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A tubo-ovarian abscess is a potential life-threatening condition. In postmenopausal women, it is rarely seen and it has fewer typical symptoms, making it difficult to diagnose.This report concerns a postmenopausal patient who was admitted with general health decline, weight loss and ascites. At first, a malignancy of the right ovary was suspected because of the sonographic and laboratory findings. On diagnostic laparoscopy, the diagnosis of pelvic inflammatory disease was made, most likely caused by a Mirena intrauterine device that had been in place for 20 years.In a postmenopausal woman a tubo-ovarian abscess should be included in differential diagnoses especially if she has an intrauterine device. Conservative treatment with antibiotics is preferred. If surgery is required, diagnostic laparoscopy is advised.

Osteoporosis is an important cause of fractures in postmenopausal women. Bisphosphonates are the first line of treatment for osteoporosis. However, long-term use of these medications has been related to atypical femoral fractures (AFF). We present a case of a 71-year-old postmenopausal woman, with a history of osteoporosis being treated with bisphosphonates for 6 years. The patient developed pain in her left hip and thigh over a period of 3-4 months. Radiographic studies showed an AFF and she was managed conservatively. Stopping bisphosphonate therapy should be an initial step in managing or limiting the progression of AFF. A drug holiday should be considered in patients who have been treated for more than 3-5 years to prevent AFFs. The risk of developing AFFs should never be ignored in this subset of patients.

Background: Breast cancer is the most common malignancy and the second leading cause of cancer-related mortality in Spanish women. Ribociclib in combination with endocrine therapy (ET) has shown superiority in prolonging survival in patients with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2−) advanced breast cancer (ABC) vs. ET alone. Methods: CompLEEment-1 is a single-arm, open-label phase 3b trial evaluating ribociclib plus letrozole in a broad population of patients with HR+, HER2– ABC. The primary endpoints were safety and tolerability. Here we report data for Spanish patients enrolled in CompLEEment-1. Results: A total of 526 patients were evaluated (median follow-up: 26.97 months). Baseline characteristics showed a diverse population with a median age of 54 years. At study entry, 56.5% of patients had visceral metastases and 8.7% had received prior chemotherapy for advanced disease. Rates of all-grade and Grade ≥3 adverse events (AEs) were 99.0% and 76.2%, respectively; 21.3% of patients experienced a serious AE, and 15.8% of AEs led to treatment discontinuation. AEs of special interest of neutropenia, increased alanine aminotransferase, increased aspartate aminotransferase and QTcF prolongation occurred in 77.8%, 14.8%, 11.4% and 4.0% of patients, respectively. Patients aged >70 years experienced increased rates of all-grade and Grade ≥3 neutropenia and anemia. Efficacy results were consistent with the global study. Conclusions: Results from Spanish patients enrolled in CompLEEment-1 are consistent with global data showing efficacy and a manageable safety profile for ribociclib plus letrozole treatment in patients with HR+, HER2− ABC, including populations of interest (NCT02941926). Trial registration: ClinicalTrials.gov NCT02941926

الملخص: الورم العضلي الأملس النقيلي الحميد هو حالة فريدة تظهر بشكل شائع عند النساء في فترة ما قبل انقطاع الطمث، خاصة أولئك اللائي لديهن تاريخ سابق في جراحة أمراض النساء مثل علاج الأورام الليفية في الرحم. تقرير الحالة هذا يحقق في حالة نادرة من الورم العضلي الأملس النقيلي الحميد في أنثى تبلغ من العمر 54 عاما بعد سن اليأس تعاني من كتلة حوض ضخمة كانت تنمو بسرعة جنبا إلى جنب مع العقيدات الرئوية. يشتبه في أن المريض مصاب بساركوما عضلية ملساء والتي تم تأكيدها في النهاية من الناحية المرضية على أنها ورم عضلي أملس نقيلي حميد. على الرغم من ندرته، فإن وصف تحديات التشخيص والمعالجة لمثل هذا الكيان أمر ضروري واعتباره أحد التشخيصات التفريقية للمرضى الذين لديهم تاريخ مشابه. Abstract: Benign metastatic leiomyoma is a unique event presenting most commonly in premenopausal women especially those with a previous history of gynecological surgery as management of uterine fibroids. In this case report, we investigate a rare case of benign metastatic leiomyoma in a 54-year-old postmenopausal female presented with a huge pelvic mass that was rapidly growing along with pulmonary nodules. The patient is suspected to have leiomyosarcoma which is eventually confirmed pathologically as benign metastatic leiomyoma. Although rare, describing the challenging diagnostic and management approach of such entity is essential and to consider it one of the differential diagnoses of patients who present with similar history.

BACKGROUND: In practice, preoperative evaluation prior to hysterectomy varies. Unnecessary preoperative evaluation may add cost and risk with little benefit to the patient. OBJECTIVE: This study aimed to describe practice patterns and the associated costs related to preoperative evaluations before hysterectomy for prolapse at a safety-net hospital. STUDY DESIGN: This was a retrospective cohort study of postmenopausal women who underwent a hysterectomy for prolapse. Nonfacility-associated cost data were obtained from the Centers for Medicare Services. The biopsy cost was estimated to be $172.55 and $125.23 for ultrasounds. RESULTS: A total of 505 postmenopausal cases were identified. Of those, 155 (31%) underwent a preoperative biopsy, 305 (60%) had an ultrasound, and 124 (25%) had both. Of those, 72.9% had an indication for a biopsy. A total of 64 biopsies and 216 ultrasounds lacked clear indication. Of those, 56 biopsies were performed for bleeding in cases with an endometrial thickness of

Background: Arthralgia is a common and debilitating toxicity of aromatase inhibitors (AI) that leads to premature drug discontinuation. We sought to evaluate the clinical and genetic risk factors associated with AI-associated arthralgia (AIAA). Methods: We performed a cross-sectional study among postmenopausal women with stage 0-III breast cancer who were prescribed a third-generation AI for adjuvant therapy. The primary outcome was patient-reported AIAA occurrence. We extracted and assayed germline DNA for single nucleotide polymorphisms (SNPs) of genes implicated in estrogen and inflammation pathways. Multivariable logistic regression models examined the association between demographic, clinical, and genetic factors and AIAA. Analyses were restricted to White participants. Results: Among 1049 White participants, 543 (52%) reported AIAA. In multivariable analyses, women who had a college education [Adjusted Odds Ratio (AOR) 1.49, 95% Confidence Interval (CI) 1.00–2.20], had a more recent transition into menopause (

