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Megan McNamara, MD, MSc
Judith Walsh, MD, MPH
The field of women's health encompasses more than the reproductive health issues commonly addressed by obstetricians and gynecologists; it evaluates diseases and conditions only seen or experienced in women or experienced by women in ways different than men, as well as the evidence-based prevention and treatment of risk factors and diseases in women. Hence, all primary care providers, including internists and family physicians, should be well versed in women's health issues. While this chapter refers to other disease-based chapters in the textbook, it also emphasizes the understanding of issues from the particular perspective of women.
Prevention of disease can be primary (preventing disease before it happens as well as identifying and modifying risk factors), secondary (identifying early disease), or tertiary (treating complications of the disease or limiting the impact of established disease). Important areas for primary prevention include encouraging women to exercise regularly to reduce the risk of coronary heart disease (CHD) and breast cancer as well as counseling women to discontinue smoking to reduce the risk of cardiac and lung diseases. Cancer screening in women focuses on secondary prevention, so that disease is detected early when prompt treatment improves outcome.
Although cardiovascular disease is the leading cause of death in women, they are often more concerned about developing breast cancer (see below) than about developing heart disease. While some heart disease risk factors such as age and family history are not modifiable, as with men, other risk factors such as hypertension, hyperlipidemia, smoking, obesity, and diabetes are potentially modifiable (see alsoChapter 1). The Framingham risk calculator (http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof) can be used to estimate a woman's 10-year risk of CHD based on her age, smoking status, blood pressure, and cholesterol levels.
Modifiable Risk Factors
Hypertension is a risk factor for CHD and stroke in both men and women (see Chapter 1). Approximately 70–80% of women over age 70 have hypertension. A woman with high blood pressure is at lower risk for CHD than a similar aged man. For many young and otherwise healthy women, medication treatment can be deferred, since their absolute risk of CHD in the next 10 years is likely to be low. When pharmacotherapy is started, the choice of medication is similar to those used in men (see Chapter 11).
Hyperlipidemia is a CHD risk factor in both men and women, but low levels of high-density lipoprotein (HDL) are more predictive of CHD risk in women. The US Preventive Services Task Force (USPSTF) recommends screening all women aged 45 and older for hyperlipidemia, whereas the National Cholesterol Education Program (NCEP) recommends screening all individuals aged 20 and over. Before screening a woman for hyperlipidemia, an important consideration is whether or not treatment recommendations will change based on the results. Since therapeutic lifestyle changes are recommended for all women, the question is at what point pharmacotherapy should be considered.
There is clear evidence that medication treatment of hyperlipidemia reduces CHD events in women who already have CHD, but when lipid-lowering medications are used in women who do not already have CHD, the evidence of benefit is less clear (see also Chapter 28). Decisions about when to initiate medication treatment should include an assessment of an individual's absolute risk of CHD in the next 10 years. Medication treatment should be targeted toward women with CHD and high-risk women who are most likely to benefit. The NCEP recommends different thresholds at which to initiate medication therapy based on individual CHD risk. For example, for a woman with known CHD, lipid-lowering medication is initiated at a low-density lipoprotein (LDL) cholesterol of > 130 mg/dL, whereas for a woman with 0–1 risk factor, medication therapy is not initiated until the LDL cholesterol measures > 190 mg/dL.
Diabetes is a CHD risk factor in both men and women. Studies have reached conflicting conclusions about the effect of tight control of diabetes on CHD outcomes in both men and women, although lipid lowering is clearly associated with a reduction in CHD events in diabetic women. All women should focus on primary prevention of diabetes with avoidance of obesity and maintenance of regular exercise. Women with diabetes also should focus on treatment of hypertension given the impact on CHD events (see Chapter 27).
Obesity has been established as an independent risk factor for CHD in women. It is not known whether or not weight loss will decrease CHD risk. Since most obese women who lose weight gain it back, the overall goal should be ongoing avoidance of weight gain above normal weight (see Chapters 1 and 29).
The use of high-sensitivity C-reactive protein (hsCRP) has increased in recent years. CRP is an inflammatory biomarker that has been shown to predict cardiovascular events. However, there is currently no evidence that screening for hsCRP improves cardiac outcomes. It has been suggested that measuring hsCRP may be useful in women for whom it would change treatment outcomes, but there is currently no evidence to support this. The USPSTF has published guidelines outlining the use of nontraditional risk factors in the evaluation of CHD. The risk factors included in the recommendation were hsCRP, ankle-brachial index, leukocyte count, fasting blood glucose, periodontal disease, carotid intima media thickness, coronary artery calcification score, electron beam CT, homocysteine, and lipoprotein (a). The USPSTF concluded that there is insufficient evidence to balance the benefits and harms of screening asymptomatic men and women with no history of CHD to predict CHD events and did not recommend routine screening.
Therapeutic Options for Reducing Risk Factors
Aspirin is clearly useful for secondary prevention of CHD in women. Among women who do not have CHD, aspirin reduces the risk of stroke, whereas in men, it reduces the risk of CHD. Before starting an aspirin regimen to reduce the risk of the stroke, women should be assessed for their risk of gastrointestinal bleeding, which is the most common adverse side effect of aspirin use. The USPSTF recommends aspirin in women aged 55–79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harms of a gastrointestinal hemorrhage. For healthy or at-risk women, 81 mg/d or 100 mg every other day is the suggested dose. For high-risk women, a dose of 75–325 mg/d is recommended.
Exercise has been associated with a reduction in all causes of cardiovascular mortality. Women often want to know how much exercise is necessary for health benefits. Studies have shown that walking 2.5–3 hours a week is associated with a reduction in cardiovascular disease. The Centers for Disease Control and Prevention and the American College of Sports Medicine recommend that all women accumulate at least 30 minutes a day of moderate intensity physical activity on most if not all days of the week. The Institute of Medicine recommends an hour a day for the goal of maintaining health and ideal body weight. See also Chapter 1.
Gutierrez J et al. Statin therapy in the prevention of recurrent cardiovascular events: a sex-based meta-analysis. Arch Intern Med. 2012 June 25;172(12):909–19. [PMID: 22732744]
Mosca L et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association. Circulation. 2011 Mar 22;123(11):1243–62. [PMID: 21325087]
U.S. Preventive Services Task Force. Screening for Lipid Disorders in Adults: U.S. Preventive Services Task Force recommendation statement.http://www.uspreventiveservicestaskforce.org/uspstf08/lipid/lipidrs.htm
Risk Factors & Risk Assessment
Breast cancer is the most commonly detected cancer in women and the second leading cause of cancer death (see also Chapter 17). Breast cancer risk is increased with age and with a family history of breast cancer. Women who drink more than two alcoholic drinks per day are at increased risk for breast cancer, and exercise is associated with a decreased risk of breast cancer. Dietary intake has not been conclusively associated with breast cancer risk. Breast density is an emerging risk factor for breast cancer; women with denser breasts as measured with mammography are at increased breast cancer risk. Although some states now mandate that women with increased breast density on mammography be notified, it is not currently known what women can do to decrease this risk.
Various models have been used to predict a woman's risk for breast cancer. The National Cancer Institute has developed the Breast Cancer Risk Assessment Tool (http://www.cancer.gov/bcrisktool/), which is based on the Gail Model, and calculates the woman's risk of developing breast cancer in the next 5 years by considering the following factors: (1) the woman's age, (2) age at which she had her first menstrual period, (3) age at delivery of first live child, (3) number of first-degree relatives with breast cancer, (4) history of any breast biopsies, and (5) history of atypical hyperplasia. The model has been validated in white women and has been evaluated in black women and found to be relatively accurate, although it may underestimate the risk in black women with a history of previous breast biopsies. It has yet to be validated in women of other ethnicities.
Primary Prevention
In addition to lifestyle modifications, such as exercise and moderation of alcohol intake, chemoprevention of breast cancer is an option for some women. The selective estrogen receptor modifiers (SERMS) tamoxifen and raloxifene have both been shown to reduce invasive breast cancer in high-risk women. However, there are risks associated with SERM treatment. Tamoxifen is associated with an increased risk of endometrial cancer and deep venous thrombosis (DVT). Although raloxifene is not associated with an increased risk of endometrial cancer, the risk of DVT remains. Aromatase inhibitors, such as exemestane, show promise for breast cancer prevention but are not currently FDA approved for this indication. The USPSTF recommends that clinicians discuss chemoprevention with women at high risk for breast cancer and at low risk for the adverse effects of chemoprevention. Clinicians should inform patients of the potential benefits and harms of chemoprevention. Breast cancer risk increases with age, but the risk of adverse effects does as well. Since the clinical trials of tamoxifen and raloxifene for breast cancer prevention used a 1.66% 5-year risk, this risk level is often used as a guide for medication treatment.
Breast Cancer Screening
Traditional breast cancer screening modalities include screening mammography, clinical breast examination, and breast self-examination (see also Chapter 17). Teaching women to do routine breast self-examination has not been shown to reduce breast cancer mortality. The USPSTF recommends against teaching women to do breast self-examination. The American Cancer Society states that it is acceptable not to do it, but that if women are performing breast self-examination, it is important to ensure that they are doing it correctly. The combination of breast examination done by a clinician and mammography is associated with a decrease in breast cancer mortality, but there is insufficient evidence to recommend clinical breast examination alone.
Mammography reduces breast cancer mortality in women aged 50–74 years and routine mammographic screening is recommended for women in this age group. For women aged 40–49 years, screening has been more controversial. Guidelines published by the USPSTF recommend that clinicians not routinely order mammography among 40- to 49-year-old women but rather that they individualize the decision to begin screening, since the number needed to invite to screen to prevent one breast cancer death is much higher in younger women and the number of false-positive and false-negative test results are much higher. Since women over age 75 have not been included in clinical trials and since the likelihood of comorbid diseases limiting life expectancy increases, routine screening of women in this age group is not recommended, but rather the decision making should be individualized.
Hubbard et al. Cumulative probability of false-positive recall or biopsy recommendation after 10 years of screening mammography: a cohort study. Ann Intern Med. 2011 Oct 18;155(8):481–92. [PMID: 22007042]
Nelson HD et al. Risk factors for breast cancer for women aged 40 to 49 years: a systematic review and meta-analysis. Ann Intern Med. 2012 May 1;156(9):635–48. [PMID: 22547473]
Colorectal cancer is the third leading cause of cancer death in both men and women. In 2013 an estimated 9% of cancer deaths in women were caused by colorectal cancer. Since the risk of colorectal cancer increases with age, all women should be screened for colorectal cancer starting at the age of 50. The USPSTF recommends routine screening in men and women age 50–75, individualized decision making about screening in individuals aged 76–85, and no screening after the age of 85. Details of the screening options and suggested screening intervals are described in Chapter 1.
U.S. Preventive Services Task Force. Screening for Colorectal Cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2008 Nov 4;149(9):627–37. [PMID: 18838716]
In contrast to most other cancers for which routine screening is recommended, the incidence of cervical cancer is higher in younger women and decreases with age. The major risk factor for cervical cancer is exposure to the human papillomavirus (HPV). Primary prevention of cervical cancer includes avoidance of smoking, postponing sexual debut, and limiting the number of sexual partners. Condom use may also be protective.
Primary Prevention
A quadrivalent HPV vaccine that includes capsid proteins against four HPV types (6, 11, 16, and 18) has been approved for use in girls and women aged 9–26 years to prevent disease associated with these HPV types (see also Chapter 18). A bivalent vaccine (Cervarix) is also available. The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination for girls aged 11 or 12 up to age 26, whereas the American Cancer Society recommends the vaccine for girls aged 11–18 but states that there is insufficient evidence to recommend for or against routine vaccination for women aged 19–26. Unanswered questions about the vaccine include the long-term effects and the length of protection. Receipt of vaccine should not change cervical cancer screening intervals in women.
Secondary Prevention
