Algorithm for treatment of premenstrual syndromes (PMS): experts' recommendations and limitations.

The number of women who seek treatment for Premenstrual Syndromes (PMS) is continually increasing. To meet their needs there are many treatment modalities that have been introduced to clinical practice. In order to assist the clinician in choosing treatment for his/her patients, treatment recommendations by experts in the field are not only available but they may also be prioritized and sequenced as treatment algorithm. Such an algorithm for treatment of women with PMS is presented here. The algorithm is the author's summary and common denominator of several experts' consensus building group processes. The strengths as well as shortcomings of the experts' opinions processes are discussed. Substantial clinically-relevant research and assessments are still needed.     

Preparation for childbirth in different cultures

Anthropologically childbirth is an enigma because every woman experiences an identical physiological and biological process, wherever the event takes place: from a hut in the jungle to a modern hospital in the United States. Differences are due to the way that pregnancy, birth and the postnatal period are treated. For most women in developing countries, being a woman means being a mother: a female is not a woman until she has given birth to a child. Therefore during pregnancy she has to follow precise rules and regulations with ritual meanings for her protection and that help her get into the role of a mother. Medicine offers important technological resources for the prevention, diagnosis and treatment of pathology during pregnancy, but with a lack of attention to emotional support. Modern society must try to give pregnant women the trust in their bodies in order to reach the harmony necessary to give birth "willingly" and "with joy".     

Fertility preservation in young women with breast cancer

When a young woman is diagnosed with breast cancer, there is often a sense of urgency by the patient and her providers to initiate treatment. This article provides guidelines for incorporating the discussion of fertility preservation with newly diagnosed young women with breast cancer.     

Drugs for the gynecologist to prescribe in the prevention of breast cancer: current status and future trends

Tamoxifen was approved for breast cancer prevention in October 1998. Thus, for the first time, we as gynecologists are being asked to prescribe this drug to healthy women. In the past each one of us has cared for women with breast cancer who have been treated with tamoxifen by oncologists or breast surgeons for the malignancy. Effects of tamoxifen on the uterus resulting in carcinomas, hyperplasia, and polyps are well known. Furthermore, tamoxifen has estrogenic properties in the venous system, increasing the incidence of deep vein thrombosis and pulmonary emboli. A new SERM (selective estrogen receptor modulator), raloxifene, has been approved for prevention and treatment of osteoporosis in postmenopausal women. It does not have stimulatory effects on the endometrium; however, it is estrogenic in the venous system. Preclinical data, as well as the breast cancer incidence reported in studies of the skeleton, seem to indicate that its effects in the breast are similar to those of tamoxifen. This article reviews tamoxifen and the new SERM, raloxifene, in an attempt to help gynecologists better understand each compound and what data are currently known, what we hope to learn from future studies, and what currently makes sense for clinical practice.     

ASSERTIVE STRATEGIES FOR THE NURSE-MIDWIFE*

In order for the nurse-midwife to provide quality maternity care, it is essential that she utilize assertive strategies in her daily clinical practice. The primary assertive problems that confront the midwife involve resolving differences in philosophy and practice between her and her colleagues and the need for her continuous role definition in relation to colleagues, administrators, and patients. Besides decreasing the midwife's anxiety and increasing her self-esteem in key interpersonal situations, assertiveness can help her meet her goals without interfering with those of others, can assist her to achieve a sense of power since she can more effectively cope with a diversity of situations, can improve her staff relationships and, ultimately, can enhance her growth and learning.     

Mastitis granulomatosa: desafío diagnóstico y terapéutico en paciente joven

Granulomatous mastitis is an uncommon disease that primarily affects young women. It represents a diagnostic and therapeutic challenge, as it might be confused with breast carcinoma. There are no mammographic or ultrasonographic findings that correlate imaging features with histological results. Therapeutic management of this disease can range from simple observation to long-term corticosteroid treatment or surgery. Because granulomatous mastitis is infrequent in clinical practice, there are no standardised protocols regarding the best treatment and follow-up for these patients. We present the case of a women diagnosed in our department, and her treatment and follow-up. We also selectively examine the available literature to support our case.     

Some lessons from Swedish midwives' experiences of approaching women smokers in antenatal care

OBJECTIVE: to describe the qualitatively different ways in which midwives make sense of how to approach women smokers. DESIGN, SETTING AND PARTICIPANTS: a more person-centred national project 'Smoke-free pregnancy' has been in progress in Sweden since 1992. Using a phenomenographic approach, 24 midwives who have been regularly working in antenatal care were interviewed about addressing smoking during pregnancy. FINDINGS: four different story types of how the midwives made sense of their experiences in addressing smoking in pregnancy were identified: 'avoiding', 'informing', 'friend-making', 'co-operating'. KEY CONCLUSION: the midwives' story types about how they approached women who smoke illustrated the difficulties of changing from being an expert who gives information and advice to being an expert on how to enable a woman in finding out why she smoked and how to stop smoking. IMPLICATIONS FOR PRACTICE: health education about smoking that is built on co-operation and dialogue was seen by the midwives as a productive way of working. The starting point should be the lay perspective of a woman, which means that her thoughts about smoking cessation are given the space to grow while she talks.     

