News From ACOG
These are press releases posted by the American College of Obstetrics and Gynecology and are intended only for information and guidance, generally for the press. As with all information on this site, it is intended solely for information and not to be used for diagnosis or treatment. Discuss these issues with you health care provider.
ACOG Lauds Court Decision Regarding Emergency Contraception
ACOG NEWS RELEASE (April 8, 2009)
Washington, DC -- The American College of Obstetricians and Gynecologists (ACOG) lauds the recent ruling by the Federal District Court in New York ordering the US Food and Drug Administration (FDA) to make emergency contraception (EC) available without a prescription to women younger than age 18. This ruling reinforces ACOG's long-held position that there is no scientific or medical reason to impose an age restriction for over-the-counter (OTC) availability of EC because it is safe and effective for adolescents and women of all ages.
EC is a higher dosage of the same hormones found in ordinary birth control pills. It is highly effective in reducing the chance of pregnancy after either a contraceptive failure or unprotected sex, including rape. If taken within 72 hours of unprotected sex, EC prevents up to 89% of pregnancies. It is most effective if taken within 24 hours.
There are more than 800,000 teen pregnancies in the US each year, many ending in abortion. Statistics show that the majority of adolescents have sex for the first time around age 17. By the time teenagers reach age 19, 70 percent have had sexual intercourse. In light of the most recent data from the Centers for Disease Control and Prevention (CDC) showing a worrisome increase in births to teens in the US, easy access to EC is all the more imperative. According to the CDC, the 2007 birth rate for teens ages 15 to 17 years increased by one percent. This rate rose four percent between 2005 and 2007, halting what had been a 45 percent decline between 1991 and 2005.
Although EC is not a silver bullet, unencumbered access is critical to help adolescents prevent unintended pregnancies and subsequent abortions. In keeping with the FDA's stated mission to promote public health and welfare, ACOG urges it to withdraw both the age restriction and the behind-the-counter status for OTC emergency contraception.
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The American College of Obstetricians and Gynecologists is the national medical organization representing over 53,000 members who provide health care for women.
Routine Screening for Hereditary Breast and Ovarian Cancer Recommended
ACOG NEWS RELEASE (March 20, 2009)
Washington, DC -- Evaluating a patient's risk of hereditary breast and ovarian cancer syndrome is an important first step in cancer prevention and early detection and should be a routine part of ob-gyn practice. Those who are likely to have the syndrome should be referred for further assessment to a clinician with expertise in genetics, according to a new Practice Bulletin jointly released today by The American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncologists. The new document also provides information on how to counsel patients with hereditary risk in cancer prevention and how to perform surgical removal of the ovaries and fallopian tubes in this population.
Hereditary breast and ovarian cancer syndrome is an inherited cancer-susceptibility syndrome marked by multiple family members with breast cancer, ovarian cancer or both; the presence of both breast and ovarian cancer in a single individual; and early age of breast cancer onset.
"The vast majority of families who have hereditary breast and ovarian cancer syndrome carry an inherited mutation of the BRCA1 or BRCA2 tumor suppressor genes. Women in these families may have a higher risk of breast, ovarian, peritoneal, and fallopian tube cancers," said Karen Lu, MD, professor of gynecologic oncology at the University of Texas MD Anderson Cancer Center, who helped develop the ACOG Practice Bulletin. "Though having a BRCA gene mutation does not mean an individual will undoubtedly develop cancer, it is better to know sooner rather than later who may be at risk."
Women with either BRCA mutation have a 65%-74% chance of developing breast cancer in their lifetime. Lifetime risk of ovarian cancer is 39%-46% in women with a BRCA1 mutation and 12-20% in women with a BRCA2 mutation. Approximately 1 in 300 to 1 in 800 individuals in the US are BRCA carriers. BRCA mutations may occur more frequently in some populations founded by small ancestral groups, such as Ashkenazi (Eastern European) Jews, French Canadians, and Icelanders. An estimated 1 in 40 Ashkenazi Jews has a BRCA1 or BRCA2 mutation.
