Brazilian Guideline on Menopausal Cardiovascular Health ­ 2024 / Guía Brasileña de Salud Cardiovascular en el Climaterio y la Menopausia ­ 2024 / Diretriz Brasileira sobre a Saúde Cardiovascular no Climatério e na Menopausa ­ 2024

Women, who represent approximately half of the global population according to estimates as of January 2024, may experience signs and symptoms of menopause for at least one-third of their lives, during which they have a higher risk of cardiovascular morbidity and mortality. The effects of menopausal hormone therapy (MHT) on the progression of atherosclerosis and cardiovascular disease (CVD) events vary depending on the age at which MHT is initiated and the time since menopause until its initiation. Beneficial effects on CVD outcomes and all-cause mortality have been observed when MHT was initiated before the age of 60 or within 10 years after menopause. The decision regarding the initiation, dose, regimen, and duration of MHT should be made individually after discussing the benefits and risks with each patient. For primary prevention of postmenopausal chronic conditions, the combined use of estrogen and progestogen is not recommended in asymptomatic women, nor is the use of estrogen alone in hysterectomized women. Hormone-dependent neoplasms contraindicate MHT. For the treatment of genitourinary syndrome of menopause, vaginal estrogen therapy may be used in patients with known cardiovascular risk factors or established CVD. For women with contraindications to MHT or who refuse it, non-hormonal therapies with proven efficacy (antidepressants, gabapentin, and fezolinetant) may improve vasomotor symptoms. Compounded hormonal implants, or "bioidentical" and "compounded" hormones, and "hormone modulation" are not recommended due to lack of scientific evidence of their effectiveness and safety.

Mujeres, que representan aproximadamente la mitad de la población mundial según estimaciones de enero de 2024, pueden experimentar signos y síntomas de la menopausia durante al menos un tercio de sus vidas, durante los cuales tienen un mayor riesgo de morbilidad y mortalidad cardiovascular. Los efectos de la terapia hormonal de la menopausia (THM) en la progresión de la aterosclerosis y los eventos de enfermedad cardiovascular (ECV) varían según la edad en que se inicia la THM y el tiempo transcurrido desde la menopausia hasta su inicio. Se han observado efectos beneficiosos en los resultados de ECV y la mortalidad por todas las causas cuando la THM se inició antes de los 60 años o dentro de los 10 años posteriores a la menopausia. La decisión sobre la iniciación, dosis, régimen y duración de la THM debe tomarse individualmente después de discutir los beneficios y riesgos con cada paciente. Para la prevención primaria de condiciones crónicas en la posmenopausia, no se recomienda el uso combinado de estrógeno y progestágeno en mujeres asintomáticas, ni el uso de estrógeno solo en mujeres histerectomizadas. Las neoplasias dependientes de hormonas contraindican la THM. Para el tratamiento del síndrome genitourinario de la menopausia, se puede usar terapia estrogénica vaginal en pacientes con factores de riesgo cardiovascular conocidos o ECV establecida. Para mujeres con contraindicaciones a la THM o que la rechazan, las terapias no hormonales con eficacia demostrada (antidepresivos, gabapentina y fezolinetant) pueden mejorar los síntomas vasomotores. Los implantes hormonales compuestos, o hormonas "bioidénticas" y "compuestas", y la "modulación hormonal" no se recomiendan debido a la falta de evidencia científica sobre su efectividad y seguridad.

As mulheres, que representam cerca de metade da população mundial segundo estimativas de janeiro de 2024, podem sofrer com sinais e sintomas da menopausa durante pelo menos um terço de suas vidas, quando apresentam maiores risco e morbimortalidade cardiovasculares. Os efeitos da terapia hormonal da menopausa (THM) na progressão de eventos de aterosclerose e doença cardiovascular (DCV) variam de acordo com a idade em que a THM é iniciada e o tempo desde a menopausa até esse início. Efeitos benéficos nos resultados de DCV e na mortalidade por todas as causas ocorreram quando a THM foi iniciada antes dos 60 anos de idade ou nos 10 anos que se seguiram à menopausa. A decisão sobre o início, a dose, o regime e a duração da THM deve ser tomada individualmente após discussão sobre benefícios e riscos com cada paciente. Para a prevenção primária de condições crônicas na pós-menopausa, não se recomendam o uso combinado de estrogênio e progestagênio em mulheres assintomáticas nem o uso de estrogênio sozinho em mulheres histerectomizadas. Neoplasias hormônio-dependentes contraindicam a THM. Para tratamento da síndrome geniturinária da menopausa, pode-se utilizar terapia estrogênica por via vaginal em pacientes com fatores de risco cardiovascular conhecidos ou DCV estabelecida. Para mulheres com contraindicação à THM ou que a recusam, terapias não hormonais com eficácia comprovada (antidepressivos, gabapentina e fezolinetante) podem melhorar os sintomas vasomotores. Os implantes hormonais manipulados, ou hormônios "bioidênticos" "manipulados", e a 'modulação hormonal' não são recomendados pela falta de evidência científica de sua eficácia e segurança.

