This is the final article in a 2-part series summarizing updates from clinical practice guidelines published in 2021 that are relevant to primary care in Canada.1 Having an easily accessible summary of key updated guidelines can help physicians adopt relevant changes in standards of care. This article allows family doctors to continue to build on their knowledge or address potential gaps. As with all literature, it is essential to consider the level of supporting evidence and reflect on recommendations using a primary care lens before integrating them in patient care.
Guideline updates
The Canadian Task Force on Preventive Health Care recommends screening of sexually active individuals younger than 30 years for chlamydia and gonorrhea annually at primary care visits, as feasible (conditional recommendation, very low–certainty evidence).2 The Canadian Task Force on Preventive Health Care reports that rates of chlamydia and gonorrhea have been increasing annually since 2000, with the highest rates found in persons between 15 and 29 years old.2 Complications include cervicitis, epididymitis, pelvic inflammatory disease, chronic pelvic pain, infertility, and ectopic pregnancies. Current guidelines from the Public Health Agency of Canada,3,4 the Centers for Disease Control and Prevention,5 and the US Preventive Services Task Force6 recommend screening of sexually active patients younger than 25 years for Chlamydia trachomatis and Neisseria gonorrhoeae infection.
The Canadian Urological Association recommends ultrasonography with a kidney, ureter, and bladder (KUB) x-ray scan as the initial imaging modality for acute ureteral stones (strong recommendation, level 1 evidence).7 The guideline authors note that, in most cases, ultrasound imaging and noncontrast computed tomography result in equivalent clinical outcomes. The addition of a KUB x-ray scan to ultrasound imaging improves the sensitivity of detection: combining KUB ultrasound and x-ray scan results in sensitivity ranging from 79% to 100% and specificity up to 100%. Follow-up imaging is recommended to confirm resolution, although the timing and imaging modality should be selected based on unique patient factors such as comorbidities and renal function.
The Society of Obstetricians and Gynaecologists of Canada (SOGC) recommends that all pregnant women be offered a routine, complete prenatal sonographic examination at 11 to 14 weeks’ gestation (strong recommendation, high level of evidence) and that for asymptomatic women this examination should replace, rather than complement, an early first-trimester sonographic examination (conditional recommendation, moderate level of evidence).8 Many international guidelines recommend the use of sonography for pregnancy dating. The ultrasound scan at 11 to 14 weeks can be used to assess viability, establish gestational age, detect fetal anomalies, and screen for signs of aneuploidies, adnexal abnormalities, and risk factors. In addition, there might be a role for uterine artery Doppler ultrasonography in screening for preeclampsia and uteroplacental vascular insufficiency. For pregnancy dating, use the earliest examination after 7 weeks’ gestation or after the crown-rump length is greater than 10 mm. Replacing the early first-trimester ultrasound scan with an ultrasound scan at 11 to 14 weeks does risk inaccuracies in dates when ordering enhanced first-trimester screening.
The SOGC has added tissue-selective estrogen complex (TSEC) and tibolone (a synthetic steroid) as treatment options for women with postmenopausal vasomotor symptoms (high level of evidence).9 Women without a uterus can take continuous estrogen therapy, while women with a uterus typically need both estrogen and progesterone for management of postmenopausal vasomotor symptoms. Both TSEC and tibolone offer a progesterone-free alternative for patients with a uterus. The first, TSEC, has antagonist effects on estrogen receptors in the uterus, providing endometrial protection. Several studies with durations of up to 2 years have shown superiority of TSEC to placebo in the treatment of vasomotor symptoms without increased risk of breast cancer.10-12 The second of the additional treatment options, tibolone, is a synthetic steroid analogue of progestin and has been found to be more effective in treating vasomotor symptoms than placebo but slightly less effective than a combined estrogen-progesterone therapy.
The SOGC recommends considering ospemifene and prasterone as second-line treatment for genitourinary syndrome of menopause (strong recommendation, high level of evidence).13 First-line treatment continues to include vaginal moisturizers a few times per week and lubricants as needed. Second-line treatment now includes vaginal estrogen therapy (without concomitant progesterone), prasterone, and ospemifene. Prasterone is a synthetic form of dehydroepiandrosterone (an inactive precursor that converts to androgens and estrogens in vulvovaginal tissues), while ospemifene is a selective estrogen receptor modulator. Both medications are effective in treating moderate to severe dyspareunia and vaginal dryness. New to the guidelines is consideration of prescribing vaginal estrogen therapy for patients who have survived breast cancer in consultation with their oncologists.
The SOGC recommends that postmenopausal women with hypoactive sexual desire disorder (HSDD) can consider flibanserin oral medication or transdermal testosterone patches (off-label) as treatment options (strong recommendation, moderate level of evidence).14 Sexual dysfunction consists of chronic symptoms occurring in 75% of sexual events and causing personal distress. The categories of sexual dysfunction are desire (HSDD), arousal, orgasm (delayed or absent), and sexual pain (dyspareunia or vaginismus). Their causes can be multifactorial, including psychosocial stress, hormone changes, aging, endocrinopathies, effects of medication, comorbidities, and pelvic floor disease. Treatment should involve education about menopause, aging, medications, foreplay, and nonpenetrative alternatives. Flibanserin (a combined serotonin agonist and antagonist) has been approved for treatment in premenopausal women with HSDD and has shown efficacy in a study as treatment for postmenopausal women. In addition, this guideline’s authors write that several reviews, including a Cochrane Review, found improved sexual desire in postmenopausal women with the use of transdermal testosterone and that 11 leading medical organizations have recently endorsed the use of transdermal testosterone for treatment of low desire, arousal, and orgasm dysfunction.
The SOGC recommends consideration of hormone therapy for perimenopausal depression with or without concomitant vasomotor symptoms (strong recommendation, high level of evidence).15 Effect size is similar to that of classic antidepressant therapy. However, hormone therapy is ineffective in treating depressive disorders in postmenopausal women, highlighting the limited time in which hormone therapy can be used for the treatment of depression. This recommendation aligns with the 2016 clinical guidelines for the management of adults with major depressive disorder from the Canadian Network for Mood and Anxiety Treatments.16 If prescribing classic antidepressant therapy, be cognizant of adverse effects that might exacerbate symptoms of menopause.
The Canadian Coalition for Seniors’ Mental Health (CCSMH) recommends that duloxetine or sertraline be considered as first-line treatment for an acute episode of depression in older adults (those 65 years or older; grade A recommendation).17 This recommendation is based on the level of evidence comparing antidepressants’ efficacy in older adults and their adverse effects, such as prolongation of heart rate–corrected QT (QTc) intervals and anticholinergic effects. The CCSMH’s recommendation14 has some similarity to that of the Canadian Network for Mood and Anxiety Treatments 2016 guideline,16 which recommended duloxetine, mirtazapine, and nortriptyline as first-line medications with the highest evidence. The CCSMH also recommends escitalopram, citalopram, venlafaxine, bupropion, mirtazapine, and vortioxetine for treatment of depression in patients in this age group. This guideline reminds clinicians that elderly patients often need longer trials, up to 12 weeks, to achieve response.17
Conclusion
This article highlighting key recommendations in infectious diseases, urology, obstetrics and gynecology, and mental health concludes a 2-part series summarizing guideline updates from 2021. Family physicians are encouraged to appraise these recommendations and explore these updates to advance their knowledge or confirm their current clinical practices.
Notes
We encourage readers to share some of their practice experience: the neat little tricks that solve difficult clinical situations. Praxis articles can be submitted online at http://mc.manuscriptcentral.com/cfp or through the CFP website (https://www.cfp.ca) under “Authors and Reviewers.”
Footnotes
Competing interests
None declared
- Copyright © 2022 the College of Family Physicians of Canada
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