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Premature ovarian insufficiency (POI) is a condition associated with estrogen deficiency which leads to decreased bone mineral density and an increased risk of osteoporosis and fractures. Estrogen-based hormone therapy is an integral component of treatment; however, to date the ideal hormone formulation for optimizing bone health has not been established.To assess the effects of estrogen-based oral contraceptives (OCP) versus hormone therapy (HT) on bone mineral density (BMD) in women with POI.A systematic review of Ovid MEDLINE, EMBASE, Cochrane Library, and Web of Science databases was conducted from conception until December 2020. Randomized controlled trials (RCTs) and observational studies that met inclusion criteria were included in the analysis. Risk of bias was assessed with the Newcastle-Ottawa Quality Assessment Scale for cohort studies and the Cochrane Risk of Bias for RCTs. The study protocol was registered with the International Prospective Register of Systematic Reviews and adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis.Our search yielded 1,227 studies; 3 RCTs and 2 observational cohort studies met inclusion criteria and were included in our study. The largest subpopulation was Turner Syndrome (n = 625), followed by idiopathic POI (n = 146). Of the four studies that assessed changes in BMD, two studies reported a significant increase in lumbar spine BMD with HT compared with OCP (+0.050 g/cm2, P 0.025; +0.019 g/cm2, P 0.01), one study found similar improvement in lumbar spine BMD across treatments (HT -0.003 g/cm2, P = 0.824), and one study did not directly compare treatments. Effects on bone turnover markers were inconsistent across three studies that evaluated this outcome.This is the first systematic review to include studies that directly compared OCP and HT on bone outcomes in POI. While two studies reported increased lumbar spine BMD with HT, this result was not consistently found across studies. There were important differences in POI etiology, treatment regimens and formulations, and risk of bias was high in many of the studies. These results indicate future, larger-scale trials are needed to further understand the optimal hormone therapy for bone density in POI.

ContextVasomotor symptoms (VMS) are common, bothersome, and can persist for years before and after menopause.ObjectiveWe aimed to assess efficacy/safety of fezolinetant for treatment of moderate to severe VMS associated with menopause.MethodsIn this double-blind, placebo-controlled, 12-week phase 3 trial with a 40-week active treatment extension (NCT04003142; SKYLIGHT 2), women aged 40 to 65 years with minimum average 7 moderate to severe VMS/day were randomized to 12 weeks of once-daily placebo, fezolinetant 30 mg, or fezolinetant 45 mg. Completers were rerandomized to fezolinetant 30/45 mg for 40 additional weeks. Coprimary efficacy endpoints were mean daily change from baseline to week 4 (W4) and W12 in VMS frequency and severity. Safety was also assessed.ResultsBoth fezolinetant doses statistically significantly reduced VMS frequency/severity at W4 and W12 vs placebo. For VMS frequency, W4 least squares mean (SE) reduction vs placebo: fezolinetant 30 mg, –1.82 (0.46; P < .001); 45 mg, –2.55 (0.46; P < .001); W12: 30 mg, –1.86 (0.55; P < .001); 45 mg, −2.53 (0.55; P < .001). For VMS severity, W4: 30 mg, −0.15 (0.06; P < .05); 45 mg, −0.29 (0.06; P < .001); W12: 30 mg, −0.16 (0.08; P < .05); 45 mg, −0.29 (0.08; P < .001). Improvement in VMS frequency and severity was observed by W1 and maintained through W52. Serious treatment-emergent adverse events were infrequent, reported by 2%, 1%, and 0% of those receiving fezolinetant 30 mg, fezolinetant 45 mg, and placebo, respectively.ConclusionDaily fezolinetant 30 and 45 mg were efficacious and well tolerated for treating moderate to severe VMS associated with menopause.

Genitourinary syndrome of menopause (GSM) may arise from the hypoestrogenism caused by ovarian function destruction following gynecological cancer treatments. GSM may also be present in menopausal ...

Assess acceptability of a 12-minute educational video before menopause clinic consultation and evaluate its impact on knowledge and treatment certainty.This was a pre-post intervention study among new patients with vasomotor symptoms (VMS) referred to a menopause clinic in Toronto, Canada. Participants completed electronic questionnaires before and after viewing a 12-minute online video covering menopause facts and VMS treatments. Participants' demographic information and referring provider type were recorded. A 19-item true/false knowledge quiz and validated Decision Conflict Scale (DCS) were administered before and after viewing the video along with a validated Acceptability questionnaire after the video. Demographic information and acceptability were summarized descriptively and independent samples t tests compared knowledge and DCS total and subscores before and after viewing the education module. Multivariable analysis was used to identify factors associated with achieving treatment certainty.Seventy-one participants completed pre- and postintervention questionnaires. Mean age was 51.4 ± 6.0 years and most were White (58/71, 81.7%), had a university degree (24/71, 63.3%) and household income$90,000 (53/71, 74.6%). After the video, there was significant increase in knowledge score (12.7 ± 2.1 vs. 16.9 ± 1.8, P0.001) and decrease in all DCS scores (total and five subscores) compared with preintervention scores (P0.001). Acceptability was high with 62/71 (87.3%) respondents indicating the tool was useful. Findings were independent of level of education, household income, and referring physician type.In a study of predominantly university-educated White women, a 12-minute education module on menopause and VMS treatment was acceptable, there was improved knowledge and decision certainty about VMS treatment.

OBJECTIVE To evaluate predictors of bilateral salpingo-oophorectomy at hysterectomy and determine rate of unnecessary bilateral salpingo-oophorectomy. METHODS Retrospective review of hysterectomies at six Ontario, Canada hospitals from July 2016 to June 2018. Data was extracted from health records coding and electronic medical records. Of patients with concurrent bilateral salpingo-oophorectomy, age, preoperative diagnoses, surgical factors (presence of endometriosis/adhesions), and surgeon training (fellowship/no fellowship) were recorded. Chi-square tests compared indicated and nonindicated bilateral salpingo-oophorectomy cases based on preoperative diagnosis. Criteria for unnecessary bilateral salpingo-oophorectomy were: age under 51 years, benign preoperative diagnosis, and absence of intraoperative endometriosis and adhesions. RESULTS Concurrent bilateral salpingo-oophorectomy occurred in 749/2,656 (28%) cases with 509/749 (68%) indicated based on preoperative diagnosis. There was interhospital variation in rate of indicated bilateral salpingo-oophorectomy based on preoperative diagnosis (45.3%-76.9%, χ2P

Background SKYLIGHT 2 (NCT04003142) investigated safety and efficacy of fezolinetant (a neurokinin-3 receptor antagonist) on frequency and severity of moderate-to-severe vasomotor symptoms (VMS) and sleep disturbance. In this analysis, persistence of fezolinetant efficacy was investigated over 52 weeks. Methods This double-blind Phase 3 study randomized women aged ≥40–65 years with moderate-to-severe VMS associated with menopause (average of ≥7 hot flashes/day) to once-daily placebo or fezolinetant 30mg or 45mg for 12 weeks. Women completing 12 weeks entered an extension period, with those on placebo re-randomized to fezolinetant 30mg or 45mg (placebo/fezolinetant), and those originally on fezolinetant remaining on their dose for an additional 40-weeks. Fezolinetant efficacy was evaluated vs placebo for 12-weeks through change in VMS frequency, VMS severity, and Patient-reported Outcomes Measurement Information System Sleep Disturbance–Short Form 8b (PROMIS) Total Score. Persistence of efficacy for fezolinetant was evaluated descriptively (without statistical comparisons) over the extension period. Results The analysis comprised 484 women (fezolinetant 30mg n=166, fezolinetant 45mg n=167, placebo/fezolinetant 30mg n=76, placebo/fezolinetant 45mg n=75). Improvement in VMS frequency and severity observed through week 12 (statistically significant differences vs placebo) was maintained throughout the 52-week total study period for those receiving fezolinetant. Fezolinetant demonstrated further reductions in VMS frequency and severity from baseline to beyond week 12. For VMS frequency, there was a least squares (LS) mean (SE) baseline-to-week 12 reduction of –6.83 (0.39) VMS/day for fezolinetant 30mg and –7.50 (0.39) for 45mg, and a mean (SD) baseline-to-week 52 reduction of –8.03 (4.53) for fezolinetant 30mg and –8.48 (3.98) for 45mg. For VMS severity, LS mean (SE) baseline-to-week 12 reduction was –0.64 (0.06) for 30mg and –0.77 (0.06) for 45mg, and mean (SD) baseline-to-week 52 reduction was –0.83 (0.82) for fezolinetant 30mg, and –0.95 (0.78) for 45mg. Women re-randomized from placebo to fezolinetant experienced a reduction in frequency and severity of VMS consistent with that in women receiving fezolinetant throughout the study. Fezolinetant also reduced PROMIS-assessed sleep disturbance, with a LS mean (SE) baseline-to-week 12 reduction of –4.1 (0.5) for fezolinetant 30mg and –5.5 (0.5) for 45mg (statistically significant difference vs placebo for fezolinetant 45mg) and a mean (SD) baseline-to-week 52 reduction of – 6.3 (7.3) for fezolinetant 30mg and –5.7 (7.9) for 45mg. The safety profile observed for the 40-week extension period was consistent with that of the 12-week placebo-controlled period. Conclusion Fezolinetant 30mg and 45mg once daily were efficacious for treatment of moderate-to-severe VMS associated with menopause. Efficacy was persistent and reductions in VMS frequency were maintained during the extension period, at levels consistent with weeks 1 through 12. Fezolinetant 45mg improved sleep at week 12 and improvement was maintained through the active treatment extension period. No safety signals of concern were apparent for either fezolinetant dose. Presentation: Saturday, June 11, 2022 12:30 p.m. - 12:45 p.m.

Patients with anal squamous cell carcinoma (SCC) are treated with sphincter-preserving radiation therapy and concurrent chemotherapy, achieving excellent oncologic outcomes. Patients, however, may experience treatment-related morbidity including sexual dysfunction. The objective of this systematic review was to review the literature on sexual dysfunction in female patients treated for anal cancer and to identify knowledge gaps.This systematic review was registered in PROSPERO prior to initiation. Databases searched included MEDLINE, Embase, PubMed, Cochrane, and Google Scholar. There were no restrictions on the study time period. Studies were limited to English. All study designs were included except review articles, letters to the editor, and case reports with less than ten patients.In total, 1801 studies were retrieved and 19 met the inclusion criteria, including: 13 cross-sectional surveys, 3 prospective studies, 1 longitudinal intervention study, 1 retrospective chart review, 1 case control study. Sexual function was assessed using the female sexual functioning index (FSFI), EORTC-QLQ-CR30 and -CR38; response rates were low (50 % in most studies). Sexual dysfunction was reported by up to 85 % of women; the most common symptoms being dyspareunia (17-65 %), vaginal dryness (22-88 %), and loss of libido (38-95 %). Gastrointestinal issues, such as bowel problems, and body image concerns additionally affected sexual function and quality of life.Sexual dysfunction is a common issue affecting most female patients treated for anal cancer and there is a paucity of evidence on the management of this important survivorship issue. There is additionally a lack of ethnic, economic, and educational diversity and there are no studies addressing the unique needs of LGBTQ individuals - future studies should make a concerted effort to include a diverse patient population.

The Ovarian-Adnexal Reporting and Data System (O-RADS) US risk stratification and management system is designed to provide consistent interpretations, to decrease or eliminate ambiguity in US reports resulting in a higher probability of accuracy in assigning risk of malignancy to ovarian and other adnexal masses, and to provide a management recommendation for each risk category. It was developed by an international multidisciplinary committee sponsored by the American College of Radiology and applies the standardized reporting tool for US based on the 2018 published lexicon of the O-RADS US working group. For risk stratification, the O-RADS US system recommends six categories (O-RADS 0-5), incorporating the range of normal to high risk of malignancy. This unique system represents a collaboration between the pattern-based approach commonly used in North America and the widely used, European-based, algorithmic-style International Ovarian Tumor Analysis (IOTA) Assessment of Different Neoplasias in the Adnexa model system, a risk prediction model that has undergone successful prospective and external validation. The pattern approach relies on a subgroup of the most predictive descriptors in the lexicon based on a retrospective review of evidence prospectively obtained in the IOTA phase 1-3 prospective studies and other supporting studies that assist in differentiating management schemes in a variety of almost certainly benign lesions. With O-RADS US working group consensus, guidelines for management in the different risk categories are proposed. Both systems have been stratified to reach the same risk categories and management strategies regardless of which is initially used. At this time, O-RADS US is the only lexicon and classification system that encompasses all risk categories with their associated management schemes.