Analysis of the impact of COVID-19 pandemic on women ́s care in an abortion situation in Latin America and the Caribbean / Análisis del impacto de la pandemia del COVID-19 en la atención de las mujeres en situación de aborto en América Latina y el Caribe / Análise do impacto da pandemia de COVID-19 sobre a atenção a mulheres em situação de aborto na América Latina e Caribe

Objective: to understand the influence of the COVID-19 pandemic on aspects of quality of care provided to women in abortion situations in sentinel centers of the CLAP MUSA-Network (a multicenter network with international cooperation with the aim of encouraging good practices in Latin America and the Caribbean). Methods: cross-sectional study between January/2017 and December/2021 with women of any age admitted for abortion or miscarriage. We analyzed the total number of cases and the proportion of legal abortions. The dependent variables were complications and use of contraceptives after abortion. The independent variables were COVID-19 pandemic, clinical and sociodemographic data. Statistical analysis was carried out using linear regression, multiple Poisson regression, Cochran-Armitage, chi-square, Mann-Whitney and Cohen tests. Results: we analyzed data from 93689 women assisted in 12 sentinel centers of the CLAP MUSA-Network, 64.55% in the pre-pandemic period (NP) and 35.45% in the pandemic period (PP) (22.73% received post-abortion care and 77.27% legal abortion). We found no differences in the number of cases over the period, regardless of the legal context. We observed a significant increase in the proportion of legal abortions in liberal and moderate contexts. In NP, 46.46% of women underwent medical abortion, while 62.18% of women underwent medical abortion in PP (h-Cohen 0.32). We found no increase in the number of complications during PP. In NP, 79.12% started contraceptives after abortion, while in PP, 70.39% started contraceptives after abortion (h-Cohen 0.20). Conclusion:the COVID-19 pandemic was not associated with a decrease in the number of cases, a decrease in the proportion of legal interruptions, or an increase in complications in sentinel centers of the CLAP MUSA-Network.

Objetivo: compreender a influência da pandemia de COVID-19 nos aspectos da qualidade da assistência prestada às mulheres em situação de abortamento nos centros sentinela da Rede CLAP-MUSA, uma rede multicêntrica com cooperação internacional visando encorajar boas práticas na América Latina e no Caribe. Metodologia: estudo transversal entre janeiro/2017 e dezembro/2021 com mulheres de qualquer idade admitidas por abortamentos espontâneos ou induzidos. Analisamos o número total de casos e a proporção de abortos legais. As variáveis dependentes foram complicações e uso de anticoncepcionais após o aborto. As variáveis independentes foram a pandemia de COVID-19, dados clínicos e sociodemográficos. A análise estatística foi realizada por meio de regressão linear, regressão múltipla de Poisson, testes de Cochran-Armitage, qui-quadrado, Mann-Whitney e Cohen. Resultados: foram analisados dados de 93.689 mulheres, atendidas em 12 centros sentinelas da Rede CLAP-MUSA, 64,55% no período pré-pandêmico (NP) e 35,45% no período pandêmico (PP) (22,73% receberam atendimento pós-aborto e 77,27%,aborto legal). Não encontramos diferenças no número de casos ao longo do período, independentemente do contexto legal. Observamos um aumento significativo na proporção de abortos legais em contextos liberais e moderados. No NP, 46,46% das mulheres realizaram aborto medicamentoso, enquanto 62,18% das mulheres realizaram aborto medicamentoso no PP (h-Cohen 0,32). Não encontramos aumento no número de complicações durante o PP. No NP, 79,12% iniciaram anticoncepcionais após o aborto, enquanto no PP, 70,39% iniciaram anticoncepcionais após o aborto (h-Cohen 0,20). Conclusão: a pandemia de COVID-19 não se associou à diminuição do número de casos, à diminuição da proporção de interrupções legais ou ao aumento de complicações nos centros sentinelas da Rede CLAP-MUSA

Objetivo: comprender la influencia de la pandemia de COVID-19 en aspectos de la calidad de la atención brindada a las mujeres en situación de aborto en los centros centinela de la Red CLAP-MUSA (una red multicéntrica de cooperación internacional con el objetivo de fomentar buenas prácticas en América Latina y el Caribe). Metodología: estudio transversal entre enero/2017 y diciembre/2021 con mujeres de cualquier edad ingresadas para abortos espontáneos o inducidos. Se analizó el número total de casos y la proporción de abortos legales. Las variables dependientes fueron las complicaciones y el uso de anticonceptivos después del aborto. Las variables independientes fueron pandemia de COVID-19, datos clínicos y sociodemográficos. El análisis estadístico se realizó mediante regresión lineal, regresión múltiple de Poisson, pruebas de Cochran-Armitage, chi-cuadrado, Mann-Whitney y Cohen. Resultados: se analizaron datos de 93689 mujeres atendidas en 12 centros centinela de la Red CLAP-MUSA, 64,55% en el período prepandemia (NP) y 35,45% en el período pandemia (PP) (22,73% recibieron atención postaborto y 77,27% aborto legal). No encontramos diferencias en el número de casos durante el período, independientemente del contexto legal. Observamos un aumento significativo en la proporción de abortos legales en contextos liberales y moderados. En NP, el 46,46% de las mujeres se sometieron al aborto con medicamentos, mientras que el 62,18% de las mujeres se sometieron al aborto con medicamentos en PP (h-Cohen 0,32). No encontramos aumento en el número de complicaciones durante el PP. En NP, 79,12% inició anticonceptivos después del aborto, mientras que en PP, 70,39% inició anticonceptivos después del aborto (h-Cohen 0,20). Conclusión:la pandemia de COVID-19 no se asoció con una disminución en el número de casos, una disminución en la proporción de interrupciones legales o un aumento en las complicaciones en los centros centinela de la Red CLAP-MUSA

Changing Paradigms in the Initial Treatment of Ectopic Pregnancy at a University Hospital in Brazil.

