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The demographics of the United States are rapidly changing, and our health care workforce is not keeping pace with the population trends. The American Society for Reproductive Medicine (formerly The American Fertility Society) recognizes the need to increase diversity and is committed to promoting diversity across our membership and leadership as well as promoting equitable quality reproductive care to all patients. In the fall of 2020, the American Society for Reproductive Medicine convened a Diversity, Equity, and Inclusion Task Force to evaluate and make recommendations on the basis of findings to increase diversity to achieve equity and inclusion of reproductive and infertility services for all women. This article focuses on specific barriers that Black or African American patients face in accessing quality care and that provider's face in training and inclusion in reproductive medicine. Multiple publications have confirmed an improvement in health outcome when there is congruence between the patient and the provider. There is a stark contrast between the racial and ethnic diversity of our providers and other support personnel compared with that of our patients. Despite our best intent to minimize the effects of implicit and explicit bias, mistrust and misunderstandings when there is discordance between patients and providers negatively impacts care. To increase provider diversity, it is crucial that we prioritize pipeline programs that recruit and support underrepresented minority in medicine physicians. Specific recommendations are made to increase diversity in the pipeline to improve patient access to culturally competent quality reproductive medicine care with optimal outcomes.

Objective To conduct a comprehensive review of racial and ethnic health disparities in infertility care and treatment. Evidence Review Systematic literature searches were performed in PubMed and Embase from inception to April 2021. Studies were eligible for inclusion if they were original research performed in humans, observational study design, focused on circumstances contributing to infertility, access to infertility care, or outcomes of infertility treatment, and provided relevant information on racial or ethnic groups. Titles and abstracts were reviewed independently by two reviewers to identify pertinent articles. In addition, references of included articles were screened. Result(s) The PubMed search yielded 2,113 articles. An additional 2,301 articles were found in the Embase search. In total, 4,414 articles were screened on the basis of title and, where necessary, abstract. Thirty-four were found to meet the inclusion criteria and included in this review. Three additional studies were found from searching references of the included articles, resulting in 37 articles for discussion: 26 retrospective cohort studies, 2 prospective cohort studies, and 9 cross-sectional studies. The overall consensus in the literature is that reproductive health disparities on the basis of race and ethnicity impact fertility, access to care, and fertility treatment outcomes. Conclusion(s) Racial and ethnic differences in access to full-spectrum reproductive care, including infertility evaluation and treatment, remain. Despite access to infertility treatment, disparate treatment outcomes persist. Intrinsic and extrinsic factors, such as the institutionalization of racism and discrimination within medicine, remain influential in the diagnosis, care, and treatment outcomes of individuals with infertility. To address these inequities, we should mitigate provider bias, fund high-quality health disparity research, improve patient reproductive health knowledge, and advocate for increased access to treatment for all.

More than 4 million menopausal women are from ethnic minority groups. Over the past 25 years, recognition of the importance of social, emotional, and physical changes of midlife to women's long-term health and well-being has emerged. Multiple factors influence how a woman perceives menopausal changes and what she addresses as associated symptoms. Factors such as educational level to socioeconomic status, health-related factors, stress, and marital status influence these choices. Increasingly, researchers are reporting on the impact of race and ethnicity on menopausal symptoms. Understanding similarities and differences among women's perceptions, attitudes, and expectations surrounding menopause improves delivery of culturally appropriate care and promotes lifestyles that may decrease symptoms and increase quality of life. Historically, the majority of the research in this area has been conducted in Western countries with clinical samples of women predominantly from European backgrounds. Thus, this population has shaped the emerging clinical picture of the midlife menopausal transition. Recently, studies of non-European women, both in the United States and internationally, indicate significant variations in their experiences during this transition, but these cultural differences have not broadened the understanding of the meaning of this universal experience. To date, there are still large knowledge gaps in race, ethnic, and cultural differences in menopausal health. The content of this review summarizes the current body of knowledge on racial differences in the menopause experience.

