Me ta -a na lysis o f RCT s lo o king a t sub g ro up who sta rte d MHT le ss tha n 10 ye a rs a fte r me no pa use Ora l o nly (tra nsde rma l no t e va lua te d) 5 tria ls a nd 9088 pa rtic ipa nts

De a th (a ll c a use ): De c re a se d 30%, NNT 146 Co ro na ry He a rt Dise a se : De c re a se d 48%, NNT 133

Summa ry o f b e ne fits a nd ha rms in yo ung e r wo me n

NNH: 214 NNH: 133 NNH: 146

Bo tto m L ine : HRT in yo ung e r po stme no pa usa l wo me n a ppe a rs to re duc e mo rta lity a nd CVD b ut with a n inc re a se in VT E a nd stro ke . No t re c o mme nde d fo r pre ve ntio n o f he a rt dise a se due to risks Ca ve a t: T he fo llo w-up time is lumpe d (ra the r tha n ye a r b y ye a r). So me e vide nc e sug g e sts a n e a rly inc re a se in CVD in pre dispo se d wo me n.

 80% o f wo me n e xpe rie nc e va so mo to r sx (VMS), mo st ra te the m mo de ra te to se ve re  Olde r studie s a nd g uide line s re po rte d VMS c o ntinue 6 mo s to 2 yrs a fte r L MP  2 o utc o me s: to ta l dura tio n o f fre q ue nt VMS (pe rime no pa use inc lude d) a nd dura tio n a fte r me no pa use .  F re q ue nt VMS= 6 o r mo re da ys in 2 wk pe rio d; ho t fla she s o r nig ht swe a ts

VMS=va so mo to r sympto ms

SWAN: Stud y o f Wo me n’ s He a lth Ac ro ss the Na tio n 17yr c o ho rt o f 3300 multi-ra c ia l/ e thnic wo me n e nro lle d a t 42-52 yo , e xc luding me no pa usa l, o n o c p o r hrt, hyste re c to my

 T

• ta l VMS dura tion: 7.4 ye a rs, a fte r L

MP 4.5 ye a rs

(ie 2 yrs VMS while pe rime no pa usa l, 5 mo re ye a rs a fte r me no pa use )

 Onse t o f VMS: I f VMS sta rt during pre o r e a rly pe rime no pa use —lo ng e r o ve ra ll dura tio n (>11.8 yrs!); if sta rt a fte r me no pa use , sho rte r dura tio n (3.4 yrs)  Ra c e / E thnic ity: AA wo me n ha d lo ng e st dura tio n (10 yrs); Ja pa ne se a nd Chine se wo me n ha d the sho rte st 4.8 a nd 5.4 ye a rs, re spe c tive ly). No n-Hispa nic White =6.5; Hispa nic =8.9  Dura tio n inc re a se d with stre ss, de pre ssio n/ a nxie ty, yo ung e r a g e , lo we r e duc

VMS=va so mo to r sympto ms SWAN: Study o f Wo me n’ s He a lth Ac ro ss the Na tio n: 17yr c o ho rt o f multi- ra c ia l& e thnic wo me n e nro lle d a t 42-52 yo

Ho w o fte n do yo ur pa tie nts c o mpla in tha t me no pa use is c a using mo o dine ss, de pre ssio n, irrita b ility o r de c re a se d a b ility to c o nc e ntra te o r pe rfo rm? Is HRT

the a nswe r?

F

• r Co g nitio n: No . (no sig diff in a ny

c o g nitive o utc o me ) F

• r Mo o d: Ma yb e , mo de st impro ve me nt

in so me sx, fo r o ra l E +P o nly (impro ve d sx

• f a nxie ty, de pre ssio n, a ng e r)

K E E PS: K ro no s E a rly E stro g e n Pre ve ntio n Study

RCT

• f o ra l o r

tra nsd e rma l E +P vs pla c e b o in re c e ntly me no pa usa l wo me n, n=693, 4 yrs f/ u

Ala K a ha ka i T ra il

Anc ie nt Ha wa iia n T ra il Ac c e ss it a t le ft side o f b e a c h—wa lk inla nd a lo ng ro c ks a nd yo u will se e it Go e s to Be a c h 69 (25 min) a nd b e yo nd to Pua ko (1 hr) Ho t, ro c ky, lo o k fo r c a irns to find tra il in pla c e s