The new document addresses the ob-gyn's role in identifying, managing, and counseling patients with an inherited cancer risk. The initial screening evaluation should include specific questions about personal and family history of breast cancer and ovarian cancer. Because BRCA mutations can be passed down from both the father's and mother's side of the family, both sides of a woman's family should be carefully examined. Obtaining a full family history may be impeded in women who were adopted, those from families that have multiple women who had a hysterectomy and oophorectomy at a young age, or those from families with few female relatives. The results of a general evaluation will help determine whether the patient would benefit from a more in-depth hereditary cancer risk assessment, which should be conducted by a health care provider with expertise in cancer genetics.
Further genetic risk assessment is recommended for women who have more than a 20%-25% chance of having an inherited predisposition to breast or ovarian cancer. These women include:
- Women with a personal history of both breast cancer and ovarian cancer
- Women with ovarian cancer and a close relative—defined as mother, sister, daughter, grandmother, granddaughter, aunt—with ovarian cancer, premenopausal breast cancer, or both
- Women of Ashkenazi Jewish decent with breast cancer who were diagnosed at age 40 or younger or who have ovarian cancer
- Women with breast cancer at 50 or younger and who have a close relative with ovarian cancer or male breast cancer at any age
- Women with a close relative with a known BRCA mutation
Genetic risk assessment may also be appropriate for women with a 5%-10% chance of having hereditary risk, including:
- Women with breast cancer by age 40
- Women with ovarian cancer, primary peritoneal cancer, or fallopian tube cancer or high grade, serous histology at any age
- Women with cancer in both breasts (particularly if the first cancer was diagnosed by age 50)
- Women with breast cancer by age 50 and a close relative with breast cancer by age 50
- Women with breast cancer at any age and two or more close relatives with breast cancer at any age (particularly if at least one case of breast cancer was diagnosed by age 50)
- Unaffected women with a close relative that meets one of the previous criteria
Before testing, a genetic counselor can discuss the possible outcomes of testing; options for surveillance, chemoprevention, and risk-reducing surgery; cost and legal and insurance matters surrounding genetic tests and test results; and the psychologic and familial implications that may follow. The counselor can also provide written materials that women can share with family members who may also have an inherited risk.
Screening, Prevention, and Surgical Intervention
Those with hereditary breast and ovarian cancer syndrome can begin a screening and prevention plan based on individual risk factors and family history. Ovarian cancer screening approaches are currently limited. For women with a BRCA mutation, ACOG recommends periodic screening with CA 125 and transvaginal ultrasonography beginning between the ages of 30 and 35 years or 5-10 years earlier than the earliest age of first diagnosis of ovarian cancer in the family.
Risk-reducing salpingo-oophorectomy surgery—which removes both of the ovaries and fallopian tubes—can reduce the risk of ovarian and fallopian tube cancer by about 85% to 90% among BRCA carriers. Women who have BRCA1 or BRCA2 mutations should be offered risk-reducing salpingo-oophorectomy by age 40 or when childbearing is complete. The ideal time for this surgery depends on the type of gene mutation.
"In this population, risk-reducing salpingo-oophorectomy and pathology review must be extremely comprehensive to check for microscopic cancers in the ovaries, fallopian tubes, and abdominal cavity," Dr. Lu said. According to the Practice Bulletin, all tissue from the ovaries and fallopian tubes should be removed, and a complete, serial sectioning that includes microscopic examination for occult cancer should be conducted. A thorough visualization of the peritoneal surfaces with pelvic washings should be performed. Any abnormal areas should undergo biopsy.
Strategies recommended to reduce breast cancer risk in women with a BRCA mutation include semiannual clinical breast examination; an annual mammogram and annual breast magnetic resonance imaging screening beginning at age 25 or sooner based on the earliest age onset in the family; chemoprevention therapy with tamoxifen; and bilateral mastectomy to remove both breasts, which reduces the risk of breast cancer by greater than 90%-95%.
