The field of family medicine is constantly evolving, making it challenging for the interprofessional healthcare team to stay up to date with recent developments. This article covers key advancements in the field that may have important implications for clinical practice.

THIS SYMPTOM SIGNALS UTI IN 83% OF CASES

A bacterial infection of the bladder and its related structures is known as a urinary tract infection (UTI). When it is uncomplicated, it may be referred to as a "lower" UTI or cystitis.^[1] The infection can be caused by various pathogens, with the most common being gram-negative bacteria such as Escherichia coli.^[2] Women are at greater risk of developing a UTI compared with men, because of the shorter distance between the bladder and external part of the body. While men may suffer from UTIs less frequently than women, the infection tends to be more complicated.^[3]

TOPLINE:

Dyspareunia (painful sexual intercourse) is a major indicator of urinary tract infections, being present in 83% of cases. The symptom is especially accurate at identifying UTIs in non-menopausal women, researchers have found.^[4]

METHODOLOGY:

• Dyspareunia is a common symptom of UTIs, especially in premenopausal women, but is rarely inquired about during patient evaluations, according to researchers from Florida Atlantic University.
• In 2010, the researchers found that among 3000 of their female Latinx patients ages 17 to 72 years in South Florida, 80% of those with UTIs reported experiencing pain during sexual intercourse.
• Since then, they have studied an additional 2500 patients from the same population.

TAKEAWAY:

• Among all 5500 patients, 83% of those who had UTIs experienced dyspareunia.
• 80% of women of reproductive age with dyspareunia had an undiagnosed UTI.
• During the perimenopausal and postmenopausal years, dyspareunia was more often associated with genitourinary syndrome than UTIs.
• 94% of women with UTI-associated dyspareunia responded positively to antibiotics.

IN PRACTICE:

"We have found that this symptom is extremely important as part of the symptomatology of UTI [and is] frequently found along with the classical symptoms," the researchers reported. "Why has something so clear, so frequently present, never been described? The answer is simple: Physicians and patients do not talk about sex, despite dyspareunia being more a clinical symptom than a sexual one. Medical schools and residency programs in all areas, especially in obstetrics and gynecology, urology, and psychiatry, have been neglecting the education of physicians-in-training in this important aspect of human health. In conclusion, this is [proof] of how medicine has sometimes been influenced by religion, culture, and social norms far away from science."

SOURCE:

The data were presented at the 2023 Menopause Meeting of the North American Menopause Society. The study was led by Alberto Dominguez-Bali, MD, from Florida Atlantic University, Boca Raton, Florida.^[4]

LIMITATIONS:

The study authors report no limitations.

DOES AN ELEVATED TSH VALUE ALWAYS REQUIRE THERAPY?

Hypothyroidism is a common endocrine disorder, estimated to impact 10% of the world’s population.^[5] It is characterized by a deficiency in thyroid hormone and may be caused by a severe deficiency in iodine or autoimmunity in iodine-saturated areas (more frequent). Symptoms of hypothyroidism are often nonspecific, affecting multiple organ systems; most commonly, patients may experience an intolerance to cold climates, fatigue, and constipation.^[6] The aim of treatment is to restore thyroid hormone levels using medication.^[7] The mainstay of treatment is levothyroxine,^[6] a synthetic version of the hormone thyroxine (ie, the thyroid hormone, also known as T4).^[8]

Indeed, thyroxine and L-thyroxine are 2 of the 10 most frequently prescribed medicinal products. "One large health insurance company ranks thyroid hormone at fourth place in the list of most-sold medications in the United States. It is possibly the second most commonly prescribed preparation," said Joachim Feldkamp, MD, PhD, director of the University Clinic for General Internal Medicine, Endocrinology, Diabetology, and Infectious Diseases at Central Hospital, Bielefeld, Germany, at the online press conference for the German Society of Endocrinology's hormone week.

The preparation is prescribed when the thyroid gland produces too little thyroid hormone. The messenger substance thyroid-stimulating hormone (TSH) is used as a screening value to assess thyroid function. An increase in TSH can indicate that too little thyroid hormone is being produced.^[9]

"But this does not mean that an underactive thyroid gland is hiding behind every elevated TSH value," said Feldkamp. Normally, the TSH value lies between 0.3 and 4.2 mU/L. "Hypothyroidism, as it's known, is formally present if the TSH value lies above the upper limit of 4.2 mU/L," said Feldkamp.

Check Again

However, not every elevated TSH value needs to be treated immediately. "From large-scale investigations, we know that TSH values are subject to fluctuations," said Feldkamp. Individual measurements must therefore be taken with a grain of salt and almost never justify a therapeutic decision. Therefore, a slightly elevated TSH value should be checked again 2 to 6 months later, and the patient should be asked if they are experiencing any symptoms.^[10] "In 50% to 60% of cases, the TSH value normalized at the second checkup without requiring any treatment," Feldkamp explained.