Objective: Women with Turner syndrome (TS) are at increased risk for chronic health conditions. Reports describing the presence of comorbidities in older adult women with TS are limited. This study...

RESUME Objectif Offrir, aux fournisseurs de soins de sante, une mise a jour de la directive clinique quant a la prise en charge de la menopause chez les femmes asymptomatiques en sante, ainsi que chez les femmes qui presentent des symptomes vasomoteurs ou urogenitaux; cette mise a jour se penche egalement sur les facteurs associes a la maladie cardiovasculaire, au cancer du sein, a l'urogynecologie et a la sexualite. Issues Les interventions quant au mode de vie, les medicaments d'ordonnance et les traitements de medecine complementaire et parallele sont presentes en fonction de leur efficacite dans la prise en charge des symptomes menopausiques. Des strategies de counseling et therapeutiques en ce qui concerne les preoccupations en matiere de sexualite au cours de la perimenopause et de la postmenopause sont passees en revue. Des approches quant a l'identification et a l’evaluation des femmes exposees a un risque eleve d'osteoporose (ainsi que des options en matiere de prevention et de traitement) sont presentees dans la directive clinique sur l'osteoporose qui accompagne les presentes. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans PubMed et The Cochrane Library, en aout et en septembre 2012, au moyen d'un vocabulaire controle (p. ex. « hormone replacement therapy », « menopause », « cardiovascular diseases » et « sexual function ») et de mots cles (p. ex. « HRT », « perimenopause », « heart disease » et « sexuality »). Les resultats ont ete restreints aux directives cliniques, aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Les resultats ont egalement ete restreints aux documents publies, en anglais ou en francais, a partir de 2009. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'au 5 janvier 2013. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l’evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques, aupres de societes de specialite medicale nationales et internationales, et dans des collections de directives cliniques. Valeurs La qualite des resultats est evaluee au moyen des criteres decrits dans le rapport du Groupe d’etude canadien sur les soins de sante preventifs (Tableau 1).

Purpose: Selective serotonin reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs) are used as alternative treatments for the vasomotor symptoms of menopause in women...

RESUME Objectif Aider les medecins qui pratiquent la chirurgie gynecologique dans leur processus decisionnel relatif aux indications benignes de l'hysterectomie. Public cible Medecins, y compris gynecologues, obstetriciens, medecins de famille, chirurgiens generalistes, urgentologues; infirmieres, y compris les infirmieres autorisees et les infirmieres praticiennes; apprentis en medecine, y compris etudiants de medecine, residents, stagiaires (fellows); et autres fournisseurs de soins de sante. Population cible Femmes adultes (18 ans et plus) qui devront subir une hysterectomie pour une indication gynecologie benigne. Options La presente directive clinique examine les differentes voies d'abord de l'hysterectomie et l'utilite des interventions chirurgicales concomitantes. Donnees probantes Pour la presente directive clinique, des recherches ont ete effectuees dans les bases de donnees PubMed, Medline et Cochrane Library pour trouver des etudes pertinentes. Les recherches ont ete effectuees parmi les publications des cinq dernieres annees (2012-2017) au moyen des termes de recherche MeSH suivants ainsi que leurs variations : vaginal hysterectomy, laparoscopic hysterectomy, robotic hysterectomy, laparoscopically assisted vaginal hysterectomy, total laparoscopic hysterectomy, standard vaginal hysterectomy et total vaginal hysterectomy. Methodes de validation Le contenu et les recommandations ont ete rediges et acceptes par les auteurs principaux et membres du comite de pratique clinique – gynecologie. Le conseil d'administration de la Societe des obstetriciens et gynecologues du Canada a approuve la version definitive aux fins de publication. La qualite des donnees probantes utilisees dans le present document a ete evaluee au moyen des criteres du cadre methodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) (tableau 1, tableau 2). Le resume des conclusions est disponible sur demande. Avantages, prejudices et couts Bien que l'hysterectomie soit commune, la pratique chirurgicale varie grandement chez les medecins specialises en gynecologie. La presente directive expose les facteurs pre- et perioperatoires a prendre en compte pour ameliorer la qualite des soins prodigues aux femmes qui doivent subir une chirurgie pour une affection gynecologique benigne. Mise a jour de la directive clinique La presente directive clinique de la Societe des obstetriciens et gynecologues du Canada sera automatiquement passee en revue cinq ans apres sa publication. Les auteurs peuvent toutefois proposer une autre date de reevaluation s'ils croient qu'une periode de cinq ans est trop courte ou trop longue en fonction de leurs connaissances du sujet a titre d'experts en la matiere. Promoteurs La presente directive clinique a ete elaboree au moyen de ressources financees par la Societe des obstetriciens et gynecologues du Canada. Declarations condensees 1La technicite correspond a la proportion des hysterectomies realisees par voie d'abord a effraction minimale (laparoscopique, assistee par laparoscopie et vaginale). L'indice de technicite eleve est lie a une amelioration de la qualite chirurgicale et des soins a la patiente (elevee). 2Les voies d'abord de l'hysterectomie a effraction minimale sont liees a moins de complications perioperatoires que la laparotomie (elevee). 3Les hopitaux et chirurgiens qui traitent un grand nombre de patientes sont les plus susceptibles de detenir un indice de technicite eleve et un taux plus faible de complications (elevee). 4Les protocoles de chirurgie d'un jour pour l'hysterectomie a effraction minimale sont rentables, n'augmentent pas les taux de complications ni de readmission et sont lies a un taux eleve de satisfaction des patientes (moyenne). 5Le risque de traumas des voies urinaires est comparable entre les differentes voies d'approche chirurgicales de l'hysterectomie (moyenne). 6La laparotomie ou la mini-laparotomie peut etre indiquee comme solution de remplacement dans des cas precis en fonction de facteurs propres a la patiente, des indications chirurgicales et des pathologies sous-jacentes (moyenne). 7Le risque de dehiscence de la tranche vaginale est rare et n'est pas lie au choix du materiel de suture ni a la voie de fermeture (moyenne). 8L'hysterectomie supracervicale n'a pas demontre qu'elle peut preserver la fonction sexuelle, diminuer le risque de prolapsus des organes pelviens, ni reduire l'incidence du trauma des voies urinaires par rapport a l'hysterectomie totale (moyenne). 9Chez les femmes qui presentent des fibromyomes uterins, un traitement medicamenteux preoperatoire a l'acetate de leuprolide ou a l'acetate d'ulipristal peut reduire la taille des myomes, diminuer les saignements et corriger l'anemie. Les risques et avantages du traitement medicamenteux doivent etre abordes avant l'intervention (elevee). 10La preparation mecanique systematique des intestins n'est pas necessaire avant une chirurgie gynecologique pour une maladie benigne (elevee). 11L'ablation des ovaires normaux lors d'une hysterectomie reduit le risque de cancer de l'ovaire, mais peut entrainer des repercussions sur la sante. L'ovariectomie bilaterale peut provoquer une manifestation aigue de symptomes menopausiques chez les femmes non menopausees; elle n'a demontre aucun avantage de survie en l'absence d'une predisposition genetique au cancer de l'ovaire (elevee). 12L'hysterectomie seule affecte la reserve ovarienne (elevee). 13La salpingectomie prophylactique lors de l'hysterectomie devrait diminuer l'incidence des cas de cancer de l'ovaire grave de haut grade (faible). 14Il n'y a aucune donnee probante solide a l'appui de la suspension systematique aux utero-sacrees ou de la voute vaginale lors de l'hysterectomie chez les femmes qui ne presentent pas de prolapsus des organes pelviens (faible). Recommandations 1Pour les indications gynecologiques benignes, l'hysterectomie devrait se faire de preference par voie d'abord vaginale ou laparoscopique (forte, elevee). 2Pour realiser une hysterectomie, la voie d'abord vaginale est toujours l'option privilegiee, mais la chirurgie laparoscopique est une option de remplacement (forte, moyenne). 3La correction preoperatoire de l'anemie (hemoglobine a 4L'antibioprophylaxie preoperatoire et les mesures pour reduire le risque de thromboembolie veineuse sont recommandees pour toutes les patientes qui doivent subir une hysterectomie (forte, elevee). 5Il est important de conseiller les femmes sur les risques et avantages de l'ablation des ovaires lors de l'hysterectomie. Cette discussion doit aborder le risque de cancer de l'ovaire et les repercussions sur la sante a long terme relativement a une menopause precoce (forte, moyenne). 6La salpingectomie prophylactique peut etre envisagee lors de l'hysterectomie, mais la voie d'abord chirurgicale ne devrait pas etre modifiee pour cette seule fin (forte, faible). 7Comme le trauma des voies urinaires est une complication connue de l'hysterectomie, les cliniciens ne doivent pas hesiter a effectuer des examens supplementaires lorsqu'ils suspectent un trauma. Il convient, pour les chirurgiens qui pratiquent l'hysterectomie, d'avoir acces a la cystoscopie diagnostique, individuellement ou sur consultation, pour examiner la vessie et evaluer l'integrite ureterale (forte, moyenne). 8Pour les patientes atteintes d'endometriose qui prevoient de subir une hysterectomie, l'excision complete des lesions endometriosiques doit etre effectuee au moment de l'intervention (forte, moyenne).

Objective Genitourinary symptoms, such as vaginal dryness and pain with sex, are commonly experienced by postmenopausal women. Comparing treatments for these genitourinary symptoms are restricted by the use of different outcome measures in clinical trials and the omission of outcomes, which may be relevant to women. The aim of this project was to develop a Core Outcome Set (COS) to be reported in clinical trials of treatments for genitourinary symptoms associated with menopause. Methods We performed a systematic review of randomized controlled trials of treatments for genitourinary symptoms associated with menopause and extracted their outcomes. This list was refined and entered into a two-round modified Delphi survey, which was open to clinicians, researchers, and postmenopausal women from November 2019 to March 2020. Outcomes were scored on a nine-point scale from "not important" to "critically important." The final COS was determined following two international consensus meetings. Results A total of 26 unique outcomes were included in the Delphi process, which was completed by 227 participants of whom 58% were postmenopausal women, 34% clinicians, and 8% researchers. Predefined thresholds were applied to the Delphi scores to categorize outcomes by importance, which informed the e consensus meetings, attended by 43 participants from 21 countries. The final COS includes eight outcomes: (1) pain with sex, (2) vulvovaginal dryness, (3) vulvovaginal discomfort or irritation, (4) discomfort or pain when urinating, (5) change in most bothersome symptom, (6) distress, bother or interference of genitourinary symptoms, (7) satisfaction with treatment, (8) side effects of treatment. Conclusion These eight core outcomes reflect the joint priorities of postmenopausal women, clinicians, and researchers internationally. Standardized collection and reporting of these outcomes in clinical trials will facilitate the comparison of different treatments for genitourinary symptoms, advance clinical practice, and ultimately improve outcomes for symptomatic women.

This study aimed to evaluate the published data on the effect of cannabis use in perimenopausal and postmenopausal women to alleviate menopausal symptoms, insomnia and anxiety. Databases searched included Ovid MEDLINE, PubMed, Ovid Embase, Web of Science, Scopus, CINAHL, PsycINFO, Cochrane, LILACS and AMED. Selected studies assessed perimenopausal or postmenopausal women, cannabis use impact and menopausal symptoms. A total of 564 studies were retrieved. Three studies met the inclusion criteria. One study controlled for participant cannabis use and reported on the effects of cannabis and placebo cigarette smoking on mood in 10 postmenopausal women. Another study assessed associations between drug use with hot flashes and insomnia in 120 HIV-infected women and found that menopausal status and cannabis use was crudely associated with the presence of hot flashes. The last study evaluated expectancies of 115 menopausal patients who endorsed lifetime cannabis use and reported that women expected cannabis to improve depression, anxiety, hot flashes and problems with sleep. None of these studies assessed quality of life as an outcome. There is a paucity of literature on the impact of cannabis use in menopause. Research into cannabis consumption in menopause is essential, as it is frequently used to alleviate symptoms without evidence of its benefits.