Objective To investigate the effects of epigallocatechin gallate (EGCG), an extract of green tea on cultured human leiomyoma cells (HuLM). Design Laboratory study. Setting University hospitals. Patient(s) Not applicable. Intervention(s) Not applicable. Main Outcome Measure(s) The HuLM cells were treated with various EGCG concentrations. Cell proliferation was assayed using Hoechst 33258 dye, and apoptosis by terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay. Total RNA was isolated, and gene expression profiling was performed on 84 key genes related to 18 different signal transduction pathways. The protein levels of PCNA, CDK4, BCL2, and BAX were examined by Western blot analysis. Result(s) The HuLM cells treated with EGCG showed a dose-dependent and time-dependent inhibition of cell proliferation. The TUNEL staining indicated a significant increase in apoptosis in HuLM cells treated with 100 μM of EGCG compared with untreated control. Gene expression profiling indicated that EGCG treatment up-regulated representative genes from the transforming growth factor β (TGF-β) and stress pathways, while inhibiting the survival pathway and NFκB–dependent inflammatory pathway. Western blot analysis confirmed that EGCG at ≥50 μM significantly decreased the expression of PCNA, CDK4, and BCL2 as well as increased the expression of the proapoptotic BAX in a dose-dependent manner. Conclusion(s) Epigallocatechin gallate inhibits the proliferation of HuLM cells and induces apoptosis. These results suggest that EGCG may be a potential anti-uterine fibroid agent acting through multiple signal transduction pathways.

Guidelines for screening of cervical cancer and pelvic exams for older women have recently changed. These changes may have unexpected sequelae in women over 65 years of age. This manuscript provides a review of gynecologic screening recommendations for older women in the U.S. and potential ramifications of these recent changes. Peer reviewed guidelines from the American College of Obstetrics and Gynecology, U.S. Preventative Task Force Services, the American Cancer Society, The Centers for Disease Control, and multiple original research articles and reviews were reviewed for this manuscript. Women over 65 are at greatest risk to develop late stage diagnoses of cancers, pelvic organ disease, incontinence, and infections. Clinicians will need to acutely consider this fact when communicating and screening this population. We conclude that practitioners should be aware of the new guidelines and should consider including gynecologic health history and symptom analysis as part of annual exams in women of all ages.

Objective Despite the high prevalence of uterine leiomyoma in women, little is known about the pathophysiology of this tumor. This study intends to define the epigenetic modulation of this tumor. Methods Twenty-three pairs of leiomyomas and their adjacent myometria were collected. Status of DNA global methylation was determined by using DNA methyl acceptance assay and immunohistochemistry staining with 5-methylcytidine antibody. MRNA level of DNA methyltransferases (DNMT1, 3A, and 3B) was assessed by quantitative real time PCR. Results DNA global hypomethylation was detected in the leiomyoma tissues as compared with the adjacent myometria. DNMT1 expression was increased in 47.5% and was equal in 47.5% in leiomyomas compared to the adjacent myometria. On the other hand, over 74% of cases showed decreased expression of DNMT3A and 3B in leiomyomas compared to the adjacent myometria. Conclusion Global hypomethylation and imbalanced expression of DNMTs in uterine leiomyoma suggested a potential mechanism of epigenetic modulation in the development of this tumor.

Objective: Increased mammographic breast density is a well-established risk factor for breast cancer development, regardless of age or ethnic background. The current gold standard for categorizing breast density consists of a radiologist estimation of percent density according to the American College of Radiology (ACR) Breast Imaging Reporting and Data System (BI-RADS) criteria. This study compares paired qualitative interpretations of breast density on digital mammograms with quantitative measurement of density using Hologic’s Food and Drug Administration–approved R2 Quantra volumetric breast density assessment tool. Our goal was to find the best cutoff value of Quantra-calculated breast density for stratifying patients accurately into high-risk and low-risk breast density categories. Methods: Screening digital mammograms from 385 subjects, aged 18 to 64 years, were evaluated. These mammograms were interpreted by a radiologist using the ACR’s BI-RADS density method, and had quantitative density measured using the R2 Quantra breast density assessment tool. The appropriate cutoff for breast density–based risk stratification using Quantra software was calculated using manually determined BI-RADS scores as a gold standard, in which scores of D3/D4 denoted high-risk densities and D1/D2 denoted low-risk densities. Results: The best cutoff value for risk stratification using Quantra-calculated breast density was found to be 14.0%, yielding a sensitivity of 65%, specificity of 77%, and positive and negative predictive values of 75% and 69%, respectively. Under bootstrap analysis, the best cutoff value had a mean ± SD of 13.70% ± 0.89%. Conclusions: Our study is the first to publish on a North American population that assesses the accuracy of the R2 Quantra system at breast density stratification. Quantitative breast density measures will improve accuracy and reliability of density determination, assisting future researchers to accurately calculate breast cancer risks associated with density increase.