OBJECTIVE: To evaluate the use of different treatment options for ectopic pregnancy and the frequency of severe complications in a university hospital. METHODS: Observational study with women with ectopic pregnancy admitted at UNICAMP Womens Hospital, Brazil, between 01/01/2000 and 12/31/2017. The outcome variables were the type of treatment (first choice) and the presence of severe complications. Independent variables were clinical and sociodemographic data. Statistical analysis was carried out by the Cochran-Armitage test, chi-square test, Mann-Whitney test and multiple Cox regression. RESULTS: In total 673 women were included in the study. The mean age was 29.0 years (± 6.1) and the mean gestational age was 7.7 (± 2.5). The frequency of surgical treatment decreased significantly over time (z = -4.69; p < 0.001). Conversely, there was a significant increase in the frequency of methotrexate treatment (z = 4.73; p < 0.001). Seventy-one women (10.5%) developed some type of severe complication. In the final statistical model, the prevalence of severe complications was higher in women who were diagnosed with a ruptured ectopic pregnancy at admission (PR = 2.97; 95%CI: 1.61-5.46), did not present with vaginal bleeding (PR = 2.45; 95%CI: 1.41-4.25), had never undergone laparotomy/laparoscopy (PR = 6.69; 95%CI: 1.62-27.53), had a non-tubal ectopic pregnancy (PR = 4.61; 95%CI: 1.98-10.74), and do not smoke (PR = 2.41; 95%CI: 1.08-5.36). CONCLUSION: there was a change in the first treatment option for cases of ectopic pregnancy in the hospital during the period of analysis. Factors inherent to a disease that is more difficult to treat are related to a higher frequency of severe complications.

OBJETIVO: Avaliar as diferentes opções de tratamento para gravidez ectópica e a frequencia de complicações graves em um hospital universitário. MéTODOS: Estudo observacional com mulheres com gravidez ectópica admitidas no Hospital da Mulher da UNICAMP, no Brasill, entre 01/01/2000 e 31/12/2017. As variáveis de desfecho foram o tipo de tratamento (primeira escolha) e a presença de complicações graves. As variáveis independents foram dados clínicos e sociodemográficos. A análise estatística foi realizada pelo teste de Cochran­Armitage, teste de qui-quadrado, teste de Mann­Whitney e Regressão de Cox Múltipla. RESULADOS: No total, 673 mulheres foram incluídas no estudo. A idade médica foi de 29.0 anos (± 6.1) e a idade gestacional media foi de 7.7 (± 2.5). A frequencia de tratamento cirúrgico diminuiu significativamente ao longo dos anos(z = -4.69; p < 0.001). Simultaneamente, houve um aumento da frequencia do tratamento clínico(z = 4.73; p < 0.001). Setenta e uma mulheres (10.5%) desenvolveram algum tipo de complicação grave. No modelo estatístico final, a prevalência de complicações graves foi maior nas mulheres que tiveram diagnóstico de gestação ectópica rota à admissão (PR = 2.97; 95%CI: 1.61­5.46), que não apresentaram sangramento vaginal (PR = 2.45; 95%CI: 1.41­4.25), sem antecedentes de laparotomia/laparoscopia (PR = 6.69; 95%CI: 1.62­27.53), com gravidez ectópica não-tubária (PR = 4.61; 95%CI: 1.98­10.74), e não tabagistas (PR = 2.41; 95%CI: 1.08­5.36). CONCLUSãO: Houve uma mudança na escolha do primeiro tratamento indicado nos casos de gravidez ectópica durante o período analisado. Os fatores inerentes a doença relacionados a maior dificuldade de tratamento foram associados a maior frequencia de complicações graves.

The Impact of the COVID-19 Pandemic on the Care of Women Experiencing Abortion in a University Hospital in Brazil.

OBJECTIVE: To evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on the care of patients with miscarriage and legal termination of pregnancy in a university hospital in Brazil. METHODS: A cross-sectional study of women admitted for abortion due to any cause at Hospital da Mulher Prof. Dr. J. A. Pinotti of Universidade Estadual de Campinas (UNICAMP), Brazil, between July 2017 and September 2021. Dependent variables were abortion-related complications and legal interruption of pregnancy. Independent variables were prepandemic period (until February 2020) and pandemic period (from March 2020). The Cochran-Armitage test, Chi-squared test, Mann-Whitney test, and multiple logistic regression were used for statistical analysis. RESULTS: Five-hundred sixty-one women were included, 376 during the prepandemic period and 185 in the pandemic period. Most patients during pandemic were single, without comorbidities, had unplanned pregnancy, and chose to initiate contraceptive method after hospital discharge. There was no significant tendency toward changes in the number of legal interruptions or complications. Complications were associated to failure of the contraceptive method (odds ratio [OR] 2.44; 95% confidence interval [CI] 1.23-4.84), gestational age (OR 1.126; 95% CI 1.039-1.219), and preparation of the uterine cervix with misoprostol (OR 1.99; 95% CI 1.01-3.96). CONCLUSION: There were no significant differences in duration of symptoms, transportation to the hospital, or tendency of reducing the number of legal abortions and increasing complications. The patients' profile probably reflects the impact of the pandemic on family planning.