OBJECTIVE Genitourinary symptoms, such as vaginal dryness and pain with sex, are commonly experienced by postmenopausal women. Comparing treatments for these genitourinary symptoms are restricted by the use of different outcome measures in clinical trials and the omission of outcomes, which may be relevant to women. The aim of this project was to develop a Core Outcome Set (COS) to be reported in clinical trials of treatments for genitourinary symptoms associated with menopause. METHODS We performed a systematic review of randomized controlled trials of treatments for genitourinary symptoms associated with menopause and extracted their outcomes. This list was refined and entered into a two-round modified Delphi survey, which was open to clinicians, researchers, and postmenopausal women from November 2019 to March 2020. Outcomes were scored on a nine-point scale from "not important" to "critically important." The final COS was determined following two international consensus meetings. RESULTS A total of 26 unique outcomes were included in the Delphi process, which was completed by 227 participants of whom 58% were postmenopausal women, 34% clinicians, and 8% researchers. Predefined thresholds were applied to the Delphi scores to categorize outcomes by importance, which informed the e consensus meetings, attended by 43 participants from 21 countries. The final COS includes eight outcomes: (1) pain with sex, (2) vulvovaginal dryness, (3) vulvovaginal discomfort or irritation, (4) discomfort or pain when urinating, (5) change in most bothersome symptom, (6) distress, bother or interference of genitourinary symptoms, (7) satisfaction with treatment, (8) side effects of treatment. CONCLUSION These eight core outcomes reflect the joint priorities of postmenopausal women, clinicians, and researchers internationally. Standardized collection and reporting of these outcomes in clinical trials will facilitate the comparison of different treatments for genitourinary symptoms, advance clinical practice, and ultimately improve outcomes for symptomatic women.

The aim of this International Menopause Society White Paper on premature ovarian insufficiency (POI) is to provide the latest information regarding this distressing condition. The impact of POI has far-reaching consequences due to its impact on general, psychological, and sexual quality of life, fertility prospects, and long-term bone, cardiovascular, and cognitive health. Progress in fully understanding the etiology, diagnosis, and optimal management options has been slow thus far due to the complexity of the condition and fragmented research. Recent advances in epidemiological and genetic research have improved our understanding of this condition and randomized prospective trials are being planned to determine the intervention strategies, which will optimize quality of life and long-term well-being. The International Menopause Society has commissioned a number of experts at the forefront of their specialty to define the state of the art in the understanding of this condition, to advise on practical management strategies, and to propose future research strategies. It is hoped that a global task force will subsequently be convened in order to formulate a consensus statement across key societies, to accelerate date collection and analysis of a global POI registry, and to facilitate progress in the key defined areas of research.

Background Abnormal uterine bleeding is the direct cause of a significant health care burden for women, their families, and society as a whole. Up to 30% of women will seek medical assistance for this problem during their reproductive years. This guideline replaces previous clinical guidelines on the topic and is aimed to enable health care providers with the tools to provide the latest evidence-based care in the diagnosis and the medical and surgical management of this common problem. Objective To provide current evidence-based guidelines for the diagnosis and management of abnormal uterine bleeding (AUB) among women of reproductive age. Outcomes Outcomes evaluated include the impact of AUB on quality of life and the results of interventions including medical and surgical management of AUB. Methods Members of the guideline committee were selected on the basis of individual expertise to represent a range of practical and academic experience in terms of location in Canada, type of practice, subspecialty expertise, and general gynaecology background. The committee reviewed relevant evidence in the English medical literature including published guidelines. Recommendations were established as consensus statements. The final document was reviewed and approved by the Executive and Council of the SOGC. Results This document provides a summary of up-to-date evidence regarding diagnosis, investigations, and medical and surgical management of AUB. The resulting recommendations may be adapted by individual health care workers when serving women with this condition. Conclusions Abnormal uterine bleeding is a common and sometimes debilitating condition in women of reproductive age. Standardization of related terminology, a systematic approach to diagnosis and investigation, and a step-wise approach to intervention is necessary. Treatment commencing with medical therapeutic modalities followed by the least invasive surgical modalities achieving results satisfactory to the patient is the ultimate goal of all therapeutic interventions. Evidence Published literature was retrieved through searches of MEDLINE and the Cochrane Library in March 2011 using appropriate controlled vocabulary (e. g., uterine hemorrhage, menorrhagia) and key words (e. g., menorrhagia, heavy menstrual bleeding, abnormal uterine bleeding). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies written in English and published from January 1999 to March 2011. Searches were updated on a regular basis and incorporated in the guideline to February 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology- related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Benefits, harms, and costs Implementation of the guideline recommendations will improve the health and well-being of women with abnormal uterine bleeding, their families, and society. The economic cost of implementing these guidelines in the Canadian health care system was not considered. Summary Statements 1Abnormal uterine bleeding is a common condition affecting women of reproductive age that has significant social and economic impact (II-2). 2Contemporary terminology used to describe abnormal uterine bleeding in reproductive-aged women aims to simplify definitions and to provide standard descriptions related to patient presentation (III). 3The consequences of abnormal uterine bleeding on an individual's overall health determine the degree to which intervention may be required (II-2). 4A thorough history and physical exam will often indicate the cause of abnormal uterine bleeding and direct the need for further investigation and treatment (III). 5Imaging and hysteroscopy offer the clinician additional information to assist in patient assessment and treatment in indicated circumstances (I). 6Once malignancy and significant pelvic pathology have been ruled out, medical treatment is an effective first-line therapeutic option for abnormal uterine bleeding (I). 7Medical treatment tailored to the individual woman's therapeutic goals, desire for contraception, underlying medical conditions, and tolerance of side effects will encourage compliance and maximize the likelihood of treatment success (III). 8Non-hysteroscopic ablation techniques offer similar patient satisfaction results with fewer risks of complications and less anaesthetic requirement than traditional hysteroscopic ablation (I-A). 9Hysterectomy provides definitive treatment for abnormal uterine bleeding. 10Abnormal uterine bleeding secondary to submucosal fibroids may be managed by hysteroscopic myomectomy. 11Inherited bleeding disorders may be an underlying cause of abnormal uterine bleeding, with von Willebrand's disease present in the majority of cases (II-2). 12Acute heavy menstrual bleeding may result in significant anemia and emergent care (III). 13Abnormal uterine bleeding in the adolescent most commonly represents ovulatory dysfunction related to immaturity of the hypothalamic-pituitary-ovarian axis (II-2). Recommendations 1Adoption of standardized international terminology for abnormal uterine bleeding should be considered (III-C). 2A complete blood count is recommended for women with heavy or prolonged bleeding (II-2A). 3If there is any possibility of pregnancy, a sensitive urine or serum pregnancy test should be performed (III-C). 4Testing for coagulation disorders should be considered only in women who have a history of heavy menstrual bleeding beginning at menarche or who have a personal or family history of abnormal bleeding (II-2B). 5Thyroid function tests are not indicated unless there are clinical findings suggestive of and index of possible suspicions of thyroid disease (II-2D). 6If imaging is indicated, transvaginal ultrasound should be the first line imaging modality for abnormal uterine bleeding (I-A). 7Saline infusion sonohysterography and diagnostic hysteroscopy should be used in the diagnosis and characterization of discrete intrauterine abnormalities such as submucosal fibroids (I-A). 8Endometrial biopsy should be considered in bleeding women over age 40 or in those with bleeding not responsive to medical therapy, as well as in younger women with risk factors from endometrial cancer (II-2A). 9Office endometrial biopsy should replace dilation and uterine curettage as the initial assessment of the endometrium for these women (II-2A). 10Focal lesions of the endometrium that require biopsy should be managed through hysteroscopy-guided evaluation (II-2A). 11Non-hormonal options such as non-steroidal anti-inflammatory drugs and antifibrinolytics can be used effectively to treat heavy menstrual bleeding that is mainly cyclic or predictable in timing (I-A). 12Combined oral contraceptive pills, depot medroxyprogesterone acetate, and levonorgestrel-releasing intrauterine systems significantly reduce menstrual bleeding and should be used to treat women with abnormal uterine bleeding who desire effective contraception (I-A). 13Cyclic luteal-phase progestins do not effectively reduce blood loss and therefore should not be used as a specific treatment for heavy menstrual bleeding (I-E). 14Danazol and gonadotropin-releasing hormone agonists will effectively reduce menstrual bleeding, and may be used for scenarios in which other medical or surgical treatments have failed or are contraindicated (I-C). 15Patients receiving a gonadotropin-releasing hormone agonist for longer than 6 months should be prescribed add-back hormone therapy, if not already initiated with gonadotropin-releasing hormone agonist commencement (I-A). 16The progestin intrauterine system has outcomes similar to endometrial ablation for women with heavy menstrual bleeding and thus may be considered prior to surgical intervention (I-A). 17In appropriate candidates, non-hysteroscopic ablation techniques should be the ablation methods of choice in view of their higher efficacy and safety than hysteroscopic techniques (I-A). 18With the exception of non-steroidal anti-inflammatory drugs, the same medical agents used to treat heavy menstrual bleeding among women with normal coagulation can effectively be used in the setting of inherited bleeding disorders (II-1B). 19Women with inherited bleeding disorders who have significant heavy menstrual bleeding or those who fail conventional medical therapy are best managed with a multidisciplinary approach (III-C). 20Hysterectomy planning or blood product therapy should be performed in consultation with a hematologist in patients with inherited bleeding disorders (III-C). 21Acute heavy menstrual bleeding should be managed promptly and systematically to minimize patient morbidity and the need for blood transfusion (III-C). 22High-dose estrogen and tranexamic acid may help decrease or arrest acute heavy menstrual bleeding (III-C). 23For the adolescent presenting with heavy menstrual bleeding at or in close approximation to menarche, history and investigations should include an assessment for an underlying bleeding disorder (II-2A).

Objective To formulate clinical recommendations for the assessment of endometrial thickening when it is found on ultrasound in a postmenopausal patient without bleeding. Outcomes Ensure that women with asymptomatic thickening and endometrial polyps found on ultrasound are managed appropriately. Evidence Published literature was retrieved through searches of English language articles from the EMBASE, Cochrane, and PubMed databases for relevant peer-reviewed articles dating from 1970 to 2009, using appropriate controlled vocabulary (e.g., "asymptomatic endometrial thickness," "endometrial cancer," "postmenopausal bleeding," "transvaginal ultrasonography," "endometrial biopsy" and "endometrial polyp"). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated in the guideline to April 2010. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The level of evidence was determined according to the criteria established by the Canadian Task Force on Preventive Health Care (Table 1). Recommendations are ranked according to this method. Benefits, harms, and costs It is anticipated that the adoption of these recommendations would save postmenopausal women unnecessary anxiety, pain, and risk of procedural complication. It is also expected to decrease the cost to the health system by eliminating unnecessary interventions. Recommendations 1.Transvaginal ultrasound should not be used as screening for endometrial cancer (II-1E). 2.Endometrial sampling in a postmenopausal woman without bleeding should not be routinely performed (II-1E). 3.Indications for tissue sampling of the endometrium in bleeding postmenopausal women with an endometrial thickness of greater than 4 to 5 mm should not be extrapolated to asymptomatic women (II-2E). 4.A woman who has endometrial thickening and other positive findings on ultrasound, such as increased vascularity, inhomogeneity of endometrium, particulate fluid, or thickened endometrium over 11 mm, should be referred to a gynaecologist for further investigations (II-1A). 5.Decisions about further investigations should be made on a case-by-case basis in asymptomatic women with increased endometrial thickening and risk factors for endometrial cancer such as obesity, hypertension, and late menopause (II-1B). 6.In asymptomatic women on tamoxifen, a routine ultrasound for endometrial thickening should not be performed (II-2E). 7.Not all postmenopausal women who have asymptomatic endometrial polyps require surgery. Women found to have asymptomatic polyps on ultrasound should be triaged for intervention according to size of the polyp, age, and other risk factors (II-1A).