Views on involving a social support person during labor in Zambian maternities

Because social support persons are excluded from modern obstetric care in Zambia, the aim of this study was to explore the views of 84 mothers and 40 health staff about allowing women to be attended by a supportive companion during labor in Zambian urban and rural maternities. Most of the mothers wanted a companion present to provide emotional and practical support. Those who were opposed to the idea had nobody to ask to be with them, or they had relatives who would interfere with the care provided. All health staff cited hospital policy as the principal reason for prohibiting social support persons from staying with laboring women. They also said that the health staff's role is to care for laboring women, and they worried that social support persons could interfere with their work by giving the laboring women traditional medicine. However, most health staff also said that a social support person could help the laboring women and give her a sense of security. The study concludes that Zambian maternity staff should be exposed to new research findings about the benefits of social support during childbirth and that this practice should be encouraged in Zambia. Ultimately, it should be the laboring woman who decides whether she wants to bring a social support person to the labor ward.     

Caring for Women Experiencing Breast Engorgement: A Case Report

Breast engorgement is an uncomfortable and sometimes painful component of the postpartum period. The effective treatment of breast engorgement may provide an avenue for clinicians to improve postpartum care for women and promote breastfeeding. This case report presents one woman's experience with breast engorgement in the early postpartum period. The etiology, evidence‐based practices for treatment, clinical implications, and recommendations for practice are reviewed. The importance of interprofessional care to minimize conflicting information a lactating woman receives is highlighted. Interprofessional teamwork can optimize care to resolve breast engorgement and facilitate a woman achieving her breastfeeding goals.     

One-to-one midwifery: restoring the "with woman" relationship in midwifery

One-to-One Midwifery, a model of care developed in the United Kingdom, provides a continuous and personal relationship between each woman and her midwife. The organization of care and the outcomes are relevant to midwifery policy in all industrialized countries. One-to-One Midwifery is not solo practice. An important principle of the organization of the practice is to enable individual midwives to take time off and to provide supportive structures for the midwives. Here the implications of One-to-One Midwifery for childbearing women and their families, and the midwives involved, are explored. The One-to-One Midwifery model has particular relevance for Canada because it is very similar to the model of practice being developed in at least two provinces. It may also be of importance in the United States, particularly for midwives working shifts in hospitals who may want to develop a system that allows them to provide continuity to the women they serve.     

Recurrent spontaneous early pregnancy loss and low dose aspirin

Miscarriage is the most common complication of pregnancy, occurring in 10-15% of pregnant women. Accurate figures on prevalence are not available but it has been estimated that 2-5% of women have 3 or more miscarriages. The lack of methodological rigour in controlled trials of treatment efficacy in women with recurrent miscarriage makes it difficult to estimate the efficacy of treatment for this condition. To date, there is no evidence of improved outcome with aspirin compared to placebo or no treatment. Furthermore, animal data and limited human data suggest that prenatal use of aspirin may be associated with increased bleeding tendency, congenital malformations and cognitive and behavioural defects in the offspring. Seen and considered the lack of efficacy of low-dose aspirin and the potential for harm to the female and her offspring, the practice of recommending aspirin to women with recurrent miscarriage should be discontinued.     

A passion for nursing. In memoriam of Dr. Sharron Smith Humenick

As epidural and cesarean rates climb, a nurse leader provides a model for effective advocacy for normal birth and supportive care for women and their infants. Dr. Sharron Smith Humenick had a passion and devoted her life to providing women with adequate support for natural, empowering birth and successful breastfeeding. Lessons from her life's work can inspire nurses in our specialty to be tireless and passionate advocates in practice, education, and public policy for supportive nursing care. Dr. Humenick died on September 9, 2006.     

Pain aspects in oocyte aspiration for IVF

The aim of this observational two-centre study was to investigate different aspects of pain in oocyte aspiration in conjunction with IVF, whether the preoperative information to women was sufficient, and which factor(s) influenced a woman's sense of security. The study group comprised 124 women who underwent IVF treatment. The visual analogue scale (VAS) was used to measure pain, and multiple-choice questions were used to evaluate satisfaction and sense of security. The women rated expected pain significantly higher than mean pain during surgery (P < 0.0001). They would have accepted significantly more pain than they experienced (P < 0.0001). In a stepwise linear regression analysis, total dose of alfentanil was the only variable that was independently associated with mean pain. Satisfaction with the preoperative information was high. Women considered staff competence to be important for their sense of security. In conclusion, women rated oocyte aspiration to be less painful than they expected before surgery. This is important information for women who are about to start IVF treatment, since it might reduce apprehension about the level of pain that could be expected during oocyte aspiration.     