Practice Bulletin #103 "Hereditary Breast and Ovarian Cancer Syndrome" is published in the April 2009 edition of Obstetrics & Gynecology.
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The American College of Obstetricians and Gynecologists is the national medical organization representing over 53,000 members who provide health care for women.
ACOG Issues New Guidelines on Managing Stillbirths
ACOG NEWS RELEASE (Feb. 20, 2009)
Washington, DC -- Approximately 1 out of every 160 deliveries in the US ends in stillbirth—a devastating experience for women and their families—yet its causes remain poorly understood. In an effort to help prevent stillbirths by improving the understanding of its risk factors and causes, The American College of Obstetricians and Gynecologists (ACOG) today issued a new Practice Bulletin for ob-gyns on the clinical management of stillbirths. The guidelines, published in the March issue of Obstetrics & Gynecology, review what is known about stillbirth and highlight the importance of uniform data collection.
Stillbirth, one of the most common negative pregnancy outcomes, is a fetal death that occurs during pregnancy at 20 weeks' or greater gestation. Fetal losses before 20 weeks are defined as miscarriages. Approximately 25,000 stillbirths are reported every year and represents 60% of all perinatal mortality in the US. In 2004, the overall stillbirth rate in the US was 6.2 per 1,000 births, a slight decrease from 6.4 per 1,000 in 2002. Since 1990, the rate of early stillbirth (20-27 weeks) has remained stable at approximately 3.2 per 1,000 births, while the rate of late stillbirth (28 weeks or greater) has decreased from 4.3 to 3.1 per 1,000 births.
"These guidelines represent a notable consensus on how we should be dealing with stillbirth in this country," said Ruth C. Fretts, MD, of Harvard Vanguard Medical Associates and Harvard Medical School, who headed the development of ACOG's new Practice Bulletin. "But we have a long way to go before we have a clearer understanding of the causes of stillbirth."
The most common risk factors associated with stillbirth are non-Hispanic black race, nulliparity (no previous births), advanced maternal age, and obesity. Black women have the highest stillbirth rate at 11.25 per 1,000 births compared with Hispanic, Asian, Native American, and white women, all of whom have rates of less than 6 per 1,000 births. Stillbirth rates remain high among black women, even among those who receive adequate prenatal care. This disparity has been attributed to higher rates of diabetes, hypertension, placental abruption, and premature rupture of membranes among black women.
Hypertension and diabetes, both risk factors for stillbirth, are two of the most common medical conditions that occur along with pregnancy. Research indicates that women who have diabetes prior to pregnancy have a two- to five-fold increased risk of stillbirth. Obesity is associated with an increased risk of both miscarriage and stillbirth. The risk of stillbirth is 8 per 1,000 births among obese pregnant women with a body mass index (BMI) between 30 and 39.9 and is even higher among pregnant women with a BMI greater than 40 (11 per 1,000). Obesity remains an independent risk factor for stillbirth even after controlling for smoking, gestational diabetes, and preeclampsia.
Multiple gestations also are related to higher stillbirth rates. A pregnancy with two or more fetuses has a stillborn rate four times higher than a singleton pregnancy. Advanced maternal age (older than 35) is yet another risk factor for stillbirth, even after taking into account other risk factors such as hypertension, diabetes, placenta previa, and multiple gestations. Older women having their first pregnancy appear to be at greater risk than older women who have given birth previously.
A significant portion of stillbirths remains unexplained despite a thorough evaluation, according to ACOG. The lack of uniform protocols for evaluating and classifying stillbirths in the US, coupled with decreasing autopsy rates, has hindered the study of specific causes. In most cases, fetal death certificates are filled out before a full investigation has been completed, and amended death certificates are rarely filed when additional information from the stillbirth evaluation surfaces. "It's worth noting that the US has the lowest stillbirth autopsy rate among developed countries," according to Dr. Fretts. "Part of the intent of these guidelines is to increase this rate by encouraging physicians to request, and families to agree to, an autopsy so that we can gain a better understanding of the causes of stillbirth."