An important focus of cervical cancer prevention is screening using the Papanicolaou smear. Cervical cancer screening is the biggest success in the history of cancer screening. Cervical cancer mortality has been reduced by about 70% with routine cervical cancer screening. One of the reasons that screening has been so successful is that there is a long preclinical phase where early changes can be detected and treated so as to avoid the development of cancer. The USPSTF updated their screening recommendations in 2012 (see Chapter 18).
U.S. Preventive Services Task Force. Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement.http://www.uspreventiveservicestaskforce.org/uspstf11/cervcancer/cervcancerrs.htm
Although lung cancer is not typically considered a "women's cancer," it is the leading cause of cancer mortality in both men and women. Primary prevention of lung cancer should be a high priority with encouragement of tobacco cessation among women who smoke (see Chapters 1 and 39). Consistent with a 2012 joint recommendation from the American Academy of Chest Physicians and the American Society of Clinical Oncology in December 2013, the USPSTF updated its screening recommendation based on NLST data recommending "annual screening for lung cancer with low-dose computed tomography in adults ages 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years."
Humphrey LL et al. Screening for lung cancer with low-dose computed tomography: a systematic review to update the U.S. Preventive services task force recommendation. Ann Intern Med. 2013 Sep 17;159(6):411–20. [PMID: 23897166]
National Lung Screening Trial Research Team; Aberle DR et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011 Aug 4;365(5):395–409. [PMID: 21714641]
Ovarian cancer is a relatively rare but dreaded cancer, with a lifetime incidence of about 1.2% in women with no family history of ovarian cancer. Because it is often detected late, treatment options may be limited.
Many of the risk factors for ovarian cancer such as age and family history are not modifiable, but there are protective factors, including having more than one full-term pregnancy, breast-feeding, and oral contraceptive use. Women at high-risk for ovarian cancer should consider the use of oral contraceptives for as long as it is feasible.
Although screening for ovarian cancer with either the serum marker CA-125 or with transvaginal ultrasound is theoretically appealing, the rarity of the disease limits their use and leads to many false-positive test results (see also Chapter 18). The USPSTF does not recommend screening for ovarian cancer.
Buys SS et al. Effect of screening on ovarian cancer mortality: the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Randomized Controlled Trial. JAMA. 2011 Jun 8;305(22):2295–303. [PMID: 21642681]
Osteoporotic fractures are increasing as the population ages. Age and female sex are major risk factors for osteoporotic fractures. Hip and vertebral fractures are associated with premature mortality. Osteoporosis risk can be assessed by measuring bone mineral density (BMD). See also Chapter 26.
The World Health Organization has developed a fracture risk assessment tool (FRAX, available at http://www.shef.ac.uk/FRAX/index.jsp) that can predict a woman's 10-year risk of having any osteoporotic fracture and the 10-year risk of hip fracture. Risk factors used in the FRAX tool include age, gender, personal history of fracture, parental history of hip fracture, low body mass index, use of oral corticosteroids, secondary osteoporosis, current smoking, and alcohol intake of three or more drinks per day. It can be used with or without BMD. The FRAX tool is particularly helpful in determining which women with osteopenia are most likely to benefit from treatment. Based on the World Health Organization algorithm adopted for the United States, treatment is recommended when there is a 10-year risk of hip fracture ≥ 3% or a 10-year risk of a major osteoporotic fracture ≥ 20%.
Primary Prevention
Although calcium supplementation is routinely recommended, evidence from the Women's Health Initiative showed that calcium supplementation did not reduce fracture risk in healthy postmenopausal women and other research has highlighted potential risks of calcium supplementation. Calcium appears to be necessary but not sufficient for fracture prevention. The USPSTF recommendations state that the evidence is insufficient to assess the balance of benefits and harms for the combination of vitamin D and calcium for primary prevention of fractures in men or premenopausal women. Recommended calcium intake for women younger than 50 years is 1000 mg/d and for women aged 51 and over, it is 1200 mg/d. Dietary calcium may be safer than calcium supplements, but calcium supplements can be given as either calcium citrate or calcium carbonate and should be given with vitamin D. Regular weight bearing exercise has also been associated with an increase in bone density although the effect is lost when the exercise is not continued.
Increasing evidence suggests that vitamin D supplementation is associated with a reduction in fracture risk. Vitamin D can be given as either D2 or D3 formulations. Recommendations are that women aged 70 and younger should consume 600 international units of vitamin D per day, whereas women aged 71 and older should consume 800 international units per day. Individuals with vitamin D deficiency (25-OH vitamin D < 20 mg/mL) may require higher doses, although most recommendations for vitamin D supplementation are based on achieving a serum 25-OH vitamin D concentration of a particular level, rather than on a clinical outcome. Whether or not women should be routinely screened for vitamin D deficiency remains an ongoing question. However, given the association of vitamin D and fractures, checking a 25-OH vitamin D level in women with osteopenia or osteoporosis is reasonable.
Bone Mineral Density Screening
The biggest risk factor for developing osteoporosis is increasing age. Although many women expect to be screened around the time of menopause, routine BMD screening is not recommended until the age of 65. The National Osteoporosis Foundation recommends screening all women age 65 and older and screening younger postmenopausal women if there is a concern based on their risk-factor profile. The USPSTF recommends screening women aged 65 and older and only screening younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. The Fracture Risk Assessment tool (FRAX) tool can be used to calculate 10-year risk of osteoporotic fracture. Most guidelines do not specifically address how often a woman should undergo BMD testing. However, decisions about when to rescreen should probably be based on the results of initial screening. Women with normal BMD or mild osteopenia at baseline can be screened less often than women who are near the threshold for osteoporosis.
Treatment is generally recommended in women who have a t score < –2.5, who have already had a fracture or who have a t score in the osteopenic range but are at high risk for fracture. Treatment options for osteoporosis are described in Chapter 26.
Gourlay ML et al; Study of Osteoporotic Fractures Research Group. Bone-density testing interval and transition to osteoporosis in older women. N Engl J Med. 2012 Jan 19;366(3):225–33. [PMID: 22256806]
Institute of Medicine (IOM). Dietary reference intakes for calcium and vitamin D. http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D.aspx
Li K et al. Associations of dietary calcium intake and calcium supplementation with myocardial infarction and stroke risk and overall cardiovascular mortality in the Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition study (EPIC-Heidelberg). Heart. 2012 Jun;98(12):920–5. [PMID: 22626900]
U.S. Preventive Services Task Force. Screening for osteoporosis: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2011 Mar 1;154(5):356–64. [PMID: 21242341]
U.S. Preventive Services Task Force. Vitamin D and calcium supplementation to prevent cancer and osteoporotic fractures. http://www.uspreventiveservicestaskforce.org/uspstf/uspsvitd.htm
World Health Organization Collaborating Centre for Metabolic Bone Diseases. Fracture Risk Assessment Tool (FRAX). http://www.shef.ac.uk/FRAX/tool.jsp
Many sexually transmitted infections are asymptomatic in women and some can lead to significant consequences. Primary prevention of sexually transmitted infections includes postponing sexual debut, limiting number of sexual partners, and regular condom use.
The USPSTF and the Centers for Disease Control and Prevention recommend annual screening for Chlamydia trachomatis and gonorrhea in sexually active women age 25 and younger (see Chapter 30). Screening should continue in women over age 25 and in women who have high-risk sexual behaviors. The USPSTF recommends screening all women for HIV: including adolescents and women of age 15-65 years, others at high risk, as well as pregnant women. All patients who have a sexually transmitted infection or who seek testing for a sexually transmitted infection should be offered HIV testing. The CDC currently recommends screening all women born between 1945 and 1965 for hepatitis C infection.
Since depression is approximately two times more common in women than in men, clinicians should be alert to symptoms suggesting depression in women. Symptoms include depressed mood, loss of interest in activities, sleep disturbance, change in appetite or weight, psychomotor retardation, difficulty concentrating, feelings of worthlessness, and thoughts of suicide (see also Chapter 25). Low energy or fatigue is a particularly common symptom in women.
There are several clinical surveys for depression screening. The two question screen appears to be effective. Patients are asked "Over the past 2 weeks, have you felt down, depressed or hopeless?" and "Over the past 2 weeks, have you felt little interest or pleasure in doing things?" There is no evidence to suggest that any particular screening tool is superior. A positive screening test should lead to more extensive evaluation.
The USPSTF recommends screening for depression if staff-assisted depression care supports are in place to ensure accurate diagnosis, effective treatment, and follow-up. If these supports are not in place, screening is not recommended.
U.S. Preventive Services Task Force. Screening for Depression in Adults. http://www.uspreventiveservicestaskforce.org/uspstf/uspsaddepr.htm
Intimate partner violence (IPV) is a pattern of abusive behavior by a person who is in some type of intimate relationship with the victim. The abuse can be physical, sexual, or emotional and can include economic deprivation. Although anyone can be a victim of IPV, women are much more likely than men to be victims. Regardless of the type of abuse, the goal of the abuser is to gain control over the victim. IPV is common but is often not diagnosed, in part because patients try to hide the abuse.
The prevalence estimate of IPV varies depending on the setting. Rates are higher when measured in emergency departments than when measured in the general population. In a randomized controlled trial of IPV screening in emergency departments, the prevalence over 12 months ranged from 4% to 18%.
Risk factors for abuse include being young (under age 35 years); being pregnant; being single, divorced, or separated; alcohol or drug abuse in the victim or the partner; smoking; and being poor.
Since patients often do not volunteer that they have been abused, clinicians must be alert to clues that suggest abuse, including an explanation of the injuries that do not fit with what is being seen; frequent visits to the emergency department; and somatic complaint such as chronic headache, abdominal pain, and fatigue. The patient may be vague about some of her symptoms and may avoid eye contact. If the abusing partner is present, he or she may answer all the questions or may decline to leave the room. It is critical that the patient have the opportunity to speak with the clinician alone. The patient's description of the events should be carefully detailed in case there are any subsequent legal issues.
Physical examination often reveals injuries in the central area of the body. There may be injuries on the forearms as well if the patient tried to defend herself. As with any situation of expected abuse, bruises that are in various stages of healing may be an important clue. All physical examination findings should be well documented.
In addition to the physical consequences, abuse can have psychological consequences. Posttraumatic stress disorder, depression, anxiety, and alcohol or other substance abuse can develop in victims. Somatization is also very common among victims.
Several instruments have been developed to screen for IPV. These include the HITS (Hurt, Insult, Threaten, Screamed at) tool, the Women Abuse Screening tool (WAST), the Partner Violence Screen (PVS), the Abuse Assessment Screen (AAS), and the Women's Experience with Battering (WEB) scale. A systematic review of these screening tools showed that most tools only had been evaluated in a relatively small number of studies and the sensitivities and specificities varied widely within and between the tools.
Inclusion of one question in the context of the medical history, "Have you ever been hit, kicked, punched or otherwise hurt by someone within the past year? If so, by whom?" has been shown to increase identification of IPV.
Many studies have addressed how the questions about IPV are asked. In one randomized trial, women preferred written questionnaires over face to face interviewing.
Screening for IPV (in contrast to asking questions when IPV is suspected) has been advocated by many experts, although there has been controversy about whether or not it improves outcomes. In January 2013, the USPSTF updated its previous guidelines and currently recommends that clinicians screen women of childbearing age for IPV including domestic violence, and provide or refer women who screen positive to intervention services.
Interventions for IPV
Interventions can include encouraging the woman to leave the abusive situation, ensuring that she has a safe place to go, and counseling so that she can adequately assess her risk of danger and create a plan for safety. There is no evidence that treatment of the abuser changes abuser behavior.
When to Refer
Moyer VA. Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. preventive services task force recommendation statement. Ann Intern Med. 2013 Mar 19;158(6):478–86. [PMID: 23338828]
Nelson HD et al. Screening women for intimate partner violence and elderly and vulnerable adults for abuse: systematic review to update the 2004 U.S. Preventive Services Task Force Recommendation. Evidence synthesis No. 92. AHRQ Publication No. 12-05167-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; May 2012. [PMID: 22675737]