 ~20% o f tho se infe c te d b e c o me ill.  Inc ub a tio n fe w da ys to 2 wks. (4-10 da ys)  Co mmo n Sx: a c ute o nse t o f fe ve r, ma c ulo pa pula r ra sh, a rthra lg ia , c o njunc tivitis (50%); L e ss c o mmo n: mya lg ia , he a da c he , re tro o rb ita l pa in, pruritus, a nd vo miting  T ypic a lly mild a nd la sts se ve ra l da ys to 1 we e k.  Guilla in-Ba rre -po ssib le b ut ra re . (<<1% o f infe c te d)

Othe r mo de s o f tra nsmissio n= ma te rna l-fe ta l, b lo o d tra nsfusio n, se xua l (ma le to fe ma le o nly)

Re ma ins a live in se me n up to 62 da ys

De te c tio n: RT

• PCR fo r vira l RNA, a ntig e n o r

a ntib o die s

T e st within 1 wk o f sx (vira l c le a ra nc e c a n o c c ur in 7 da ys) T e sts pe rfo rme d a t CDC a nd limite d sta te DPH’ s. Up to da te info a t CDC we b site

As o f july 6 Ge t upda te a t CDC: http:/ / www.c d c .g o v/ zika / g e o / a c tive -c o untrie s.html

Ra pidly c ha ng ing re c o mme nda tio ns: g o to CDC fo r la te st info

Pre g na nt wo me n a nd Zika

No t a t inc re a se d risk o r se ve rity whe n pre g na nt Ma te rna l-fe ta l tra nsmissio n c a n o c c ur a ny time F e ta l e ffe c ts: mic ro c e pha ly, b ra in a tro phy, ve ntric ula r e nla rg e me nt, intra c ra nia l c a lc ific a tio ns. (Po ssib le : o c ula r de fe c ts, sc a lp rug a e ,

jo int c o ntra c ture s.) Usua lly c a nnot dia g nose until a fte r la te 2nd T

ri

DE E T & pic a ridin sa fe thro ug ho ut pre g na nc y If ma le pa rtne r po te ntia lly e xpo se d c o ndo ms thro ug ho ut pre g na nc y (a nd 6 mo nths prio r to c o nc e ptio n)

NEJM July 7 Risk o f mic ro c e pha ly g re a te st with infx a t <18wks, Risk o f mic ro c e pha ly 1- 13%

Wha t’ s missing in the CDC a dvic e ? ……Ro le o f a b o rtio n

“How would the re sults of a mniotic fluid te sting for Zika virus inform c linic a l ma na g e me nt of pre g na nt wome n?

A po sitive Zika virus RT

• PCR re sult fro m a mnio tic fluid

wo uld b e sug g e stive o f intra ute rine infe c tio n. T his info rma tio n wo uld b e use ful fo r pre g na nt wo me n a nd the ir he a lth c a re pro vide rs to a ssist in de te rmining c linic a l ma na g e me nt (e .g ., a nte pa rtum te sting , sc he duling se ria l ultra so unds, de live ry pla nning ).“

Wha t’ s missing in the CDC a dvic e ? ……Ro le o f a b o rtio n

 So no g ra phic e vide nc e o f fe ta l tra nsmissio n

• c c urs la te in 2nd trime ste r, e a rly 3rd trime ste r.

T

• o la te fo r le g a l a b o rtio n in mo st sta te s

 No std de finitio n o f mic ro c e pha ly, unc le a r ne uro c o g nitive o utc o me b a se d o n he a d size  T he re fo re , diffic ult to c o unse l wo me n o r re c o mme nd a b o rtio n  None the le ss, in US, a bortion should be

disc usse d a s a n option (no t re c o mme nde d ,

just disc usse d) a fte r suspe c te d Zika e xpo sure e ve n witho ut c o nfirma to ry te sting o r wa iting to ha ve so no e vide nc e o f fe tus b e ing a ffe c te d Why isn’ t a nyo ne ta lking a b o ut a b o rtio n?

Just this we e k… A link o n ACOG’ s we b site (b ut its a b o ut a b o rtio n in

• the r c o untrie s).

Still no thing a b o ut it in the ir a lg o rithms

Zika virus outbre a k: re pr

• duc tive he a lth a nd

rig hts in L a tin Ame ric a .

