What does Liletta cost 
to non-340B providers?



Once these evaluative priorities have been completed, a diagnosis can be considered and treatment options determined. But only then.
Phillip P. Smith, MD

Farmington, Connecticut

Dr. Nager responds:
Dr. Smith provides a very nice review of what the bladder and urethra need to do. As he points out, the most appropriate question is: When should one consider urodynamic evaluation before making a diagnosis requiring therapy? Well, when a reliable diagnosis cannot be made by history, physical examination, and simple office tests.

The literature suggests that a neurologically normal woman without prolapse and without previous incontinence surgeries can receive a reliable diagnosis without urodynamic testing. If she demonstrates SUI on office stress testing, she is not storing urine normally and urodynamics will confirm urodynamic stress incontinence 97% of the time.1 If she voluntarily voids with a normal postvoid residual, her emptying function has been assessed and is normal.

I think Dr. Smith and I both agree that, “In an otherwise healthy 45-year-old vaginally parous woman with SUI symptoms, it is unlikely that there is a problem.” We also both agree that whenever the diagnosis is unclear, or the situation is complicated, urodynamic testing is a helpful tool to assess the bladder’s storage and emptying function. I perform urodynamics regularly in my practice; it just is not necessary before surgery in a woman without prolapse and without previous incontinence surgeries who demonstrates her SUI and has a normal urinalysis and normal postvoid residual. We seem to agree on that point also.


  1. Nager C, Brubaker L, Litman H, et al; Urinary Incontinence Treatment Network. A randomized trial of urodynamic testing before stress-incontinence surgery. N Engl J Med. 2012;366(21):1987–1997.


Should Provera still be used?
Dr. Kaunitz provided an excellent review of the Women’s Health Initiative (WHI) study and a recent testosterone trial in women in his update on hormone therapy in menopause.

After the WHI revealed differences between the estrogen-alone and estrogen–progestin study arms, implicating medroxyprogesterone acetate for increased risk of breast cancer, why is Provera still being advocated by the American College of Obstetricians and Gynecologists as a progestin safe for use in menopause?
Kathleen Norman, MD

Phoenix, Arizona

Dr. Barbieri responds:
Many insurance formularies favor the use of Provera because it is inexpensive. I try to avoid using it in my practice. Many experts do not yet diligently avoid the use of Provera; some are worried about the cost impact for patients.

For additional information on reducing the use of Provera, see my July 2014 editorial, “Hormone therapy for menopausal vasomotor symptoms,” at

Dr. Kaunitz responds:
My preference is to use micronized oral progesterone (formulated in peanut oil) for endometrial protection in menopausal women using estrogen. I use progesterone 100 mg nightly in women taking standard-dose estrogen (estradiol patch 0.05 mg, oral estradiol 1 mg, or conjugated equine estrogen 0.625 mg). However, some patients request generic medroxyprogesterone acetate because it is so inexpensive (often $4 each month).

Share your thoughts on this article! Send your Letter to the Editor to Please include your name and the city and state in which you practice.

Next Article:

What you should know about the latest change in mammography screening guidelines

Related Articles