Eating disorders are common in women. Anorexia nervosa and bulimia nervosa are described in detail in Chapter 29. The female athlete triad, disordered eating in diabetics, and binge eating disorders are other eating disorders that should be considered in appropriate women.
Disordered eating.
Menstrual disorders.
Low BMD.
General Considerations
Female athletes who participate in sports and activities valuing thinness are at increased risk for developing the female athlete triad. The definition of the triad includes disordered eating (a spectrum of abnormal patterns of eating, including bingeing; purging; food restriction; prolonged fasting; and the use of diet pills, diuretics, or laxatives), menstrual disorders, and low BMD. Half of all athletes with amenorrhea have bone density at least 1.0 standard deviation below the mean. The bone density is decreased even in those areas subjected to stress during exercise. The diagnosis is made when the individual meets the three criteria of the triad.
Clinical Findings
Individuals with the female athlete triad display some pattern of disordered eating and have some menstrual irregularities. Many women have amenorrhea but others have irregular menses. Typically, the patient has concerns about weight and body image. A history of stress fractures should also raise the clinician's concern.
Depending on the severity of the symptoms and whether or not the patient is bingeing and purging, the laboratory abnormalities can be similar to those seen in anorexia nervosa or bulimia nervosa. BMD, if measured, is decreased.
Differential Diagnosis
The main differential diagnoses include anorexia nervosa, bulimia nervosa as well as endocrine disorders such as hyperthyroidism and diabetes mellitus.
Little evidence is currently available about treatment of the female athlete triad. Strategies such as counseling, cognitive behavior therapy, and possibly exercise restriction may be helpful. A multidisciplinary approach, including consultation with a nutritionist and communication with the coach and trainers, may enable common goal setting. The desire to participate in sports and the lure of a performance enhancing diet may motivate some patients to pursue treatment.
Binge eating.
Purging with laxatives or vomiting.
Insulin omission.
Taking less insulin than prescribed to lose weight.
General Considerations
Eating disturbances have been estimated to be present in up to one-third of young women with diabetes. Eating disorders are more common in adolescents with diabetes than in their non-diabetic peers. Mortality is particularly high in individuals with both diabetes and eating disorders.
For diabetes, the dietary regimen emphasizes intense meal timing and consistency. In addition, the hunger associated with hypoglycemia encourages binge eating. Diabetics with disordered eating have been shown to have an increased risk of retinopathy. Given the emphasis that young women often place on body weight, maintaining optimal diabetes control is a particular challenge. The diagnosis is typically made in a diabetic who has worsening diabetic control, when other causes of worsening control have been ruled out.
Clinical Findings
Diabetics may report polydipsia, polyuria, or weight loss. In addition, upon questioning, they may report disturbed eating patterns. Other symptoms associated with eating disorders, such as disturbance of body image and menstrual irregularities, may also be present.
The main laboratory finding will be a trend of increasing levels of hemoglobin A1C.
Differential Diagnosis
The main differential diagnosis includes looking for other causes of worsening glycemic control such as underlying infection or metabolic disease such as hyperthyroidism.
There is currently no evidence to support any particular strategies for the treatment of disordered eating in diabetic patients. Proposed strategies for at risk diabetic patients include nutritional counseling to promote healthy eating instead of dietary restraint, regular (instead of fixed) meal and snack times, less intensive insulin therapy to reduce weight gain, and family counseling to improve communication.
No studies have evaluated the optimal treatment of diabetic patients with established eating disorders. Presumably, strategies that are effective for patients without diabetes, such as cognitive behavioral therapy and medications, will be effective. In addition, diabetic management strategies that do not require the patient to constantly think about food may be beneficial.
Binge eating disorder consists of episodes of eating a large amount of food in a discreet period of time with a sense of lack of control.
Binge episodes characterized by at least three of the following:
– Eating large amounts of food when not feeling hungry.
– Eating more rapidly than normal.
– Eating until feeling uncomfortably full.
– Eating alone because of embarrassment about the amount of food consumed.
– Feeling disgusted, depressed, or guilty after eating.
Episodes occur at least two times a week for at least 6 months.
No compensatory behavior (purging, fasting, or excessive exercise) after eating.
General Considerations
Binge eating disorder is more common than either anorexia nervosa or bulimia nervosa, and, with the publication of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V), it is recognized formally as a diagnosable eating disorder.
Binge eating disorder is much more common in women and is associated with obesity, although not all individuals with binge eating disorder are obese. Obesity-related complications are likely to occur, and the disorder may be more common in weight cycling patients.
Clinical Findings
The patient may present with weight gain or may describe disordered eating patterns and binge eating episodes. There are no specific laboratory findings for binge eating disorder.
Differential Diagnosis
The main differential diagnosis includes other psychiatric and eating disorders. Other diagnostic possibilities include hypothyroidism and Prader-Willi syndrome.
Treatment goals focus on decreasing the patient's binge eating episodes and may include weight loss and treatment of other psychiatric comorbidities. As in bulimia nervosa, cognitive behavioral therapy is the mainstay of treatment. Interpersonal therapy has also been shown to be effective. Pharmacotherapy with selective serotonin reuptake inhibitors is also helpful, but does not appear to be better than cognitive behavioral therapy.
National Institute for Health and Clinical Excellence. Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders.http://www.nice.org.uk/CG009
Young V et al. Eating problems in adolescents with Type 1 diabetes: a systematic review with meta-analysis. Diabet Med. 2013 Feb;30(2):189–98. [PMID: 22913589]
Sexual health is defined by the World Health Organization as a state of physical, emotional, mental, and social well-being in relation to sexuality. Healthy sexual functioning therefore depends on a complex interplay of physical, psychological, and societal factors. Among the more than 30,000 women who were surveyed about their sexuality in the PRESIDE study, 9–12% reported having a sexual problem that caused personal distress or interpersonal difficulties. The female sexual disorders identified in the DSM-V include female sexual interest/arousal disorder, sexual aversion disorder, female orgasmic disorder, and genito-pelvic pain/penetration disorder (these are discussed in detail in Chapters 18 and 25). Several medical conditions (depression, diabetes, urinary incontinence, and multiple sclerosis) and medications (antidepressants, hormonal therapy, antihypertensives) can contribute to the development of female sexual disorders. Clinicians should routinely assess patients' sexual health during office visits; even a brief assessment provides patients with reassurance that this is an important topic. Providers can broach the subject using a broad question, such as "What concerns or questions do you have about your sexual functioning?" and then follow-up with more specific questions, including "Do you have difficulty with desire, arousal, or orgasm?" and "If you are not currently sexual, are there any particular problems that are contributing to your lack of sexual behavior?" Patient concerns can then be delineated more fully during the complete sexual assessment, which encompasses details about medical, surgical, and psychiatric problems, as well as medications and reproductive history. Treatment options depend on the diagnosed disorder and can include psychosexual and hormonal therapy (seeChapter 18).
Kingsberg SA et al. Female sexual disorders: assessment, diagnosis, and treatment. CNS Spectr. 2011 Feb;16(2):49–62. [PMID: 21419070]
World Health Organization. Measuring sexual health: conception and practical considerations and related indicators. World Health Organization, 2010, Geneva, Switzerland.http://www.who.int/reproductivehealth/publications/monitoring/who_rhr_10.12/en/index.html
Noncyclic pain.
Duration of 6 months or more.
Localized to anatomic pelvis, anterior abdominal wall at or below the umbilicus, the lumbosacral back, or buttocks.
Associated with functional disability.
General Considerations
Chronic pelvic pain (CPP) is defined as noncyclic pain lasting at least 6 months that localizes to the pelvic girdle region; it must be of sufficient severity to cause functional disability or necessitate medical care. CPP may result from gynecologic, urologic, gastrointestinal, musculoskeletal, or neurologic disorders. Although endometriosis is the most common gynecologic condition associated with CPP, postoperative adhesions, pelvic congestion, and chronic pelvic inflammatory disease should also be considered. Interstitial cystitis, irritable bowel syndrome, and myofascial pain syndrome arising from trigger points in the abdominal musculature or pelvic floor have all been associated with CPP. Sensation to the pelvis is supplied by nerves arising from thoracolumbar and sacral nerve roots. Thus, spinal pathology or direct injury to the pudendal nerve can produce CPP. It is important to remember that most women with CPP have multiple diagnoses contributing to their pain.
Clinical Findings
Certain features of the history and physical examination can provide clues to the underlying diagnosis. Patients should be asked about the location, quality, and intensity of their pain as well as the relationship with the menstrual cycle, sexual activity, urination, and defecation. Dysmenorrhea and dyspareunia are often experienced by patients with endometriosis, whereas dysuria, urgency, and frequency in association with pelvic pain are characteristic of interstitial cystitis. Pain related to pelvic varices is usually postural, worsening with prolonged standing and improving with leg elevation. Patients with irritable bowel syndrome often report abdominal pain, distention, and diarrhea or constipation. Clinicians should ask patients about surgery or direct trauma involving the spine or pelvis, which may suggest musculoskeletal sources of pain. The physical examination, including the pelvic examination, is usually quite painful in the patient with CPP and should be done carefully. Palpation of the thoracic and lumbar spine, pelvic girdle, and abdomen can reveal areas of discomfort that refer to the pelvic area. A positive Carnett test (constituted by an increase in tenderness when the abdominal muscles are tensed) can be helpful for identifying abdominal wall trigger points. A single-digit internal vaginal examination should be done to localize the exact area of pain and to assess for trigger points along the pelvic floor muscles. Palpation of the pelvic viscera can help identify localized areas of tenderness in women with endometriosis or chronic pelvic inflammatory disease. The external genitalia should also be examined carefully to identify areas of vulvar discomfort because vulvodynia often coexists in patients with CPP. Notably, the absence of physical examination findings does not rule out significant pathology.
Women who are at high risk for pelvic infection should be screened with cervical swabs for chlamydia and gonorrhea.
Pelvic ultrasonography is useful for evaluating the pelvic anatomy, investigating localized areas of tenderness, and identifying pathology. Laparoscopy may be helpful for diagnosing endometriosis or pelvic adhesions, although 35% of diagnostic laparoscopies are normal in patients with CPP.
Differential Diagnosis
CPP is frequently a manifestation of another disease, as noted above. When considering various diagnoses, it is important to differentiate extra-pelvic from intra-pelvic sources of pain. Musculoskeletal disorders involving the spine, hips, and sacroiliac joints may cause referred pelvic pain, whereas endometriosis, chronic pelvic inflammatory disease, and pelvic congestion are typically associated with tenderness of the pelvic viscera. Similarly, abdominal wall or hip girdle trigger points that cause CPP can be easily differentiated from trigger points in the levator ani and perineal muscles.
Medical treatment may focus on managing the chronic pain, the underlying condition, or both. Analgesics are commonly used, and nonsteroidal anti-inflammatory drugs (NSAIDs) are typically helpful. However, patients and clinicians should be cautious about long-term use of these medications because long-term NSAID therapy can be associated with significant gastric toxicity. Antidepressants (eg, amitriptyline) and antiseizure medications (eg, gabapentin) (see Table 5–4), which have demonstrated efficacy in the treatment of other pain syndromes, may also be useful for CPP. Opioid therapy improves pain but not functional or psychological outcomes and should generally be avoided.
Hormonal therapies are used primarily for treating gynecologic sources of CPP. Women with endometriosis often benefit from treatment with combined oral contraceptive pills, which suppress ovulation and reduce dysmenorrhea. Gonadotropin-releasing hormone (GnRH) agonists and progestins improve pain associated with endometriosis and pelvic varices. The decrease in BMD associated with GnRH agonist treatment can be mitigated with estrogen or progesterone add-back therapy. Treatment with medroxyprogesterone improved pain scores in women with pelvic congestion, but symptoms returned with cessation of treatment.
Medical therapies directed at the treatment of nongynecologic sources of CPP, including interstitial cystitis and irritable bowel syndrome, are discussed in Chapters 15 and 23. Physical therapy and injection of identified trigger points provide significant pain relief in patients with musculoskeletal sources of pain. Psychological evaluation and treatment should also be strongly considered as many women with CPP experience anxiety and depression.