Fetal growth restriction (FGR), when a fetus does not grow in size appropriately, is one known cause of stillbirth and is associated with certain genetic defects, fetal infections, maternal smoking, hypertension, autoimmune disease, obesity, and diabetes. Placental abruption, a condition in which the placenta tears away from the uterine wall, is another common cause of stillbirth. Cocaine and other illegal drug use, smoking, hypertension, and preeclampsia all significantly contribute to placental abruption.
Chromosomal and genetic abnormalities can be found in approximately 8% to 13% of stillborn fetuses. The most common identifiable abnormalities found among stillborns include Down syndrome, Turner syndrome, Edward's syndrome, and Patau syndrome. Infections such as parvovirus, cytomegalovirus, syphilis, and Listeria monocytogenes are all causally associated with stillbirth.
Although umbilical cord problems and abnormalities are frequently blamed for stillbirths, ACOG's guidelines state that other causes should be excluded before making this diagnosis because cord abnormalities are found in nearly one-third of all normal live births. A stillbirth attributed to a cord problem should have evidence of obstruction or circulatory compromise.
After a stillbirth, sensitivity to the family's emotional state is important. Parents should be given the opportunity to hold their baby and perform cultural or religious activities, such as baptism. The issue of performing an autopsy is especially sensitive, but clinicians should emphasize that the results may be valuable in planning future pregnancies. Less invasive evaluation methods such as photographs, X-rays, ultrasound, magnetic resonance imaging, and samples of skin or blood of the stillborn may help identify a cause for parents who object to a full autopsy.
"Parents want answers when they have a stillbirth, so clinicians should not be afraid to request an autopsy. Without a thorough evaluation it will be difficult to counsel women on their risk of having another stillbirth," said Dr. Fretts.
A general examination of the stillborn fetus should be performed promptly after delivery. Examination of the placenta and the umbilical cord is an essential component of stillbirth evaluation. ACOG recommends that genetic testing be performed in all stillbirths after parental permission is obtained.
A thorough maternal history also should be taken, including obstetric history, exposures to medications and viruses, and family history. Maternal testing for such things as lupus, thyroid problems, and antibodies to human parvovirus, as well certain genetic conditions may provide information that could affect future pregnancies.
Counseling and Prevention
Counseling women on their risk of having another stillbirth may be quantifiable when specific risk factors are identified. In low-risk women with an unexplained stillbirth, the risk of recurrence after 20 weeks' gestation is estimated at 7.8 to 10.5 per 1,000 births with most of the risk occurring before 37 weeks' gestation. After 37 weeks, the risk of recurrence drops to 1.8 per 1,000. Women with a history of live birth complicated by FGR, however, have a much higher stillbirth rate of 21.8 per 1,000. Diabetes, hypertension, and a history of placental abruption also carry higher rates of recurrent fetal loss.
Although there is no sure-fire method to prevent stillbirths, losing weight, quitting smoking, and abstaining from drugs and alcohol are all lifestyle modifications that women can make before becoming pregnant. Women with diabetes should get their glucose levels under tight control before becoming pregnant and throughout pregnancy. Preconception and prenatal care can also help identify and screen women for other risk factors that may increase their stillbirth risk.
"In terms of preventing stillbirth, women should try to optimize their health prior to pregnancy. This includes getting enough folic acid before they become pregnant and getting both preconception and prenatal care," said Dr. Fretts. "We also need to educate women that delaying their first birth until after age 40 is associated with an increased risk of adverse outcomes, including an increased risk of stillbirth."
Practice Bulletin #102, "Management of Stillbirth," is published in the March 2009 issue of Obstetrics & Gynecology.
