Abnormal uterine bleeding.

The most probable etiology of abnormal uterine bleeding relates to the patient's reproductive age, as does the likelihood of serious endometrial pathology. The specific diagnostic approach depends on whether the patient is premenopausal, perimenopausal or postmenopausal. In premenopausal women with normal findings on physical examination, the most likely diagnosis is dysfunctional uterine bleeding (DUB) secondary to anovulation, and the diagnostic investigation is targeted at identifying the etiology of anovulation. In perimenopausal patients, endometrial biopsy and other methods of detecting endometrial hyperplasia or carcinoma must be considered early in the investigation. Uterine pathology, particularly endometrial carcinoma, is common in postmenopausal women with abnormal uterine bleeding. Thus, in this age group, endometrial biopsy or transvaginal ultrasonography is included in the initial investigation. Premenopausal women with DUB may respond to oral contraceptives, cyclic medroxyprogesterone therapy or cyclic clomiphene. Perimenopausal women may also be treated with low-dose oral contraceptives or medroxyprogesterone. Erratic bleeding during hormone replacement therapy in postmenopausal women with no demonstrable pathology may respond to manipulation of the hormone regimen.

Trends in United States ovarian cancer mortality, 1979-1995.

OBJECTIVE: To describe the epidemiology of ovarian cancer mortality in the United States from 1979 to 1995. METHODS: The mortality data of the Centers for Disease Control and Prevention were accessed using the Wide-ranging Online Data for Epidemiologic Research (WONDER). We selected all deaths among women with International Classification of Diseases, Ninth Revision (ICD-9) code 183.0 (ovarian malignant neoplasm). Mortality data for the years 1979-1995 were age-adjusted to the United States 1990 female population, and mortality rates for each year were calculated for females of all ages by age category, by race, and by geographic location. Trends were obtained for the periods 1979-1983 to 1991-1995, and the impact on the number of ovarian cancer deaths was calculated. RESULTS: Age-adjusted ovarian cancer mortality rates have changed little in the United States from 1979 to 1995, but rates are increasing in older women (65 years and older) and decreasing in younger women. Age-adjusted mortality rates are higher among whites than in blacks. Ovarian cancer mortality rates are higher in northern compared with southern states. CONCLUSION: The trends in ovarian cancer mortality among younger and older women parallel published changes in incidence and may be due to changes in risk factors, such as the use of oral contraceptives. The reasons for the higher ovarian cancer death rates in northern states are unknown. Better understanding of how modifiable risk factors and treatment methods affect ovarian cancer mortality trends is needed.

Screening men for partner violence in a primary care setting. A new strategy for detecting domestic violence.

BACKGROUND: Health care domestic violence initiatives have given little attention to screening men for violent behavior toward their partners. We conducted this study to assess whether men would answer questions about partner violence in a health care setting, to estimate the prevalence of violent behavior in male primary care patients, and to identify characteristics associated with violent behavior. METHODS: We used an anonymous written survey at three family medicine clinics. The survey instrument included the Conflict Tactics Scale to measure aggressive and violent behavior. Standard questions assessed demographic variables and health behaviors. RESULTS: Three hundred seventy-five men were seen during the study. Of these, 317 (85%) participated and 237 met inclusion criteria. Thirty-two men (13.5%, 95% confidence interval (CI), 9.1-17.9) disclosed physical violence toward their partner in the previous 12 months. Ten men (4.2%, 95% CI, 3.7-4.8) reported severe violence. Men with increased alcohol consumption, depression, or history of abuse as children were more likely to report violent behavior. Presence of all three variables resulted in a probability of violence of 41%, compared with a baseline probability of 7% if no risk factors were present. CONCLUSIONS: Primary care physicians should consider screening male patients for aggressive behavior toward their intimate partners. Physicians should be especially cognizant of this possibility in men who are depressed, heavy alcohol users, or were childhood victims of abuse.

Gay and lesbian physicians in training: family practice program directors' attitudes and students' perceptions of bias.

BACKGROUND: Disclosure of homosexual orientation by medical students or physicians has generally been regarded as having dire professional consequences. We surveyed family practice residency directors to determine how knowledge of homosexual orientation might affect a residency applicant's ranking. We then surveyed gay and lesbian medical students to better understand their attitudes and beliefs about disclosure of orientation during residency application. METHODS: A survey was mailed to all family practice residency directors and a convenience sample of third- and fourth-year gay and lesbian medical students. RESULTS: The program director response rate was 73%. Of these respondents, 67% showed accepting attitudes toward homosexuality, 25% were neutral, and 8% had negative views. One of four directors admitted they "might rank" or "most certainly" would rank an applicant known to be gay lower than a heterosexual one. The medical student response rate was 81%. When choosing a specialty, 42 students (71%) considered how other physicians might accept them as a lesbian or gay provider. Psychiatry and family practice were perceived as the most accepting specialties. Thirty-one student respondents (52%) agreed that at most residency programs, an applicant known to be gay or lesbian would be ranked lower than an applicant assumed to be heterosexual. CONCLUSIONS: Most family practice residency directors have accepting attitudes toward gays and lesbians in general, but 25% of directors express hesitation in matching openly gay residents. Gay and lesbian medical students want to match in residency programs where they will be welcomed and respected but fear discrimination if they disclose their orientation.