Surgical treatment of CPP requires referral to a gynecologist. Condition-specific surgical treatments include ovarian or pelvic vein embolization in women with pelvic congestion syndrome or adhesiolysis in patients with pelvic adhesions. Women with endometriosis may be offered laparoscopic surgical destruction of implants or laparoscopic utero-sacral (LUNA) nerve ablation for relief of their chronic pain. Importantly, the efficacy of some of these surgical techniques is controversial. According to a recent systematic review, lysis of adhesions and LUNA were no more effective than diagnostic laparoscopy for improvement in pain scores. Women with endometriosis who have persistent disease after medical and surgical therapies may benefit from hysterectomy, although it is controversial as to whether concomitant oopherectomy improves symptoms further.
When to Refer
Patients should be referred to a gynecologist for diagnostic or therapeutic surgical procedures, if the underlying diagnosis is unclear, or if the provider feels uncomfortable managing side effects associated with medical treatments (ie, GnRH agonist therapy).
Andrews J et al. Noncyclic chronic pelvic pain therapies for women: comparative effectiveness [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Jan. Available fromhttp://www.ncbi.nlm.nih.gov/books/NBK84586/[PMID: 22439157]
Engler D et al; European Association of Urology. Guidelines on chronic pelvic pain, 2012. http://www.uroweb.org/gls/pdf/24_Chronic_Pelvic_Pain_LR%20II.pdf
Shin JH et al. Management of chronic pelvic pain. Curr Pain Headache Rep. 2011 Oct;15(5):377–85. [PMID: 21556711]
Stacy J et al. Persistent pelvic pain: rising to the challenge. Aust N Z J Obstet Gynaecol. 2012 Dec;52(6):502–7. [PMID: 22998335]
Infection, malignancy, and extramammary conditions can cause breast pain.
Abnormal physical examination findings, such as a breast mass or skin abnormalities, should prompt radiographic imaging.
General Considerations
Breast pain, or mastalgia, is categorized as cyclical, noncyclical, or extramammary. Although minor breast discomfort is commonly associated with the normal menstrual cycle, women with cyclical mastalgia typically have moderate to severe pain that can last more than 5 days. Cyclical mastalgia can be diagnosed only in reproductive-age women who experience breast pain as a result of the hormonally-mediated proliferation in breast tissue that occurs with ovulation. In contrast, noncyclical mastalgia has no relationship to the menstrual cycle and can occur in premenopausal or postmenopausal women. Causes of noncyclical mastalgia include large breast size (with stretching of Cooper ligaments), medications, pregnancy, thrombophlebitis, or inflammatory breast cancer. Extramammary mastalgia is caused by pain that is referred from other anatomic locations, including the chest wall, heart, gallbladder, or spine. Trauma or previous surgery may also produce extramammary pain.
Clinical Findings
Cyclical mastalgia is often described as a deep, heavy, aching pain, which is typically diffuse and bilateral and is clearly associated with the menstrual cycle. Conversely, noncyclical pain, which may be constant or intermittent, is variable in location and can involve one or both breasts. Chest wall pain, a frequent cause of extramammary mastalgia, typically causes unilateral, burning pain that may be either localized or diffuse. Malignancy-associated mastalgia is often severe, progressive, and unilateral.
Breast cancer may be associated with mastalgia, and thus a careful physical examination is essential in all women who report breast pain. Large, pendulous breasts may be observed in women who have noncyclical pain caused by stretching of Cooper ligaments. Chest wall pain is usually related to inflammation or injury to the pectoralis major muscle; it may be reproduced by palpation or by having the patient place her hand on her hip and push inward. Any palpable breast mass must be evaluated further with radiologic imaging.
An ultrasound, mammogram, or both should be obtained in women who have a palpable breast mass or localized breast pain or who are at an increased risk for breast cancer. Women with diffuse breast pain who are at average risk for breast cancer and who have a normal physical examination do not require further imaging and can be reassured. However, the clinician should ensure that all patients with mastalgia are up to date on routine screening mammography, as appropriate for their age and personal risk factors.
Differential Diagnosis
Malignancy must be ruled out in all patients with mastalgia, and this is usually accomplished through a careful history, physical examination, and diagnostic imaging in patients with clinical abnormalities, such as a palpable breast mass. Extramammary causes of breast pain include chest wall pain, spinal or gallbladder disease, and myocardial ischemia.
Women with cyclical mastalgia who have a normal physical examination and are up to date on routine mammographic screening should be reassured about the benign nature of their symptoms and monitored closely. Cyclical and noncyclical mastalgia often improve with use of a supportive bra. Although there is conflicting evidence regarding the benefit of vitamin E, some experts advocate its use (at a dose of 2000–3000 mg daily) for women with cyclical breast pain. Topical NSAIDs, such as diclofenac gel or patch, improve localized breast pain.
Women who experience severe and persistent cyclical mastalgia despite adherence to conservative measures may be offered hormonal treatment. Danazol, a synthetic androgen that inhibits ovulation, is the only medication that has been approved by the Food and Drug Administration (FDA) for the treatment of cyclical mastalgia. However, side effects associated with treatment are common and include weight gain, menstrual irregularities, voice deepening, and hot flashes. Tamoxifen therapy is tolerated well by most women, and many experts recommend it as first-line therapy for the treatment of cyclical mastalgia. Patients treated with tamoxifen should be counseled about the possibility of hot flashes and menstrual irregularities (experienced by up to 10% of women), as well as the risk for more serious adverse events, such as thromboembolic disease and endometrial cancer.
Symptoms of cyclical and noncyclical mastalgia improve without pharmacologic treatment in most women.
When to Refer
Patients with mastalgia and a palpable breast mass should be referred to a breast surgeon, even if the results of diagnostic imaging are normal.
Rungruang B et al. Benign breast diseases: epidemiology, evaluation, and management. Clin Obstet Gynecol. 2011 Mar; 54(1):110–24. [PMID: 21278510]
Salzman B et al. Common breast problems. Am Fam Physician. 2012 Aug 15;86(4):343–9. [PMID: 22963023]
Diagnostic imaging is essential for any women with a palpable dominant breast mass, regardless of her age.
Ultrasound is the initial test of choice for women under the age of 30; diagnostic mammography with or without ultrasonography is performed initially in women over the age of 30.
General Considerations
Palpable breast masses may be detected by a patient during breast self-examination, or may be identified by the provider during a routine physical examination. A breast mass may be a presenting symptom of breast cancer, and thus a thorough work-up of any palpable breast mass is essential, regardless of age and personal risk factors for breast cancer (see Chapter 17). Common benign causes of palpable breast masses include fibrocystic condition, cysts, and fibroadenomas.
In general, the benign causes of a palpable breast mass have a favorable prognosis. Many women with breast pain and palpable masses due to fibrocystic condition have spontaneous resolution or have improvement in their symptoms with menopause. Benign simple cysts that are asymptomatic may be followed clinically, and symptomatic cysts should resolve with aspiration.
Certain pathologic diagnoses increase the risk of breast cancer, including papillary lesions, radial scars, atypical ductal or lobular hyperplasia, and lobular carcinoma in situ. FNA biopsy or core-needle biopsy results that indicate one of these diagnoses necessitate referral to a breast surgeon for further evaluation and management.
When to Refer
– If diagnostic imaging indicates that the mass \has suspicious features.
– If the mass persists and diagnostic imaging is normal.
– If the mass is categorized as probably benign on diagnostic imaging, but there are worrisome features on physical examination or there is a high clinical suspicion for malignancy.
– If diagnostic imaging demonstrates a complex cyst, or aspiration of a simple cyst reveals a bloody aspirate.
– If the biopsy demonstrates a lesion with an increased risk of breast cancer (papillary lesions, radial scars, atypical hyperplasia, lobular carcinoma in situ).
– If the biopsy results are discordant with the physical examination and radiographic findings.
Ferrara A. Benign breast disease. Radiol Technol. 2011 May–Jun;82(5):447M–62M. [PMID: 21572066]
Rungruang B et al. Benign breast diseases: epidemiology, evaluation, and management. Clin Obstet Gynecol. 2011 Mar; 54(1):110–24. [PMID: 21278510]
Salzman B et al. Common breast problems. Am Fam Physician. 2012 Aug 15;86(4):343–9. [PMID: 22963023]
Nipple discharge is a common breast complaint but is rarely indicative of malignancy. Nipple discharge that comes from multiple ducts, is bilateral, and is produced only with squeezing is considered physiologic, and no further work-up is necessary. Milky discharge that is bilateral, spontaneous, and not associated with pregnancy or breastfeeding is termed "nonlactational galactorrhea." The most common cause of nonlactational galactorrhea is an elevated prolactin level, which may be associated with pituitary or hypothalamic lesions, systemic diseases (hypothyroidism, renal disease), or medications. Women who have bloody discharge, persistent spontaneous unilateral discharge from a single duct, or discharge associated with a palpable breast mass should be referred for diagnostic mammography and ultrasonography and surgical consultation. These features are suggestive of a pathologic diagnosis, such as papilloma, duct ectasia, or malignancy. Surgical excision of the involved duct is the gold standard for diagnosis. See also Chapter 17.
Huang W et al. Evaluation and management of galactorrhea. Am Fam Physician. 2012 Jun1;85(11):1073–80. [PMID: 22962879]
Salzman B et al. Common breast problems. Am Fam Physician. 2012 Aug 15;86(4):343–9. [PMID: 22963023]
Female pattern hair loss (FPHL) affects more than 20 million women in the United States. This type of alopecia is characterized by shortening of the anagen (growth) phase and follicle miniaturization. Clinically, presenting signs include diffuse thinning over the central scalp and a prominent midline part; the frontal hairline is typically spared. Although occasionally FPHL may be a sign of hyperandrogenism associated with congenital adrenal hyperplasia, androgen-secreting tumors, or polycystic ovarian syndrome, most women have normal levels of serum testosterone.
Topical minoxidil is currently the only medication that has been approved by the FDA for the treatment of FPHL. In a systematic review of several treatments for FPHL, treatment with topical minoxidil was consistently shown to result in moderate hair re-growth in affected women. When both are applied twice daily, the 2% solution of minoxidil is as effective as the 5% solution and is associated with fewer adverse events. The most common side effect of minoxidil is facial hypertrichosis, which can affect 3–5% of women, but this typically resolves after 1 year of treatment. Spironolactone and cyproterone acetate are oral antiandrogens that have been used for the treatment of FPHL, although there are limited data to support this practice. Importantly, both of these medications can cause feminization of a male fetus and should be used cautiously in reproductive-age women.
Atanaskova Mesinkovska N et al. Hair: what is new in diagnosis and management? Female pattern hair loss update: diagnosis and treatment. Dermatol Clin. 2013 Jan;31(1):119–27. [PMID: 23159181]
van Zuuren EJ et al. Evidence-based treatments for female pattern hair loss: a summary of a Cochrane systematic review. Br J Dermatol. 2012 Nov;167(5):995–1010. [PMID: 23039053]
Minimally invasive aesthetic procedures are now commonly used to treat mild to moderate age-related changes in the face. These procedures are generally safe and are associated with long-lasting and natural results.
Visible signs of aging in the face result from changes in muscular tone and balance, volume loss, decreased skin elasticity, and changes in skin color and texture. Facial rejuvenation procedures can be grouped into three categories based on their mechanism of action. Neuromodulators are used to produce temporary chemodenervation of hyperactive facial muscles, thereby smoothing facial wrinkles. Soft-tissue fillers restore volume loss, and laser and light-energy based devices improve skin laxity and reflectance. Chemical peels and topical medications are considered adjunctive treatments for improving skin appearance.
For each of the three treatment categories, several options are available. The injectable neuromodulators currently approved by the FDA include various formulations of botulinum toxin A. Dermal fillers include collagen, hydroxylapatite, hyaluronic acid, and injectable poly-L-lactic acid, and differ from each other in their degree of cross-linking, gel hardness, and ability to resist dilution. Among these, hyaluronic acid fillers have become increasingly popular and have been approved by the FDA for treatment of nasolabial folds and lip augmentation; they have also been used off-label to treat wrinkles and improve facial volume. Combination therapy with botulinum toxin A and hyaluronic acid is often used in the eyebrow and eyelid regions to achieve more satisfying cosmetic results. Light-based therapy, which includes laser, radiofrequency, and infrared devices, is typically used to improve elasticity in in the upper eye area. Skin laxity may improve by as much as 30–50% with one treatment, depending on the device used.
Kontis TC et al. Contemporary review of injectable facial fillers. JAMA Facial Plast Surg. 2013 Jan;15(1):58–64. [PMID: 23183718]
Sundaram H et al. Nonsurgical rejuvenation of the upper eyelid and brow. Clin Plast Surg. 2013 Jan;40(1):55–76. [PMID: 23186756]
Wollina U et al. Minimally invasive aesthetic procedures in young adults. Clin Cosmet Investig Dermatol. 2011;4:19–26. [PMID: 21673871]