OBJETIVO: Avaliar o impacto da pandemia de coronavirus disease 2019 (Covid-19) no atendimento de pacientes com aborto espontâneo e interrupção legal da gravidez em um hospital universitário no Brasil. MéTODOS: Estudo transversal com mulheres admitidas por aborto por qualquer causa no Hospital da Mulher Prof. Dr. J. A. Pinotti da Universidade de Campinas (UNICAMP), Brasil, entre julho de 2017 e setembro de 2021. As variáveis dependentes foram complicações relacionadas ao aborto e interrupção legal da gravidez. As variáveis independentes foram período pré-pandemia (até fevereiro de 2020) e período pandêmico (a partir de março de 2020). O teste de Cochran-Armitage, teste do qui-quadrado, teste de Mann-Whitney e regressão logística múltipla foram utilizados para análise estatística. RESULTADOS: Foram incluídas 561 mulheres, 376 no período pré-pandemia e 185 no período pandêmico. A maioria das pacientes durante a pandemia era solteira, sem comorbidades, teve gravidez não planejada e optou por iniciar método anticoncepcional após a alta hospitalar. Não houve tendência significativa para mudanças no número de interrupções legais ou complicações. As complicações foram associadas a: falha do método contraceptivo (razão de chances [RC] 2,44; intervalo de confiança [IC] 95% 1,23­4,84), idade gestacional (RC 1,126; IC 95% 1,039­1,219) e preparo do colo uterino com misoprostol (RC 1,99; IC 95% 1,01­3,96). CONCLUSãO: Não houve diferenças significativas na duração dos sintomas, transporte ao hospital ou tendência de redução do número de abortos legais e aumento de complicações. O perfil das pacientes provavelmente reflete o impacto da pandemia no planejamento familiar.

The Impact of the COVID-19 Pandemic on the Care of Women Experiencing Abortion in a University Hospital in Brazil / O Impacto da pandemia de COVID-19 no atendimento de mulheres que vivenciam o aborto em um hospital universitário no Brasil

Abstract Objective To evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on the care of patients with miscarriage and legal termination of pregnancy in a university hospital in Brazil. Methods A cross-sectional study of women admitted for abortion due to any cause at Hospital da Mulher Prof. Dr. J. A. Pinotti of Universidade Estadual de Campinas (UNICAMP), Brazil, between July 2017 and September 2021. Dependent variables were abortion-related complications and legal interruption of pregnancy. Independent variables were prepandemic period (until February 2020) and pandemic period (from March 2020). The Cochran-Armitage test, Chi-squared test, Mann-Whitney test, and multiple logistic regression were used for statistical analysis. Results Five-hundred sixty-one women were included, 376 during the prepandemic period and 185 in the pandemic period. Most patients during pandemic were single, without comorbidities, had unplanned pregnancy, and chose to initiate contraceptive method after hospital discharge. There was no significant tendency toward changes in the number of legal interruptions or complications. Complications were associated to failure of the contraceptive method (odds ratio [OR] 2.44; 95% confidence interval [CI] 1.23-4.84), gestational age (OR 1.126; 95% CI 1.039-1.219), and preparation of the uterine cervix with misoprostol (OR 1.99; 95% CI 1.01-3.96). Conclusion There were no significant differences in duration of symptoms, transportation to the hospital, or tendency of reducing the number of legal abortions and increasing complications. The patients' profile probably reflects the impact of the pandemic on family planning.

Resumo Objetivo Avaliar o impacto da pandemia de coronavirus disease 2019 (Covid-19) no atendimento de pacientes com aborto espontâneo e interrupção legal da gravidez em um hospital universitário no Brasil. Métodos Estudo transversal com mulheres admitidas por aborto por qualquer causa no Hospital da Mulher Prof. Dr. J. A. Pinotti da Universidade de Campinas (UNICAMP), Brasil, entre julho de 2017 e setembro de 2021. As variáveis dependentes foram complicações relacionadas ao aborto e interrupção legal da gravidez. As variáveis independentes foram período pré-pandemia (até fevereiro de 2020) e período pandêmico (a partir de março de 2020). O teste de Cochran-Armitage, teste do qui-quadrado, teste de Mann-Whitney e regressão logística múltipla foram utilizados para análise estatística. Resultados Foram incluídas 561 mulheres, 376 no período pré-pandemia e 185 no período pandêmico. A maioria das pacientes durante a pandemia era solteira, sem comorbidades, teve gravidez não planejada e optou por iniciar método anticoncepcional após a alta hospitalar. Não houve tendência significativa para mudanças no número de interrupções legais ou complicações. As complicações foram associadas a: falha do método contraceptivo (razão de chances [RC] 2,44; intervalo de confiança [IC] 95% 1,23-4,84), idade gestacional (RC 1,126; IC 95% 1,039-1,219) e preparo do colo uterino com misoprostol (RC 1,99; IC 95% 1,01-3,96). Conclusão Não houve diferenças significativas na duração dos sintomas, transporte ao hospital ou tendência de redução do número de abortos legais e aumento de complicações. O perfil das pacientes provavelmente reflete o impacto da pandemia no planejamento familiar.