Resume Objectif Formuler des recommandations cliniques pour l'evaluation de l'epaississement endometrial lorsque sa presence est constatee par echographie chez une patiente postmenopausee ne connaissant pas de saignements. Issues S'assurer que les femmes chez lesquelles la presence d'un epaississement asymptomatique et de polypes endometriaux a ete constatee par echographie font l'objet d'une prise en charge appropriee. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans les bases de donnees EMBASE, Cochrane et PubMed et visant les articles pertinents de langue anglaise publies entre 1970 et 2009, au moyen d'un vocabulaire controle approprie (p. ex. « asymptomatic endometrial thickness », « endometrial cancer », « postmenopausal bleeding », « transvaginal ultrasonography », « endometrial biopsy » et « endometrial polyp »). Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Les recherches ont ete mises a jour de facon reguliere et leurs resultats ont ete incorpores a la directive clinique jusqu'en avril 2010. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs Le niveau de resultat a ete determine conformement aux criteres etablis par le Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1). Les recommandations ont ete evaluees en fonction de cette methode. Avantages, desavantages et couts Nous prevoyons que l'adoption de ces recommandations permettrait aux femmes postmenopausees de ne pas etre exposees inutilement a de l'anxiete, a de la douleur et a des risques de complication interventionnelle. Nous prevoyons egalement qu'elle permettrait d'abaisser les couts imposes au systeme de sante en eliminant les interventions inutiles. Recommandations 1.L'echographie transvaginale ne devrait pas etre utilisee aux fins du depistage du cancer de l'endometre (II-1E). 2.Chez les femmes postmenopausees qui ne presentent pas de saignements, le prelevement endometrial ne devrait pas etre mis en œuvre de facon systematique (II-1E). 3.Les indications menant au prelevement de tissu endometrial chez les femmes postmenopausees presentant des saignements et une epaisseur endometriale superieure a 4–5 mm ne devraient pas etre extrapolees aux femmes asymptomatiques (II-2E). 4.Les femmes qui presentent un epaississement endometrial au moment de l'echographie et d'autres resultats positifs (vascularite accrue, inhomogeneite de l'endometre, liquide particulaire, endometre excessivement epaissi [ > 11 mm]) devraient etre orientees vers des gynecologues aux fins de la tenue d'explorations plus approfondies (II-1A). 5.Chez les femmes qui presentent un epaississement endometrial accru et des facteurs de risque de cancer de l'endometre (tels que l'obesite, l'hypertension et la menopause tardive), les decisions quant a la tenue d'explorations plus approfondies devraient etre prises au cas par cas (II-1B). 6.Chez les femmes asymptomatiques qui prennent du tamoxifene, une echographie visant a determiner l'epaississement endometrial ne devrait pas etre mise en œuvre de facon systematique (II-2E). 7.Le recours a la chirurgie ne s'avere pas necessaire chez toutes les femmes postmenopausees qui presentent des polypes endometriaux asymptomatiques. Les femmes chez lesquelles des polypes asymptomatiques sont decouverts au moment de l'echographie devraient faire l'objet d'un triage (en vue d'une intervention) en fonction de la taille des polypes, de l'âge et d'autres facteurs de risque (II-1A).

Objective Provide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence. Target Population Perimenopausal and postmenopausal women. Benefits, Harms, and Costs Target population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment. Evidence Databases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020, and MeSH search terms were specific for each topic developed through the 7 chapters. Validation Methods The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). Intended Audience physicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population. SUMMARY STATEMENTS 1 Women who initiate menopausal hormone therapy shortly after menopause are, in general, at low risk for events in the next few years (high). Evidence supports aggressive identification and modification of risk factors as the most effective means of reducing cardiovascular risk (high). 2 Women who initiate menopausal hormone therapy 10 or more years after menopause are at increased risk for adverse cardiac events (high). 3 With respect to stroke, increased risk has been identified in all age groups using standard formulations of menopausal hormone therapy; however, the incidence in young women is extremely low (low). 4 Incidence of venous thrombotic events increase with age (> 60 y) and BMI, even in otherwise healthy women; menopausal hormone therapy increases the risk (high). 5 Menopausal hormone therapy is not indicated for primary or secondary prevention of cardiovascular disease (moderate). 6 Women with premature or early-onset menopause appear to be at an increased risk of adverse cardiovascular outcomes, and this risk may be prevented by the use of menopausal hormone therapy until the average age of menopause (moderate). 7 Menopausal hormone therapy increases the risk of venous thromboembolism; oral and combined hormone therapy preparations are more closely associated with risk of venous thromboembolism than either with transdermal preparations or estrogen alone (moderate). 8 There is a lack of high-quality data to provide guidance on the impact of routes of estrogen administration on the risk of venous thrombotic events or cardiovascular disease (low). RECOMMENDATIONS 1 Menopausal hormone therapy should be offered as the most effective treatment for the relief of menopausal symptoms (strong, high). 2 When prescribing menopausal hormone therapy, the lowest effective dose of estrogen, and, where indicated, estrogen-only therapy, should be offered to minimize the associated risk of venous thromboembolism (conditional, low). 3 The lowest effective dose of estrogen, either oral or transdermal, should be prescribed to minimize the risk of stroke (conditional, low). 4 When prescribing combined hormone therapy, choice of progestogen should favour those least likely to affect markers for cardiovascular disease. (strong, moderate). 5 A tissue selective estrogen complex may be used without a progestin to provide menopausal hormone therapy and uterine protection for relief of early menopausal symptoms (conditional, moderate). To date, these agents do not appear to be associated with cardiovascular risk.

RESUME Objectif Proposer des strategies pour ameliorer les soins aux femmes en perimenopause ou menopausees d'apres les plus recentes donnees probantes publiees. Population cible Femmes en perimenopause ou menopausees. Benefices, risques et couts La population cible beneficiera des plus recentes donnees scientifiques publiees que leur communiqueront les fournisseurs de soins de sante. Aucun cout ni prejudice ne sont associes a cette information, car les femmes seront libres de choisir parmi les differentes options therapeutiques, y compris le statu quo, pour la prise en charge des symptomes et morbidites associes a la menopause. Donnees probantes Les auteurs ont interroge les bases de donnees PubMed, Medline et Cochrane Library pour extraire des articles publies entre 2002 et 2020 en utilisant des termes MeSH specifiques a chacun des sujets abordes dans les 7 chapitres. Methodes de validation Les auteurs ont evalue la qualite des donnees probantes et la force des recommandations en utilisant le cadre methodologique d’evaluation, de developpement et d’evaluation (GRADE). Voir l'annexe A en ligne ( tableau A1 pour les definitions et tableau A2 pour l'interpretation des recommandations fortes et faibles). Professionnels concernes medecins, y compris gynecologues, obstetriciens, medecins de famille, internistes, urgentologues; infirmieres, y compris infirmieres autorisees et infirmieres praticiennes; pharmaciens; stagiaires, y compris etudiants en medecine, residents, moniteurs cliniques; et autres fournisseurs de soins aupres de la population cible. DECLARATIONS SOMMAIRES 1 Les femmes qui amorcent un traitement hormonal de la menopause peu de temps apres la menopause ont generalement un faible risque d’evenements cardiovasculaires dans les annees suivantes (elevee). Les donnees probantes soutiennent que les efforts determines de detection et modification des facteurs de risque constituent le moyen le plus efficace pour reduire le risque cardiovasculaire (elevee). 2 Les femmes qui amorcent un traitement hormonal de la menopause 10 ans ou plus apres la menopause ont un risque accru d’evenements cardiaques defavorables (elevee). 3 On observe une augmentation du risque d'accidents vasculaires cerebraux dans tous les groupes d’âge utilisant une preparation standard de traitement hormonal de la menopause, mais ils sont extremement rares chez les femmes jeunes (faible). 4 La frequence des evenements thrombotiques veineux chez les femmes autrement en bonne sante augmente avec l’âge (> 60 ans) et l'IMC, et le traitement hormonal de la menopause en augmente le risque (elevee). 5 Le traitement hormonal de la menopause n'est pas indique pour la prevention primaire ou secondaire des maladies cardiovasculaires (moyenne). 6 Les femmes ayant eu une menopause prematuree ou precoce semblent avoir un risque accru d’evenements cardiovasculaires defavorables, mais il est possible de les prevenir par l'administration d'un traitement hormonal de la menopause jusqu’a l’âge moyen de la menopause (moyenne). 7 Le traitement hormonal de la menopause augmente le risque de thromboembolie veineuse; l'hormonotherapie en preparation orale ou combinee est plus etroitement associee au risque de thromboembolies veineuses que les preparations transdermiques ou l’œstrogene seul (moderee). 8 En raison du manque de donnees de haute qualite, il n'est pas possible de formuler des recommandations relativement aux effets de la voie d'administration des œstrogenes sur le risque d’evenements thrombotiques veineux ou de maladies cardiovasculaires (faible). RECOMMANDATIONS 1 Il y a lieu d'offrir le traitement hormonal de la menopause comme traitement le plus efficace pour soulager les symptomes de la menopause (forte, elevee). 2 Pour le traitement hormonal de la menopause, il convient de prescrire la plus faible dose efficace d’œstrogene; l'hormonotherapie a œstrogenes seuls doit quant a elle etre prescrite lorsqu'indiquee pour reduire le risque associe de thromboembolies veineuses (conditionnelle, faible). 3 Il est recommande de prescrire la plus faible dose efficace d’œstrogene, par voie orale ou transdermique, pour reduire le risque d'accidents vasculaires cerebraux (conditionnelle, faible). 4 Au moment de prescrire l'hormonotherapie combinee, il est bon d'envisager les progestatifs qui sont les moins susceptibles d'agir sur les marqueurs de maladies cardiovasculaires (forte, moyenne). 5 On peut utiliser les complexes œstrogeniques a action tissulaire selective (TSEC) sans progestatif pour le traitement hormonal de la menopause et la protection de l'uterus afin de soulager les symptomes menopausiques precoces (conditionnelle, moyenne). A ce jour, ces agents ne semblent pas associes a un risque cardiovasculaire.

Objective Provide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence. Target Population Perimenopausal and postmenopausal women. Benefits, Harms, and Costs Target population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment. Evidence Databases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020, and MeSH search terms were specific for each topic developed through the 7 chapters. Validation Methods The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A ( Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). Intended Audience physicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population. SUMMARY STATEMENTS 1 The association between breast cancer risk and menopausal hormone treatment is complex (moderate). 2 Systemic menopausal hormone therapy is contraindicated in women with a personal history of any type of breast cancer (high). 3 Non-hormonal options for systemic symptom management can be used in women who have had breast cancer (high). 4 Menopausal hormone therapy does not significantly increase breast cancer risk in premenopausal BRCA carriers who have had risk-reducing salpingo-oophorectomy (moderate). 5 Menopausal hormone therapy does not appear to increase breast cancer risk in unaffected BRCA1 or BRCA2 mutation carriers (moderate). RECOMMENDATIONS 1 When indicated, prescribe the menopausal hormone therapy regimen that confers the lowest possible breast cancer risk (conditional, moderate). 2 Modifiable risk factors, such as weight, smoking, alcohol use, and exercise, should be optimized among menopausal patients considering treatment (strong, high). 3 Non-pharmacotherapeutic options for the management of vasomotor symptoms in breast cancer patients include paced breathing, acupuncture, and cognitive behavioural therapy (strong, moderate). 4 Venlafaxine is the first-line non-hormonal alternative for the management of vasomotor symptoms in breast cancer patients (conditional, moderate). 5 Paroxetine, gabapentin, oxybutynin, and clonidine are non-hormonal options for refractory vasomotor symptoms. Paroxetine should be used with caution in patients receiving tamoxifen (conditional, moderate). 6 Non-hormonal options for the management of genitourinary syndrome of menopause in breast cancer survivors include vaginal moisturizers, lubricants for intercourse, pelvic floor physiotherapy, and dilators or vibrators (strong, moderate). 7 Local vaginal estrogens can be considered in breast cancer survivors. Clinical trials are ongoing to establish safety of vaginal hormonal products in breast cancer survivors taking aromatase inhibitors (conditional, moderate). 8 Vaginal dehydroepiandrosterone and oral ospemifene are alternatives to local estrogen treatment for genitourinary syndrome of menopause; however, further studies are needed in breast cancer survivors (conditional, low). 9 Menopausal hormone therapy regimens should be individualized and preference given to estrogen-alone therapy in any patient who has undergone hysterectomy (conditional, high).

