BACKGROUND: Adenomyosis symptoms are disabling. Populationbased data on incidence and prevalence of adenomyosis are lacking that could guide future evidence-based treatments and clinical management. OBJECTIVE: To evaluate the incidence, 10-year secular trends, and prevalence of adenomyosis diagnoses and to describe symptoms and treatment patterns in a large U.S. cohort. STUDY DESIGN: We performed a retrospective population-based cohort study of women aged 16e60 years in 2006e2015, enrolled in Kaiser Permanente Washington, a mixed-model health insurance and care delivery system. Adenomyosis diagnoses identified by ICD codes from the International Classification of Diseases 9th and 10th editions and potential covariates were extracted from computerized databases. Women with prior hysterectomy, and for incidence estimates women with prior adenomyosis diagnoses, were excluded. Linear trends in incidence rates over the 10-year study period were evaluated using Poisson regression. Rates and trend tests were examined for all women adjusting for age using direct standardization to the 2015 study population, by age groups, and by race/ethnicity. Chart reviews were performed to validate diagnostic accuracy of ICD codes in identifying adenomyosis incidence. Symptoms and treatment patterns at diagnosis and in the following 5 years were assessed. RESULTS: A total of 333,693 women contributed 1,185,855 woman-years (2006e2015) for incidence calculations. Associated symptom-related codes (menorrhagia or abnormal uterine bleeding, dysmenorrhea or pelvic pain, dyspareunia, and infertility) were observed in 90.8%; 18.0% had co-occurrent endometriosis codes and 47.6% had cooccurrent uterine fibroid codes. The overall adenomyosis incidence was 1.03% or 28.9 per 10,000 woman-years, with a high of 30.6 in 2007 and a low of 24.4 in 2014. Overall age-adjusted estimated incidence rates declined during the 10-year study interval (linear trend P < .05). Incidence was highest for women aged 41e45 years (69.1 per 10,000 womanyears in 2008) and was higher for black (highest 44.6 per 10,000 woman-years in 2011) vs white women (highest 27.9 per 10,000 womanyears in 2010). Overall prevalence in 2015 was 0.8% and was highest among women aged 41e45 years (1.5%). Among the 624 potential adenomyosis cases identified by diagnostic codes in 2012e2015 and with sufficient information in the medical record to determine true case status, 490 were confirmed as incident cases, yielding a 78.5% (95% confidence interval, 75.1%, 81.7%) positive predictive value of adenomyosis ICD-9/ICD-10 codes for identifying an incident adenomyosis case. Health care burden was substantial: 82.0% of women had hysterectomies, nearly 70% had imaging studies suggestive of adenomyosis, and 37.6% used chronic pain medications. CONCLUSION: Adenomyosis burden to the individual and the health care system is high. Incidence rates are disproportionately high among black women. These findings are of concern, as currently available longterm medical therapies remain limited beyond hysterec...

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For women with menorrhagia, hysteroscopic resection of endometrial tissue, combined with myomectomy and polypectomy when indicated, offers an alternative to hysterectomy. Favorable short-term results have been documented, but the long-term outcome may be less impressive. This study examined long-term outcomes in 279 women with menorrhagia, seen consecutively in the years 1990-1999, who underwent hysteroscopic endometrial resection with or without myomectomy. Follow-up data were available for 259 women, 93% of those operated on, after a mean postoperative interval of 6 years. More than one-third of the women received hormonal therapy for endometrial suppression preoperatively.Operative complications occurred in 15 women, about 6% of the total group. Eight women with postoperative endometritis responded well to antibiotic therapy. Endometrial abnormalities were identified in 41% of cases. Onefourth of women had hysteroscopic resection of fibroids as well, and 9% had polypectomy. Late complications were recorded in nearly 8% of women who were followed up. A large majority of the 18 patients with hematometra had undergone tubal ligation. More than one-third of women had one or more gynecological procedures during follow-up, and 61 of them underwent hysterectomy. Indications for hysterectomy included, in order of declining frequency, myomas, adenomyosis, persistent menorrhagia or endometrial hyperplasia, and perioperative or postoperative complications. More than 80% of hysterectomies were done within 5 years after hysteroscopic surgery. On multivariate analysis, both past tubal ligation and a uterine cavity measuring 9 cm or more in length were associated with an increased risk of hysterectomy. Half of the women who did not require hysterectomy were amenorrheic on long-term follow-up, and none had more than slight menstrual bleeding.These findings show that hysteroscopic resection of endometrium and fibroids provide lasting benefit to women with menorrhagia and is a suitable alternative to hysterectomy. This approach may prove effective for women who have not been satisfied by use of a levonorgestrel-releasing intrauterine system GYNECOLOGY ABSTRACT Human papilloma virus (HPV) is a key factor in the development of cervical carcinoma. High-risk types of this virus are found in nearly all squamous-cell cervical cancers. HPV infection precedes cervical intraepithelial neoplasia (CIN), and is viewed as the most important factor in both premalignant cell changes and invasive cancer. HPV testing is highly sensitive for CIN lesions. The Pap smear is less sensitive but more specific. Many of the approximately 500 women in Sweden who are found each year to have cervical cancer have chosen not to be screened. A self-sampling device (SSD) for collecting vaginal smears now is available.This study compared the results of three sampling methods in 43 women who previously had abnormal cervical cytology. The women collected vaginal samples by inserting the SSD into the bottom of the vagina and rotating it one turn. The upper part of...

There is now an unprecedented opportunity to improve the care of the over 5 million people who are living with Alzheimer's disease and related dementias and many more with cognitive impairment due to brain injury, systemic diseases, and other causes. The introduction of a new Medicare care planning benefit-long sought openly by advocacy organizations and clinicians and badly needed by patients and families-could greatly improve health care quality, but only if widely and fully implemented. We describe the components of this new benefit and its promise of better clinical care, as well as its potential to create a new platform for clinical and health outcomes research. We highlight external factors-and some that are internal to the benefit structure itself-that challenge the full realization of its value, and we call for broad public and professional engagement to ensure that it will not fail.

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BACKGROUND: Intrauterine devices are effective and safe, longacting reversible contraceptives, but the risk of uterine perforation occurs with an estimated incidence of 1 to 2 per 1000 insertions. The European Active Surveillance Study for Intrauterine Devices, a European prospective observational study that enrolled 61,448 participants (2006e2012), found that women breastfeeding at the time of device insertion or with the device inserted at 36 weeks after delivery had a higher risk of uterine perforation. The Association of Uterine Perforation and Expulsion of Intrauterine Device (APEX-IUD) study was a Food and Drug Administrationemandated study designed to reflect current United States clinical practice. The aims of the APEX-IUD study were to evaluate the risk of intrauterine deviceerelated uterine perforation and device expulsion among women who were breastfeeding or within 12 months after delivery at insertion. OBJECTIVE: We aimed to describe the APEX-IUD study design, methodology, and analytical plan and present population characteristics, size of risk factor groups, and duration of follow-up.

Key Points Question What are the effects of estradiol or vaginal moisturizer on the vaginal microbiota, metabolome, and pH after 12-week treatment in postmenopausal women? Findings In this secondary analysis of 144 participants in a randomized clinical trial of postmenopausal women with moderate to severe vulvovaginal symptoms, women using vaginal 10 μg estradiol tablet demonstrated larger changes in the vaginal microbiota and metabolome compared with women using vaginal moisturizer or placebo, despite a decrease in pH within each intervention group. Meaning These findings suggest that treatment of genitourinary symptoms of menopause with topical estradiol changes the vaginal microenvironment in ways that may promote genitourinary health.