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Separate names with a comma.
Discussion in 'Football' started by RedBlooded, Dec 7, 2011.
anyone know where to find them?
Color it Cardinal - Welcome to Cy's Locker Room - The Official Store of the Iowa State Cyclones - Gear Up Today!
Listed as "In-stock 12/9/2011"
those are cool as ****
I wonder if RU is doing the same
Here's the direct link to the Bowl products:
Pinstripe Bowl :: Cy's Locker Room
I doubt it. Better buy a bunch of these before they run out.
Iowa State University Bookstore : Merchandise List
Not complaining about the apparel but will there be anymore items that anyone knows of? I wanted to get my dad a nice fleece, zip up jacket or something alittle nicer than a tshirt with the Pinstripe logo...
Also, does anyone know whether they will be getting in apparel with helmets or logos from both teams on them like they usually do a little later?
I am actually pretty underwhelmed by what is there...am I missing something?
Agreed those are ugly, any chance Nike could come out with something?
I found a pretty good deal on New Eras website...
If you go to the New Era and do a search for Pinstripe you will get this: New Era - Authentic headwear and apparel including the official on-field cap of MLB. Fly Your Own Flag.
If you get the first 3 items (hat, shirt & knit) you get free shipping. (has to be over $30)....use promo code neweravip and that will take off 15%. So you get all three items for $27 bucks shipped! Not a bad deal imo