Asymptomatic adnexal masses are commonly encountered in daily radiology practice. Although the vast majority of these masses are benign, a small subset have a risk of malignancy, which require gynecologic oncology referral for best treatment outcomes. Ultrasound, using a combination of both transabdominal, transvaginal, and duplex Doppler technique can accurately characterize the majority of these lesions. MRI with and without contrast is a useful complementary modality that can help characterize indeterminate lesions and assess the risk of malignancy is those that are suspicious. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2024 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: Postmenopausal women exhibit higher rates of disability and cardiovascular disease (CVD) with aging compared to men. Whereas habitual exercise training is a known strategy to enhance physiologic function in men and premenopausal women, exercise-related adaptations are often modest in postmenopausal women. We propose dietary nitrate (beetroot juice) administered prior to exercise training may be a feasible approach to improve mobility and cardio-metabolic health outcomes in postmenopausal women. Methods: Our randomized, placebo-controlled study aims to determine preliminary effects sizes for changes in functional mobility and endothelium-dependent vasodilation across three study arms: exercise only (EX), exercise + placebo (EX + PL), and exercise + beetroot (EX + BR). Thirty-six postmenopausal women are recruited in small cohorts wherein group exercise is implemented to facilitate social support and adherence to an 8-week training progression. Participants are randomized to one of three study arms (n = 12 per group) following baseline assessments. Post-intervention assessments are used to determine pre-post changes in outcome measures including distance covered during a 6 min walk test, walking economy, muscle speed and power, and endothelial-dependent vasodilation as determined by flow-mediated dilation. Measures of feasibility include recruitment, retention, adherence to exercise prescription, perceived exercise session difficulty, and adverse event rates. Discussion: Evidence-based, translational strategies are needed to optimize exercise training-related adaptations in postmenopausal women. Findings will inform larger randomized clinical trials to determine if pre-exercise consumption of beetroot juice is an efficacious strategy to promote mobility and attenuate CVD disease risk.

Background: Iron deficiency and 25-hydroxyvitamin D (25(OH)D) deficiency are among the most common nutrient deficiencies in the world. Osteoporosis, a major bone disorder, is prevalent globally as well as in Saudi Arabia. The relationship between these micronutrient deficiencies with osteoporosis is less investigated. Hence, the current study aimed to determine the relationship between iron and 25(OH)D deficiencies among postmenopausal Saudi women with osteoporosis and their associations with bone biomarkers. Methodology: A total of 184 postmenopausal Saudi women ≥ 45 years old [N = 75 osteoporosis group; N = 109 without osteoporosis or control group] were enrolled in this cross-sectional study. Anthropometrics and bone mineral density were measured. Serum iron indices, 25(OH)D and bone biomarkers [β-carboxyterminal telopeptide of type 1 collagen (β-crosslap), osteocalcin (OC), osteoprotegerin (OPG), osteopontin (OPN) and bone-specific alkaline phosphatase (BsALP) were determined. Results: In all subjects, significant associations were observed between serum iron and OC (r = 0.19; p = 0.02) as well as OPN (r = 0.17; p = 0.05). Also, serum 25(OH)D was inversely associated with BsALP (r = −0.25; p = 0.02), and positively with β-crosslap (r = 0.38; p = 0.01). An inverse significant association was observed between 25(OH)D and OPG (r = −0.25; p = 0.01) in the control group and BsALP (r = −0.31; p = 0.02) in the osteoporosis group. Conclusion: Significant associations between circulating iron and 25(OH)D with select bone biomarkers were observed in postmenopausal Arab women with osteoporosis, suggesting that these micronutrients may affect bone metabolism.

Background: Oncotype Dx® (ODX) is the most used prognostic and predictive assay for ER + breast cancer (BCa) and is categorized into low (< 18), intermediate (18 to 30), or high (≥31) risk of recurrence. Prosigna® is a prognostic signature to estimate distant recurrence-free survival for stage I/II, ER+ cancer in postmenopausal women treated with adjuvant therapy. The goal of the study is to assess the agreement between ODX and Prosigna®. Materials and Methods: 100 previously ODX classified peri and postmenopausal, early-stage (I or II) BCa patients were retrieved and Prosigna assay was performed on archived tumor blocks on a NanoString nCounter® DX Analysis System. Results: ODX assay was assigned as follows: 57% low, 39% intermediate, and 4% high. There were 8% two-step disagreements (high to low or vice versa) between ODX and Prosigna®; and 42% one-step disagreement (low to intermediate or vice versa). 78% were classified by Prosigna as luminal A and 22% as luminal B. The majority of luminal A cases (67/78; 85.9%) had low ROR score whereas ODX classified almost two-thirds (50/78~ 64%) as low RS. An insignificant percentage of luminal B cases (1/22 – 4.5%) were classified as high RS by ODX, and a modest percentage were classified as high ROR by Prosigna (15/22 ~68%). According to our follow up results, recurrence was detected in three cases. In all three cases; Prosigna was a better indicator of recurrence. Conclusions: The agreement between ODX and Prosigna® is low, and this has management implications, especially when chemotherapy is needed.

Objective: This study aimed to develop and evaluate a machine learning model utilizing non-invasive clinical parameters for the classification of endometrial non-benign lesions, specifically atypical hyperplasia (AH) and endometrioid carcinoma (EC), in postmenopausal women., Methods: Our study collected clinical parameters from a cohort of 999 patients with postmenopausal endometrial lesions and conducted preprocessing to identify 57 relevant characteristics from these irregular clinical data. To predict the presence of postmenopausal endometrial non-benign lesions, including atypical hyperplasia and endometrial cancer, we employed various models such as eXtreme Gradient Boosting (XGBoost), Random Forest (RF), Logistic Regression (LR), Support Vector Machine (SVM), Back Propagation Neural Network (BPNN), as well as two ensemble models. Additionally, a test set was performed on an independent dataset consisting of 152 patients. The performance evaluation of all models was based on metrics including the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, precision, and F1 score., Results: The RF model demonstrated superior recognition capabilities for patients with non-benign lesions compared to other models. In the test set, it attained a sensitivity of 88.1% and an AUC of 0.93, surpassing all alternative models evaluated in this study. Furthermore, we have integrated this model into our hospital's Clinical Decision Support System (CDSS) and implemented it within the outpatient electronic medical record system to continuously validate and optimize its performance., Conclusions: We have trained a model and deployed a system with high discriminatory power that may provide a novel approach to identify patients at higher risk of postmenopausal endometrial non-benign lesions who may benefit from more tailored screening and clinical intervention., Competing Interests: Declaration of competing interest We declare that we have no financial and personal relationships with other people or organizations that can inappropriately influence our work, and there is no professional or other personal interest of any nature or kind in any product, service and/or company that could be construed as influencing the position presented in, or the review of, the manuscript entitled., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objectives: The increase in body fat mass (BFM) and the loss of lean body mass (LBM) or muscle strength with age affects bone mineral (BMD). These factors increase the prevalence and incidence of obesity and sarcopenia, which have unclear effects on bone mineral density. The purpose of this study was to determine how the above selected factors affect BMD. Methods: A cross-sectional study was conducted involving 58 women (aged 62.1 ± 4.8 years). Total body, left proximal femur, lumbar spine BMD, and body composition parameters were measured with dual-energy x-ray absorptiometry. Isokinetic flexion and extension strength of the dominant leg were measured at 60 deg./s. Grip strength was measured with the dominant upper extremity. To determine the volume of physical activity (PA), the PA level was monitored for seven consecutive days using an ActiGraph model GT1M accelerometer. Results: BFM was positively associated with BMD of the proximal femur (β = 0.31; P

