Osteoporose – Prävention: warum und wie?

Osteoporosis is a common and debilitating disease. Targeted prevention would avoid bone fractures, and loss of mobility and quality of life. Influencing factors on bone density are already active in premenopausal women: hormonal factors, exercise, dieting, weight, and medications with negative influences on bone density are important. Minimal trauma fractures and low bone density should prompt gynecologists to consider treatments to prevent osteoporosis. Specific osteoporosis therapy, including hormone therapy if needed, should be selected individually for each patient.     

Hormontherapie um die Menopause Ein aktueller Blick

Während in den frühen 1990er Jahren die generelle Anwendung einer Hormonersatztherapie für postmenopausale Frauen zur Prävention von Alterserkrankungen, insbesondere von Herz-Kreislauf-Erkrankungen, Osteoporose und Demenzerkrankungen zunehmend empfohlen wurde, zeigten neuere Studienergebnisse keine Senkung des Risikos durch Hormonersatztherapie bei Frauen nach Herzinfarkt (Heart and Estrogen Replacement Study: HERS). Bei im Mittel 63-jährigen Frauen offenbarte sich in der Womens Health Initiative (WHI-Studie) sogar eine Risikoerhöhung. Wie die Risikoverteilung für alleinige Östrogenanwendung (bei Frauen nach Hysterektomie) liegt, wird in etwa 2 Jahren bekannt sein, wenn der entsprechende weiterlaufende Teil der WHI-Studie ausgewertet ist. Für eine generelle Verwendung der kombinierten Hormonersatztherapie nach dem Gießkannenprinzip oder nach Herzinfarkt, bzw. Schlaganfall ist keine Datenbasis mehr vorhanden. Eine objektive Klärung der Vor- und Nachteile von in Deutschland gebräuchlichen Hormonpräparaten für Frauen mit verschiedenen Risikofaktoren und Wechseljahresbeschwerden oder Osteoporose erscheint dringend erforderlich, da die WHI-Studie diese Fragestellungen nicht zum Inhalt hatte.     

Contraception in patients with congenital heart defects

The number of women with congenital cardiac disease, who mature into adulthood is increasing. Unfortunately, there are no prospective data published about the relative risk of different forms of contraception for these patients. Most women with congenital cardiac disease can safely use oral contraceptives, especially low-estrogen combination or progestin-only preparations, with the exception of those, who are at particular risk because of thromboembolic complications (especially in cyanosis, pulmonary hypertension, Eisenmenger reaction, rhythm disturbances), fluid retention (especially in reduced ventricular function and congestive heart failure), arterial hypertension (important in coarctation), infectious complications (endocarditis) or hyperlipidemia. Oral contraceptives should be avoided in patients at increased risk for thromboembolic events. Intrauterine devices are very effective, have no metabolic side effects and merely carry a small risk of endocarditis. Newer devices containing progesterone only may put the patients at a still smaller risk. Contraceptive subdermal implants (e.g. levonorgestrel) are used with good results in the United States for patients with contraindications to estrogen-containing oral contraceptives and may well become more widely accepted in patients in Germany in the coming years. Barrier methods can be used, but have a higher failure rate, which may be unacceptable in patients at risk (e.g. Eisenmenger's). Especially in Eisenmenger's, permanent sterilisation should be advised.     

A three step protocol for the treatment of idiopathic subfertility

650 couples with idiopathic subfertility (mean duration: 5.7 year, range 2–21 years) were treated during 2870 cycles by three assisted conception methods (each involving mild ovarian stimulation): I timed intercourse (TI), II intrauterine insemination (IUI), III in vitro fertilization/embryo transfer (IVF/ET). Treatment started with TI in most cases and then changed to IUI after three to six cycles. Couples who failed to conceive were treated after another 3–9 cycles by IVF/ET. An overall cumulative pregnancy rate of 80.2% was reached after 18 treatment months. The pregnancy rates per treatment cycle were: TI 5.3%, IUI 6.9%, IVF/ET 15.8% (per oocyte retrieval)     

Phytotherapie bei klimakterischen Beschwerden

Gynäkologische Endokrinologie -     

Health technology assessment of utilization,practice and ethical issues of self-pay services in the German ambulatory health care setting

Objectives

The provision of self-pay medical services is common across health care systems, but understudied. According to the German Medical Association, such services should be medically necessary, recommended or at least justifiable, and requested by the patient. We investigated the empirical evidence regarding frequency and practice of self-pay services as well as related ethical, social, and legal issues (ELSI).

Methods

A systematic literature search in electronic databases and a structured internet search on stakeholder websites with qualitative and quantitative information synthesis.

Results

Of 1,345 references, we included 64 articles. Between 19 and 53 % of insured persons received self-pay service offers from their physician; 16–19 % actively requested such services. Intraocular pressure measurement was the most common service, followed by ultrasound investigations. There is a major discussion about ELSI in the context of individual health services.

Conclusions

Self-pay services are common medical procedures in Germany. However, the empirical evidence is limited in quality and extent, even for the most frequently provided services. Transparency of their provision should be increased and independent evidence-based patient information should be supplied.