subset: commoncrawl


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A few years ago, we did a super fun unit from Discipletown called "How to Use My Bible". We taught the kids all about the Bible dictionary, index, concordance, along with maps and atlases. Of course, we started to look for ways for kids to practice using these "Cool Bible Tools". One week, after I had taught a lesson on on the 12 Spies (Numbers 13), I assigned a key word from the story to each student. I set up tables like the picture below, complete with crayons and cool Bible … [Read more...]
Archives for October 2013
Day 30: Journey to the Promise Land {31 Days of Bible Crafts}
Ark of the Covenant {31 Days of Bible Crafts}
We did this craft the week we talked about crossing the Jordan river in Children's Church (Joshua 3), but it would fit a number of passages. In fact, this week in Kids' Club, we're in 2 Samuel 6 (David dances before the Lord) and it would be perfect for that lesson as well! Based on the description in Exodus 25, we know that the ark was covered in gold. I wanted to give the ark a bit of sparkle, but we had just used glitter the week before and I didn't want to push my luck too much with the … [Read more...]
Day 28: 12 Spies {31 Days of Bible Crafts}
Today's crafts and activities are based on the story of the 12 Israelite Spies found in Numbers 13. If you'd like to check out all the posts from this 31 Days of Bible Crafts Series, head to the introduction post. Lesson Time During the lesson time, I gathered the kids around a small floor stage and used little people to tell the story. I created a Canaanite giant using a covered oatmeal canister. The kids absolutely loved the presentation. It was new and novel for them and they were … [Read more...]
Moses and the Burning Bush {31 Days of Bible Crafts}
This Bible craft is based on Exodus 3 and would be great for almost any age. This is actually a craft from my kids' Tiny Tots class (ages 2-3). I absolutely love the teachers in that class and it is so fun hearing all about their lesson each week. Keep up the good work, friends! What You Need: Green Construction paper, cut into tree shape (if you have little ones) Brown Construction paper, cut into tree shape (as shown) Small square pieces of orange, red, and yellow tissue … [Read more...]
Fall Block Party: Pumpkin Sign Up Sheet
It's that time of year again: Halloween. Time for churches to decide how they are going to address this controversial holiday. We've been doing a block party for about 3 years now (read my reasoning here). This year, we're adding glow-in-the-dark balloons with our church's name imprinted on them, so I'm pretty excited about that (pictures to come!). As with last year, we decided to do our main recruitment with a pumpkin sign-up board. However, we also included a sign up form in the … [Read more...]
Day 24: Who's Who in the Bible {31 Days of Bible Crafts}
I hope you've been enjoying this 31 Days of Bible Crafts series at Growing Kids Ministry! I can't believe this month is almost up. We've been busy planning our Halloween Block party and I can't believe how quickly the big day is coming up. Today, I'm going to share more of an activity than a craft, but I think you'll still find it quite useful. Early this year we went through Zondervan's "The Story", and one week we talked about three central characters: Manasseh, Josiah, and Jeremiah. … [Read more...]


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Don't Throw Pity Parties!
- 2015 28 Aug
Danica set alone in her living room weeping; she was grieving. She had lived in her present home for close to 6 years. She had lovingly decorated each and every room. She was relocating for her new job.
Danica was excited to start her new career, but was overwhelmed with memories and the sadness of leaving what she knew. There was a knock at the door. A neighbor, who had recently moved, came to say hello and share news.
The elderly couple down the street was going through a very difficult time; the husband had cancer and was not expected to recover. Danica and her ex-neighbor had been praying for the couple. What a joy to find they had both accepted the Lord. What a jolt in perspective for Danica; her pity party was over!
(Psalms 71:21) You will increase my honour and comfort me once again.
Dr. David Hawkins is the director of the Marriage Recover Center where he counsels couples in distress. He is the author of over 30 books, including Dealing With the CrazyMakers in Your Life, 90 Days to a Fantastic Marriage, and When Pleasing Others is Hurting You. Dr. Hawkins grew up in the beautiful Pacific Northwest and lives with his wife on the South Puget Sound where he enjoys sailing, biking, and skiing. He has active practices in two Washington cities. You can also find Dr. Hawkins on Facebook and Twitter. Dr. Hawkins offers a free, 20 minute consultation, with requests sent to his email address at [email protected]. Also, remember his guarantee at The Marriage Recovery Center: 3 Days To A New Marriage, Guaranteed!


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- Please select a date to see the proper prices!
Description of the accommodation:
Rooms, services Santa Marina Hotel Agios Nikolaos is offering 198 comfortable rooms to guests looking for accommodation in Agios Nikolaos. The fans of actively spent leisure time may take the billiard opportunities nearby. For meetings and nice evening chats the local café or the bar will provide an ideal location. In the safe you may secure your valuables. If you wish to learn more about the exact scope of services provided by Santa Marina Hotel Agios Nikolaos (including any available for an extra fee), you will find them on the information sheet below.
Payment Advance payment by credit card or providing credit card guarantee may be necessary for finalizing the reservation, depending on the chosen date, room and price.
Arrival, opening hours You will be able to speak with the personnel in Greek and English languages.
Santa Marina Hotel Agios Nikolaos rooms Rooms
- Please select a date to see the proper prices!
Accommodation services
- Pool (Outdoor - seasonally open)
Garden, Bar, Cafe, Elevator, Safe deposit box
Hairdryer, Fridge


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7UNION "Skull Rocks" Snapback Cap
Posted by Maui, May 28th, 2013 03:05 am under 7Union
Skulls generally are viewed as death in metaphorical sense. However, with 7UNION's new " Skull Rocks" cap, it's actually quite the opposite experience. What brings the cap alive is the front embroidery on a Black canvas. Next to the snaps in the back "F**k You Heroes" is written in White. Get yours now at http://store.esptrickstar.com/.


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CFA Society Chicago Events
Event Detail
Candidate Mix & Mingle! (Private Invitation Only) (Ended)
Date, Time, and Location:
Program Description
Kaplan representatives will be available to answer any questions you may have about the upcoming exams. They will also be raffling off prizes including a *FREE Live 3-day Review for the Chicago location for April 28-30 (must be present to win)!
Kaplan Representative:
Fee: Complimentary by Email Invitation Only
Attire: Business Casual
Menu: Drinks and appetizers
Note: This event is Private Invitation Only. Invitees will receive an email with a private link that must be used to register online for this event. Cancellations accepted until 5:00 pm, March 24.
Hosted by: CFA Society Chicago and Kaplan Schweser
Kaplan Schweser Raffle Prize Details
* The Live 3-Day Review Workshop
With a balanced mix of CFA® curriculum review and problem solving, Schweser's 3-Day Review Workshop is just the thing to get you exam-ready. After reviewing each topic of the CFA curriculum, instructors use problems and exam-like questions to help reinforce your knowledge, practice your exam techniques, and improve your exam-taking skill and speed. It's exactly what you need during the final weeks of preparation in order to build your confidence and perform effectively on the CFA exam. The workshop includes:
*Special Notes Regarding Fees:
Passport Program
Content shared during CFA Society Chicago programs is not, and nothing in it should be construed as, an offer, invitation or recommendation of any specific financial services company or professional, or an offer, invitation or recommendation to sell, or a solicitation of an offer to buy, any securities in any jurisdiction. By registering for and attending this event, you acknowledge that any photographs that may be taken are the property of CFA Society Chicago and give your consent to their use in CFA Society Chicago's online and print business communications and marketing.


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First Time Offer1 PINE CT -
First time Offering on this great home to entertain family and friends in. Exterior Features include 20 x 36 in ground pool surrounded with patio area ,pool cabana, basketball court ,2 car carport,garage on a beautiful corner lot located in a wonderful neighborhood of Wynantskill. Interior offers mother in law quarters. Kitchen leads to the additional dining room and upstairs covered porch. New windows and roof all done for you. Come See !
Listing information
- Year Built: 1963
- Status: Sold on 12/17/2014
- Parking Type Description: Built-In / Tuckunder 2 cars
- Below Ground Sq. Feet: 702
- County: Rensselaer
- Property ID: 103505494
- Beds: 4
- Total Rooms: 8
- New Construction: No
- Lot Size: 125 X 120
- Neighborhood: Wynantskill
- Style: Raised Ranch
- Baths: 2 (Full: 1 3/4: 0 1/2: 1 Other: 0)
- Stories: 2
- Total Square Footage: 1,348 ($133.46 per sq. foot)
- Estimated Annual Taxes: $4,300
- School District: Wynantskill
Age Description Estimated
Amenities Bay Window, Built In Cabinets, Ceramic Tile, Wood Floors
Appliances Range W Oven, Refrigerator, Washer Dryer
Attic Hatch
Basement Slab
Condition Good
Cooling Type Central Air
Exterior Vinyl
Exterior Features Patio, Pool In Ground, Porch, Shed
Garage Description Under Residence
Heat Fuel Natural Gas
Heat System Hot Air
Interior Features Garage Door Opener
Lot Description Corner
Other Lot - 125 X 120, Possession - At Closing, Tax Id Section - 124.9, Tax Identification Block - 18, Tax Identification Lot - 4
Roof Asphalt Shingle
Sewer Public
Sign Yes
Total Taxes Description Estimated
Water Public
Bedroom Main Level
Bedroom Main Level
Bedroom Main Level
Dining Room Main Level
Kitchen Main Level
Living Room Main Level
Bedroom Basement
Family Room Basement
Listed by Judy Sanders of Coldwell Banker Prime Properties 518-477-1000