Changing Paradigms in the Initial Treatment of Ectopic Pregnancy at a University Hospital in Brazil / Mudança de paradigmas do tratamento inicial de gravidez ectópica em um hospital universitário no Brasil

Abstract Objective To evaluate the use of different treatment options for ectopic pregnancy and the frequency of severe complications in a university hospital. Methods Observational study with women with ectopic pregnancy admitted at UNICAMP Womeńs Hospital, Brazil, between 01/01/2000 and 12/31/2017. The outcome variables were the type of treatment (first choice) and the presence of severe complications. Independent variables were clinical and sociodemographic data. Statistical analysis was carried out by the Cochran-Armitage test, chi-square test, Mann-Whitney test and multiple Cox regression. Results In total 673 women were included in the study. The mean age was 29.0 years (± 6.1) and the mean gestational age was 7.7 (± 2.5). The frequency of surgical treatment decreased significantly over time (z = -4.69; p < 0.001). Conversely, there was a significant increase in the frequency of methotrexate treatment (z = 4.73; p < 0.001). Seventy-one women (10.5%) developed some type of severe complication. In the final statistical model, the prevalence of severe complications was higher in women who were diagnosed with a ruptured ectopic pregnancy at admission (PR = 2.97; 95%CI: 1.61-5.46), did not present with vaginal bleeding (PR = 2.45; 95%CI: 1.41-4.25), had never undergone laparotomy/laparoscopy (PR = 6.69; 95%CI: 1.62-27.53), had a non-tubal ectopic pregnancy (PR = 4.61; 95%CI: 1.98-10.74), and do not smoke (PR = 2.41; 95%CI: 1.08-5.36). Conclusion there was a change in the first treatment option for cases of ectopic pregnancy in the hospital during the period of analysis. Factors inherent to a disease that is more difficult to treat are related to a higher frequency of severe complications.

Resumo Objetivo Avaliar as diferentes opções de tratamento para gravidez ectópica e a frequencia de complicações graves em um hospital universitário. Métodos Estudo observacional com mulheres com gravidez ectópica admitidas no Hospital da Mulher da UNICAMP, no Brasill, entre 01/01/2000 e 31/12/2017. As variáveis de desfecho foram o tipo de tratamento (primeira escolha) e a presença de complicações graves. As variáveis independents foram dados clínicos e sociodemográficos. A análise estatística foi realizada pelo teste de Cochran-Armitage, teste de qui-quadrado, teste de Mann-Whitney e Regressão de Cox Múltipla. Resulados No total, 673 mulheres foram incluídas no estudo. A idade médica foi de 29.0 anos (± 6.1) e a idade gestacional media foi de 7.7 (± 2.5). A frequencia de tratamento cirúrgico diminuiu significativamente ao longo dos anos(z = -4.69; p < 0.001). Simultaneamente, houve um aumento da frequencia do tratamento clínico(z = 4.73; p < 0.001). Setenta e uma mulheres (10.5%) desenvolveram algum tipo de complicação grave. No modelo estatístico final, a prevalência de complicações graves foi maior nas mulheres que tiveram diagnóstico de gestação ectópica rota à admissão (PR = 2.97; 95%CI: 1.61-5.46), que não apresentaram sangramento vaginal (PR = 2.45; 95%CI: 1.41-4.25), sem antecedentes de laparotomia/laparoscopia (PR = 6.69; 95%CI: 1.62-27.53), com gravidez ectópica não-tubária (PR = 4.61; 95%CI: 1.98-10.74), e não tabagistas (PR = 2.41; 95%CI: 1.08-5.36). Conclusão Houve uma mudança na escolha do primeiro tratamento indicado nos casos de gravidez ectópica durante o período analisado. Os fatores inerentes a doença relacionados a maior dificuldade de tratamento foram associados a maior frequencia de complicações graves.

Building a network of sentinel centres for the care of women in an abortion situation: advances in Latin America and the Caribbean.

Previous reports have already estimated the overall number of abortions and the number of unsafe abortions in Latin America. Conversely, there are few reliable data from this region to inform public policies aiming to meet women's needs. In this context, the Latin American Centre of Perinatology (Centro Latinoamericano de Perinatología (CLAP)) created a network specialising in the care of women in an abortion situation (CLAP MUSA-Network) in an attempt to strengthen healthcare surveillance in Latin America by using the Perinatal Information System (Sistema Informático Perinatal (SIP)). This system was developed by the CLAP with a special module named SIP Abortion (SIP-A), a data collection tool designed by Latin American experts to be routinely used in cases of legal and incomplete abortions. The SIP-A follows the standards established by WHO, allowing investigators to systematise information, generate local reports and monitor changes after training and follow-up interventions based on national guidelines. This network promotes collaborative work between institutions to strengthen epidemiological surveillance, cooperative investigation and development of a critical mass of professionals skilled in sexual and reproductive health. Currently, 29 sentinel centres from 13 countries jointly work exchanging information to improve surveillance of healthcare indicators of women in an abortion situation. Latin America was the first region in the world to have a network of sentinel centres that continuously monitors healthcare provision to these women. Data collected by this network are already being used to design, implement and evaluate public policies.