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The American College of Obstetricians and Gynecologists is the national medical organization representing over 53,000 members who provide health care for women
ACOG Applauds Congressional Introduction of
Women's Health Care Reform Plan
ACOG NEWS RELEASE (Feb. 11, 2009)
Washington, DC -- The American College of Obstetricians and Gynecologists (ACOG) today applauds Senator Debbie Stabenow and Representative Jan Schakowsky for introducing legislation that calls on Congress and President Obama to enact health care reform that fully addresses the health care needs of women. The resolution is based on ACOG's Health Care for Women, Health Care for All campaign.
"The Health Care for Women resolution introduced by Rep. Jan Schakowsky (D-IL) and Sen. Debbie Stabenow (D-MI) sends a strong signal to everyone involved in the health care reform debate, that health care reform must be accomplished this year and that no reform is complete without fully and specifically addressing women's health," says ACOG Immediate Past President Kenneth L. Noller, MD, MS. (Click here to view the House Resolution and Senate Resolution.)
The congressional resolution calls for legislation that guarantees health care for women and all individuals and establishes coverage that enables women to attain good health throughout their lives-from childhood and adolescence, through the reproductive years and childbirth, and into menopause and beyond. The resolution closely echoes ACOG's Health Care for Women, Health Care for All campaign.
"Right now, more than 17 million women in the US have no health insurance," adds Dr. Noller. "As ob-gyns, we see the unfortunate effects of being underinsured or uninsured. Health care coverage is more important than ever in today's economic crisis."
According to ACOG, uninsured women are three times less likely to have had a Pap test in the last three years, with a 60% greater risk of late-stage cervical cancer. Breast cancer is 30% to 50% more fatal to uninsured women. Pregnancy-related maternal deaths are 3-4 times higher among women who receive no prenatal care. And going without prenatal care increases infant death rates by more than six times.
For more information about ACOG's Health Care for Women, Health Care for All: A Reform Agenda, go to www.acog.org/goto/healthcarereform.
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ACOG Reiterates Stance on So-Called "Bioidentical" Hormones
ACOG NEWS RELEASE (Feb. 3, 2009)
Washington, DC -- In response to recent media attention being given to so-called bioidentical hormones, The American College of Obstetricians and Gynecologists (ACOG) reiterates its position that there is no scientific evidence supporting the safety or efficacy of compounded bioidentical hormones.
In November 2005, ACOG issued a committee opinion regarding "Compounded Bioidentical Hormones" that stated its concerns about bioidenticals. More recently, the US Food and Drug Administration (FDA) issued warning letters in 2008 to several pharmacies in the US that make compounded bioidentical hormones. Some of these pharmacies claimed that compounded hormones were superior to FDA-approved hormone therapies and that they also prevented or treated serious diseases, such as Alzheimer's disease, stroke, and various cancers. The FDA stated that the pharmacies' claims of safety and effectiveness were false, misleading, and a violation of federal law. Women are encouraged to learn more by reading the FDA's consumer article "Bioidenticals: Sorting Myths from Facts" at www.fda.gov/consumer/updates/bioidenticals040808.html.
Despite celebrity testimonials touting scientifically unfounded benefits of compounded bioidentical hormones, the bottom line is that most have not undergone rigorous clinical testing for safety or efficacy, nor are they approved by the FDA. ACOG also stresses that salivary testing of a woman's hormone levels is not useful because they vary within each woman depending on her diet, time of day, the specific hormone being tested, and other variables. Although monitoring salivary hormone levels is promoted by some as a means of 'tailoring' a hormone treatment to an individual, hormone therapy does not require customized dosing.
The decision of whether or not to take hormone therapy for menopausal symptoms is highly individualized, based on a woman's health, risk factors, and personal wishes. There are a number of FDA-approved hormone therapy products available in a variety of formulations. ACOG advises women to talk with their doctor about both the benefits and risks of HT.
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The American College of Obstetricians and Gynecologists is the national medical organization representing over 52,000 members who provide health care for women.