Purpose: Guidelines for screening for cervical cancer and pelvic exams for women over age 65 have recently changed. Goals of these guidelines have shifted from yearly Pap smears and exams to longer intervals or discontinuation in this age group. This manuscript analyzes the implications for practice as this population of women lives longer without gynecologic care. Data Sources: Published and peer reviewed guidelines from the American College of Obstetrics and Gynecology, U.S. Preventative Task Force Services, the American Cancer Society, The Centers for Disease Control, and multiple original research articles and reviews were used for this manuscript. Conclusions: The potential for women to develop later stage diagnoses of cancers, pelvic organ issues, incontinence, and infections is of great concern, especially as women over the age of 65 will be the greatest proportion of the American population in years to come. Implications for Practice: Practitioners need to be aware of new guidelines and best practices to improve the overall health of women. Practitioners of primary care should include gynecologic health as part of annual exams in all women of all ages.

Objective: To determine the effects of elevated endogenous E 2 levels on in vitro platelet function in patients undergoing controlled ovarian hyperstimulation (COH). Design: Women with normal ovulatory cycles and patients undergoing COH on cycle day 3 and near ovulation (preovulatory follicles were at least 16 mm in diameter) were studied. Serum E 2 , Thrombostat 4000, (V. d. Goltz, Seeon, Germany), von Willebrand factor antigen (vWF-Ag), and platelet aggregation and adenosine triphosphate (ATP) release to adenosine diphosphate (ADP), collagen (COL), and arachidonic acid (AA) were measured. Setting: University-based outpatient infertility clinic. Patient(s): Twenty-two consenting infertile women undergoing COH cycles and 14 women with documented ovulatory cycles. Main Outcome Measure(s): Whole blood platelet aggregation with ADP, COL, AA, and Thrombostat 4000. Result(s): Estradiol levels rose significantly at peak times (P = 0.011). No changes were noted in in vitro platelet function measured by the Thrombostat 4000 and by whole blood platelet aggregation with ADP and AA and in ATP release with ADP, COL, or AA. Aggregation with collagen was increased because of likely elevations in vWF-Ag levels. Conclusion(s): No significant changes in in vitro platelet function were noted in 19 women undergoing COH with E 2 levels two to three times that observed in oral contraceptive or hormone replacement therapy users, suggesting no increased risk for arterial thromboembolism.

Uterine fibroids are common smooth muscle tumors of myometrial cells, which can result in substantial symptoms affecting the quality of life of women. Currently, patients have several options available for treatment ranging from uterine-sparing surgeries (myomectomy), hysterectomy, and nonsurgical options, such as uterine artery embolization, magnetic resonance-guided focused ultrasound (MRgFUS), or cryoablation. MRgFUS is one of the least invasive treatment options outside medical therapy. MRgFUS ablation combines therapy delivered by an ultrasound transducer with imaging, guidance for therapy, and thermal feedback provided by magnetic resonance imaging. In 2004, the MRgFUS system ExAblate 2000 (InSightec, Haifa, Israel) was approved by the United States Food and Drug Administration for clinical treatments of uterine fibroids. Data on safety and long-term efficacy are ongoing to establish the unique usefulness of this therapy in targeted treatment of leiomyoma through the integration of MR imaging. Multiple clinical trials detail several efficacy outcomes including symptom improvement, leiomyoma shrinkage, and use of alternative procedures. Additionally, favorable pregnancy outcomes following MRgFUS have been reported. Applications of MRgFUS have recently expanded into the realm of adenomyosis treatment. MRgFUS has been deemed a safe and effective method of fibroid treatment and offers the advantages of no incisions or blood loss, speedy recovery, and a cost-effective means of treatment.

Both basic science and clinical studies support the concept that vitamin D deficiency is involved in the pathogenesis of cardiovascular and renal diseases through its association with diabetes, obesity, and hypertension. Understanding the underlying mechanisms may provide a rationale for advocating adequate intake of vitamin D and calcium in all populations, thereby preventing many chronic diseases. This review explores the effect of vitamin D deficiency in the development of cardiovascular and renal diseases, and the role of vitamin D supplementation on cardiovascular outcomes. In addition, it highlights the importance of vitamin D intake for the prevention of adverse long-term health consequences, and in ways to facilitate the management of cardiovascular disease. This is particularly true for African American and postmenopausal women, who are at added risk for cardiovascular disease. We suggest that the negative cardiovascular effects of low vitamin D in postmenopausal women could be improved by a combined treatment of vitamin D and sex steroids acting through endothelium-dependent and/or -independent mechanisms, resulting in the generation of nitric oxide and calcitonin gene-related peptide (CGRP).