RESUME Objectif Proposer des strategies fondees sur les plus recentes donnees publiees pour ameliorer les soins aux femmes menopausees ou en perimenopause. Population cible Les femmes menopausees ou en perimenopause. Benefices, risques et couts La population cible beneficiera des plus recentes donnees scientifiques publiees communiquees par leurs fournisseurs de soins de sante. Aucun cout ni prejudice ne sont associes a cette information, car les femmes seront libres de choisir parmi les differentes options therapeutiques, y compris le statu quo, pour la prise en charge des symptomes et morbidites associes a la menopause. Donnees probantes Les auteurs ont interroge les bases de donnees PubMed, MEDLINE et Cochrane Library pour extraire des articles publies entre 2002 et 2020 en utilisant des termes MeSH specifiques a chacun des sujets abordes dans les 7 chapitres. Methodes de validation Les auteurs ont evalue la qualite des donnees probantes et la force des recommandations en utilisant l'approche d’evaluation, de developpement et d’evaluation (GRADE). Voir l'annexe A en ligne ( tableau A1 pour les definitions et tableau A2 pour l'interpretation des recommandations fortes et conditionnelles [faibles]). Professionnels concernes gynecologues, obstetriciens, medecins de famille, internistes, urgentologues, infirmieres (autorisees et praticiennes), pharmaciens, stagiaires (etudiants en medecine, residents, moniteurs cliniques) et autres fournisseurs de soins de sante pour la population cible. DECLARATIONS SOMMAIRES 1 La perimenopause est une periode particulierement propice a la manifestation de symptomes depressifs et d’episodes depressifs caracterises, meme chez les femmes sans antecedent de depression (elevee). 2 Des facteurs lies ou non a la menopause contribuent a la manifestation et a l'intensite des symptomes thymiques autour de la cinquantaine. Les facteurs lies a la menopause se rapportent au contexte ou au moment, notamment les symptomes vasomoteurs, les troubles du sommeil et les problemes de sante, tandis que les facteurs qui ne sont pas lies a la menopause s'inscrivent dans un continuum de risques anterieurs a la menopause ou sont des facteurs de risque longitudinaux, comme le chomage, le tabagisme et les antecedents d'anxiete de longue date (elevee). 3 De recentes etudes de grande envergure revelent un risque eleve de depression chez les femmes apres avoir subi une hysterectomie, avec ou sans ovariectomie. Les antecedents d'insuffisance ovarienne primitive, qui survient chez 1 % des femmes, sont egalement associes a une augmentation du risque de depression (elevee). 4 Le sommeil de mauvaise qualite, d'apres une evaluation subjective et objective, est frequent chez les femmes en perimenopause ou menopausees (elevee). 5 Il n'est pas rare que des symptomes cognitifs, comme la deterioration de la memoire et le ralentissement de la cognition, se manifestent chez les femmes au debut de la postmenopause, et ces symptomes ont ete observes dans des etudes prospectives longitudinales (moyenne). RECOMMANDATIONS 1 Il est conseille que les options therapeutiques eprouvees pour la depression a tout moment de la vie (p. ex., antidepresseurs, therapie cognitivo-comportementale et autres psychotherapies comportementales) demeurent les options de traitement de premiere intention pour les symptomes et episodes depressifs pendant la transition menopausique et la postmenopause (forte, elevee). 2 Pour les femmes qui vivent des episodes recurrents de depression pendant la perimenopause, il y a lieu de prendre en compte leur reponse et tolerabilite aux antidepresseurs precedemment utilises au moment de selectionner un antidepresseur (forte, moyenne). 3 Chez les femmes atteintes d'un premier episode de depression, on doit tenir compte des effets indesirables des antidepresseurs (p. ex., dysfonction sexuelle, variation du poids) et des interactions medicamenteuses (p. ex., entre certains ISRS et le tamoxifene) specifiques a cette population (fortes, moderees). 4 Certaines donnees indiquent que l'hormonotherapie a des effets antidepresseurs d'une ampleur semblable a celle des agents antidepresseurs classiques lorsqu'ils sont administres aux femmes en perimenopause atteintes de depression avec ou sans symptomes vasomoteurs concomitants (forte, elevee). Cependant, l'hormonotherapie est inefficace pour traiter les troubles depressifs chez les femmes menopausees, ce qui suggere une periode propice aux effets antidepresseurs de l'hormonotherapie en perimenopause (forte, moderee). 5 Pour les femmes ayant un sommeil de mauvaise qualite pendant la transition menopausique, il y a lieu d'adopter une strategie visant d'abord l’education en matiere d'hygiene du sommeil et l'exclusion des troubles du sommeil primaires (forte, elevee). 6 Les symptomes vasomoteurs constituent un important facteur de perturbation du sommeil et doivent donc etre traites; l'hormonotherapie peut ameliorer le sommeil en cas de symptomes vasomoteurs (forte, elevee). 7 Plusieurs autres traitements se sont averes benefiques pour ameliorer la qualite du sommeil, notamment la therapie cognitivo-comportementale de l'insomnie (forte, elevee), l'exercice aerobique, l'eszopiclone, la venlafaxine, l'actee a grappes noires et la racine de valeriane (forte, moyenne). 8 Pour les femmes qui expriment une plainte cognitive, le changement des habitudes de vie est recommande afin de reduire le risque de declin cognitif. Il est notamment conseille de pratiquer des exercices aerobiques et de manger des legumes plus souvent, en plus de limiter les consequences potentielles de l'hypertension, du diabete et de la maladie atherosclereuse (forte, elevee). 9 Les donnees probantes indiquent que l'hormonotherapie menopausique sur plusieurs annees d'utilisation n'ameliore pas significativement les mesures de la fonction cognitive (forte, moyenne).

Objective Provide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence. Target Population Perimenopausal and postmenopausal women. Benefits, Harms, and Costs Target population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment. Evidence Databases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020, and MeSH search terms were specific for each topic developed through the 7 chapters. Validation Methods The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). Intended Audience physicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population. SUMMARY STATEMENTS 1 The perimenopausal period is a window of vulnerability for the development of depressive symptoms and major depressive episodes, even in women with no history of depression (high). 2 Factors related and unrelated to menopause contribute to the occurrence and severity of mood symptoms in mid-life. Factors related to menopause are those that are context-related or timing-related, such as vasomotor symptoms, sleep disturbances, and health problems, whereas those unrelated to menopause represent a continuum of risk that precedes menopause, or longitudinal risk factors, such as unemployment, smoking, and lifetime history of anxiety (high). 3 Recent large-scale studies show an elevated risk of depression in women following hysterectomy, with or without oophorectomy. A history of primary ovarian insufficiency, which occurs in 1% of women, is also associated with an increased risk of depression (high). 4 Poor sleep quality, as measured both subjectively and objectively, is common among women in the perimenopausal and postmenopausal periods (high). 5 Cognitive symptoms, such as worsening memory and slower cognitive speed, are often reported among newly menopausal women, and these symptoms have been demonstrated in prospective, longitudinal studies (moderate). RECOMMENDATIONS 1 Proven therapeutic options for depression at any life stage (i.e., antidepressants, cognitive behavioural therapy, and other behaviour-based psychotherapies) should remain the first-line treatment options for depressive symptoms and episodes during the menopausal transition and postmenopausal years (strong, high). 2 For women experiencing recurrent episodes of depression during the perimenopausal period, selection of antidepressants should consider the patient's response to and toleration of previous trials of antidepressants (strong, moderate). 3 For women experiencing new-onset depression, both adverse effects (e.g., sexual dysfunction, weight changes) and drug–drug interactions (e.g., between specific selective serotonin reuptake inhibitors and tamoxifen) specific to this population should be considered (strong, moderate). 4 There is some evidence that hormone therapy has antidepressant effects similar in magnitude to those observed with classic antidepressant agents in perimenopausal women with depression, with or without concomitant vasomotor symptoms (strong, high). However, hormone therapy is ineffective in treating depressive disorders in postmenopausal women, suggesting a possible window of opportunity for the antidepressant benefits of hormone therapy in perimenopause (strong, moderate). 5 The approach to poor sleep during the menopausal transition should initially include education about sleep hygiene, and primary sleep disorders should be ruled out (strong, high). 6 Vasomotor symptoms are a significant contributor to sleep disruption and should be addressed; hormone therapy may improve sleep when vasomotor symptoms are present (strong, high). 7 Several other therapies for sleep have shown benefit, including cognitive behavioural therapy–insomnia (strong, high), aerobic exercise, eszopiclone, venlafaxine, black cohosh, and valerian root (strong, moderate). 8 For women with cognitive complaints, lifestyle modifications are recommended to decrease the risk of cognitive decline. These include increasing aerobic exercise and including vegetables in the diet more often, as well as limiting the potential influence of hypertension, diabetes, and atherosclerotic disease (strong, high). 9 Menopausal hormone therapy has not been shown to significantly improve measures of cognitive function over several years of use (strong, moderate).

Objective Provide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence. Target Population Perimenopausal and postmenopausal women. Benefits, Harms, and Costs Target population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment. Evidence Databases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020, and MeSH search terms were specific for each topic developed through the 7 chapters. Validation Methods The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A ( Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). Intended Audience physicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population. SUMMARY STATEMENTS 1 Low sexual desire in combination with distress is most common in women in mid-life (high). 2 Vaginal atrophy is a common cause of sexual pain in menopausal women (high). 3 Sexual dysfunction in menopausal women can be categorized as disorders involving desire, arousal, pain, and orgasm. These categories often overlap (high). 4 A brief sexual history is part of the evaluation of menopausal women (moderate). 5 The treatment of sexual dysfunctions involves a multifaceted approach that addresses medical, psychological, and relationship issues (high). 6 Local estrogen therapy treats genitourinary syndrome of menopause (high). 7 Pelvic physiotherapy is an excellent adjuvant treatment for hypercontracted pelvic floor muscles (often referred to as vaginismus) and genito-pelvic pain (low). 8 Flibanserin has been shown to improve desire in women (moderate). 9 Transdermal testosterone has been shown to increase desire, arousal, and satisfying sexual events, and to decrease personal distress (high). 10 Psychological therapies, including cognitive behavioural therapy, mindfulness-based therapy, couples’ therapy, and sexual therapies, are useful for treating sexual dysfunctions (moderate). 11 Sexual dysfunction is common in patients with depression, those on selective serotonin reuptake inhibitors (SSRIs), women with primary ovarian insufficiency, and those with a history of breast cancer (high). RECOMMENDATIONS 1 The patient's problem should be categorized as related to desire, arousal, pain, or orgasm, in order to facilitate treatment and to triage care (strong, moderate). 2 Health care providers should include a sexual screening history and physical examination in the initial evaluation of menopausal women (strong, low). 3 Vaginal estrogens, lubricants and moisturizers, vaginal dehydroepiandrosterone, and ospemifene may be used as treatments for vaginal atrophy related to menopause (strong, high). 4 For postmenopausal women with hypoactive sexual desire disorder, the best current options include managing pain, addressing any biopsychological factors, counselling, and prescribing transdermal testosterone (off-label) or flibanserin (strong, moderate). 5 Patients with breast cancer and symptomatic genitourinary syndrome of menopause can be offered local vaginal estrogen if local lubricants and moisturizers are ineffective, after consulting with the patient's oncologist (conditional, moderate).

RESUME Objectif Proposer des strategies fondees sur les plus recentes donnees publiees pour ameliorer les soins aux femmes menopausees ou en perimenopause. Population cible Les femmes menopausees ou en perimenopause. Benefices, risques et couts La population cible beneficiera des plus recentes donnees scientifiques publiees communiquees par leurs fournisseurs de soins de sante. Aucun cout ni prejudice ne sont associes a cette information, car les femmes seront libres de choisir parmi les differentes options therapeutiques, y compris le statu quo, pour la prise en charge des symptomes et morbidites associes a la menopause. Donnees probantes Les auteurs ont interroge les bases de donnees PubMed, MEDLINE et Cochrane Library pour extraire des articles publies entre 2002 et 2020 en utilisant des termes MeSH specifiques a chacun des sujets abordes dans les 7 chapitres. Methodes de validation Les auteurs ont evalue la qualite des donnees probantes et la force des recommandations en utilisant l'approche d'evaluation, de developpement et d'evaluation (GRADE). Voir l'annexe A en ligne (tableau A1 pour les definitions et tableau A2 pour l'interpretation des recommandations fortes et conditionnelles [faibles]). Professionnels concernes gynecologues, obstetriciens, medecins de famille, internistes, urgentologues, infirmieres (autorisees et praticiennes), pharmaciens, stagiaires (etudiants en medecine, residents, moniteurs cliniques) et autres fournisseurs de soins de sante pour la population cible.