Self-care agency and associated factors in postmenopausal women.

OBJECTIVE: The aging process in women is marked by several changes, including the transition to menopause. The evaluation of self-care management is essential and has great relevance for public health. The aim of the present study was to evaluate self-care management and associated factors in postmenopausal women. METHOD: This study was a cross-sectional study performed with 260 postmenopausal women who attended routine consultations at the Menopause Outpatient Clinic of the Hospital of the State University of Campinas-SP. Women aged 50 years or older with amenorrhea for at least 12 months were included. The women were interviewed by a researcher during the routine consultation, and the self-care agency assessment was performed using the Appraisal of Self-Care Agency Scale-Revised questionnaire. RESULTS: The average total self-care score for the women in this study was 62.27 (± 9.64). Higher Appraisal of Self-Care Agency Scale-Revised scores were associated with performing outdoor activities, better self-perceived health, and a higher score on knowledge about vitamin D. Active smoking was associated with a lower self-care score. CONCLUSION: We observed that the self-care management of postmenopausal women was satisfactory and was associated with lifestyle, self-perceived health, and knowledge about vitamin D.

Factors Associated with Abortion Complications after the Implementation of a Surveillance Network (MUSA Network) in a University Hospital.

OBJECTIVE: To evaluate the factors associated with abortion complications following the implementation of the good-practice surveillance network Mujeres en Situación de Aborto (Women Undergoing Abortion, MUSA, in Spanish). METHODS: A cross-sectional study with women who underwent abortion due to any cause and in any age group at UNICAMP Women's Hospital (part of MUSA network), Campinas, Brazil, between July 2017 and Agust 2019. The dependent variable was the presence of any abortion-related complications during hospitalization. The independent variables were clinical and sociodemographic data. The Chi-square test, the Mann-Whitney test, and multiple logistic regression were used for the statistical analysis. RESULTS: Overall, 305 women were enrolled (mean ± standard deviation [SD] for age: 29.79 ± 7.54 years). The mean gestational age was 11.17 (±3.63) weeks. Accidental pregnancy occurred in 196 (64.5%) cases, 91 (29.8%) due to contraception failure. At least 1 complication was observed in 23 (7.54%) women, and 8 (34.8%) of them had more than 1. The most frequent complications were excessive bleeding and infection. The factors independently associated with a higher prevalence of complications were higher gestational ages (odds ratio [OR]: 1.22; 95% confidence interval [95%CI]: 1.09 to 1.37) and contraceptive failure (OR: 3.4; 95%CI: 1.32 to 8.71). CONCLUSION: Higher gestational age and contraceptive failure were associated with a higher prevalence of complications. This information obtained through the surveillance network can be used to improve care, particularly in women more susceptible to unfavorable outcomes.

OBJETIVO: Avaliar os fatores associados às complicações em casos de aborto após a implementação da rede de vigilância de boas práticas Mujeres en Situación de Aborto (Mulheres em Situação de Aborto, MUSA, em espanhol). MéTODOS: Um estudo transversal, com mulheres admitidas por aborto de qualquer causa e em qualquer faixa etária, no Hospital da Mulher da UNICAMP (parte da rede MUSA), Campinas, Brasil, entre julho de 2017 e agosto de 2019. A variável dependente foi a presença de qualquer complicação relacionada ao quadro de aborto durante a hospitalização. As variáveis independentes foram dados clínicos e sociodemográficos. O teste de qui-quadrado, o teste de Mann-Whitney, e a regressão logística múltipla foram usados na análise estatística. RESULTADOS: Foram incluídas 305 mulheres (média ± desvio padrão [DP] da idade: 29,79 ± 7,54 anos). A idade gestacional média foi de 11,17 (±3,63) semanas. A gravidez não foi planejada em 196 (64,5%) casos, 91 (29,8%) devido a falha de contraceptivo. Pelo menos 1 complicação foi observada em 23 (7,64%) mulheres, 8 (34,8%) das quais apresentaram mais de uma complicação. As complicações mais frequentes foram sangramento excessivo e infecção. Os fatores independentemente associados à maior prevalência de complicações foram idades gestacionais maiores (razão de chances [OR]: 1.22; intervalo de confiança de 95% [IC95%]: 1.09 a 1.37) e falha de contraceptivo (OR: 3.4; IC95%: 1.32 a 8.71). CONCLUSãO: Maior idade gestacional e falha de contraceptivo estiveram associados à maior prevalência de complicações. As informações obtidas pela rede de vigilância podem ser usadas para melhorar o cuidado, particularmente nas mulheres mais suscetíveis a desfechos desfavoráveis.

Abortion-related morbidity in six Latin American and Caribbean countries: findings of the WHO/HRP multi-country survey on abortion (MCS-A).