Maternal Confidence in coping with labor A Self-Efficacy Concept

The clinical study of labor pain suggests that a woman's confidence in her ability to cope with labor contributes significantly to her perception of pain during labor. Self-efficacy theory is examined as a framework for evaluating women's confidence in their ability to cope with labor. The major propositions of self-efficacy theory are described and related to the experience of women approaching labor. The implications for nursing practice are presented, and directions for the study of maternal confidence are proposed.     

Doctors and their resistance to abortion

Complex motivations for abortion not perceived by some doctors, the scale and reality of abortion in medical practice, unconscious fantasies experienced by some abortionists, and the reactions of general practitioners, psychiatrists, and gynecologists to abortion are discussed. Most women are in a state of acute stress when they request abortion, psychological suffering based on normal ambivalence or sometimes on personality problems. Some doctors are incapable of accepting pluralism, of separating morality from psychology, and do not realize the numbers of abortions being performed. Some analysts have found voyerism, exhibitionism, aggression, oedipal conflicts and manicheanism inherent in the act of abortion by a male operator. General practitioners, usually the 1st to be approached, see a panicked woman ready to agree to anything in order to convince the doctor to grant her an abortion; they often respond by treating her as a symptom. Psychiatrists may range from very analytical to perfunctory in signing the required form. They are faced with the paradox that only healthy women can handle an abortion, but only in neurotic women are abortions justified. Gynecologists have problems because abortion patients rarely return for other care, forcing them to perform abortion procedures only. Some develop depression, hypersexuality, or even become opposed to abortions.     

The case for routinely offering prenatal testing for human immunodeficiency virus

Infections with human immunodeficiency virus are becoming increasingly common among women of reproductive age. The consequences of these infections on maternal and child health are substantial. Evidence has been published that suggests that testing only those women recognized as being at risk through physician-elicited, patient-volunteered testing programs will fail to identify substantial numbers of infected patients. This article develops the arguments that informing infected women of their serologic status is of critical importance and that in clinical practice identification of women with sexually transmitted diseases such as human immunodeficiency virus can only be accomplished with routine testing (with consent, confidentiality, and counseling).     

Obstetrical delivery of the HIV-positive woman: legal and ethical considerations

Every year, thousands of perinatally HIV-infected children are born, resulting in debate about appropriate HIV treatment and interventions for pregnant women. Recent medical studies endorse the use of the cesarean delivery to reduce vertical (mother to infant) transmission of HIV. In addition to medical questions, this practice raises legal and ethical considerations for the attending physician. In the context of AIDS prevention, the potential exists for reasoned and well-informed decision making to give way to encouragement, and even duress, in cases where a woman refuses recommended surgical delivery. However, in such cases, the role of the physician should remain as that of an informed educator and counselor, enabling the patient to exercise her autonomy and personal choice within her social and cultural context.     

Alcohol abuse in women seeking gynecologic care

In several retrospective studies, alcoholic women have reported menstrual problems significantly more often than nonalcoholic women. There is no information, however, comparing the prevalence of alcohol abuse in women who receive periodic gynecologic care and those who seek care for menstrual disorders such as the premenstrual syndromes. This question was studied in two private practice settings. Women seeking periodic care were obtained from a suburban, general gynecology practice. Women seeking treatment for premenstrual syndrome (PMS) were obtained from a practice that specialized in the care of PMS. Ninety-five patients with PMS and 147 patients seeking periodic care were screened with the CAGE questions--a mnemonic for attempts to Cut back on drinking, being Annoyed at criticism about drinking, feeling Guilty about drinking, and using alcohol as an Eye-opener. Women who gave affirmative responses to one or more of the CAGE questions were evaluated for the presence of alcohol abuse. In the women seeking periodic care, 33% were CAGE positive and 12% were alcohol abusers. In the PMS practice, 51% were CAGE positive and 21% were alcohol abusers. Alcohol abuse is a common problem in gynecologic practice. Women who seek medical care for PMS are at much greater risk to be alcohol abusers.     

Comprehensive health care for women in a public hospital in S?o Paulo, Brazil.

This paper describes a model of integrated reproductive health care services for women at the primary health care level, put into practice at the Pérola Byington Hospital, S?o Paulo, Brazil, from 1991 to 1998. Some 2,000 women from poor social strata, whose health condition was poor, were being seen every day in the last two years of the programme, including new consultations and women with a previous attendance returning. Women were attended first by nurse-assistants, who had been trained to screen for the most frequent gynaecological problems, and then a physician. Because doctors spent less time with each patient, four times as many women could be seen. Programmes were set up for the diagnosis and treatment of gynaecological cancers, STDs, HIV/AIDS, hypertension and other degenerative disorders such as diabetes. Screening and treatment programmes for cervical and breast cancer achieved significant improvements in the stage at which a diagnosis was made, allowing more lives to be saved. This model also succeeded in decreasing the costs for these health services per woman seen.