I have several patients in their 70s who are ongoing users of HT. Regrettably, no data from randomized trials are available to provide guidance to providers or patients about the benefits or risks of extended HT. Because the patient Dr. O’Regan describes is taking estradiol and progesterone, she presumably has an intact uterus. We know that the risk of breast cancer increases with increasing duration of estrogen-progestin therapy, so it is important to counsel long-term users proactively about this concern and encourage them to keep up to date with screening mammography.
Even at age 70, there is a substantial risk that vasomotor symptoms will return if HT is discontinued, and it is not clear whether tapering the dose of HT offers any advantages over abrupt discontinuation in this regard.1 Given that age is an independent risk factor for VTE, I agree that transdermal estradiol is more appropriate than oral estrogen in a 70-year-old woman.
In my practice, I encourage older HT users to consider trying a lower dose. If bothersome vasomotor symptoms do not recur, I either continue with a very low dose (especially if the patient has risk factors for osteoporosis) or ultimately discontinue hormone therapy.
Although we know that the selective estrogen receptor modulators (SERMs) tamoxifen and raloxifene provide protection against osteoporosis and breast cancer, I am not aware that ospemifene has been studied in regard to these outcomes. For most of my patients with symptomatic genital atrophy, I plan to continue recommending vaginal estrogen (creams, ring, or tablets). For symptomatic women who would prefer oral therapy, however, ospemifene should prove to be a welcome new option.
Reference
- North American Menopause Society. Position statement: The 2012 hormone therapy position statement of the North American Menopause Society. Menopause. 2012;19(3):257–271.
Another technique for resolving shoulder dystocia
I find another maneuver useful for a shoulder dystocia emergency: I locate the axilla of the anterior shoulder and place my index finger or index and middle finger in the axilla from the posterior aspect and gently rotate the anterior shoulder anteriorly (adduction), thereby reducing the diameter of the shoulders. This maneuver has an effect similar to that of Rubin’s maneuver: It reduces pressure on the shoulder under the pubic bone by applying traction posteriorly toward the maternal perineum.
A key point: To avoid injury, do not apply pressure into the pit of the axilla.
Daniel Sacks, MD
West Palm Beach, Florida
My first maneuver: Deliver the posterior shoulder
I agree with Dr. Barbieri that delivering the posterior shoulder is the preferable method of resolving a shoulder dystocia emergency. If the posterior arm is fully extended, then by applying pressure in the cubital fossa and pushing it posteriorly, one might facilitate flexion of the arm and make it easier to reach the forearm and follow it to the wrist, finally grasping and pulling it. A large mediolateral episiotomy is essential.
This procedure also can be applied during cesarean delivery for a macrosomic fetus. Delivering the posterior shoulder will facilitate the delivery and reduce the risk of extending the incision laterally into the uterine vessels.
Raymond Michael, MD
Marshall, Minnesota
Help the baby “deliver itself”
I first attempt to elevate the head, the opposite approach to what everyone else suggests. This maneuver causes the posterior shoulder to move past the plane of the pubic symphysis and helps disengage the anterior shoulder. Then, with or without suprapubic pressure, I rotate the posterior shoulder anteriorly while ensuring that the “turning of the screw” keeps this shoulder moving anteriorly in front of the plane of the pubic symphysis, and the baby usually just delivers itself.
This maneuver has yet to fail, so I have not had to move on to other techniques, which have usually been performed before I am called.
Robert Graebe, MD
Long Branch, New Jersey
Article on shoulder dystocia prompted anxious memory
The May issue of OBG Management was superb, with great information about cervical management, menopause, cesarean delivery, and more. But the article about shoulder dystocia gave me anxiety because it took me back to the one time I experienced this frightening emergency. After my patient had had a normal pregnancy and uneventful labor, it happened…and the instant “Oh no!” moment of fear. That moment was followed by immediate recall and focused, determined implementation of necessary maneuvers to remedy the matter as soon as possible.
I am happy to report that the baby (just under 7 lb at birth) is now grown and doing quite well.