INTRODUCTION: Abortion-related complications are a significant cause of morbidity and mortality among women in many Latin American and Caribbean (LAC) countries. The objective of this study was to characterise abortion-related complication severity, describe the management of these complications and report women's experiences with abortion care in selected countries of the Americas region. METHODS: This is a cross-sectional study of 70 health facilities across six countries in the region. We collected data on women's characteristics including socio-demographics, obstetric history, clinical information, management procedures and using Audio Computer-Assisted Self-Interviewing (ACASI) survey the experience of abortion care. Descriptive bivariate analysis was performed for women's characteristics, management of complications and reported experiences of abortion care by severity of complications, organised in five hierarchical mutually exclusive categories based on indicators present at assessment. Generalised linear estimation models were used to assess the association between women's characteristics and severity of complications. RESULTS: We collected data on 7983 women with abortion-related complications. Complications were classified as mild (46.3%), moderate (49.5%), potentially life-threatening (3.1%), near-miss cases (1.1%) and deaths (0.2%). Being single, having a gestational age of ≥13 weeks and having expelled products of conception before arrival at the facility were significantly associated with experiencing severe maternal outcomes compared with mild complications.Management of abortion-related complications included both uterotonics and uterine evacuation for two-thirds of the women while one-third received uterine evacuation only. Surgical uterine evacuation was performed in 93.2% (7437/7983) of women, being vacuum aspiration the most common one (5007/7437, 67.4%).Of the 327 women who completed the ACASI survey, 16.5% reported having an induced abortion, 12.5% of the women stated that they were not given explanations regarding their care nor were able to ask questions during their examination and treatment with percentages increasing with the severity of morbidity. CONCLUSIONS: This is one of the first studies using a standardised methodology to measure severity of abortion-related complications and women's experiences with abortion care in LAC. Results aim to inform policies and programmes addressing sexual and reproductive rights and health in the region.

Factors Associated with Abortion Complications after the Implementation of a Surveillance Network (MUSA Network) in a University Hospital / Fatores associados a complicações do aborto após a implementação de um sistema de vigilância (Rede MUSA) em um hospital universitário

Abstract Objective To evaluate the factors associated with abortion complications following the implementation of the good-practice surveillance network Mujeres en Situación de Aborto (Women Undergoing Abortion, MUSA, in Spanish). Methods A cross-sectional study withwomen who underwent abortion due to any cause and in any age group at UNICAMP Women's Hospital (part of MUSA network), Campinas, Brazil, between July 2017 and Agust 2019. The dependent variable was the presence of any abortion-related complications during hospitalization. The independent variables were clinical and sociodemographic data. The Chi-square test, the Mann-Whitney test, and multiple logistic regression were used for the statistical analysis. Results Overall, 305 women were enrolled (mean±standard deviation [SD] for age: 29.79±7.54 years). The mean gestational age was 11.17 (±3.63) weeks. Accidental pregnancy occurred in 196 (64.5%) cases, 91 (29.8%) due to contraception failure. At least 1 complication was observed in 23 (7.54%) women, and 8 (34.8%) of them had more than 1. The most frequent complications were excessive bleeding and infection. The factors independently associated with a higher prevalence of complications were higher gestational ages (odds ratio [OR]: 1.22; 95% confidence interval [95%CI]: 1.09 to 1.37) and contraceptive failure (OR: 3.4; 95%CI: 1.32 to 8.71). Conclusion Higher gestational age and contraceptive failure were associated with a higher prevalence of complications. This information obtained through the surveillance network can be used to improve care, particularly in women more susceptible to unfavorable outcomes.

Resumo Objetivo Avaliar os fatores associados às complicações em casos de aborto após a implementação da rede de vigilância de boas práticas Mujeres en Situación de Aborto (Mulheres em Situação de Aborto, MUSA, em espanhol). Métodos Um estudo transversal, com mulheres admitidas por aborto de qualquer causa e em qualquer faixa etária, no Hospital da Mulher da UNICAMP (parte da rede MUSA), Campinas, Brasil, entre julho de 2017 e agosto de 2019. A variável dependente foi a presença de qualquer complicação relacionada ao quadro de aborto durante a hospitalização. As variáveis independentes foram dados clínicos e sociodemográficos. O teste de qui-quadrado, o teste de Mann-Whitney, e a regressão logística múltipla foram usados na análise estatística. Resultados Foram incluídas 305 mulheres (média±desvio padrão [DP] da idade: 29,79±7,54 anos). A idade gestacional média foi de 11,17 (±3,63) semanas. A gravidez não foi planejada em 196 (64,5%) casos, 91 (29,8%) devido a falha de contraceptivo. Pelo menos 1 complicação foi observada em 23 (7,64%) mulheres, 8 (34,8%) das quais apresentaram mais de uma complicação. As complicações mais frequentes foram sangramento excessivo e infecção. Os fatores independentemente associados à maior prevalência de complicações foram idades gestacionais maiores (razão de chances [OR]: 1.22; intervalo de confiança de 95% [IC95%]: 1.09 a 1.37) e falha de contraceptivo (OR: 3.4; IC95%: 1.32 a 8.71). Conclusão Maior idade gestacional e falha de contraceptivo estiveram associados à maior prevalência de complicações. As informações obtidas pela rede de vigilância podem ser usadas para melhorar o cuidado, particularmente nas mulheres mais suscetíveis a desfechos desfavoráveis.

Topical estrogen, testosterone, and vaginal dilator in the prevention of vaginal stenosis after radiotherapy in women with cervical cancer: a randomized clinical trial.