RESUME Objectif Proposer des strategies fondees sur les plus recentes donnees publiees pour ameliorer les soins aux femmes menopausees ou en perimenopause. Population cible Les femmes menopausees ou en perimenopause. Benefices, risques et couts La population cible beneficiera des plus recentes donnees scientifiques publiees communiquees par leurs fournisseurs de soins de sante. Aucun cout ni prejudice ne sont associes a cette information, car les femmes seront libres de choisir parmi les differentes options therapeutiques, y compris le statu quo, pour la prise en charge des symptomes et morbidites associes a la menopause. Donnees probantes Les auteurs ont interroge les bases de donnees PubMed, MEDLINE et Cochrane Library pour extraire des articles publies entre 2002 et 2020 en utilisant des termes MeSH specifiques a chacun des sujets abordes dans les 7 chapitres. Methodes de validation Les auteurs ont evalue la qualite des donnees probantes et la force des recommandations en utilisant l'approche d'evaluation, de developpement et d'evaluation (GRADE). Voir l'annexe A en ligne (tableau A1 pour les definitions et tableau A2 pour l'interpretation des recommandations fortes et conditionnelles [faibles]). Professionnels concernes gynecologues, obstetriciens, medecins de famille, internistes, urgentologues, infirmieres (autorisees et praticiennes), pharmaciens, stagiaires (etudiants en medecine, residents, moniteurs cliniques) et autres fournisseurs de soins de sante pour la population cible.

Objective Provide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence. Target Population Perimenopausal and postmenopausal women. Benefits, Harms, and Costs Target population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment. Evidence Databases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020, and MeSH search terms were specific for each topic developed through the 7 chapters. Validation Methods The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A ( Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). Intended Audience physicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population. SUMMARY STATEMENTS 1 The vast majority of women in mid-life experience menopausal symptoms, the hallmark being vasomotor symptoms. A significant portion of these women have severe symptoms that greatly affect their quality of life (high). 2 For the management of vasomotor symptoms, menopausal hormone therapy is the most effective option and can be safely initiated in women without contraindications who are younger than 60 years of age or less than 10 years post-menopause (high). 3 Options for menopausal hormone therapy for vasomotor symptoms in women with a uterus include estrogen-progestogen therapy, a tissue-selective estrogen complex, or tibolone. Estrogen alone can be used in women who have had a hysterectomy (high). 4 The safety and efficacy of compounded bioidentical hormone therapy have not been assessed with the same rigour as those of menopausal hormone therapy products approved by Health Canada (moderate). 5 Non-hormonal prescription therapies, including certain antidepressant agents, gabapentinoids, clonidine, and oxybutynin, may offer some relief from hot flashes but have their own adverse effects (moderate). 6 There is emerging evidence that cognitive behavioural therapy may have positive effects on vasomotor symptoms (high). 7 There is insufficient evidence to support the effectiveness of any one natural health product for the management of moderate to severe hot flashes (low). 8 A healthy diet during menopause can reduce the risk of future chronic conditions, aid in weight management, and improve energy levels (high). RECOMMENDATIONS 1 Health care providers should offer menopausal hormone therapy as the most effective option for managing vasomotor symptoms (strong, high). 2 Menopausal hormone therapy can be safely initiated in women without contraindications who are younger than 60 years of age or less than 10 years post-menopause (strong, high). 3 Menopausal hormone therapy should be individualized after careful consideration of symptoms, medical conditions, health risks, family history, treatment goals, patient preferences, and timing of last menstrual period (strong, high). 4 Duration of menopausal hormone therapy should be individualized to the patient, based on ongoing symptoms, benefits, and personal risks. Periodic re-evaluation of menopausal hormone therapy is recommended (strong, high). 5 Women who have experienced loss of ovarian function or with decreased ovarian function before the age of 45 years should consider replacement hormone therapy until the average age of menopause (strong, high). 6 Estrogen-progestogen regimens can be continuous (i.e., estrogen-progestogen taken every day) or follow a cyclic regimen, with estrogen taken every day and progestogen taken for 12–14 days every month. In women with hysterectomy, estrogen alone can be taken every day (strong, high). 7 Options for perimenopausal women include progestogen alone, low-dose combined hormonal contraceptives, menopausal hormone therapy, or estrogen in combination with a levonorgestrel-releasing intrauterine system. (strong, moderate) 8 Non-hormonal prescription therapies can be considered when hormone therapy is contraindicated or not desired (strong, moderate). 9 For cultural traditional therapies, women should be offered the opportunity to work with a cultural leader; health care providers can discuss this option in partnership with women, in order to ensure cultural humility and cultural safety (strong, moderate).

Objective: Premature ovarian failure associated with Turner syndrome presents clinicians with a vast range of health concerns, including infertility, cardiovascular disease, and decreased bone mineral density, in addition to psychological sequelae. Hormone therapy is paramount in managing these complications, but the additional needs in the postpartum period for those who are able to carry out a successful pregnancy have not been described. Methods: We present a case of severe postpartum depression (PPD) with psychotic features in a patient with Turner syndrome, which presented at 4 weeks after the birth of her first child via egg donation Results: We describe the case of a previously well 32-year-old patient with an 46 X, i(Xq) karyotype, who went through a 4-week intensive inpatient treatment course for PPD, requiring electroconvulsant therapy for persistent infanticidal and suicidal ideation. It was hypothesized that an estrogen-depleted state secondary to premature ovarian insufficiency and lactation may have been more pronounced during her postpartum course when hormone levels dramatically decrease. To buffer the dramatic drop in sex steroid levels postpartum for her second pregnancy, she was immediately started on estrogen and progesterone replacement, and did not experience any change in mood or similar psychiatric disturbance during this postpartum course. Four years after the PPD episode, her mood remains stable. Conclusion: This case highlights the complex interplay between ovarian steroids, depletion of their levels, and psychiatric sequelae. The postpartum period represents a particularly vulnerable time for patients with premature ovarian insufficiency, which requires very close monitoring and early replacement of depleted hormone levels.

The First International Consensus Conference on Adnexal Masses was convened to thoroughly examine the state of the science and to formulate recommendations for clinical assessment and management. The panel included representatives of societies in the fields of gynecology, gynecologic oncology, radiology, and pathology and clinicians from Europe, Canada, and the United States. In the United States, there are approximately 9.1 surgeries per malignancy compared to the European International Ovarian Tumor Analysis center trials, with only 2.3 (oncology centers) and 5.9 (other centers) reported surgeries per malignancy, suggesting that there is room to improve our preoperative assessments. The American College of Obstetricians and Gynecologists Practice Bulletin on "Management of Adnexal Masses," reaffirmed in 2015 (Obstet Gynecol 2007; 110:201-214), still states, "With the exception of simple cysts on a transvaginal ultrasound finding, most pelvic masses in postmenopausal women will require surgical intervention." The panel concluded that patients would benefit not only from a more conservative approach to many benign adnexal masses but also from optimization of physician referral patterns to a gynecologic oncologist in cases of suspected ovarian malignancies. A number of next-step options were offered to aid in management of cases with sonographically indeterminate adnexal masses. This process would provide an opportunity to improve risk stratification for indeterminate masses via the provision of alternatives, including but not limited to evidence-based risk-assessment algorithms and referral to an "expert sonologist" or to a gynecologic oncologist. The panel believed that these efforts to improve clinical management and preoperative triage patterns would ultimately improve patient care.

Hematopoietic cell transplantation (HCT) is associated with well-described gynecologic sequelae, including vulvovaginal graft-versus-host disease (GVHD). Vulvovaginal GVHD is a common complication of allogeneic HCT, but has been under-reported in the literature. Guidelines have been published only recently to recommend common terminology, treatment, and surveillance. This review summarizes the presentation, management, and surveillance aspects of vulvovaginal GVHD. We recommend a standardized referral between women undergoing HCT and an experienced gynecologist capable of managing this disease and treating sexual side effects.

Background: In addition to short stature and ovarian insufficiency, women with Turner syndrome (TS) are at increased risk for multiple chronic health conditions, especially as they age. Reports describing the presence of comorbidities in older adult women with TS are limited. The objective of this study was to examine the prevalence of endocrine, gynecological, and other chronic medical conditions in a large cohort of adult TS patients. Methods: We performed a retrospective chart review of women with TS attending our adult TS clinic jointly run by gynecology and endocrinology at a university-based ambulatory hospital in Toronto, Canada. All patients had a diagnosis of TS based on karyotype testing and attended at least one clinic visit between February 1, 2015 and July 1, 2018. Data were collected from electronic medical records and included information on patients’ medical conditions, results of screening and blood tests and clinical measurements. Prevalence of diseases was determined for the whole cohort and stratified by age, 40 years of age at clinic visit. The mean age at diagnosis was 11.4 years. The mean height of was 146.8cm (+/-8.06) and the mean BMI was 27.1 (+/-6.24). The majority of patients (84.4%) were on hormone therapy, with the most common type being the oral contraceptive pill (47.6%). Regarding endocrine conditions, 24.5% had hypothyroidism, 16% had dysglycemia (either diabetes or pre-diabetes), and 27.9% had decreased bone mass (either osteoporosis, osteopenia or low bone density). The prevalence of hypothyroidism and dysglycemia were significantly higher among older women (hypothyroidism 36.7% age ≥ 40 vs. 17.8% age < 40, p=0.018; dysglycemia 24.5% age ≥ 40 vs. 5.5% age 40 years had a higher prevalence of hearing impairment (59.1% age > 40 years vs. 28.8% age < 40 years, p=0.0008), while the prevalence of cardiac, renal abnormalities and celiac disease was similar between age groups. Conclusions: The results of this study indicate a high prevalence of medical and gynecological conditions in women with TS, especially those > 40 years of age. This cohort is unique given the older age of our patients as well as the high burden of comorbid disease that we identified. Our study further underscores the importance of multidisciplinary adult TS clinics for monitoring and screening women with TS for comorbidities throughout adulthood.

Objective To assist physicians performing gynaecologic surgery in decision making surrounding hysterectomy for benign indications. Intended Users Physicians, including gynaecologists, obstetricians, family physicians, general surgeons, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; medical trainees, including medical students, residents, and fellows; and all other health care providers. Target Population Adult women (18 years and older) who will undergo hysterectomy for benign gynaecologic indications. Options The approach to hysterectomy and utility of concurrent surgical procedures are reviewed in this guideline. Evidence For this guideline relevant studies were searched in the PubMed, Medline, and Cochrane Library databases. The following MeSH search terms and their variations for the last 5 years (2012-2017) were used: vaginal hysterectomy, laparoscopic hysterectomy, robotic hysterectomy, laparoscopically assisted vaginal hysterectomy, total laparoscopic hysterectomy, standard vaginal hysterectomy, and total vaginal hysterectomy. Validation methods The content and recommendations were drafted and agreed upon by the principal authors and members of the Gynaecology Committee. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology framework (Tables 1 and 2). The Summary of Findings is available upon request. Benefits, Harms, and Costs Hysterectomy is common, yet surgical practice still varies widely among gynaecologic physicians. This guideline outlines preoperative and perioperative considerations to improve the quality of care for women undergoing benign gynaecologic surgery. Guideline Update This Society of Obstetricians and Gynaecologists of Canada clinical practice guideline will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter. Sponsors This guideline was developed with resources funded by the Society of Obstetricians and Gynaecologists of Canada. Summary Statements 1Technicity is defined as the proportion of hysterectomies performed by a minimally invasive route (laparoscopic, laparoscopic-assisted, and vaginal). Increased technicity index is associated with improved surgical quality and patient care (High). 2Minimally invasive approaches to hysterectomy are associated with fewer perioperative complications compared to laparotomy (High). 3Higher-volume hospitals and surgeons are more likely to have higher technicity and lower complication rates (High). 4Same-day discharge protocols following minimally invasive hysterectomy are cost-effective, do not increase complications or re-admission rates, and are associated with high patient satisfaction (Moderate). 5Urinary tract injuries are comparable among surgical approaches to hysterectomy (Moderate). 6Laparotomy or mini-laparotomy may be appropriate as an alternative approach in specific circumstances depending on patient factors, indication for surgery, and underlying pathology (Moderate). 7The risk of vaginal cuff dehiscence is rare and not related to the choice of suture material or route of closure (Moderate). 8Supracervical hysterectomy has not been shown to preserve sexual function, decrease pelvic organ prolapse, or reduce incidence of urinary tract injuries compared to total hysterectomy (Moderate). 9For women with uterine leiomyomas, preoperative medical treatment with leuprolide acetate or ulipristal acetate can reduce myoma size, decrease bleeding, and correct anemia. Risks and benefits of medical treatment should be discussed preoperatively (High). 10Mechanical bowel preparation is not routinely required prior to gynaecologic surgery for benign disease (High). 11Removal of normal ovaries at the time of hysterectomy decreases the risk of ovarian cancer but may be associated with health ramifications. Bilateral oophorectomy may lead to acute development of menopausal symptoms in premenopausal women and has not been shown to offer a survival benefit in the absence of genetic predisposition to ovarian cancer (High). 12Hysterectomy alone affects ovarian reserve (High). 13Opportunistic salpingectomy at the time of hysterectomy is expected to decrease the incidence of high-grade serous ovarian cancer (Low). 14There is no strong evidence to support routine uterosacral or vaginal vault suspension at the time of hysterectomy in patients without pelvic organ prolapse (Low). Recommendations 1Hysterectomy for benign indications should preferably be approached by either vaginal or laparoscopic routes (Strong, High). 2Vaginal hysterectomy is still considered the preferred route of hysterectomy, but laparoscopic hysterectomy is an appropriate alternative minimally invasive approach (Strong, Moderate). 3Correction of preoperative anemia (hemoglobin 4Preoperative antibiotic prophylaxis and measures to decrease risk of venous thromboembolism are recommended for all patients undergoing hysterectomy (Strong, High). 5Women should be counselled about the benefits and risks of removing the ovaries at the time of the hysterectomy. This should include discussion about the risk of ovarian cancer as well as the long-term health implications of earlier menopause linked to bilateral oophorectomy (Strong, Moderate). 6Opportunistic salpingectomy can be considered at the time of hysterectomy but the planned surgical approach should not be changed for this sole purpose (Strong, Low). 7Urinary tract injury is a known complication of hysterectomy, and clinicians should have a low threshold for further investigation in cases where injury is suspected. Surgeons performing hysterectomy should have access to diagnostic cystoscopy, individually or though consultation, to evaluate for bladder and ureteric integrity (Strong, Moderate). 8If patients with endometriosis are planning to undergo hysterectomy, full excision of local endometriosis should be performed concurrently (Strong, Moderate).