Context: The diagnosis of ovarian hormone-secreting neoplasm in postmenopausal women is currently based on imaging modalities and selective venography. However, these diagnostic tests are not always accurate. In order to improve and simplify the diagnosis, we propose a noninvasive hormonal test. Objective: To report our experience using noninvasive hormonal test for the diagnosis of ovarian hormone producing tumor in two postmenopausal women. Design and intervention: Evaluation of androgen and estradiol serum levels following 1. Adrenal hormonal depression, 2. ovarian hormonal depression and 3. ovarian hormonal stimulation. Setting: Tertiary care medical center. Main outcome measures: Changes in androgen and estradiol levels. Results: In the first case, total testosterone, free androgen index and estradiol serum levels decreased following ovarian depression by GnRH-antagonist (6.9 nmol/L, 67 nmol/L and

Background: The burden of osteoporosis in the Asia-Pacific region is not well characterized. The Medication Use Patterns, Treatment Satisfaction, and Inadequate Control of Osteoporosis Study in the Asia-Pacific Region (MUSIC OS-AP) was designed to better understand the association of gastrointestinal events with patient-reported outcomes in postmenopausal women of this region. Methods: MUSIC OS-AP is a prospective, multinational, observational cohort study of postmenopausal women ≥50 years of age diagnosed with osteoporosis. The study was conducted in five Asia-Pacific countries: Australia, New Zealand, Taiwan, Korea, and India. MUSIC OS-AP has three components: a physician questionnaire, a retrospective chart review, and a prospective cohort study. The physician questionnaire investigated the role of gastrointestinal events in physicians' pharmacologic management of osteoporosis. The retrospective chart review, also completed by physicians, recorded rate of osteoporosis treatment and the types of osteoporosis medications prescribed to osteoporosis patients. The prospective cohort study investigated the associations between gastrointestinal events and patient-reported outcomes among patients taking oral medications for osteoporosis as well as reasons for non-treatment in patients who remained untreated. The prospective cohort study enrolled two groups of patients: untreated, and treated with oral osteoporosis medications. Untreated patients completed only the baseline surveys, providing information on gastrointestinal event rates, quality of life, health care resource use, and reasons for non-treatment. Treated patients, who were either new to osteoporosis medication or continuing an ongoing medication course, completed surveys at baseline and 3, 6, and 12 months post-baseline. The evaluations recorded patient characteristics, gastrointestinal events, health-related and osteoporosis-specific quality of life, health care resource use, medication adherence, and satisfaction with treatment. Results: Physicians at 59 sites completed the physician questionnaire, and data for 300 patients from 26 sites were abstracted for the retrospective chart review. Enrollment and baseline data collection for the prospective cohort study were conducted between July 2013 and August 2014 for 301 untreated and 3287 treated patients, of whom 1416 were new users and 1871 were experienced users of oral osteoporosis medications. Conclusions: The results of MUSIC OS-AP will highlight the association of gastrointestinal events with patient-reported outcomes among postmenopausal women with osteoporosis and elucidate physicians' management of gastrointestinal events among this patient population in the Asia-Pacific region.

In South Asians, a unique obesity phenotype of high abdominal fat is associated with increased cardiovascular risk. Low cardiorespiratory fitness (CRF) is associated with abdominal fat and an increased risk of cardiovascular disease. The purpose of this paper is to determine whether CRF as assessed by VO2 peak, in post-menopausal South Asian women, was associated with body fat distribution and abdominal fat. Physically inactive post-menopausal South Asian women (n = 55) from the Greater Vancouver area were recruited and assessed from January to August 2014. At baseline, VO2 peak was measured with the Bruce Protocol, abdominal fat with CT imaging, and body composition with dual energy X-ray absorptiometry. ANOVA was used to assess differences in subcutaneous abdominal adipose tissue (SAAT), visceral adipose tissue (VAT) and total abdominal adipose tissue (TAAT) between tertiles of CRF. Bivariate correlation and multiple linear regression analyses explored the association between VO2 peak with SAAT, VAT, TAAT and body composition. Models were further adjusted for body fat and body mass index (BMI). Compared to women in the lowest tertile of VO2 peak (13.8–21.8 mL/kg/min), women in the highest tertile (25.0–27.7 mL/kg/min) had significantly lower waist circumference, BMI, total body fat, body fat percentage, lean mass, SAAT, VAT and TAAT (p

Background: Type 2 diabetes mellitus (T2DM) is associated with diabetic retinopathy (DR), but effective interventions are lacking. The relationship between osteocalcin (OC) and DR in postmenopausal women with T2DM is understudied., Methods: This study examined 950 postmenopausal women with T2DM (T2DR group: n = 299; T2DM group: n = 651)., Results: Significant differences (p < 0.05) were observed between the groups in disease duration, age, gender, body mass index (BMI), glycated haemoglobin (HbA1c), low-density lipoprotein (LDL-C), parathyroid hormone (PTH), total type I collagen amino acid-prolonging peptide (TPINP), OC, and 25 hydroxyvitamin D (25(OH)D3). Logistic regression revealed associations of LDL-C, PTH, and 25(OH)D3 with DR. A non-linear relationship (p < 0.05) between OC and DR was found. The lowest DR risk occurred at OC levels of 15.0-25.3 ng/ml (OR, 0.66; 95 % CI, 0.44, 0.98) compared to 11.1-15.0 ng/ml. Risk remained unchanged below 11.1 ng/ml or above 25.3 ng/ml., Conclusion: In conclusion, among postmenopausal women with T2DM, OC levels showed a non-linear relationship with DR. Optimal OC levels (15.0-25.3 ng/ml) were associated with minimal DR occurrence, while risk was constant below 11.1 ng/ml or above 25.3 ng/ml. Maintaining optimal OC levels may reduce DR risk in this population., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Phenolic compounds from berries have shown bone protective effects in animal studies. We hypothesized that consumption of 45 g of blackberries or blueberries for 9 months will prevent smoking-induced bone loss in postmenopausal women. Postmenopausal smokers (n = 45) and nonsmokers (n = 20) were recruited. Smokers were randomly assigned to treatment groups: smoker control (n = 21); smoker + 45 g freeze-dried blackberries (n = 8); or smoker + 45 g freeze-dried blueberries (n = 16). We measured bone mineral density (BMD) at 0 and 9 months, urinary deoxypyridinoline, bone alkaline phosphate, osteocalcin, thiobarbituric acid reactive substances (TBARS) and highly sensitive C-reactive protein at 0, 3, 6, 9 months. Bone loss of total body BMD was statistically significant in S-C and S-BL groups, but not in S-BB and NS groups (p = 0.0284). Findings indicated that blackberries but not blueberries modestly protected against smoking-induced bone loss in postmenopausal smokers.