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Dr. Yagnik Road Corner, Near Malaviya Petrol Pump,
Starting from
Rs 1195
Hotel Overview
Hotel Silver Palace, among the premier 3 Star Business Hotel in Rajkot, the economic capital of Saurashtra is characterised by the traditional Kathiawari hospitality.
Hotel Silver Palace offers the most luxurious accommodation in Rajkot. Each room is elegantly well appointed and equipped with complete amenities. Contemporary design having touch of elegance, with subtle tones of neutral colours, soft and discrete lighting, plush decor and finest hospitality makes Silver Palace the ideal choice for businessmen & tourists. We have 4 types of room category : - Comfort Room Standard Room Deluxe Room Exe Deluxe Room
Flavours Internationally styled restaurants in Rajkot, provide you a thoroughly restful, totally pampered marvellous ambience with superb hospitality. We mainly serves Indian, Chinese, Mexican & Continental Cuisine.
Check-Out-Time : - 12:00 noon.
Hotel Silver Palace
Dr. Yagnik Road Corner, Near Malaviya Petrol Pump, Gujarat, India, - 360001


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360Cut 360Sport - Mango
Product Overview
360Cut 360Sport - Mango
360Cut 360Sport - Mango
Sport Performance Supplement
319 Grams
AllegroMedical.com presents The 360Cut 360Sport - Mango Sport Performance Supplement. Performance Supplements; BCAA & MCT Formula; Dietary Supplement; Great tasting formula promotes optimal athletic performance*; All natural MCT oil promotes lean muscle mass production & fat burning*; Boosts energy, endurance & muscle recovery* (*These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.)
As a dietary supplements, mix 1-2 scoops with 8-20 oz. of water during workout. Read warnings and only use as directed. This product may also be sipped on throughout the day during non-workout times. Individuals over 200lbs may take 2 or more scoops as desired.
Natural and Artificial Flavors, Citric Acid, Sucralose, and Silicon Dioxide.
Not intended for persons under the age of 18. Do not use if pregnant or nursing. Consult a healthcare professional prior to consumption if you have any pre-existing medical conditions or are taking any prescription medications. Improper use of this product will not improve results and is potentially hazardous to a person's health. Use only as directed. Do not use if the safety seal is missing or broken. If you experience ill feelings or any other adverse effects discontinue this product immediately and consult with healthcare professional. KEEP OUT OF REACH OF CHILDREN.
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360Cut 360Sport - Mango
360Cut 360Sport - Mango Reviews Summary
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360Cut 360Sport - Mango
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Part Number(s): 171 582560 01
Mfg Part Number(s): 7870016
Scrip Part Number(s): 171 582560 01
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Adding this item to your shopping cart won't require you to buy it. However, our prices do change. If you decide to purchase this item now you are guaranteed the price now displayed in your shopping cart. Complete your purchase by clicking on the "checkout" button or simply remove the product from your cart if you decide not to make your purchase at this time.


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Rode SM5 Camera Ring-Clamp Shock Mount for NT3/4/5 and NTG1/2/3
The Rode NTSM5 is a suspension shock mount with ring clamp adaptor for RØDE Microphones to be used with high end cameras. The design of the suspension shock mount means the microphone is physically isolated from the stand ensuring that there is no unwanted rumble or vibrations in your recording.
Main Features
- Shock mount with ring clamp adaptor
- Isolates your mic from unwanted vibration
- Compatible microphones : NT3, NT4, NT5, NT55, NTG-1, NTG-2, NTG-3
- This product will be ordered in from our suppliers as required. Please contact us for availability.
This item is normally sent to Mainland UK addresses by DPD who generally provide a one-hour window of delivery on the morning of delivery by email or text message. If you need this item faster, please upgrade to a Before 12 service at checkout.
Mainland UK: £3.50 within mainland UK ( Orders over £99 are delivered FREE )
UK Non-Mainland: £ 12
Rep. of Ireland and Mainland Europe: from £ 15 (calculated at checkout).
Order this item before 4pm and receive it on the next working day, mainland UK only*
1 Recommended Accessory
Additional Information
On demo in store No Brand Rode Condition New


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Woodside Buys ConocoPhillips's Senegal interests
Woodside completed the transaction to buy 100% of the shares in ConocoPhillips Senegal B.V.
The total purchase price was US$350 million plus net customary adjustments of approximately US$90 million.
Woodside CEO Peter Coleman said the acquisition was an exciting addition to Woodside's global growth portfolio.
"We look forward to working with the Government of Senegal and joint venture participants Cairn Energy, FAR Limited, and Petrosen, the Senegal National Oil Company, to progress the commercial development of the SNE and FAN discoveries.
"Woodside will bring to the joint venture expertise in deep water drilling, development and operation of subsea infrastructure and floating production storage and offloading vessels.
"We acknowledge the work of ConocoPhillips in closing this deal," he said.
The transaction includes a 35% working interest in three offshore exploration blocks, which contain the SNE and FAN deep water oil discoveries.


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Stock Graphic >> Icon - Juicicons 47499 by nerdstuff. @ CreativeMarket
File Size: 7.63 MB; Layered: Yes; Vector: Yes.
A Juicy & Delicious Icon Set
Over 200 Pixel Perfect, Fully Scalable Tasty Treats.
Juicicons look and taste just like real icons. Crafted in Illustrator, Juicicons are available in a wide variety of flavours including AI, PS, PNG, SVG, & SKETCH. All icons are royalty free for personal and commercial use, customize as you see fit and add sugar to taste. Enjoy!
1. Ai Source Files - Adobe Illustrator vector source files with editable layers
2. PS Source Files - Pixel perfect Adobe Photoshop source files
3. Sketch Source Files - Bohemian Coding's Sketch 3 source files
4. PNG Files - Individual PNG files for each icon
5. SVG Files - Use SVG files to quickly create web fonts
6. Lotta Love - Countless hours of tears and sweat into each icon
Keywords: icons, icon, juicicons, outline, line, iconset, set, vector, svg, simple, elegant, clean, illustrator, minimal, web design, shapes, retina, weather, commerce, food.


text: Human Rights Observatory Obama Hails Climate Deal as 'Best Chance' to Save Planet President Barack Obama is hailing the climate change agreement reached in Paris as a potential turning point for the world. "This agreement represents the best chance we've had to save the one planet that we've got," he said Saturday. In an eight-minute statement, Obama said that by approving the deal, 195 nations have shown that they have both the will and the ability to take on the challenge of climate change by reducing carbon emissions and committing to a low-carbon...Read complete article© Voice of America - Saturday, December 12, 2015


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Mixing instructions:
In a large container, mix the same amount of Gin, Sprite, and Grape Juice. Mix well and cool. Serve in shot glasses.
Creator/contributor's comments:
Great drink for parties. Good drink to make new friends. Drink it just like if it was a tequila shot!
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When a business decides to become a business, what you're seeing is the ability of what may be years account of plan culminating into a concrete reality. As allotment of this business's aboriginal "musts" is the accomplishing of an able business strategy. After all, any business that understands the apple of business knows that you've got to get the bulletin out to the apple about who you are and what your business is all about. Otherwise, you'll get absent in the sea of antagonism and abort out.
The botheration with creating a business action is that abounding businesses accomplish austere errors in their planning. Now, accept that any business will accomplish mistakes at some point, but the achievement is you plan with, and around, these errors in the hopes that the anew emerged business article is stronger. Still, these mistakes, if grave enough, can do added than amount time & money to a aggregation – it can abort them.
Rather than accept it's success or abortion with annihilation in between, actuality are 5 accepted mistakes businesses accomplish with their business action but aswell bureau in which they can be avoided:
1. Don't Aim for Perfection – If some companies start-up, they try to abuse aggregate in agreement of their name and presentation. Others are blessed with area they are but adjudge to actualize an advance on the senses by pushes their business way too through abundant channels like amusing media. Experts accede that is you're assured in your launch, move forward. Moreover, you're apprenticed to apprentice added & get accessible acknowledgment from the public, which, in turn, let's you apperceive area the changes in your presentation are best made.
2. Get To Apperceive Your Admirers – Business bureau extensive your admirers in altered ways, and that is the key. There are abounding bureau to ability the humans you see as abeyant clients. By alive if they acknowledge best to assertive amusing media outlets, you apperceive area to ambition your message. It takes time to accomplish this work, but you can advice yourself out by agreeable your admirers and allurement for feedback.
3. Exhaust Your Options – Some companies wish to actualize the "Murderer's Row" of business teams and alpha revolutionizing the business arena if what they may be accomplishing is in actuality crumbling money. Remember, there are a amount of bureau to ambition your business efforts that are chargeless or low-cost. A solid, bargain advantage would be hiring a bounded business agency.
4. Keeping Up – Apperceive how your antagonism is accomplishing & how they're accomplishing it is key so you can apprentice from their successes and maybe even body on them. You certainly, though, charge to abstain artful their every move as it can about-face off customers. You can aswell chase so carefully that you lose afterimage of the actuality that your antagonism is able to apply altered business strategies because they accept added basic or a massive business staff. Be assured in what you accompany to the table.
5. Analysis Data – You charge to accumulate clue of aggregate you do in business. This bureau numbers and absolutely a lot of them. You in actuality charge to analysis this advice so you can see area things formed and area they didn't accommodated expectations. Learning from your mistakes helps you try bigger strategies if needed.
An able business action is the mark of a aggregation that has taken the time to get things appropriate but aswell knows that it have to be aqueous & activating in attributes as it faces changes for the future.


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What is it?
The meaning and potential of Baukultur: Baukultur is essential for creating a built environment that is considered worth living in. In addition to social, ecological, and economic aspects, Baukultur also has an emotional and aesthetic dimension. Its creation, appropriation, and use are social processes that are based on a broad understanding about qualitative values and objectives. The involvement in Baukultur makes sense from the point of view of many of those involved in the process – private building owners can create the conditions for the long-term maintenance of, and increase in, the value of their investments. With their projects, public authorities can contribute to the uniqueness of our cities and thereby foster local and national identity. Politicians are able to address potential dissatisfaction and guide it into productive channels and, in this way, achieve broad approval of developments and changes. For all these, Baukultur is the key to creating social and commercial added value – Baukultur is an investment in the living spaces of the future.