Aider les médecins qui pratiquent la chirurgie gynécologique dans leur processus décisionnel relatif aux indications bénignes de l'hystérectomie.Médecins, y compris gynécologues, obstétriciens, médecins de famille, chirurgiens généralistes, urgentologues; infirmières, y compris les infirmières autorisées et les infirmières praticiennes; apprentis en médecine, y compris étudiants de médecine, résidents, stagiaires (fellows); et autres fournisseurs de soins de santé.Femmes adultes (18 ans et plus) qui devront subir une hystérectomie pour une indication gynécologie bénigne.La présente directive clinique examine les différentes voies d'abord de l'hystérectomie et l'utilité des interventions chirurgicales concomitantes. DONNéES PROBANTES: Pour la présente directive clinique, des recherches ont été effectuées dans les bases de données PubMed, Medline et Cochrane Library pour trouver des études pertinentes. Les recherches ont été effectuées parmi les publications des cinq dernières années (2012-2017) au moyen des termes de recherche MeSH suivants ainsi que leurs variations : vaginal hysterectomy, laparoscopic hysterectomy, robotic hysterectomy, laparoscopically assisted vaginal hysterectomy, total laparoscopic hysterectomy, standard vaginal hysterectomy et total vaginal hysterectomy. MéTHODES DE VALIDATION: Le contenu et les recommandations ont été rédigés et acceptés par les auteurs principaux et membres du comité de pratique clinique - gynécologie. Le conseil d'administration de la Société des obstétriciens et gynécologues du Canada a approuvé la version définitive aux fins de publication. La qualité des données probantes utilisées dans le présent document a été évaluée au moyen des critères du cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) (tableau 1, tableau 2). Le résumé des conclusions est disponible sur demande. AVANTAGES, PRéJUDICES ET COûTS: Bien que l'hystérectomie soit commune, la pratique chirurgicale varie grandement chez les médecins spécialisés en gynécologie. La présente directive expose les facteurs pré- et périopératoires à prendre en compte pour améliorer la qualité des soins prodigués aux femmes qui doivent subir une chirurgie pour une affection gynécologique bénigne. MISE à JOUR DE LA DIRECTIVE CLINIQUE: La présente directive clinique de la Société des obstétriciens et gynécologues du Canada sera automatiquement passée en revue cinq ans après sa publication. Les auteurs peuvent toutefois proposer une autre date de réévaluation s'ils croient qu'une période de cinq ans est trop courte ou trop longue en fonction de leurs connaissances du sujet à titre d'experts en la matière.La présente directive clinique a été élaborée au moyen de ressources financées par la Société des obstétriciens et gynécologues du Canada. DéCLARATIONS CONDENSéES: RECOMMANDATIONS.

RESUME Objectifs Fournir des recommandations pour une strategie systematique d'exploration initiale et la prise en charge des masses ovariennes benignes et faciliter l'orientation de la patiente pour une prise en charge par un gynecologue oncologue. Professionnels concernes Obstetriciens, gynecologues, medecins de famille, internistes, infirmieres praticiennes, radiologistes, chirurgiens generalistes, etudiants en medecine, residents en medecine, stagiaires et autres fournisseurs de soins de sante. Population cible Les femmes de ≥ 18 ans consultant pour l'evaluation d'une masse ovarienne (y compris les masses kystiques simples et uniloculaires, les endometriomes, les teratomes kystiques matures, les fibromes et les kystes hemorragiques) et qui ne presentent aucun symptome aigu ni aucune predisposition genetique connue au cancer ovarien. Resultats La presente directive clinique vise a favoriser la prise en charge conservatrice et a reduire le nombre d'interventions chirurgicales inutiles et de complications de sante a long terme, a maintenir la fertilite, a reduire les couts operationnels et a ameliorer la prestation globale des soins et les issues pour les patientes en fournissant des criteres d'orientation des patientes vers un gynecologue oncologue en cas d'observation echographique evoquant une tumeur maligne. Donnees probantes Bases de donnees utilisees : MEDLINE, Cochrane et PubMed. Termes medicaux utilises : benign asymptomatic and symptomatic ovarian cysts, adnexal masses, oophorectomy, ultrasound diagnosis of cysts, simple ultrasound rules, surgical and medical therapies for cysts, screening for ovarian cancer, ovarian torsion, et menopause. La recherche initiale a ete terminee en 2017 et mise a jour en 2018. Les criteres d'exclusion etaient les masses kystiques ovariennes malignes, les traitements de l'endometriose et les autres pathologies annexielles non liees a l'ovaire. Methodes de validation Le contenu et les recommandations ont ete rediges et acceptes par les auteurs. Le conseil d'administration de la Societe des obstetriciens et gynecologues du Canada a approuve la version definitive avant publication. La qualite des donnees probantes a ete evaluee a partir des criteres de l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation). Benefices, risques et couts La mise en œuvre de ces recommandations pourrait reduire les couts lies aux interventions chirurgicales et hospitalisations inutiles et diminuer le nombre de journees de travail perdues ainsi que le risque de perte de fertilite, de menopause precoce et de complications chirurgicales. DECLARATIONS SOMMAIRES (Classement GRADE entre parentheses) 1Les masses ovariennes suivantes presentent generalement des caracteristiques echographiques benignes classiques : masse kystique simple ou uniloculaire, kyste hemorragique, endometriome, teratome kystique mature (kyste dermoide) et fibrome (elevee). 2Le risque de malignite pour les masses kystiques ovariennes simples est faible ( 3Les patientes ayant une masse ovarienne d'un diametre de ≥ 5 cm presentent un risque accru de torsion ovarienne (moyenne). 4La laparoscopie est la strategie recommandee pour la prise en charge chirurgicale des masses ovariennes benignes symptomatiques, car elle est non seulement techniquement realisable et sure, mais par rapport a la laparotomie, elle a l'avantage de permettre un sejour a l'hopital plus court, un meilleur temps de recuperation et moins de douleurs et de saignements (elevee). 5L'evaluation preoperatoire complete est necessaire afin de determiner le risque de malignite d'une masse ovarienne avant de choisir la prise en charge chirurgicale appropriee (elevee). 6L'hemostase par electrocauterisation doit etre utilisee avec parcimonie afin de reduire le risque de lesions aux tissus ovariens sains et de limiter la formation d'adherences (elevee). RECOMMANDATIONS (Classement GRADE entre parentheses) 1Chez les patientes asymptomatiques, le suivi initial des masses classees benignes par echographie peut se faire au moyen d'une echographie 8 a 12 semaines plus tard, de preference dans la phase proliferative du cycle menstruel pour les femmes non menopausees. L'echographie de suivi peut ensuite etre effectuee annuellement pour les masses stables qui ne manifestent aucune caracteristique maligne (forte, moderee). 2La prise en charge conservatrice est envisageable chez la plupart des masses asymptomatiques de 3En cas d'intervention chirurgicale pour traiter une masse symptomatique classee benigne a l'echographie, il est possible d'envisager l'ovariectomie unilaterale ou bilaterale chez les femmes menopausees (forte, faible); la kystectomie ovarienne est envisageable chez les femmes non menopausees si l'intervention est techniquement realisable (forte, faible). Chez les femmes en perimenopause, la decision d'effectuer une kystectomie avec possibilite de salpingectomie par opposition a une ovariectomie doit faire partie d'un processus decisionnel conjoint entre la patiente et son fournisseur de soins de sante (forte, faible). 4La kystectomie ovarienne laparoscopique est la voie chirurgicale recommandee pour l'elimination des masses kystiques au lieu de la fenestration avec ponction evacuatrice (forte, moyenne). 5La prise en charge laparoscopique doit comprendre l'examen des surfaces peritoneales, de l'appendice, du haut de l'abdomen, du cul-de-sac posterieur et de la vessie en plus de l'uterus, des trompes et des ovaires afin de detecter toute lesion. En plus du lavage pelvien pour cytologie, il y a lieu d'effectuer une biopsie des surfaces peritoneales aux fins d'analyse histopathologique seulement en cas de malignite soupconnee (forte, elevee). 6Une cytologie peritoneale et un examen sur coupe en congelation doivent idealement etre effectue lors de la prise en charge chirurgicale d'une masse ovarienne en cas de malignite soupconnee. Pour ameliorer l'exactitude du diagnostic, les pieces d'exerese doivent idealement etre interpretees par un anatomopathologiste specialise en gynecologie, si les ressources le permettent (forte, elevee). 7Lorsqu'une masse ovarienne initialement presumee benigne se revele maligne d'apres les resultats anatomopathologiques, il y a lieu d'effectuer une stadification chirurgicale exhaustive aux mains d'un chirurgien experimente en gynecologie oncologique si les ressources le permettent (forte, elevee).