Background: Preclinical studies suggest that blueberry consumption is associated with improved bone health., Objectives: We conducted a blueberry dose-response study in ovariectomized (OVX)-rats that informed a study in postmenopausal women using the urinary appearance of calcium (Ca) tracers from prelabeled bone to reflect changes in bone balance. We hypothesized that blueberry consumption would reduce bone loss in a dose-dependent manner compared with no treatment., Methods: OVX rats were fed 4 doses of blueberry powder (2.5%, 5%, 10%, and 15%) in randomized order to determine bone 45 Ca retention. Fourteen healthy, nonosteoporotic women ≥4 y past menopause were dosed with 50 nCi of 41 Ca, a long-lived radioisotope, and equilibrated for 5 mo to allow 41 Ca deposition in bone. Following a 6-wk baseline period, participants were assigned to a random sequence of 3 6-wk interventions, a low (17.5 g/d), medium (35 g/d), or high (70 g/d) dose of freeze-dried blueberry powder equivalent to 0.75, 1.5, or 3 cups of fresh blueberries incorporated into food and beverage products. Urinary 41 Ca:Ca ratio was measured by accelerator mass spectrometry. Serum bone resorption biomarkers and urinary polyphenols were measured at the end of each control and intervention period. Data were analyzed using a linear mixed model and repeated measures analysis of variance., Results: In both OVX rats and postmenopausal women, blueberry interventions benefited net bone calcium balance at lower but not at higher doses. In women, net bone calcium retention increased by 6% with the low (95% CI: 2.50, 8.60; P < 0.01) and 4% with the medium (95% CI: 0.96, 7.90; P < 0.05) dose compared with no treatment. Urinary excretion of hippuric acid increased dose-dependently with blueberry consumption. No significant relationships were found between bone resorption biomarkers, 25-hydroxyvitamin D, and interventions., Conclusions: Moderate consumption (<1 cup/d) of blueberries may be an effective strategy to attenuate bone loss in healthy postmenopausal women. This trial was registered at clinicaltrials.gov as NCT02630797., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Vaginal estrogen is considered to be the standard of care for recurrent urinary tract infection prevention in women with hypoestrogenism. However, literature supporting its use is limited to small clinical trials with narrow generalizability., Objective: This study aimed to assess the association between vaginal estrogen prescription and the frequency of urinary tract infections over the following year in a diverse population of women with hypoestrogenism. Secondary objectives included evaluation of medication adherence and predictors of postprescription urinary tract infection., Study Design: This multicenter retrospective review included women who were prescribed vaginal estrogen for the indication of recurrent urinary tract infection from January 2009 through December 2019. Recurrent urinary tract infection was defined as having ≥3 positive urine cultures (separated by at least 14 days) in the 12 months preceding the index vaginal estrogen prescription. Patients were asked to fill their prescriptions and continue care within Kaiser Permanente Southern California system for at least 1 year. Exclusion criteria included anatomic abnormalities, malignancy, or mesh erosion of the genitourinary tract. Data on demographics, medical comorbidities, and surgical history were collected. Adherence was captured through refill data after the index prescription. Low adherence was defined as no refills; moderate adherence was defined as 1 refill; high adherence was defined as ≥2 refills. Data were abstracted from the electronic medical record system using the pharmacy database and diagnosis codes. A paired t test was used to compare pre- and postprescription urinary tract infections over the year preceding and following the vaginal estrogen prescription. A multivariate negative binomial regression was used to evaluate predictors of postprescription urinary tract infection., Results: The cohort included 5638 women with a mean (±standard deviation) age of 70.4 (±11.9) years, body mass index of 28.5 (±6.3) kg/m 2 , and baseline urinary tract infection frequency of 3.9 (±1.3). Most of the participants were White (59.9%) or Hispanic (29.7%) and postmenopausal (93.4%). The mean urinary tract infection frequency in the year following the index prescription decreased to 1.8 (P<.001) from 3.9 in the year preceding the prescription, which is a 51.9% reduction. During the 12 months after the index prescription, 55.3% of patients experienced ≤1 urinary tract infections, and 31.4% experienced no urinary tract infections. Significant predictors of postprescription urinary tract infection included age of 75 to 84 years (incident rate ratio, 1.24; 95% confidence interval, 1.05-1.46) and >85 years (1.41; 1.17-1.68), increased baseline urinary tract infection frequency (1.22; 1.19-1.24), urinary incontinence (1.14; 1.07-1.21), urinary retention (1.21; 1.10-1.33), diabetes mellitus (1.14; 1.07-1.21), and moderate (1.32; 1.23-1.42) or high medication adherence (1.33; 1.24-1.42). Patients with high medication adherence demonstrated more frequent postprescription urinary tract infections than patients with low adherence (2.2 vs 1.6; P<.0001)., Conclusion: In this retrospective review of 5600 women with hypoestrogenism who were prescribed vaginal estrogen for the prevention of recurrent urinary tract infections, the frequency of urinary tract infection decreased by more than 50% in the following year. Baseline urinary tract infection frequency, increasing age, urinary incontinence or retention, and diabetes were associated with an increased risk of postprescription urinary tract infection. The paradoxical finding that women with moderate and high medication adherence experienced the lowest-magnitude reduction in urinary tract infection frequency may represent unobserved selection or unmeasured confounding., (Copyright © 2023. Published by Elsevier Inc.)