The TSH value could be elevated for several reasons:

• Fluctuations depending on the time of day.^[11] At night and early in the morning, the TSH value is much higher than in the afternoon. An acute lack of sleep can lead to higher TSH values in the morning.
• Fluctuations depending on the time of year. In winter, TSH values are slightly higher than in the summer owing to adaptation to cooler temperatures. Researchers in the Arctic, for example, have significantly higher TSH values than people who live in warmer regions.^[12,13]
• Age-dependent differences. Children and adolescents have higher TSH values than adults do. The TSH values of adolescents cannot be based on those of adults because this would lead to incorrect treatment. In addition, TSH values increase with age, and slightly elevated values are initially no cause for treatment in people aged 70 to 80 years.^[14] Caution is advised during treatment, because overtreatment can lead to cardiac arrhythmias and a decrease in bone density.
• Sex-specific differences. The TSH values of women are generally a little higher than those in men.^[14]
• Obesity. In obesity, TSH increases and often exceeds the normal values usually recorded in persons of normal weight. The elevated values do not reflect a state of hypofunction, but rather the body's adjustment mechanism. If these patients lose weight, the TSH values will drop spontaneously. Slightly elevated TSH values in obese people should not be treated with thyroid hormones.^[15]

The nutritional supplement biotin (vitamin H or vitamin B7), which is often taken for skin, hair, and nail growth disorders, can distort measured values. In many of the laboratory methods used, the biotin competes with the test substances used. As a result, it can lead to falsely high and falsely low TSH values. At high doses of biotin (eg, 10 mg), there should be at least a 3-day pause (and ideally a pause of 1 week) before measuring TSH.^[16]

Hasty Prescriptions

"Sometimes, because of the assumption that every high TSH value is due to sickness-related hypothyroidism, thyroid hormones can be prescribed too quickly," said Feldkamp. This is also true for patients with thyroid nodules due to iodine deficiency, who are often still treated with thyroid hormones.

"These days, because we are generally an iodine-deficient nation, iodine would potentially be given in combination with thyroid hormones, but not with thyroid hormones alone. There are lots of patients who have been taking thyroid hormones for 30 or 40 years due to thyroid nodules. That should definitely be reviewed," said Feldkamp.

When to Treat?

Feldkamp does not believe that standard determination of the TSH value is sensible and advises that clinicians examine patients with newly occurring symptoms, such as excess weight, impaired weight regulation despite reduced appetite, depression, or a high need for sleep.

If there are symptoms, the thyroid function must be clarified further. "This includes determination of free thyroid hormones T3 and T4, detection of antibodies against autologous thyroid tissue such as TPO-Ab [antibody against thyroid peroxidase], TG-Ab [antibody against thyroglobulin], and TRAb [antibody against TSH receptor], and ultrasound examination of the metabolic organ," said Feldkamp. Autoimmune-related hypothyroidism (Hashimoto thyroiditis) is the most common cause of an overly high TSH level.

Treatment should take place in the following situations^[17]:

• In young patients with TSH values > 10 mU/L;
• In young (< 65 years) symptomatic patients with TSH values of 4 to < 10 mU/L;
• With elevated TSH values that result from thyroid surgery or radioactive iodine therapy;
• In patients with a diffuse enlarged or severely nodular thyroid gland; and
• In pregnant women with elevated TSH values.

ADOLESCENTS' ACUTE CARE USE FOR EATING DISORDERS HAS RISEN

During the COVID-19 pandemic, a rise in eating disorders was observed among children and young people. However, trends among adults are yet to be elucidated. In order to determine the rate of emergency department (ED) visits and hospitalizations for eating disorders and adolescents, researchers conducted a repeated cross-sectional study that examined population-based data from January 2017 through August 2022.^[18]

They found that ED visits and hospital admissions for eating disorders increased significantly among adolescents during the COVID-19 pandemic. ED visits increased by 121% above expected levels, and hospital admissions increased by 54% above expected among patients aged 10 to 17 years during the pandemic.

"We are hoping this study continues to heighten awareness of the importance of eating disorders, and also to bolster support for eating disorder programs so that we can adequately care for patients and address the increasing demand for treatment and services," lead author Alene Toulany, MD, an adolescent medicine specialist and researcher at the Hospital for Sick Children in Toronto, told Medscape Medical News.

The study was published in the Canadian Medical Association Journal.^[18]

"A Pressing Concern"

The researchers used linked health administrative databases that included all patients in Ontario who were eligible for the Ontario Health Insurance Plan, which is publicly funded. They compared observed and expected rates of ED visits and hospitalizations for eating disorders between a prepandemic period (January 1, 2017, to February 29, 2020) and a pandemic period (March 1, 2020, to August 31, 2022). The researchers examined the following 4 age categories: adolescents (ages 10 to 17 years), young adults (ages 18 to 26 years), adults (ages 27 to 40 years), and older adults (ages 41 to 105 years).

Among adolescents, the observed rate of ED visits during the 30 pandemic months studied was 7.38 per 100,000 population, compared with 3.33 per 100,000 before the pandemic (incidence rate ratio [IRR], 2.21). The rate of ED visits among young adults increased by 13% above the expected rate. It reached 2.79 per 100,000, compared with 2.46 per 100,000 in the prepandemic period (IRR, 1.13). Among older adults, ED visits increased from 0.11 per 100,000 in the prepandemic period to 0.14 per 100,000 in the pandemic period (IRR, 1.15). The rate of ED visits among adults remained approximately the same.

The rate of hospital admissions among adolescents increased by 54% above the expected rate during the pandemic. The observed rate of hospital admissions before the pandemic was 5.74 per 100,000, vs 8.82 per 100,000 during the pandemic (IRR, 1.54). Hospital admissions remained stable or decreased for the other age groups.

"Eating disorders have increased globally in children and adolescents during COVID," said Toulany. "There are a number of risk factors contributing to this pandemic rise, including isolation, more time on social media, decreased access to care (as many in-person services were not available due to the pandemic), as well as fear of getting infected. All of these could contribute to an increased risk of developing an eating disorder or of making an existing one worse."

Regardless of the cause, more investment in eating disorders research and eating disorder programs for adolescents and adults is needed, she said. "The pandemic served as a catalyst, because it started to shed light on the prevalence of eating disorders, especially in young people. But it's very important that we recognize that this has been a long-standing issue and a pressing concern that has been consistently overlooked and underfunded," said Toulany.

Surging Eating Disorders

Commenting on the findings for Medscape, Victor Fornari, MD, director of child and adolescent psychiatry at Zucker Hillside Hospital/Northwell Health in Glen Oaks, New York, said, "Our experience in the United States parallels what is described in this Canadian paper. This was a surge of eating disorders the likes of which I had not experienced in my career." Fornari did not participate in the current study.

"I've been here for over 40 years, and the average number of our inpatients in our eating disorder program has been 3 to 5 and about a dozen patients in our day clinic at any one time. But in the spring of 2020, we surged to 20 inpatients and over 20 day patients," Fornari said.

"We can speculate as to the reasons for this," he continued. "Kids were isolated. School was closed. They spent more time on social media and the internet. Their sports activities were curtailed. There was anxiety because the guidance that we were all offered to prevent contagion was increasing people's anxiety about safety and danger. So, I think we saw dramatic rises in eating disorders in the same way we saw dramatic rises in anxiety and depression in adolescents, as well."

Fornari also cited social media as an important contributing factor to eating disorders, especially among vulnerable teenagers. "Many of these vulnerable kids are looking at pictures of people who are very thin and comparing themselves, feeling inadequate, feeling sad. Social media is one of the reasons why the rates of psychopathology amongst teens has skyrocketed in the last decade. The surgeon general recently said we should delay access to social media until age 16 because the younger kids are impressionable and vulnerable. I think there is wisdom there, but it is very hard to actually put into practice."

Worsening Mental Health

"I thought this was very relevant research and an important contribution to our understanding of eating disorders during pandemic times," said Simon Sherry, PhD, professor of psychology and neuroscience at Dalhousie University in Halifax, Nova Scotia. "It also dovetails with my own experience as a practitioner." Sherry was not involved in the research.

The pandemic has been difficult for people with disordered eating for many reasons, Sherry said. "There was a massive disruption or 'loss of normal' around food. Restaurants closed, grocery shopping was disrupted, scarcity of food occurred, hoarding of food occurred. That meant that eating was difficult for all of us, but especially for individuals who were rigid and controlling around the consumption of food. In this COVID era, you would need flexibility and acceptance around eating, but if you had a narrow range of preferred foods and preferred shopping locations, no doubt the pandemic made this a lot worse."

Certain forms of disordered eating would be much more likely during the pandemic, Sherry noted. "For example, binge eating is often triggered by psychological, social, and environmental events," and those triggers were abundant at the beginning of the pandemic. Boredom, anxiety, depression, stress, loneliness, confinement, and isolation are among the triggers. "COVID-19-related stress was and is very fertile ground for the growth of emotional eating, binge eating, or turning to food to cope. Eating disorders tend to fester amid silence and isolation and inactivity, and that was very much our experience during the lockdown phase of the pandemic," he said.

Sherry agrees with the need for more funding for eating disorders research. "We know in Canada that eating disorders are a very important and deadly issue that is chronically underfunded. We are not funding disordered eating in proportion to its prevalence or in proportion to the amount of harm and destruction it creates for individuals, their family members, and our society at large. The authors are absolutely correct to advocate for care in proportion to the prevalence and the damage associated with eating disorders," he said.

Earn Credit