Objective To provide recommendations for a systematic approach to the initial investigation and management of a benign ovarian mass and facilitate patient referral to a gynaecologic oncologist for management. Intended Users Obstetricians, gynaecologists, family physicians, internists, nurse practitioners, radiologists, general surgeons, medical students, medical residents, fellows, and other health care providers. Target Population Women ≥18 years of age presenting for evaluation of an ovarian mass (including simple and unilocular cystic masses, endometriomas, dermoids, fibromas, and hemorrhagic cysts) who are not acutely symptomatic and without known genetic predisposition to ovarian cancer. Outcomes This guideline aims to encourage conservative management and help reduce unnecessary surgery and long-term health complications, maintain fertility, and decrease operative costs and improve overall patient care and outcomes by providing criteria for referral of patients with ultrasound imaging findings suggestive of a malignant mass to a gynaecologic oncologist. Evidence Databases searched: Medline, Cochrane, and PubMed. Medical terms used: benign asymptomatic and symptomatic ovarian cysts, adnexal masses, oophorectomy, ultrasound diagnosis of cysts, simple ultrasound rules, surgical and medical therapies for cysts, screening for ovarian cancer, ovarian torsion, and menopause. Initial search was completed by 2017 and updated in 2018. Exclusion criteria were malignant ovarian cystic masses, endometriosis therapies, and other adnexal pathologies unrelated to the ovary. Validation Methods The content and recommendations were drafted and agreed upon by the authors. The Society of Obstetricians and Gynaecologists of Canada's Board of Directors approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation methodology framework. Benefits, Harms, Costs Implementation of the recommendations could reduce costs due to unnecessary surgeries and hospitalizations and reduce lost work days and the risk of loss of fertility, early menopause, and surgical complications. SUMMARY STATEMENTS (GRADE ratings in parentheses) 1The following ovarian masses typically demonstrate classic benign features on ultrasound: simple or unilocular cystic mass, hemorrhagic cyst, endometrioma, mature cystic teratoma (dermoid), and fibroma (high). 2The risk of malignancy for simple ovarian cystic masses is low ( 3Patients with an ovarian mass ≥5 cm in diameter are at increased risk for ovarian torsion (moderate). 4Laparoscopy is the recommended approach for surgical management of symptomatic benign ovarian masses because it not only is technically feasible and safe but also provides the advantages of shorter hospital stays, faster recovery times, and less pain and bleeding compared with laparotomy (high). 5Comprehensive preoperative evaluation is necessary in order to determine the risk of malignancy of an ovarian mass before deciding on the appropriate surgical management (high). 6Electrocautery for hemostasis should be used sparingly in order to reduce the risk of damage to healthy ovarian tissue and minimize adhesion formation (high). RECOMMENDATIONS (GRADE ratings in parentheses) 1In the asymptomatic patient, masses characterized as benign on ultrasound can be followed initially by repeat ultrasound in 8 to 12 weeks, preferably in the proliferative phase of the menstrual cycle for premenopausal women. Follow-up ultrasound can then be done yearly for masses that remain stable and do not develop malignant features (strong, moderate). 2Most asymptomatic masses 3If surgery is performed for a symptomatic mass characterized as benign on ultrasound, unilateral or bilateral oophorectomy can be considered for postmenopausal women (strong, low) and ovarian cystectomy can be considered for premenopausal women if technically feasible (strong, low). For perimenopausal women, the decision to perform a cystectomy with a possible salpingectomy versus an oophorectomy should be part of a shared decision-making discussion between the patient and her health care provider (strong, low). 4Laparoscopic ovarian cystectomy is the recommended surgical approach for removal of cystic masses, rather than fenestration and aspiration (strong, moderate). 5Laparoscopic management should involve examination of the peritoneal surfaces, appendix, upper abdomen, posterior cul-de-sac, and bladder in addition to uterus, tubes, and ovaries for evidence of disease. In addition to pelvic washing for cytology, a biopsy of peritoneal surfaces should be taken for histopathology only if malignancy is suspected (strong, high). 6Peritoneal washing for cytology and frozen section for analysis should be undertaken at the time of surgical management of an ovarian mass if there is a suspicion of malignancy. To improve the diagnostic accuracy, specimens should be interpreted by a pathologist with gynaecologic expertise, if resources permit (strong, high). 7When pathology results reveal malignancy in an ovarian mass that had originally been presumed benign, comprehensive surgical staging should be performed by a surgeon with expertise in gynaecologic oncology, if resources permit (strong, high).

Abnormal uterine bleeding (AUB) is the direct cause of a significant health care burden for women, their families, and society as a whole. Up to 30% of women will seek medical assistance for the problem during their reproductive years.To provide current evidence-based guidelines on the techniques and technologies used in endometrial ablation (EA), a minimally invasive technique for the management of AUB of benign origin.Members of the guideline committee were selected on the basis of individual expertise to represent a range of practical and academic experience in terms of both location in Canada and type of practice, as well as subspecialty expertise and general background in gynaecology. The committee reviewed all available evidence in the English medical literature, including published guidelines, and evaluated surgical and patient outcomes for the various EA techniques. Recommendations were established by consensus.Published literature was retrieved through searches of MEDLINE and The Cochrane Library in 2013 and 2014 using appropriate controlled vocabulary and key words (endometrial ablation, hysteroscopy, menorrhagia, heavy menstrual bleeding, AUB, hysterectomy). RESULTS were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies written in English from January 2000 to November 2014. Searches were updated on a regular basis and incorporated in the guideline to December 2014. Grey (unpublished) literature was identifies through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).This document reviews the evidence regarding the available techniques and technologies for EA, preoperative and postoperative care, operative set-up, anaesthesia, and practical considerations for practice.Implementation of the guideline recommendations will improve the provision of EA as an effective treatment of AUB. Following these recommendations would allow the surgical procedure to be performed safely and maximize success for patients.EA is a safe and effective minimally invasive option for the treatment of AUB of benign etiology. Summary Statements 1. Endometrial ablation is a safe and effective minimally invasive surgical procedure that has become a well-established alternative to medical treatment or hysterectomy to treat abnormal uterine bleeding in select cases. (I) 2. Endometrial preparation can be used to facilitate resectoscopic endometrial ablation (EA) and can be considered for some non-resectoscopic techniques. For resectoscopic EA, preoperative endometrial thinning results in higher short-term amenorrhea rates, decreased irrigant fluid absorption, and shorter operative time than no treatment. (I) 3. Non-resectoscopic techniques are technically easier to perform than resectoscopic techniques, have shorter operative times, and allow the use of local rather than general anaesthesia. However, both techniques have comparable patient satisfaction and reduction of heavy menstrual bleeding. (I) 4. Both resectoscopic and non-resectoscopic endometrial ablation (EA) have low complication rates. Uterine perforation, fluid overload, hematometra, and cervical lacerations are more common with resectoscopic EA; perioperative nausea/vomiting, uterine cramping, and pain are more common with non-resectoscopic EA. (I) 5. All non-resectoscopic endometrial ablation devices available in Canada have demonstrated effectiveness in decreasing menstrual flow and result in high patient satisfaction. The choice of which device to use depends primarily on surgical judgement and the availability of resources. (I) 6. The use of local anaesthetic and blocks, oral analgesia, and conscious sedation allows for the provision of non-resectoscopic EA in lower resource-intense environments including regulated non-hospital settings. (II-2) 7. Low-risk patients with satisfactory pain tolerance are good candidates to undergo endometrial ablation in settings outside the operating room or in free-standing surgical centres. (II-2) 8. Both resectoscopic and non-resectoscopic endometrial ablation are relatively safe procedures with low complication rates. The complications perforation with potential injury to contiguous structures, hemorrhage, and infection. (II-2) 9. Combined hysteroscopic sterilization and endometrial ablation can be safe and efficacious while favouring a minimally invasive approach. (II-2) Recommendations 1. Preoperative assessment should be comprehensive to rule out any contraindication to endometrial ablation. (II-2A) 2. Patients should be counselled about the need for permanent contraception following endometrial ablation. (II-2B) 3. Recommended evaluations for abnormal uterine bleeding, including but not limited to endometrial sampling and an assessment of the uterine cavity, are necessary components of the preoperative assessment. (II-2B) 4. Clinicians should be vigilant for complications unique to resectoscopic endometrial ablation such as those related to fluid distention media and electrosurgical injuries. (III-A) 5. For resectoscopic endometrial ablation, a strict protocol should be followed for fluid monitoring and management to minimize the risk of complications of distension medium overload. (III-A) 6. If uterine perforation is suspected to have occurred during cervical dilatation or with the resectoscope (without electrosurgery), the procedure should be abandoned and the patient should be closely monitored for signs of intraperitoneal hemorrhage or visceral injury. If the perforation occurs with electrosurgery or if the mechanism of perforation is uncertain, abdominal exploration is warranted to obtain hemostasis and rule out visceral injury. (III-B) 7. With resectoscopic endometrial ablation, if uterine perforation has been ruled out acute hemorrhage may be managed by using intrauterine Foley balloon tamponade, injecting intracervical vasopressors, or administering rectal misoprostol. (III-B) 8. If repeat endometrial ablation (EA) is considered following non-resectoscopic or resectoscopic EA, it should be performed by a hysteroscopic surgeon with direct visualization of the cavity. Patients should be counselled about the increased risk of complications with repeat EA. (II-2A) 9. If significant intracavitary pathology is present, resectoscopic endometrial ablation combined with hysteroscopic myomectomy or polypectomy should be considered in a non-fertility sparing setting. (II-3A).

Objectives (1) To determine exposure to and general knowledge on premature ovarian insufficiency (POI) among Canadian senior obstetrics and gynaecology residents. (2) To identify opportunity to improve trainee exposure to POI. Methods Canadian PGY-4 and PGY-5 obstetrics and gynaecology residents were approached to complete an electronic survey. The questions in the survey included the basic POI knowledge, previous exposure to POI, and comfort level in managing POI patients. Data from the survey was summarized descriptively and compared between two trainee groups (PGY-4 and PGY-5) using chi-square or Fisher exact tests. Results Responses were received from trainees in all Canadian residency programs with an overall response rate of 45% (95/210 residents). Most respondents (79%, 75/95 residents) identified correct age for POI diagnosis, and 65% (62/95 residents) recognized the most common aetiology. A majority (99%, 92/93 residents) would prescribe hormone therapy for POI patients. Most trainees (62%, 59/95 residents) lack access to a POI clinic at their centre and 63% (59/94 residents) have seen less than six POI patients during residency training. Most feel somewhat comfortable managing POI patients (67%, 64/95 residents), but 22% (21/95 residents) feel totally uncomfortable with a majority of respondents (83%, 78/94 residents), indicating they would benefit from additional training. Compared with PGY-4 residents, the proportion of trainees who could identify the correct age for diagnosis of POI was significantly higher in PGY-5 residents (89% vs. 70%, P = 0.024). Conclusion Many senior obstetrics and gynaecology residents in Canada lack knowledge around POI, and most indicate need for further exposure to POI during residency training. We identified an opportunity for improved POI curricula.

The First International Consensus Conference on Adnexal Masses was convened to thoroughly examine the state of the science and to formulate recommendations for clinical assessment and management. The panel included representatives of societies in the fields of gynecology, gynecologic oncology, radiology, and pathology and clinicians from Europe, Canada, and the United States. In the United States, there are approximately 9.1 surgeries per malignancy compared to the European International Ovarian Tumor Analysis center trials, with only 2.3 (oncology centers) and 5.9 (other centers) reported surgeries per malignancy, suggesting that there is room to improve our preoperative assessments. The American College of Obstetricians and Gynecologists Practice Bulletin on "Management of Adnexal Masses," reaffirmed in 2015 (Obstet Gynecol 2007; 110:201-214), still states, "With the exception of simple cysts on a transvaginal ultrasound finding, most pelvic masses in postmenopausal women will require surgical intervention." The panel concluded that patients would benefit not only from a more conservative approach to many benign adnexal masses but also from optimization of physician referral patterns to a gynecologic oncologist in cases of suspected ovarian malignancies. A number of next-step options were offered to aid in management of cases with sonographically indeterminate adnexal masses. This process would provide an opportunity to improve risk stratification for indeterminate masses via the provision of alternatives, including but not limited to evidence-based risk-assessment algorithms and referral to an "expert sonologist" or to a gynecologic oncologist. The panel believed that these efforts to improve clinical management and preoperative triage patterns would ultimately improve patient care.

Resume Objectif Offrir, aux fournisseurs de soins de sante, une mise a jour de la directive clinique quant a la prise en charge de la menopause chez les femmes asymptomatiques en sante, ainsi que chez les femmes qui presentent des symptomes vasomoteurs ou urogenitaux; cette mise a jour se penche egalement sur les facteurs associes a la maladie cardiovasculaire, au cancer du sein, a l'urogynecologie et a la sexualite. Issues Les interventions quant au mode de vie, les medicaments d'ordonnance et les traitements de medecine complementaire et parallele sont presentes en fonction de leur efficacite dans la prise en charge des symptomes menopausiques. Des strategies de counseling et therapeutiques en ce qui concerne les preoccupations en matiere de sexualite au cours de la perimenopause et de la postmenopause sont passees en revue. Des approches quant a l'identification et a l'evaluation des femmes exposees a un risque eleve d'osteoporose (ainsi que des options en matiere de prevention et de traitement) sont presentees dans la directive clinique sur l'osteoporose qui accompagne les presentes. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans PubMed et The Cochrane Library , en aout et en septembre 2012, au moyen d'un vocabulaire controle (p. ex. « hormone replacement therapy », « menopause », « cardiovascular diseases » et « sexual function ») et de mots cles (p. ex. « HRT », « perimenopause », « heart disease » et « sexuality »). Les resultats ont ete restreints aux directives cliniques, aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Les resultats ont egalement ete restreints aux documents publies, en anglais ou en francais, a partir de 2009. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'au 5 janvier 2013. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques, aupres de societes de specialite medicale nationales et internationales, et dans des collections de directives cliniques. Valeurs La qualite des resultats est evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau).