A new look at abnormal uterine bleeding.

New universal terminology, classifications, and definitions recommended by the International Federation of Gynecology and Obstetrics and supported by the American College of Obstetricians and Gynecologists to describe abnormal uterine bleeding abnormalities in reproductive women are presented. Identification and management of anovulatory and ovulatory uterine bleeding are explored.

Development of an instrument to measure adherence to strength training in postmenopausal breast cancer survivors.

PURPOSE/OBJECTIVES: To develop a theory-based instrument for assessing barriers and motivators to strength- or weight-training exercise (SWTE) in postmenopausal breast cancer survivors with measurable bone loss after treatment. DESIGN: Exploratory, descriptive, and methodologic. SETTING: Academic oncology clinics in the midwestern United States, homes, and a fitness center. SAMPLE: 85 women, predominantly Caucasian (99%), breast cancer survivors, aged 35-75 years, six months after treatment, who were enrolled in a larger study were randomized to receive SWTE; 65 completed the instrument. METHODS: Development of a 47-item Likert-type instrument using interviews, contributions from experts, published research, and Self-Efficacy Theory. MAIN RESEARCH VARIABLES: Barriers and motivators of adherence to SWTE. FINDINGS: Four subscales emerged that accounted for 26%-59% of the variance. Factor subscales for barriers were "not prioritizing time for self" and "overcoming other barriers to adherence." Subscales for motivators included "education and feedback" and "social support." CONCLUSIONS: The final instrument contained 47 items dispersed across four subscales. Additional psychometric testing of the instrument with a larger population is indicated. IMPLICATIONS FOR NURSING: Nurses and healthcare professionals may use the instrument to readily identify barriers and motivators to SWTE adherence to improve program design and implementation efforts aimed at facilitating enhanced exercise adherence in breast cancer survivors with measurable bone loss after treatment.

An exercise intervention for breast cancer survivors with bone loss.

PURPOSE: (a) to determine if 110 postmenopausal breast cancer survivors (BCS) with bone loss who participated in 24 months of strength and weight training (ST) exercises had improved muscle strength and balance and had fewer falls compared to BCS who did not exercise; and (b) to describe type and frequency of ST exercises; adverse effects of exercises; and participants' adherence to exercises at home, at fitness centers, and at 36-month follow up. DESIGN: Findings reported are from a federally funded multicomponent intervention study of 223 postmenopausal BCS with either osteopenia or osteoporosis who were randomly assigned to an exercise (n=110) or comparison (n=113) group. METHODS: Time points for testing outcomes were baseline, 6, 12, and 24 months into intervention. Muscle strength was tested using Biodex Velocity Spectrum Evaluation, and dynamic balance using Timed Backward Tandem Walk. Adherence to exercises was measured using self-report of number of prescribed sessions attended and participants' reports of falls. FINDINGS: Mean adherence over 24 months was 69.4%. Using generalized estimating equation (GEE) analyses, compared to participants not exercising, participants who exercised for 24 months had significantly improved hip flexion (p=0.011), hip extension (p=0.0006), knee flexion (p<0.0001, knee extension (p=0.0018), wrist flexion (p=0.031), and balance (p=0.010). Gains in muscle strength were 9.5% and 28.5% for hip flexion and extension, 50.0% and 19.4% for wrist flexion and extension, and 21.1% and 11.6% for knee flexion and extension. Balance improved by 39.4%. Women who exercised had fewer falls, but difference in number of falls between the two groups was not significant. CONCLUSIONS: Many postmenopausal BCS with bone loss can adhere to a 24 month ST exercise intervention, and exercises can result in meaningful gains in muscle strength and balance. CLINICAL RELEVANCE: More studies are needed for examining relationships between muscle strength and balance in postmenopausal BCS with bone loss and their incidence of falls and fractures.

Vitamin D insufficiency and musculoskeletal symptoms in breast cancer survivors on aromatase inhibitor therapy.

Breast cancer survivors (BCSs) on aromatase inhibitor (AI) therapy often experience musculoskeletal symptoms (joint pain and stiffness, bone and muscle pain, and muscle weakness), and these musculoskeletal symptoms may be related to low serum levels of vitamin D. The primary purpose of this pilot exploratory study was to determine whether serum levels of 25-hydroxyvitamin D (25[OH]D) concentration were below normal (<30 ng/mL) in 29 BCSs on AI therapy and if musculoskeletal symptoms were related to these low vitamin D levels. The mean (SD) serum 25(OH)D level was 25.62 (4.93) ng/mL; 86% (n = 25) had levels below 30 ng/mL. Patients reported muscle pain in the neck and back, and there was a significant inverse correlation between pain intensity and serum 25(OH)D levels (r = -0.422; P < .05 [2 tailed]). This sample of BCSs taking AIs had below normal levels of serum 25(OH)D despite vitamin D supplements. This is one of the few studies to document a significant relationship between vitamin D levels and muscle pain in BCSs on AI therapy. Findings from this pilot study can be used to inform future studies examining musculoskeletal symptoms in BCSs on AI therapy and relationships with low serum levels of vitamin D.

Bone mineral density and bone turnover in postmenopausal women treated for breast cancer.

Chemotherapy and endocrine treatments for breast cancer are believed to increase risk of osteoporosis by causing early menopause in premenopausal women and by further depleting estrogen levels in postmenopausal women. Multivariate analyses were used to evaluate the contributions of 7 predictors (age, body mass index [BMI], family history of osteoporosis, months since menopause, past use of chemotherapy, and current use of tamoxifen or aromatase inhibitors) in explaining variability in bone mineral density (BMD) at the hip and the spine and bone turnover in 249 postmenopausal women who are breast cancer survivors. This report was an analysis of baseline data from a federally funded (1 R01 NR07743-01A1) intervention study on osteoporosis prevention. Mean age of the women was 58.5 years, and average BMI was 26.7 kg/m; 98% were white. All had measurable bone loss, 167 had chemotherapy, 76 were on tamoxifen, and 21 were on aromatase inhibitors. Women with higher BMI had higher BMD at the hip (P < .001) and the spine (P = .004). Women on tamoxifen had lower measures of bone formation (Alkphase B) (P < .001), suggesting less bone turnover, and higher BMD at the hip (P = .035). There was a trend for women who had received chemotherapy to have lower BMD at the spine (P = .06). The implications of these findings are discussed in the article.

Perimenopausal symptoms, quality of life, and health behaviors in users and nonusers of hormone therapy.

PURPOSE: This pilot study was designed to determine the difference in frequency and distress related to perimenopausal symptoms in users and nonusers of hormone therapy (HT), to identify the difference in quality of life (QoL) indicators, and to determine if there is a relationship between QoL and frequency and distress of symptoms for users and nonusers of HT between the ages of 40 and 55 years. DATA SOURCE: Self-reported responses to the Perimenopause Assessment Questionnaire with five QoL indicators imbedded, the Women's Health Assessment Scale, height, weight, and body mass index from 77 users and 89 nonusers of HT. CONCLUSIONS: More users reported using HT to control perimenopausal symptoms than for birth control or gynecological problems. Nonusers reported a higher percentage of a variety of symptoms compared to users, with more psychosomatic symptoms being reported. Both groups identified lack of energy as the most frequent and distressful symptom. There was a significant difference in frequency of symptoms between groups and a significant difference in distress of symptoms. There were significant negative correlations with the five QoL indicators and frequency and distress of symptoms for users and nonusers of HT, with exception of stress and frequency of symptoms for users. More psychosomatic symptoms were correlated with QoL for nonusers. Cold sweats, loss of interest, miserable and sad, and life not worth living were highly significant for nonusers with QoL, while feeling unattractive, decreased well-being, and lack of enjoyment for users was highly significant. IMPLICATIONS FOR PRACTICE: Perimenopause is more than hot flashes and abnormal menses. A checklist of perimenopausal symptoms should be used as an assessment tool at each annual visit or more frequently to determine the significance of the symptoms a woman might be experiencing. Assessing the perimenopausal knowledge base is very important. Most importantly, there is a need for perimenopausal educational programs to be developed and implemented.

Health behaviors in breast cancer survivors experiencing bone loss.

PURPOSE: To describe the baseline healthy lifestyle behaviors (dietary, calcium, vitamin D, caffeine and alcohol intake, smoking history, and physical activity) of postmenopausal breast cancer survivors (BCS); and to identify any relationship of healthy lifestyle behaviors with bone mineral density (BMD) at the forearm, total hip and spine, L1-L4. DATA SOURCES: Self-reported responses to a demographic and health status questionnaire, to a 3-day Diet Record, and to the 7-Day Physical Activity Questionnaire-Adapted provided data for the lifestyle behaviors. Baseline BMD (g/cm(2)) was determined with dual-energy x-ray absorptiometry (DEXA). Height, weight, and body mass index (BMI) were also measured in each of the 249 postmenopausal BCS. CONCLUSIONS: There was an imbalance between consumed kilocalories and expenditure of energy. The majority of BCS were overweight or obese. They consumed less fruit and vegetable servings than recommended by the new 2005 U.S. Department of Agriculture's dietary guidelines, less dairy products, below average recommended grains and fiber, less protein and carbohydrate intake, and a slightly higher fat gram intake. Approximately, 43% did not take any supplemental calcium, with 46% taking less than 1000 mg a day. Likewise, 52.59% consumed less than 400 IU of vitamin D with both supplemental and dietary intake. This group of BCS consumed below accepted levels of caffeine and alcohol. Only 18 BCS continued to smoke. This group spent an average of 10.36 h in light (sedentary) activities on a daily basis. There were significant negative relationships with bone mass (g/cm(2)) at the total hip and daily intake of caffeine/mg and daily grams of alcohol. Weight and BMI both demonstrated a significant relationship with bone mass (g/cm(2)) at the total hip, spine L1-L4, and the forearm. IMPLICATIONS FOR PRACTICE: The healthcare provider must incorporate appropriate teaching strategies, intensive counseling, and coaching, along with a support mechanism, to enable BCS to understand the importance of a healthy diet, calcium, and vitamin D supplement, and a regular strength/weight program that will be integrated into their daily lifestyle. Early DEXA screens should be part of the protocol with BCS, and there is a particular need for forearm DEXA screens to be included in the treatment protocol for BCS.

Challenges of recruitment of breast cancer survivors to a randomized clinical trial for osteoporosis prevention.

Recruitment of participants was a challenging issue for a statewide, 4-site, randomized, longitudinal trial for osteoporosis prevention. The accrual goal was 273 healthy breast cancer survivors. This federally funded study included a home-based followed by a fitness center-based 24-month intervention with follow-up at 36 months. In this report, recruitment planning, monitoring, and modifications are described, and the cost per enrolled participant is identified. Monthly monitoring of accrual numbers per recruitment strategy at each of 4 catchment areas allowed for early identification of necessary changes in recruitment strategies. Modifications were necessary when only 39% of the overall accrual goal had been attained at the 66% time point into the 18-month recruitment phase. Successful recruitment strategies were intensified, and new strategies were implemented, addressing motivators and deterrents for participation in clinical trials. Because approximately 81% of women were demonstrating bone loss via free dual energy x-ray absorptiometry screening, prevalence of the bone loss problem in survivors was incorporated into the recruitment information. Of 708 women screened via telephone and laboratory/dual energy x-ray absorptiometry testing, 249 were enrolled with 67% at 2 metropolitan sites and 33% at 2 rural sites. Recruitment media costs were approximately US$35 per enrolled participant. When combined with skeletal and laboratory screening, costs were approximately US$480 per enrolled participant. Tracking recruitment efforts in large clinical trials should be ongoing, site-specific, and cost-effective. Changes incorporated early in the recruitment phase addressed unique aspects of rural versus metropolitan areas and resulted in near achievement of accrual goals.

Facilitative strategies, psychological factors, and strength/weight training behaviors in breast cancer survivors who are at risk for osteoporosis.

INTRODUCTION/PURPOSE: Many women who have been treated for breast cancer are at increased risk for bone loss. Strength/weight training exercises (SWTE) may be effective in preventing bone loss and subsequent fractures. The purpose of this exploratory study was to examine psychological factors (self-efficacy, perceived benefits vs. costs, and processes of change) and their relationship to adherence and progression in use of heavier weights in breast cancer survivors (BCS). SAMPLE: Twenty-three BCS with mean age of 54.8 (SD = 7.2) years, mean time since menopause of 5.8 (SD = 5.3) years, and mean time since cancer treatment completion of 4.1 (SD = 3.0) years. METHODS: Exploratory one-group design with multicomponent intervention inclusive of medication, calcium with vitamin D supplement, and home-based SWTE with facilitative strategies by nurses and personal exercise trainers based on the Transtheoretical Model. FINDINGS: BCS doing SWTE for 6 months: (1) maintain a high level of self-efficacy, (2) perceive increasing benefits for 6 months, (3) use cognitive processes more frequently than behavioral ones, (4) were highly adherent to the SWTE, and (5) demonstrate that behavioral processes are positively related to increase in pounds lifted. DISCUSSION/CLINICAL IMPLICATIONS: Larger randomized trials studies are needed to determine the most effective strategies for assuring adherence to and progression of SWTE in this population at risk for osteoporosis.

Testing an intervention for preventing osteoporosis in postmenopausal breast cancer survivors.

PURPOSE: To test a 12-month multicomponent intervention for preventing or treating osteoporosis in 21 postmenopausal women who had completed treatment (except Tamoxifen) for breast cancer, and for whom hormone replacement therapy (HRT) was contraindicated. DESIGN: Pilot intervention study. METHODS: The intervention consisted of home-based strength and weight training exercises, 5 or 10 mg alendronate per day, 1500 mg calcium per day, 400 IU vitamin D per day, education on osteoporosis, and facilitative strategies to promote adherence to the intervention. Outcome measures were: adherence to the intervention, dynamic balance, muscle strength, and bone mineral density (BMD) of the hip, spine, and forearm. FINDINGS AND CONCLUSIONS: Adherence to calcium, vitamin D, and alendronate therapy was above 95%, and adherence to strength training exercises was above 85%. Over the 12 months, the 21 participants had significant improvements in dynamic balance, muscle strength for hip flexion, hip extension, and knee flexion, and BMD of the spine and hip. Participants had a significant decrease in BMD of the forearm. Three of the 21 women who had measurable bone loss at baseline had normal BMD after 12 months of the intervention.

Postmenopausal breast cancer survivors at risk for osteoporosis: physical activity, vigor, and vitality.

PURPOSE/OBJECTIVES: To test a multicomponent intervention to prevent and treat osteoporosis in breast cancer survivors. DESIGN: Descriptive, correlational. SETTING: Midwestern urban and rural sites. SAMPLE: 27 postmenopausal breast cancer survivors between the ages of 42-65 who had completed treatment, except for tamoxifen, and were not candidates for hormone replacement therapy. METHODS: Bone mineral density (BMD) of the hip, spine, and forearm was measured using dual-energy x-ray absorptiometry. Physical activity was recorded using the Seven-Day Physical Activity Recall-Adapted, which classifies activities as light, moderate, hard, or very hard. Vigor was measured with the eight-item subscale of the Profile of Mood State based on the previous week. Vitality was measured using the four-question subscale of the Medical Outcomes Study 36-Item Short Form Health Survey. MAIN RESEARCH VARIABLES: Physical activity, vigor, vitality, and BMD. FINDINGS: More than half reported no very hard physical activity, and 37% reported no hard activity. The association of vigor with total metabolic equivalents for combined moderate, hard, and very hard activities was significant (r = 0.536, p = 0.007), as were the hours spent in the combined moderate to very hard activities. No relationship was found between vigor, vitality, or any level of activity and BMD. CONCLUSIONS: Survivors reported high levels of perceived vigor and vitality but spent more time engaged in light versus hard or very hard activities. Positive correlations between higher levels of vitality and vigor with metabolic equivalents support the idea that activity promotes perceptions of energy and positive feelings. IMPLICATIONS FOR NURSING: Breast cancer survivors are at risk for osteoporosis. Nurses should be aware of increased risk, recommend screening for bone health, and encourage physical activity.

The relationship of actual height loss with health-seeking behaviors and risk factors in perimenopausal and menopausal women.

PURPOSE: To explore whether there is a difference in the perceived height and actual height in the perimenopausal or menopausal woman and discover the difference's effect on osteoporosis health-seeking preventive behaviors and risk factor awareness. DATA SOURCES: Sixty-three perimenopausal and menopausal women, aged 45-70 years, who presented at three Midwestern clinics for their annual physical exam. Data were collected with The Osteoporosis Questionnaire, which included the Osteoporosis Risk Questionnaire, Health-O-Meter height measuring stick, tape measure with inch-rule for arm span measurements, and balance scale for weight. CONCLUSIONS: There were a significant relationship between actual height loss and osteoporosis risk factors (r = 0.41595, p = 0.0007) and a trend for a relationship between adjusted height loss and osteoporosis risk factors (r = 0.2407, p = 0.0574). IMPLICATIONS FOR PRACTICE: Due to the great expense of current testing for bone mass density loss, the results of this study may help clinicians more readily identify markers for increased risk of osteoporosis through simple height measurements and osteoporosis risk factor assessments during annual visits.