Background: Obesity is a leading risk factor for chronic diseases, potentially related to excess abdominal adiposity. Phthalates are environmental chemicals that have been suggested to act as obesogens, driving obesity risk. For the associations between phthalates and adiposity, prior studies have focused primarily on body mass index. We hypothesize that more refined measures of adiposity and fat distribution may provide greater insights into these associations given the role of central adiposity in chronic disease risk., Objectives: To evaluate associations between urinary phthalate biomarkers and both visceral and subcutaneous adipose tissue (VAT and SAT) among postmenopausal women enrolled in the Women's Health Initiative (WHI)., Methods: We included 1125 WHI participants with available, coincident measurements of urinary phthalate biomarkers (baseline, year 3) and VAT and SAT (baseline, year 3, year 6). VAT and SAT measurements were estimated from DXA scans. Multilevel mixed-effects models estimated the prospective associations between urinary phthalate biomarkers at baseline and VAT and SAT three years later., Results: In multivariable adjusted models, we observed positive associations between some phthalate biomarkers, including the sum of di-isobutyl phthalate (ΣDiBP) biomarkers, MCNP, and ΣDEHP, with VAT three years later. For example, we observed positive associations between concentrations of ΣDiBP and VAT (Q4 vs Q1 β = 7.15, 95% CI -1.76-16.06; Q3 vs Q1 β = 10.94, 95% CI 3.55-18.33). Associations were generally attenuated but remained significant after additional adjustment for SAT. MBzP was positively associated with SAT. Other phthalate biomarkers investigated (MEP, MCOP, MCPP, ΣDBP) were not significantly associated with VAT or SAT., Discussion: Based on robust measures of adiposity, this study provides supportive evidence that higher urinary concentrations of select phthalate compounds were associated with higher VAT levels over time in postmenopausal women. Efforts to replicate these findings are needed., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Katherine Reeves reports financial support was provided by National Institute of Environmental Health Sciences., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Breast cancer is the most common malignancy and the second leading cause of cancer-related mortality in Spanish women. Ribociclib in combination with endocrine therapy (ET) has shown superiority in prolonging survival in patients with hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2-) advanced breast cancer (ABC) vs. ET alone., Methods: CompLEEment-1 is a single-arm, open-label phase 3b trial evaluating ribociclib plus letrozole in a broad population of patients with HR+, HER2- ABC. The primary endpoints were safety and tolerability. Here we report data for Spanish patients enrolled in CompLEEment-1., Results: A total of 526 patients were evaluated (median follow-up: 26.97 months). Baseline characteristics showed a diverse population with a median age of 54 years. At study entry, 56.5% of patients had visceral metastases and 8.7% had received prior chemotherapy for advanced disease. Rates of all-grade and Grade ≥3 adverse events (AEs) were 99.0% and 76.2%, respectively; 21.3% of patients experienced a serious AE, and 15.8% of AEs led to treatment discontinuation. AEs of special interest of neutropenia, increased alanine aminotransferase, increased aspartate aminotransferase and QTcF prolongation occurred in 77.8%, 14.8%, 11.4% and 4.0% of patients, respectively. Patients aged >70 years experienced increased rates of all-grade and Grade ≥3 neutropenia and anemia. Efficacy results were consistent with the global study., Conclusions: Results from Spanish patients enrolled in CompLEEment-1 are consistent with global data showing efficacy and a manageable safety profile for ribociclib plus letrozole treatment in patients with HR+, HER2- ABC, including populations of interest (NCT02941926)., Trial Registration: ClinicalTrials.gov NCT02941926., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Androgens are endogenous hormones that play a crucial role in the paracrine and intracrine hormone system to perform and maintain vital physiological functions. Altered levels of androgens are implicated in many diseases such as sexual dysregulation, breast cancer, prostate cancer, and heart diseases etc. In this manuscript we describe a liquid chromatography-mass spectrometry (LC-MS) method using multiple reaction monitoring (MRM) for quantitatively measuring specific androgens such as dehydroepiandrosterone, testosterone, androsterone sulphate, androstenedione, and dihydrotestosterone in serum and urine samples. Serum acquired from nine different subjects (three pre-menopausal women, three postmenopausal women, and three healthy males) were used to evaluate the developed methods. In the sample preparation methods for serum either protein precipitation or liquid-liquid extraction (LLE) was used while the analysis of urinary androgens used LLE. The extracted androgens were quantitatively measured using LC-MRM-MS to which known amounts of stable isotope labeled standards were added. This manuscript also presents a LC-MRM-MS method mode for the analysis of oxime derivatized androgens potentially to enhance the sensitivity of the assay if required, from urine and venous-drawn serum samples., (Published by Elsevier Inc.)