L a tin Ame ric a n he a lth ministe rs re c o mme nde d po stpo ning pre g na nc y fo r 6 mo nths to 2 ye a rs  56% o f pre g na nc ie s in the re g io n a re uninte nde d  L a rg e g ro ups o f wo me n do no t ha ve c o ntro l o ve r the ir se xua l a nd re pro duc tive live s due to …“ Po o r q ua lity o f se x

e d uc a tio n, po o r a c c e ss to c o ntra c e ptio n, hig h pre va le nc e o f ra pe , a nd c ultura l b a rrie rs tha t ma ke it d iffic ult fo r wo me n to ne g o tia te the use o f c o ntra c e ptio n with the ir pa rtne rs.”

 …”a nd the ir ho using a nd lo c a l e nviro nme nts dispro po rtio na te ly e xpo se the m to a re a s tha t a re b re e ding

g ro unds fo r mo sq uito e s.  “If g o ve rnme nts d o no t ta ke this o ppo rtunity [to impro ve a c c e ss to c o ntra c e ptio n], the Zika virus will no t o nly b e a pub lic he a lth

issue , b ut a lso e xa c e rb a te e xisting g e nde r ine q ua litie s a nd

so c ia l injustic e .

Mo nic a Ro a , L a nc e t, 2016

NE L HA: Na tura l E ne rg y L a b o f Ha wa ii

Just pa st a irpo rt Re se a rc h a nd inc ub a to r fa c ility T

• urs: 10:00a m M-F

Buy tix o nline

Ne w pa tho lo g ic a nd limite d e pide mio lo g ic e vide nc e sug g e sts e pithe lia l o va ria n c a nc e r a rise s fro m the F a llo pia n tub e , no t the o va ry

Ob se rva tio na l studie s sho w de c re a se d o va ria n c a nc e r in wo me n who ’ ve ha d prio r tub a l lig a tio n

T his is a ve ry la rg e , po pula tio n-b a se d study in Swe de n fro m 1973-2009 to e va lua te g yn surg e ry fo r b e nig n re a so ns a nd risk o f o va ria n c a nc e r

 L inka g e s o f Swe dish na tio nwide he a lth re g iste rs o f a ll re side nts b e twe e n ho spita l a dmissio ns,

• pe ra tio ns, c a nc e r re g istry, de a th re g istry

 Surg e ry fro m1973 to 1997  251,500 wo me n with surg e ry, 5.5M witho ut

81,658 ste riliza tio n 34,400 with sa lping e c to my, o nly 3051 b ila te ra l Numb e rs do n’ t a dd up: “3051 wo me n we re ide ntifie d with two -side d sa lping e c to my a nd 19552 with o ne -side d sa lping e c to my”

Any sa lping e c to my a sso c with 33% de c re a se d risk o f o va ria n c a nc e r.

Unila te ra l 27% de c re a se ; b ila te ra l 54% de c re a se

Ste riliza tio n simila r with a 31% de c re a se Mo unting e pide mio lo g ic e vide nc e tha t tub a l lig a tio n o r sa lping e c to my de c re a se risk o f

• va ria n c a nc e r

Ca utio n Sho uld we re c o mme nd this witho ut pro spe c tive studie s o r b e tte r ye t, c linic a l tria ls?

Wha t is risk o f sa lping e c to my? (e g inste a d o f a tub a l lig a tio n o r a t the time o f a hyste re c to my) Do e s a dding a sa lping e c to my to a hyste re c to my c ha ng e the ro ute o f hyst to a riskie r o ne (e g fro m va g hyst to la pa ro sc o pic o ne )

Misc a rria g e Pre ve ntio n/ Ma na g me nt

PROMI SE : Pro g e ste ro ne in Re c urre nt Misc a rria g e s

 Misc a rria g e is c o mmo n: 15-25% o f re c o g nize d pre g na nc ie s a nd a sso c ia te d with g rie f—mo re so tha n we o fte n re a lize

 Re c urre nt misc a rria g e , 3 o r mo re , muc h le ss c o mmo n a t 1-2%. Only 50% ha ve id e ntifia b le c a use

 L ute a l pha se supple me nta tio n is b e ne fic ia l fo r wo me n unde rg o ing I VF

• r I

UI with g o na do tro pic stimula tio n  F

• r ye a rs, pa tie nts ha ve b e e n g ive n pro g e ste ro ne to

pre ve nt misc a rria g e in spo nta ne o us pre g na nc ie s de spite a la c k o f e vide nc e a nd no g uide line s re c o mme nding this  One sma ll me ta -a na lysis o f 4 sma ll, me tho do lo g ic a lly c ha lle ng e d studie s re ve a le d a po ssib le b e ne fit in pre ve nting re c urre nt misc a rria g e