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Picture: Chaz Bono, Jennifer Elia 22nd Annual GLAAD Media Awards held at the Westin Bonaventure Hotel Los Angeles, California - 10.04.11
Chaz Bono, the American writer and musician, appeared on the Oprah Winfrey show today (10th April 2011) to speak about her recent sex change. Formerly known as Chastity Bono, Chaz Bono opened up about the transition to becoming a man and discussed how her mother Cher has taken the change, reports ABC News.
The 42-year-old daughter of Cher and Sonny Bono told Oprah, "Life was always so much more difficult. It also felt like my body was literally betraying me.You have this image of yourself and all of a sudden your body does the exact opposite of what you feel". Chaz appears in the new documentary 'Becoming Chaz', which airs on Winfrey's OWN network tomorrow (10th April 2011). The film premiered at the Sundance Film Festival in January and Chaz says her mother has already given it her seal of approval, saying, "She really liked it a lot. But I think it was probably hard to see.She has finally gotten that this is the thing that's making me happy". Dressed in a pinstriped blazer, checked shirt and trousers, Chaz told Oprah how he has been injecting himself with testosterone to help the transitional process.
Chaz Bono also releases his new book 'Transition: The Story of How I Became a Man' today (10th April 2011).


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Burundi government urges EU to remove sanctions
10-10-2017 ■ During the 47th Parliamentary Assembly of African, Caribbean and Pacific States and the European Community held in Belgium this 9 October, Spès Caritas Njebarikanuye, first- vice speaker of Burundi Senate, said Burundi will not have the courage to ratify the Economic Partnership Agreement in the context of economic sanctions (...)
5th EAC annual Secretary General's forum held in Bujumbura
06-23-2017 ■ From 22 to 23 June 2017, Burundi has hosted the fifth annual forum of the Secretary General of the East African Community comprising the private sector, civil society and other interest groups both from the national and regional levels under the central theme "15 years of the EAC :Towards (...)
Experts prospected for oil indices in Lake Tanganyika, says Minister of Energy
06-07-2017 ■ Burundi is hosting the 8th East African Petroleum Conference and Exhibition from 7 to 9 June 2017 under the theme 'East Africa, the emerging hotspot for oil and gas exploration, infrastructure, development and commercialization.' The East African Community organizes biannual conference and exhibition on the petroleum potential and investment (...)
EAC Heads of State seem to neglect Burundi crisis, politicians say
05-23-2017 ■ The EAC Heads of State met on 20 May, in Dar-Es-Salaam-Tanzania, in the 18th ordinary summit. Burundi politicians differ over the outcomes of the summit. "The outcomes of the 18th EAC Heads of state are somehow a satisfaction and disappointment", says Tatien Sibomana, a politician from Uprona party. He (...)
EAC and ICGLR eager to tackle regional issues together
03-27-2017 ■ The East African Community (EAC) and the International Conference for the Great Lakes Region (ICGLR) jointly has organized from 27 March, a two-day meeting in the capital Bujumbura to discuss the regional challenges. "We shall seek to develop common positions in tackling the political problems affecting some of the (...)
Single tourist visa still pending in Burundi Parliament
02-09-2017 ■ Léontine Nzeyimana, Minister of EAC Affairs says the project of joining other partner states in the use of the single tourist visa is ongoing. "The adoption of the bill to harmonize with other countries is still pending in Burundi Parliament. We transmitted numerous bills but MPs have not yet (...)
2nd East African Community Child Rights Conference held in Nairobi
09-15-2016 ■ The 2nd EAC Child Rights Conference was held at the Desmond Tutu Conference Centre in Nairobi, Kenya from 25-26 August. The conference, placed under the theme "Coordinated and Sustained Investment in Children," saw thirty children from Burundi, Kenya, Uganda, Tanzania and South Sudan come together to discuss children's rights (...)
Kigali: Business threatened by Burundian crisis
09-13-2016 ■ Heads of two leading travel agencies in Kigali say they have sustained major financial losses due to the border closure between Burundi and Rwanda. In late July, the Burundi government suspended food exports to Rwanda – allegedly due to drought – and Burundian security officers have since prevented passengers' (...)
Burundi hotel sector below EAC standards
09-02-2016 ■ The Burundi National Tourism Office (ONT), issued certificates to 11 assessors who received training in hotel classification from December 2012 to February 2013. According to Leonidas Habonimana, the ONT Managing Director, the hotels classification is an extremely important step in improving the tourism sector. "Tourists need to know the (...)
Burundi hardly promotes agribusiness
08-31-2016 ■ In a press conference held yesterday in Bujumbura on the project "Promoting Agriculture, Climate and Trade Linkages in East African Community, Second Phase (PACT- EAC2)", Severin Sindayikengera, director of the national food technology centre (CNTA) explained that Burundi is facing many challenges in relation to the promotion of the (...)


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Karachi: Pakistan cricketers threatened to cancel their upcoming tour of New Zealand if the Black Caps abandon a scheduled tour of Pakistan due to start later this month because of security concerns.
If New Zealand do not fulfil their obligation, we are not going to tour New Zealand, Pakistan Cricket Board (PCB) chairman Lt Gen. Tauqir Zia said.
New Zealand Cricket officials said on Friday they would decide by Monday whether the tour of Pakistan would go ahead after threats made against the players in an e-mail message.
Full details of the threats have not been released but NZC chief executive Martin Snedden said it was very direct it is explicit about the Black Caps in Pakistan and a warning not to go.The email message certainly threatened consequences if the team were to ignore the warning.
Pakistan are scheduled to play two Test matches and five one-dayers from December 5, during a tour to New Zealand. It is a policy decision that we will not go to New Zealand if it does not come to play in Pakistan, Lt Gen. Zia said. The PCB termed the letter a hoax.
South Africa also received a similar hoax letter before coming to Pakistan but after we gave them the assurance they believed us and sent their team, a PCB spokesman said.
Definitely shaken
Meanwhile, NZC officials said Friday they will decide by Monday at the latest whether the tour of Pakistan will go ahead this month after threats were made against the players if the series proceeds.
Four players and an official who decided not to tour had withdrawn before the threat was received earlier this week.
Craig McMillan, Scott Styris, Lou Vincent, Ian Butler and team video analyst Zach Hitchcock made themselves unavailable because of trauma from witnessing a fatal bomb blast in Karachi during New Zealands tour of Pakistan last year.
Heath Mills, manager of New Zealand Players Association, said members of the New Zealand team currently playing in India were definitely shaken by the threat, but he could not say if more players would refuse to go to Pakistan.
Snedden said officials were gathering as much information as they could about the threat and until weve really gone through that process its a bit difficult to know if the tour will go ahead. He said a decision would be made by Sunday or Monday.
New Zealands ambassador to Iran, Niels Holm, who is also accredited to Pakistan, described the e-mail as vaguely threatening, the Dominion Post reported. He said it was not unusual, particularly in Pakistan. Its the sort of thing that if you saw it painted on a wall you wouldnt pay a blind bit of attention to it.
The Black Caps cut short their tour of Pakistan last year following a bomb explosion outside their hotel in Karachi and the country became a no-go zone for other cricketing nations until Bangladesh toured in August this year, and South Africa followed last month.
Security is perfect. Recently South Africa toured Pakistan and played five one-day games and three Test matches, so thats not a problem, the PCB spokesman said.
The revised New Zealand itinerary, due to start on November 22, also avoids Karachi.


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{All You Need Is Love} FREE Printable Artwork!
- At August 23, 2013
- By jennimckay
- In Artwork, Firefly Invitations
- 0
I was inspired by this picture on Pinterest today:
so I quickly designed this pretty new artwork:
and I decided to make it FREE printable artwork available for download. Enjoy, and pass the love along today.
Don't forget to check out all of our new customizable artwork including a birth announcement graphic, your family's important dates, and alphabet artwork for kids, all available to purchase in our Etsy shop.


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Make-up for Media and Performance FAQ
1) What do you need to see in my portfolio?
We are particularly interested to see evidence of your creative artistic ability and potential. We would like to see the way you think and work so your portfolio should include examples of investigation and development leading to a two or three-dimensional conclusion. We like to see your visual understanding of the human body, life drawing, portrait studies and observational drawing and experimental ideas along with a strong sense of colour, shape, style and form. Examples of any experience in make-up transformation, hair dressing or sculpture work are useful and we would like you to show and tell us about your interest and passion for make-up through your research in sketchbooks, design pages or photographs. We will be interested to discuss which make-up artist's work and productions inspire you.
2) How are interviews carried out?
Firstly, as a group, candidates will have a brief tour of the studio environment and will be introduced to the course structure in a short presentation. This is then followed with an individual interview; we invite you to showcase your work, discuss any experience to date and will be a positive learning experience.
3) What work experience is available?
Live projects, work-related learning and work placement are an important and an integral part of this course. Make-up artists are essential members of any Film, Television, Fashion, Catwalk and Stage production and work extensively with others within the creative industries. Collaborative working is a highly valued and important part of life at the University. Make-up students have opportunities to work with film production teams from the Film course, with the Arts University's student actors and costume students on the School of Performance Productions and with Fashion and Photography students on editorial shoots and fashion shows, all of which simulate work in the professional arena. National and inter-national placements are also encouraged developing exciting network opportunities for students.
4) What are the employment prospects?
On successful completion of this course students will have acquired accomplished discipline specific and transferable skills needed in order to enter a highly competitive and sometimes unpredictable make-up industry which requires graduates with a robust work ethic. Graduate career pathways from BA (Hons) Make-up for Media and Performance will include creative design related pathways such as: make-up and hair trainee, assistant, artist, supervisor, chief or designer for television, film or the music industries; wig assistant, wig master/mistress or wig supervisor for commercial or repertory theatre; freelance make-up artist or designer for fashion editorial work, live fashion performance and commercial make-up promotion; prosthetics make-up assistant, artist or designer within a special effects team or prosthetic company. Career opportunities will focus on working closely with directors, designers and other creative departments in film, television, live performance and fashion which could include CGI technicians, photographers, model makers, sculptors, animatronics designers, visual effects artists and fashion stylists.
5) Are there any extra costs?
Students applying for this course are required to purchase a professional make-up kit at the beginning of the first year and a prosthetic make-up kit at the beginning of the second year. See here for more information.