Background: MONALEESA-3 demonstrated an overall survival (OS) benefit for ribociclib plus fulvestrant (R+F) in postmenopausal women with hormone receptor (HR) positive, HER2 negative advanced breast cancer (ABC). This study estimated quality-adjusted (QA) survival outcomes for patients receiving R+F vs. placebo (P)+F in MONALEESA-3., Methods: Kaplan-Meier OS was partitioned into health states: (1) toxicity (TOX)=time spent with grade 3 -4 adverse events before progression (DP); (2) progression (PROG)=time between DP and death; and (3) time without symptoms or toxicity (TWiST)=time not in TOX or PROG. QA time was calculated by combining estimated mean time in each health state with treatment-group specific health-state utility values estimated using EQ-5D-5L questionnaire. Outcomes included QA progression-free survival (QAPFS), QAOS, and QA TWiST (Q-TWiST). Q-TWiST was calculated with health-state utility values for TOX and PROG defined relative to TWiST., Results: Mean PFS and OS were significantly greater with R+F vs. P+F (difference 0.56 and 0.19 years). Mean time in TOX and TWiST were greater with R+F; mean time in PROG was greater with P+F. QAPFS was 0.45 years (95% CI 0.27 -0.63) greater with R+F than P+F (P <.001). QAOS was numerically greater with R+F vs. P+F (0.16 years, 95% CI 0.07 -0.45, P = .0569). Q-TWiST was 0.23 years greater with R+F (95% CI 0.07 -0.45, P = .0069). In a sensitivity analysis using an estimate of disutility for PROG, the difference in QAOS was 0.23 years (95% CI 0.08 -0.41, P = .0022)., Conclusion: R+F in postmenopausal women with HR+/HER2- ABC improves QAPFS, resulting in clinically important improvements in Q-TWiST and may improve QAOS., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: There is little data as to whether exposure to residential greenness is associated with the incidence of breast cancer. Lack of physical activity and obesity are two of the accepted risk factors for postmenopausal breast cancer and living near green areas may contribute to an active lifestyle and maintaining a normal body mass index and, consequently, residential greenness may be associated with lower incidence rates., Objectives: The objective of this study was to determine whether there was an association between past exposure to residential greenness and the incidence of invasive postmenopausal breast cancer among Canadian women living in Montreal, Quebec, in the mid-2000s., Methods: We conducted a population-based, case-control study of incident postmenopausal breast cancer in Montreal, Canada, and herein we show analyses by level of greenness surrounding participants' homes. Incident cases were identified between 2008 and 2011 from all but one hospital that treated breast cancer in the Montreal area. Population controls were identified from provincial electoral lists of Montreal residents and frequency-matched to cases on age. Residential greenness was estimated using the maximum daily normalized difference vegetation index averaged over the growing season ("maximum NDVI"). Maximum NDVI was assigned at the home address of recruitment for the years 1992-1998 (about 15 years before diagnosis), and we measured subjects' personal information, exposure to NO 2 and ultrafine particles, and area-wide variables to control for potential confounding effects. Odds ratios (OR) and 95% confidence intervals (CI) for breast cancer associated with residential greenness were estimated using logistic regression models adjusting for various combinations of potential confounders. We assessed the functional form of maximum NDVI using natural cubic splines., Results: We found that the response functions between incident postmenopausal breast cancer and maximum NDVI were consistent with linearity. The age-adjusted and fully-adjusted ORs, per increase in the interquartile range (IQR=0.13) of maximum NDVI measured with a 250 m buffer around residences, were 0.95 (95%CI: 0.86-1.04) and 1.00 (95%CI: 0.84-1.11), respectively. For maximum NDVI measured using a 1000 m buffer (IQR=0.05), these were 0.98 (95%CI: 0.94-1.02) and 0.99 (95%CI: 0.95-1.03), respectively., Conclusions: Our findings suggest that exposure to NDVI evaluated where participants were interviewed is not associated with the risk of incident postmenopausal breast cancer., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Severely energy-restricted diets that utilize meal-replacement products are the most effective dietary treatment for obesity. However, there are concerns they may fail to educate individuals on how to adopt a healthy food-based diet after weight loss., Objectives: The aim of this research was to compare changes in diet quality following total meal replacement compared with food-based weight-loss diets., Methods: In this secondary analysis of a randomized controlled trial, 79 postmenopausal women aged 45-65 y, with a BMI (in kg/m2) of 30-40, were randomly assigned to either a total meal-replacement diet (energy intake restricted by 65-75% relative to requirements) for 16 wks, followed by a food-based diet (energy intake restricted by 25-35% relative to requirements) until 52 wks, or the food-based diet for the entire 52-wk period. Diet quality was scored at baseline and 52 wks using the Healthy Eating Index for Australian Adults, with score changes compared between groups using an independent t test., Results: Diet quality improved from baseline in both groups, but less so in the total meal-replacement group, with a mean (SD) increase of 3.6 (10.8) points compared with 11.8 (13.9) points in the food-based group, resulting in a mean between-group difference of -8.2 (P = 0.004; 95% CI: -13.8, -2.7) points. This improvement in diet quality within both groups was mostly driven by a reduction in the intake of discretionary foods. Intake remained below the recommendations at 52 wks for 4 of the 5 food groups in both dietary interventions., Conclusions: In postmenopausal women with obesity, weight-loss interventions that involve either a total meal-replacement diet or a food-based diet both improve diet quality, however, not sufficiently to meet recommendations. This highlights the importance of addressing diet quality as a part of all dietary weight-loss interventions. This trial is registered with the Australia and New Zealand Clinical Trials Registry as 12612000651886., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Osteoporosis is characterized by reduced bone mass leading to diminished skeletal integrity and an increased risk for fracture. Multiple agents exist that are effective for the treatment of osteoporosis. These can be broadly categorized into those that reduce the risk for additional loss of bone mass (anti-resorptive agents) and those that augment existing bone mass (anabolic agents). This article reviews the different medications within each class, and discusses more recent data regarding the combination and sequential use of these medications for optimization of skeletal health in patients at high risk for fracture., Competing Interests: Disclosure Neither D. Saul nor M.T. Drake have any relevant disclosures., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Acute pelvic pain is a common presenting complaint in both the emergency room and outpatient settings. Pelvic pain of gynecologic origin in postmenopausal women occurs less frequently than in premenopausal women; however, it has important differences in etiology. The most common causes of postmenopausal pelvic pain from gynecologic origin are ovarian cysts, uterine fibroids, pelvic inflammatory disease, and ovarian neoplasm. Other etiologies of pelvic pain are attributable to urinary, gastrointestinal, and vascular systems. As the optimal imaging modality varies for these etiologies, it is important to narrow the differential diagnosis before choosing the initial diagnostic imaging examination. Transabdominal and transvaginal ultrasound are the best initial imaging techniques when the differential is primarily of gynecologic origin. CT with intravenous (IV) contrast is more useful if the differential diagnosis remains broad. MRI without IV contrast or MRI without and with IV contrast, as well as CT without IV contrast may also be used for certain differential considerations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2021 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Evidence of clinical and/or biochemical androgen excess poses a unique differential in postmenopausal women. Some signs and symptoms of postmenopausal hyperandrogenism can be normal and attributed to the natural aging process. However, the causes of androgen excess in this group include both nontumorous and tumorous causes. Treatment of androgen excess may improve both quality of life and long-term metabolic outcomes., Competing Interests: Disclosure Dr A. Zaman has received grant F32 DK123878 from NIH. The other author has nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Oncotype Dx® (ODX) is the most used prognostic and predictive assay for ER + breast cancer (BCa) and is categorized into low (< 18), intermediate (18 to 30), or high (≥31) risk of recurrence. Prosigna® is a prognostic signature to estimate distant recurrence-free survival for stage I/II, ER+ cancer in postmenopausal women treated with adjuvant therapy. The goal of the study is to assess the agreement between ODX and Prosigna®., Materials and Methods: 100 previously ODX classified peri and postmenopausal, early-stage (I or II) BCa patients were retrieved and Prosigna assay was performed on archived tumor blocks on a NanoString nCounter® DX Analysis System., Results: ODX assay was assigned as follows: 57% low, 39% intermediate, and 4% high. There were 8% two-step disagreements (high to low or vice versa) between ODX and Prosigna®; and 42% one-step disagreement (low to intermediate or vice versa). 78% were classified by Prosigna as luminal A and 22% as luminal B. The majority of luminal A cases (67/78; 85.9%) had low ROR score whereas ODX classified almost two-thirds (50/78~ 64%) as low RS. An insignificant percentage of luminal B cases (1/22 - 4.5%) were classified as high RS by ODX, and a modest percentage were classified as high ROR by Prosigna (15/22 ~68%). According to our follow up results, recurrence was detected in three cases. In all three cases; Prosigna was a better indicator of recurrence., Conclusions: The agreement between ODX and Prosigna® is low, and this has management implications, especially when chemotherapy is needed., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Women with human immunodeficiency virus have higher rates of abnormal cervical and vaginal cytology and, subsequently, of cervical and vaginal cancers. Although professional bodies currently advocate for indefinite cytology screening for women living with human immunodeficiency virus, these recommendations are based on expert opinion, not evidence-based. In the general population, women who have never had an abnormal cytology result can cease screening at age 65 years. This is due to the relatively low incidence of dysplasia in this group and the risk of false-positive results as women age, invasive follow-up testing, and destructive treatments of lesions that are unlikely to progress to cancer. What is unclear, however, is how human immunodeficiency virus-infected women over age 65 years who have no history of abnormal cytology should be screened to maximize benefit while reducing harms of overscreening. This is a crucial question, as women over age 65 years who are living with human immunodeficiency virus comprise a rapidly growing population., Objective: To describe the incidence of abnormal cervical and vaginal cytology results in women over the age of 65 years living with human immunodeficiency virus, with the goal of providing evidence for screening recommendations., Materials and Methods: A retrospective chart review was performed, identifying 69 women who received gynecologic follow-up in a county hospital system in Houston, Texas, between 2000 and 2018 and who met study criteria. Incidence of abnormal cytology after age 65 was determined by analyzing all available cytology results after age 65. Demographic and clinical risk factors, including human immunodeficiency virus-specific clinical risk factors, were analyzed. Matched cervical and vaginal pathology results, if conducted, were also evaluated. Statistical analyses were conducted using Stata 15, including χ 2 tests and Wilcoxon rank-sum tests for