PRO MISE: Prog e ste rone in Re c urre nt Misc a rria g e s; 36 site s in UK a nd Ne the rla nds; n=836; va g ina l mic ro nize d pro g e ste ro ne vs pla c e b o ; <=6 wks thro ug h 12 wks, b linde d; Outc o me =live b irth

All wo me n ha d a t le a st 3 prio r SAb Re sults- L

ive birth ra te: 66% pro g e ste ro ne g ro up 63% pla c e b o g ro up RR 1.04 (0.94-1.15)

Bottom L

ine : E

ve n in wo me n with 3 prio r sa b s, c ha nc e o f live b irth is >60% AND pro g e ste ro ne do e sn’ t impro ve tha t Se c o nda ry a na lysis o f the E ffe c ts o f Aspirin in Ge sta tio n a nd Re pro duc tio n tria l 1,083 wo me n a g e d 18–40 ye a rs with o ne to two prio r e a rly lo sse s F

• llo we d fo r up to six me nstrua l c yc le s a nd, fo r

wo me n a c hie ving pre g na nc y, until pre g na nc y

• utc o me .

E AGe R, E ffe c ts

• f Aspirin in

Ge sta tio n a nd Re pro duc tio n

Co uple s with a sho rte r “inte r-trying inte rva l” ie 0–3- mo nth inte rva l (n=765 [76.7%]) vs g re a te r tha n 3-mo nth (n=233 [23.4%]) ha d:  Hig he r live b irth ra te (53% vs 36%, p<0.001)  Sig nific a ntly sho rte r time to pre g na nc y le a ding to live b irth (me dia n 5 c yc le s, ra ng e 3-8)  Hig he r fe c unda b ility OR 1.71 (1.3-2.2)  No diffe re nc e in o b o utc o me s fo r wo me n who a c hie ve d pre g na nc y

Bottom L

ine : Ok to a tte mpt pre g na nc y a s so o n a s

e mo tio na lly re a dy

E AGe R, E ffe c ts

• f Aspirin in

Ge sta tio n a nd Re pro duc tio n

K a lo pa Sta te Pa rk

Sho rt na ture hike

• r up to 5 mile s

Ne a r Ho no ka ’ a , 15 mile s pa st Wa ime a

F a mily Pla nning

L e g isla tive Histo ry

• 1. In 2011, le g isla ture c ut F

P b udg e t b y 66% a nd re -a llo c a te d to o the r pro g ra ms82 F P c linic s c lo se d

• 2. In 2011, c re a te d 3 tie re d prio rity syste m fo r

a llo c a ting re ma ining funds suc h tha t spe c ia lize d F P c linic s we re in lo we st tie r

• 3. In 2013, c re a te d sta te -funde d pro g ra m (to

re pla c e fe de ra lly-funde d pro g ra ms) tha t e xc lude d o rg a niza tio ns a ffilia te d with a b o rtio n pro vide rs the re b y e xc luding a ll PP a ffilia te s

E xc lusio n o f Pla nne d Pa re ntho o d in sta te a dministe re d , fe de ra lly funde d fa mily pla nning pro g ra ms ha s b e e n a do pte d o r pro po se d in 17 sta te s a nd the US c o ng re ss. T e xa s wa s the first to e na c t a nd e nfo rc e suc h a la w.

T he impa c t o n F P se rvic e s in T e xa s  25% o f sta te ’ s fa mily pla nning pro g ra ms c lo se d, 31% re duc e d se rvic e ho urs  F unding : Spe c ia lize d F P c linic s ha d 75% de c re a se in sta te funds. Othe r c linic s o ffe ring F P se rvic e s a lso sa w a 50% de c re a se in funding .  L ARC a c c e ss: In 2011, 71% o f c linic s o ffe re d L ARC; in 2013: 46%  Co nfide ntia l se rvic e s fo r a do le sc e nts: 19% fe we r c linic s  Pa tie nts se rve d: 54% fe we r

Pub lic a lly funde d fa mily pla nning c linic s a re a ke y c o mpo ne nt

• f the he a lth c a re

sa fe ty ne t fo r lo w- inc o me wo me n in the US.