Objective To systematically review the reporting of race/ethnicity in Society for Assisted Reproductive Technology (SART) Clinic Outcome Reporting System (CORS) publications. Design Systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology of literature published in PubMed on race/ethnicity that includes data from SART CORS. Setting Not applicable. Patient(s) Not applicable. Intervention(s) In vitro fertilization cycles reported to SART. Main Outcome Measure(s) Any outcomes reported in SART CORS. Result(s) Seven publications were identified that assessed racial/ethnic disparities in IVF outcomes using SART data. All reported a racial/ethnic disparity. However, more than 35% of cycles were excluded from analysis because of missing race/ethnicity data. Conclusion(s) Review of current publications of SART data suggests significant racial/ethnic disparities in IVF outcomes. However, the potential for selection bias limits confidence in these findings, given that fewer than 65% of SART reported cycles include race/ethnicity. Our understanding of how race/ethnicity influences ART outcome could be greatly improved if information on race/ethnicity was available for all reported cycles.

The purpose of this study was to investigate the effect of epigallocatechin gallate (EGCG) on rat leiomyoma (ELT3) cells in vitro and in a nude mice model.ELT3 cells were treated with various concentrations of EGCG. Cell proliferation, proliferation cell nuclear antigen (PCNA), and cyclin-dependent kinase 4 (Cdk4) protein levels were evaluated. ELT3 cells were inoculated subcutaneously in female athymic nude mice. Animals were fed 1.25 mg EGCG (in drinking water)/mouse/day. Tumors were collected and evaluated at 4 and 8 weeks after the treatment.Inhibitory effect of EGCG (200 micromol/L) on ELT3 cells was observed after 24 hours of treatment (P.05). Ator = 50 micromol/L, EGCG significantly decreased PCNA and Cdk4 protein levels (P.05). In vivo, EGCG treatment dramatically reduced the volume and weight of tumors at 4 and 8 weeks after the treatment (P.05). The PCNA and Cdk4 protein levels were significantly reduced in the EGCG-treated group (P.05).EGCG effectively inhibits proliferation and induces apoptosis in rat ELT3 uterine leiomyoma cells in vitro and in vivo.

Vasomotor symptoms (VMS) affect up to 80% of menopausal women and are the most common reason these women seek treatment. Approximately 60% of midlife women seek medical care or advice at least once because of VMS, 1 which adversely affect quality of life in domains that include work, social and leisure activities, and sexual health. 2 Previous research from the Study of Women’s Health Across the Nation (SWAN) 2,3 demonstrated that having VMS at least 6 days in the previous 2 weeks was highly associated with other conditions such as anxiety, depression, sleep problems, qualityof-life impairment, cardiovascular risks, and poorer bone health. Despite the high prevalence of VMS among midlife women, surprisingly little research has been done on the underlying etiology, individual differences in symptom presentation, sociodemographic and clinical correlates, or duration of symptoms. Early publications reported the duration of VMS to be generally less than 2 years, 4 whereas recent evidence (eg, the study by Avis et al 5 in the current issue of JAMA Internal Medicine) suggests that the mean duration of symptoms is considerably longer. The findings from recent studies underscore the limitations of the earlier evidence base on VMS that has guided clinical practice for many decades. 4 The study by Avis et al 5 contributes important data on duration and correlates of VMS from the SWAN, a large multiracial/ multiethnic cohort of women followed up through the menopausal transition and into the postmenopausal years. The

The reproductive cycle in the female is a coordinated interaction between the hypothalamus and pituitary in concert with the ovary, uterus, endometrium, and fallopian tubes. Any derangement in the function of the reproductive system may result in infertility or subfertility.

OBJECTIVE: The purpose of this study was to evaluate the effect of elevated levels of circulating estradiol on the clotting and fibrinolytic system in patients undergoing controlled ovarian hyperstimulation. STUDY DESIGN: Fifty-two patients undergoing controlled ovarian hyperstimulation with human menopausal gonadotropins or urofollotropin were asked to participate. Blood for hemostasis parameters was obtained on the days that patients returned for estradiol sampling. Sample days were identified as cycle days 1 to 5 (baseline), 6 to 9, and 10 to 14. Each factor was analyzed by repeated-measures analysis of variance and correlation analysis. RESULTS: A significant decline was observed for tissue plasminogen activator antigen and plasminogen activator inhibitor type 1 activity from baseline to cycle days 10 to 14. As serum estradiol levels increased throughout each phase (maximum mean estradiol 739.8 pg/ml), a significant linear decrease was observed for both tissue plasminogen activator antigen and plasminogen activator inhibitor type 1 activity, whereas thrombin-antithrombin III complexes did not change significantly. A significant positive correlation was also observed for plasminogen activator inhibitor activity and tissue plasminogen activator antigen level over all cycle days examined. CONCLUSION: Down-regulation of the fibrinolytic system was observed as estradiol levels increased. However, thrombin formation did not change, thus suggesting that elevated circulating estradiol alone does not predispose to a thromboembolic event.