categorical and continuous variables, respectively. Estimates of the cumulative probability of developing an abnormal cytology result was calculated using the Kaplan-Meier method., Results: Among 69 women with no history of abnormal cervical cytology, 12 (17%) went on to develop abnormal cytology results, including 3 (4%) showing high-grade squamous intraepithelial lesions. The incidence rate was 3.5 cases per 100 woman-years (95% confidence interval, 1.58, 7.81). No demographic or gynecologic characteristics were associated with abnormal cytology. A CD4 count of <200 at the time of human immunodeficiency virus diagnosis or at the time of cytology was associated with an abnormal Papanicolaou test result (P < .0001, P = .031). Of women with pathology results in the county hospital system (n = 8), 4 (50%) had cervical intraepithelial neoplasia 2+ or vaginal intraepithelial neoplasia 2+. No women developed invasive cancer. However, 50% of women who had an abnormal Papanicolaou test result in the study period were lost to follow-up; outcomes for these patients are unknown., Conclusion: Given the relatively high proportion (4%) of women with high-grade squamous intraepithelial lesions/cervical intraepithelial neoplasia 2+/vaginal intraepithelial neoplasia 2+ during the study period, we agree with current screening recommendations for continued routine Papanicolaou testing after the age of 65 years in women with human immunodeficiency virus. More evidence from larger studies is needed to solidify evidence-based screening recommendations in this unique and growing population., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Arthralgia is a common and debilitating toxicity of aromatase inhibitors (AI) that leads to premature drug discontinuation. We sought to evaluate the clinical and genetic risk factors associated with AI-associated arthralgia (AIAA)., Methods: We performed a cross-sectional study among postmenopausal women with stage 0-III breast cancer who were prescribed a third-generation AI for adjuvant therapy. The primary outcome was patient-reported AIAA occurrence. We extracted and assayed germline DNA for single nucleotide polymorphisms (SNPs) of genes implicated in estrogen and inflammation pathways. Multivariable logistic regression models examined the association between demographic, clinical, and genetic factors and AIAA. Analyses were restricted to White participants., Results: Among 1049 White participants, 543 (52%) reported AIAA. In multivariable analyses, women who had a college education [Adjusted Odds Ratio (AOR) 1.49, 95% Confidence Interval (CI) 1.00-2.20], had a more recent transition into menopause (<10 years) (5-10 years AOR 1.55, 95% CI 1.09-2.22; <5 years AOR 1.78, 95% CI 1.18-2.67), were within one year of starting AIs (AOR 1.61, 95% CI 1.08-2.40), and those who received chemotherapy (AOR 1.38, 95% CI 1.02-1.88) were significantly more likely to report AIAA. Additionally, SNP rs11648233 (HSD17B2) was significantly associated with higher odds of AIAA (AOR 2.21, 95% CI 1.55-3.16)., Conclusions: Time since menopause and start of AIs, prior chemotherapy, and SNP rs11648233 within the HSD17B2 gene in the estrogen pathway were significantly associated with patient-reported AIAA. These findings suggest that clinical and genetic factors involved in estrogen withdrawal increase the risk of AIAA in postmenopausal breast cancer survivors., Competing Interests: Declaration of competing interest None., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objective: Data: Fat mass has been shown to increase in aging women; however, the extent to which menopausal status mediates these changes remains unclear. The purpose of this review was to determine (1) how fat mass differs in quantity and distribution between premenopausal and postmenopausal women, (2) whether and how age and/or menopausal status moderates any observed differences, and (3) which type of fat mass measure is best suited to the detection of differences in fat mass between groups., Study: This review with metaanalyses is reported according to Metaanalysis of Observational Studies in Epidemiology guidelines., Study Appraisal and Synthesis Methods: Studies (published up to May 2018) were identified via PubMed to provide fat mass measures in premenopausal and postmenopausal women. We included 201 cross-sectional studies in the metaanalysis, which provided a combined sample size of 1,049,919 individuals and consisted of 478,734 premenopausal women and 571,185 postmenopausal women. Eleven longitudinal studies were included in the metaanalyses, which provided a combined sample size of 2472 women who were premenopausal at baseline and postmenopausal at follow up., Results: The main findings of this review were that fat mass significantly increased between premenopausal and postmenopausal women across most measures, which included body mass index (1.14 kg/m 2 ; 95% confidence interval, 0.95-1.32 kg/m 2 ), bodyweight (1 kg; 95% confidence interval, 0.44-1.57 kg), body fat percentage (2.88%; 95% confidence interval, 2.13-3.63%), waist circumference (4.63 cm; 95% confidence interval, 3.90-5.35 cm), hip circumference (2.01 cm; 95% confidence interval, 1.36-2.65 cm), waist-hip ratio (0.04; 95% confidence interval, 0.03-0.05), visceral fat (26.90 cm 2 ; 95% confidence interval, 13.12-40.68), and trunk fat percentage (5.49%; 95% confidence interval, 3.91-7.06 cm 2 ). The exception was total leg fat percentage, which significantly decreased (-3.19%; 95% confidence interval, -5.98 to -0.41%). No interactive effects were observed between menopausal status and age across all fat mass measures., Conclusion: The change in fat mass quantity between premenopausal and postmenopausal women was attributable predominantly to increasing age; menopause had no significant additional influence. However, the decrease in total leg fat percentage and increase in measures of central fat are indicative of a possible change in fat mass distribution after menopause. These changes are likely to, at least in part, be due to hormonal shifts that occur during midlife when women have a higher androgen (ie, testosterone) to estradiol ratio after menopause, which has been linked to enhanced central adiposity deposition. Evidently, these findings suggest attention should be paid to the accumulation of central fat after menopause, whereas increases in total fat mass should be monitored consistently across the lifespan., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Empiric therapy for urinary tract infection is difficult in postmenopausal women because of the higher rates of confounding lower urinary tract symptoms and differential resistance profiles of uropathogens in this population., Objective: The objective of the study was to determine the least costly strategy for treatment of postmenopausal women with the primary complaint of dysuria., Study Design: We performed a cost minimization analysis modeling the following clinical options: (1) empiric antibiotic therapy followed by urine culture, (2) urinalysis with empiric antibiotic therapy only if positive nitrites and leukocyte esterase, or (3) waiting for culture prior to initiating antibiotics. For all strategies we included nitrofurantoin, trimethoprim/sulfamethoxazole, fosfomycin, ciprofloxacin, or cephalexin. Pathogens included Escherichia coli, Enterococcus faecalis, Klebsiella pneumonaie, or Proteus mirabalis. Pathogens, resistance, treatment success, and medication side effects were specific to postmenopausal women., Results: Cost minimization modeling with TreeAge Pro assumed 73.4% of urinary tract infections were caused by Escherichia coli with 24.4% resistance to nitrofurantoin, trimethoprim/sulfamethoxazole. With our assumptions, empiric antibiotics with nitrofurantoin, trimethoprim/sulfamethoxazole was the least costly approach ($89.64/patient), followed by waiting for urine culture ($97.04/patient). Except for empiric antibiotics with fosfomcyin, empiric antibiotics was always less costly than using urinalysis to discriminate antibiotic use. This is due to the cost of urinalysis ($38.23), high rate of both urinary tract infection (91%), and positive urinalysis (69.3%) with dysuria in postmenopausal women and resultant high rate of antibiotic use with or without urinalysis. Options with fosfomycin were the most expensive because of the highest drug costs ($98/dose), and tornado analyses showed fosfomycin cost was the most impactful variable for model outcomes. Sensitivity analyses showed empiric fosfomycin became the least costly option if drug costs were $25.80, a price still more costly than almost all modeled baseline drug costs. This outcome was largely predicated on low resistance to fosfomycin. Conversely, ciprofloxacin was never the least costly option because of higher resistance and side effect cost, even if the drug cost was $0. We modeled 91% positive urine culture rate in postmenopausal women with dysuria; waiting for the urine culture prior to treatment would be the least costly strategy in a population with a predicted positive culture rate of <65%., Conclusion: The least costly strategy was empiric antibiotics with nitrofurantoin and trimethoprim/sulfamethoxazole, followed by waiting on culture results. Local resistance patterns will have an impact on cost minimization strategies. Empiric fosfomycin would be least costly with reduced drug costs, even at a level at which drug costs were higher than almost all other antibiotics. In a population with high posttest probability of positive urine culture, urinalysis adds unnecessary cost. Antibiotic stewardship programs should continue efforts to decrease fluoroquinolone use because of high resistance, side effects, and increased cost., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Hormone-receptor positive, HER2 negative breast cancers account for the vast majority of early stage breast cancers, particularly in postmenopausal women. Adjuvant endocrine therapy is an essential component of multimodality therapy for such cancers, lowering the risk of local-regional and of metastatic recurrence, improving overall survival, and enabling "less" in the way of breast or axillary surgery and radiation therapy for many women. In the past decade, advances in adjuvant endocrine therapy in postmenopausal women include widespread use of aromatase inhibitors instead of or in sequence with tamoxifen, and use of extended durations of endocrine treatment beyond the classical "5 years" of recommended therapy. However, the judicious use of these treatments to optimize outcomes depends on considering features of the tumor stage and biology and careful attention to and management of symptoms related to these treatments., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Due to the higher incidence of hormone responsive tumours in women >50, the safety of hormone replacement therapy (HRT) in older breast cancer survivors may differ from younger age groups. The primary outcome in this review was the risk of tumour recurrence and secondary outcome the relationship with breast cancer-related mortality. Medline, CINAHL, Cochrane, Google Scholar and EMBASE databases were searched through August 2018 for studies reporting exposure to HRT in survivors ≥50 at primary diagnosis. Random effects models were used to estimate the combined relative risk (RR) of tumour recurrence and breast cancer-related mortality using the Mantel-Haenszel method and the quality of evidence determined for the primary outcome. Overall, nine studies (four cohort, one case-control, four RCTs; n = 16,002) were included. Very low quality evidence from observational studies demonstrated no adverse effect on tumour recurrence with HRT use (RR 0.80, 95% CI 0.53 to 1.19; I 2  = 66%; n = 11,984), while moderate quality evidence from RCTS demonstrated an adverse effect (RR 1.46, 95% CI 1.20 to 1.77; I 2  = 17%; n = 4108). Similarly, observational studies demonstrated no adverse effect on breast cancer-related mortality (RR 0.32, 95% CI 0.21 to 1.49; I 2  = 0%, n = 2182), while RCTs demonstrated a non-significant higher risk (RR 1.07, 95% CI 0.77 to 1.49; I 2  = 0%; n = 3918). Ultimately, despite conflicting findings, evidence of sufficient quality suggests that HRT may increase the risk of tumour recurrence in older survivors. However, adverse effect on mortality is unlikely. Caution with HRT use in survivors is further advised., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