F unding c uts a ffe c te d b o th F P-o nly c linic s (T ie r 3) a nd DPH a nd F QHC prima ry c a re c linic s (T ie r 1/ 2)

T he impa c t o n wo me n’ s he a lth in T e xa s  Co ntra c e ptio n use

L ARC : 36% de c re a se DMPA : 31% de c re a se OCP e tc : no c ha ng e

 In wo me n using DMPA:

On-time re -inje c tio n 57% in 2011 to 38% in 2013 in c o untie s with PP (slig ht inc re a se in c o ntro l c o untie s) Me d ic a id fund e d b irths within 18 mo nths inc re a se d 1.9% (27% re la tive inc re a se ) in c o untie s with PP; it de c re a se d in c o ntro l c o untie s

Be c a use o f c ha ng e s in funding o f F P se rvic e s, lo w inc o me wo me n’ s c ho ic e s o f c o ntra c e p tio n a re no w c o nstra ine d b y the spe c ific funding so urc e fo r the ir c a re .

L ARC (IUD, Ne xpla no n) a re use d le ss fre q ue ntly in US tha n o the r c o untrie s (9% vs 23% in F ra nc e ) OCP’ s (fa ilure ra te o f 9%) a nd c o ndo ms (fa ilure ra te 18%) a re mo st c o mmo nly Rx’ d me tho ds IUD’ s g e ne ra lly o ffe re d to re stric te d sub g ro up (pa ro us, ma rrie d) ra the r tha n b ro a dly to yo ung wo me n a t risk (a do le sc e nt, nullipa ro us)

RCT

• f 40 PPF

A c linic s in US. Clinic s ra ndo mize d to re c e ive o r no t re c e ive ½ da y tra ining to inte g ra te I UDs a nd impla nts into ro utine c o ntra c e p tive c a re . Prima ry o utc o me : use

• f L

ARC, 2nda ry: pre g na nc ie s within 12 mo nths. N=1500 wo me n

 Mo re c o unse lling a b o ut L ARC (71% vs 39%)a nd g re a te r upta ke o f L ARC (28% vs 17%; OR 1.9 (1.3-2.8)  Pre g na nc y ra te : 15 pe r 100-py vs 18.5 in c o ntro l g ro up (no t sig ). But:  Pre g na nc y ra te muc h hig he r in a b o rtio n c linic s vs F P c linic s. Stra tify b y type o f c linic :

 F

P c linic s: 7.9 vs 15.4 pe r 100 pe rson ye a r (py); HR 0.54 (0.34- 0.85)

Ab c linic s: 26.5 vs 22.3; HR 1.35 (0.9-2.0) NS

 Bottom line : If we wa nt to de c re a se uninte nde d pre g na nc y, we ne e d to b e a b le to o ffe r imme dia te a c c e ss to full ra ng e o f c o ntra c e ptio n, inc luding L ARC

99% o f wo me n in b o th g ro ups re po rte d a uto no my in de c isio n L ARC no t a s re a dily a va ila b le in Ab c linic s vs F P c linic s b / c o f la c k o f sub sidize d c o ntra c e p tio n. Of wo me n c ho o sing L ARC, 44% c o uld

• b ta in a t Ab c linic vs

73% a t F P c linic

Pla te lunc h, lo c o mo c o , a nd ma la sa da s

Ho no ka a , pa st Wa ime a

• n the wa y to Hilo o r

Wa ipio Va lle y

Dyspla sia : Prima ry HPV sc re e ning

3 sc re e ning stra te g ie s

• 1. “Cyto lo g y”: Cyto lo g y w re fle x HPV fo r a sc us
• 2. “Hyb rid”: # 1 fo r 25-29 yo a nd c o te st fo r

>=30yo (c urre nt US stra te g y)

• 3. “HPV prima ry” fo r >=25yo . Alg o rithm:

 Ne g HPVre sc re e n 3 yr  +16/ 18 c o lpo  + o the r type s c yto lo g y

Ba se line : 10% HPV+; 6% po sitive c yto lo g y

AT HE NA: Ad dre ssing the Ne e d fo r Adva nc e d HPV Dia g no stic s 3 yr c o ho rt study lo o king a t va rio us sc re e ning stra te g ie s. N=41K >25yo . Pa p plus c o b a s HPV. Co lpo if e ithe r a b no rma l. Co lpo w/ b io psy a t study e nd. E ndpo ints: CI N2+ de te c tio n, numb e r sc re e ning te sts a nd c o lpo s Co b a s HPV: 3 se pa ra te re sults fo r hpv 16, 18 a nd 12 o the r hig h risk type s