BACKGROUND: We aimed to evaluate the effects of different therapeutic options to prevent the evolution of vaginal stenosis after pelvic radiotherapy in women with cervical cancer. METHODS: open-label randomized clinical trial of 195 women, stage I-IIIB, aged 18-75 years, using topical estrogen (66), topical testosterone (34), water-based intimate lubricant gel (66), and vaginal dilators (29) to assess the incidence and severity of vaginal stenosis after radiotherapy at UNICAMP-Brazil, from January/2013 to May/2018. The main outcome measure was vaginal stenosis assessed using the Common Terminology Criteria for Adverse Events (CTCAE) scale and percental changes in vaginal volume. The women were evaluated at four different times: shortly after the end of radiotherapy, and four, eight, and 12 months after the beginning of the intervention. Statistical analysis was carried out using Symmetry test, Kruskal-Wallis test and multiple regression. RESULTS: the mean age of women was 46.78 (±13.01) years, 61,03% were premenopausal and 73,84% had stage IIB-IIIB tumors. The mean reduction in vaginal volume in the total group was 25.47%, with similar worsening in the four treatment groups with no statistical difference throughout the intervention period. There was worsening of vaginal stenosis evaluated by CTCAE scale after 1 year in all groups (p < 0.01), except for the users of vaginal dilator (p = 0.37). CONCLUSIONS: there was a reduction in vaginal volume in all treatment groups analyzed, with no significant difference between them. However, women who used vaginal dilators had a lower frequency and severity of vaginal stenosis assessed by the CTCAE scale after one year of treatment. TRIAL REGISTRATION: Brazilian Registry of Clinical Trials, RBR-23w5fv . Registered 10 January 2017 - Retrospectively registered.

Factors Associated with the Complications of Hysteroscopic Myomectomy.

OBJECTIVE: To evaluate the factors associated with complete myomectomy in a single surgical procedure and the aspects related to the early complications. METHODS: A cross-sectional study with women with submucous myomas. The dependent variables were the complete myomectomy performed in a single hysteroscopic procedure, and the presence of early complications related to the procedure. RESULTS: We identified 338 women who underwent hysteroscopic myomectomy. In 89.05% of the cases, there was a single fibroid to be treated. According to the classification of the International Federation of Gynecology and Obstetrics (Fédération Internationale de Gynécologie et d'Obstétrique, FIGO, in French), most fibroids were of grade 0 (66.96%), followed by grade 1 (20.54%), and grade 2 (12.50%). The myomectomies were complete in 63.31% of the cases, and the factors independently associated with complete myomectomy were the diameter of the largest fibroid (prevalence ratio [PR]: 0.97; 95% confidence interval [95%CI]: 0.96-0.98) and the classification 0 of the fibroid according to the FIGO (PR: 2.04; 95%CI: 1.18-3.52). We observed early complications in 13.01% of the hysteroscopic procedures (4.44% presented excessive bleeding during the procedure, 4.14%, uterine perforation, 2.66%, false route, 1.78%, fluid overload, 0.59%, exploratory laparotomy, and 0.3%, postoperative infection). The only independent factor associated with the occurrence of early complications was incomplete myomectomy (PR: 2.77; 95%CI: 1.43-5.38). CONCLUSIONS: Our results show that hysteroscopic myomectomy may result in up to 13% of complications, and the chance of complete resection is greater in small and completely intracavitary fibroids; women with larger fibroids and with a high degree of myometrial penetration have a greater chance of developing complications from hysteroscopic myomectomy.

OBJETIVO: Avaliar os fatores associados a miomectomia por histeroscopia completa em um único procedimento e as suas complicações. MéTODOS: Estudo de corte transversal com mulheres submetidas a histeroscopia para exérese de miomas submucosos. As variáveis dependentes foram a miomectomia completa realizada em um tempo cirúrgico único, e a presença de complicações precoces relacionadas ao procedimento. RESULTADOS: Analisamos 338 mulheres que foram submetidas a miomectomia histeroscópica. Em 89,05% dos casos, o mioma a ser tratado era único. Quanto à classificação da Federação Internacional de Ginecologia e Obstetrícia (Fédération Internationale de Gynécologie et d'Obstétrique, FIGO, em francês), a maioria era de grau 0 (66,96%), seguidos pelos graus 1 (20,54%) e 2 (12,50%). As miomectomias foram completas em 63,31% das mulheres, sendo que os fatores independentemente associados à miomectomia completa foram o diâmetro do maior mioma (razão de prevalência [RP]: 0,97; intervalo de confiança de 95% [IC95%]: 0,96­0,98) e a classificação FIGO grau 0 (RP: 2,04; IC95%: 1,18­3,52). Foram observadas complicações precoces em 13,01% dos procedimentos (4,44% apresentaram sangramento excessivo durante o procedimento, 4,14%, perfuração uterina, 2,66%, falso pertuito, 1,78%, intoxicação hídrica, 0,59%, laparotomia exploradora, e 0,3%, infecção pós-operatória). O único fator independentemente associado à ocorrência de complicações precoces foi a realização de miomectomia incompleta (RP: 2,77; IC95%: 1,43­5,38). CONCLUSãO: Nossos resultados mostram que as complicações da miomectomia por histeroscopia podem ocorrer em até 13% dos procedimentos. A chance de ressecção completa é maior em miomas pequenos e completamente intracavitários; mulheres com miomas maiores e com maior grau de penetração miometrial têm maiores chances de desenvolver complicações.