The presence of vaginal fluid as a bio-stain in the crime scene of sexual assaults provides pivotal evidence. The vaginal secretions are known to be rich in Lactobacillus; hence the current work aims to identify vaginal secretions via detection and quantification of Lactobacillus DNA in pre and postmenopausal females and to test its stability over storage time using Critical Threshold method applied by Polymerase chain reaction approach. Comparative study is done by Critical Threshold and Relative Expression methods aiming to evaluate the two methods. Results showed that (ΔCT) <9 powerfully indicates the presence of vaginal fluids. Values of ΔCT in all vaginal samples are stable and not affected by storage. Two novel cutoff values are obtained in order to differentiate between premenopausal and postmenopausal vaginal fluid samples which are (8.42) using the Critical Threshold method and (0.24) using the Relative Expression method. One novel cutoff value is obtained to differentiate between fresh and stored vaginal samples by the Relative Expression method which is (0.39). It is concluded that Lactobacillus DNA quantification via PCR is a good positive identifier for vaginal secretions which is remarkably stable over storage time., (Copyright © 2019 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Background: In the Mammary Oncology Assessment of LEE011's (Ribociclib's) Efficacy and Safety (MONALEESA-2) study, combination treatment with the selective inhibitor of cyclin-dependent kinases 4/6 ribociclib with letrozole significantly improved progression-free survival (PFS) versus letrozole alone in postmenopausal women with hormone receptor-positive HR + /HER2 - advanced breast cancer (ABC). Herein we present results from the subset of US patients enrolled in MONALEESA-2., Patients and Methods: Postmenopausal women with HR + /HER2 - ABC without previous treatment for advanced disease were randomized (1:1) to ribociclib 600 mg/d (3 weeks on/1 week off) with letrozole 2.5 mg/d (continuous) or placebo with letrozole. The primary end point was locally assessed PFS., Results: Overall, 213 US patients were enrolled in MONALEESA-2 (ribociclib, n = 100; placebo, n = 113). Baseline characteristics were similar between treatment groups and consistent with the global population. With a median follow-up of 27 months, 38 (38%) and 29 (26%) patients in the ribociclib and placebo groups, respectively, had continued to receive treatment. Median PFS was 27.6 months with ribociclib and 15.0 months with placebo (hazard ratio, 0.53). The most common all-cause adverse events were neutropenia (ribociclib, 72.0% [n = 72]; placebo, 4.6% [n = 5]), nausea (ribociclib, 69.0% [n = 69]; placebo, 44.0% [n = 48]), and fatigue (ribociclib, 60.0% [n = 60]; placebo, 50.5% [n = 55]). Two patients (ribociclib, 2.0%; placebo, 0%) experienced febrile neutropenia., Conclusion: In the US subset of MONALEESA-2, ribociclib with letrozole showed superior efficacy versus letrozole alone. These findings are consistent with the global population and support first-line use of ribociclib with letrozole in patients with HR + /HER2 - ABC., (Copyright © 2019. Published by Elsevier Inc.)