 Prima ry HPV stra te g y ha d hig he r se nsitivity tha n c yto lo g y a nd hyb rid b ut lo we r spe c ific ity

Inc re a se d se nsitivity o f prima ry HPV stra te g y due to e a rlie r initia tio n o f HPV sc re e ning (25yo fo r prima ry HPV g ro up, 30yo fo r hyb rid g ro up)

 Prima ry HPV stra te g y ha d mo re c o lpo sc o pie s c o mpa re d with c yto lo g y b ut simila r to hyb rid stra te g y  Cyto lo g y ha d the lo we st numb e r o f sc re e ning te sts fo llo we d b y HPV prima ry the n hyb rid stra te g y

AT HE NA: Ad dre ssing the Ne e d fo r Adva nc e d HPV Dia g no stic s 3 yr c o ho rt study lo o king a t va rio us sc re e ning stra te g ie s. N=41K >25yo . Pa p plus c o b a s HPV. Co lpo if e ithe r a b no rma l. Co lpo w/ b io psy a t study e nd. E ndpo ints: CI N2+ de te c tio n, numb e r sc re e ning te sts a nd c o lpo s Co b a s HPV: 3 se pa ra te re sults fo r hpv 16, 18 a nd 12 o the r hig h risk type s

 A ne g a tive hrHPV te st pro vide s g re a te r re a ssura nc e o f lo w CIN3+ risk tha n a ne g a tive c yto lo g y re sult  Ca n prima ry hrHPV sc re e ning be consider ed a s a n a lte rna tive to c urre nt

U.S. c e rvic a l c a nc e r sc re e ning me thods? Ye s o nly fo r >=25yo a nd no t

ye t re c o mme nde d in ma jo r g uide line s  How should one ma na g e a positive

hrHPV re sult? Se e a lg o rithm

 Use o nly the F DA a ppro ve d Co b a s te st

>=3 yrs No t spe c ifie d ho w, c o te st?

Que stio ns re ma in: prima ry HPV sc re e ning

 Any stra te g y tha t inc lude s HPV sc re e ning inc re a se s the numb e r o f po sitive re sults a nd numb e r o f c o lpo sc o pie s pe rfo rme d.

Ne e d c o mpa ra tive e ffe c tive ne ss studie s tha t c o nside r life time numb e r o f sc re e ning te sts, c o lpo s, fo llo w-up visits a nd c o st c o mpa riso ns

 Unc le a r why the re c o mme nda tio n to do prima ry HPV sc re e ning a t >25yo whe n USPST F re c o mme nds a g a inst a ny HPV te sting in <30yo (“D” g ra de )  L

• ng -te rm o utc o me s re ma in unc e rta in. (studie s o nly

3-5 yrs. AT HE NA o nly o ne sc re e ning ro und)  Give n stro ng po te ntia l fo r b ia s due to study spo nso rship b y Ro c he , sho uld we wa it fo r mo re studie s b e fo re a do pting ?

Role of the sponsor Ro c he Mo le c ula r Syste ms, Ple a sa nto n, CA wa s invo lve d in a ll a spe c ts

• f the de sig n a nd c o nduc t
• f the study; c o lle c tio n,

ma na g e me nt, a na lysis, a nd inte rpre ta tio n o f the da ta . Ca the rine Be hre ns a nd Ab ha Sha rma who a re Ro c he e mplo ye e s we re inte g ra l to the pre pa ra tio n

• f the ma nusc rip t a nd the

spo nso r re vie we d the fina l ma nusc rip t.

sna psho ts

 USPST F —de pre ssio n sc re e ning no w re c o mme nde d in a ll pre g na nt wo me n  OCP no t a sso c ia te d with b irth de fe c ts  L e tro zo le no b e tte r tha n c lo mid fo r o vula tio n induc tio n  CDC re c o mme nds te st o f c ure fo r wo me n with T ric ho mo na s infe c tio n  F e rtility drug s no t a sso c ia te d with de ve lo pme nt o f b o rde rline o va ria n tumo rs b ut pro g e ste ro ne use wa s (RR 1.8 fo r a ny use , 2.6 fo r >4 c yc le s)

Que stio ns?