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Physicians: .25 AMA PRA Category I CreditsTM
Family Physicians: .25 Prescribed credits
Nurse Practitioners: .25 Contact hours

Release Date: July 16, 2014
Expiration Date: July 16, 2015

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon above.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:

1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD
Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP
Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: This enduring material activity, DynaMed EBM Focus Volume 9, has been reviewed and is acceptable for up to 15.25 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 5, 2014. Term of approval is for one year from this date. Each EBM Focus is approved for .25 Prescribed credits. Credit may be claimed for one year from the date of each update. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour(s) of continuing education by the American Association of Nurse Practitioners. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards.

Program ID: 1405237I

Last week 325 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 164 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article was selected by the DynaMed Editorial Team.

Letrozole Associated With Increased Live Birth Rate Compared to Clomiphene Citrate in Women With Anovulatory Polycystic Ovary Syndrome
Reference: N Engl J Med 2014 Jul 10;371(2):119 (level 2 [mid-level] evidence)

Polycystic ovary syndrome (PCOS) affects 4%-8% of women of reproductive age and is a common cause of anovulatory subfertility (Arch Gynecol Obstet 2012 Jun;285(6):1737). Clomiphene citrate is a selective estrogen receptor modulator that induces ovarian stimulation, and has traditionally been the first-line therapy for infertility in this patient population. More recently, other treatments such as metformin and aromatase inhibitors have been evaluated, but these agents have not consistently been shown to be superior to clomiphene for fertility outcomes. A new randomized trial compared the safety and efficacy of the aromatase inhibitor letrozole to clomiphene for treatment of infertility in 750 women aged 18-40 years with PCOS.

Included women had ≥ 1 patent fallopian tube and normal uterine cavity, a male partner with a sperm concentration ≥ 14 million sperm/mL, and mutual agreement with their partner to have regular intercourse during the study period. Women received either letrozole 2.5 mg/day orally vs. clomiphene citrate 50 mg/day orally on cycle day 3 for 5 days and for up to 5 menstrual cycles. The live birth rate was 27.5% for women receiving letrozole vs. 19.1% for those receiving clomiphene (p = 0.007, NNT 12), with no significant differences between groups in the rates of congenital anomalies in live births, pregnancy loss, or twin pregnancy. Compared to clomiphene, letrozole was associated with a significantly decreased frequency of hot flushes, but significantly increased frequency of fatigue and dizziness.

Previously unpublished data from this trial are contained within a recent Cochrane review of 26 randomized trials evaluating letrozole in women with anovulatory PCOS. This review found that letrozole was associated with increased live birth and pregnancy rates compared to clomiphene citrate, with the improvement in live birth rate primarily being driven by this new trial (Cochrane Database Syst Rev 2014 Feb 24;(2):CD010287). In addition, the data from this trial have been incorporated into a new guideline by the Endocrine Society, which reviewed an earlier conference abstract of these data. Although the guideline did not include any recommendations on comparative efficacy of letrozole or clomiphene, it now includes a strong recommendation for clomiphene citrate, or comparable estrogen modulators such as letrozole, as first-line treatment of anovulatory infertility in women with PCOS (J Clin Endocrinol Metab 2013 Dec;98(12):4565). Letrozole has been approved by the U.S. Food and Drug Administration for several breast cancer indications, but is not currently indicated for infertility treatment in women with PCOS.

For more information see the Polycystic ovary syndrome and Treatment of infertility in women topics in DynaMed.

Earn CME Credit for reading this e-Newsletter. For more information on this educational activity, see the CME sidebar.

EBSCO Health Launches Pediatric Clinical Information Mobile App

PEMSoft Now Available For iPhone, iPad, and Android Devices

A mobile app designed specifically for pediatricians, emergency department physicians, physicians-in-training and other medical providers caring for children with acute illnesses and injury, is now available from EBSCO Health, the leading provider of clinical decision support solutions for the healthcare industry.

Designed by pediatricians, emergency physicians and other medical specialists, PEMSoft is a pediatric evidence-based point-of-care medical reference tool for hospitals, emergency departments, clinics, pediatric group practices, transport services, and medical schools. The vast content in PEMSoft addresses the entire spectrum of neonatal, infant, child, adolescent and young adult health. PEMSoft authors adhere to a strict evidence-based editorial policy focused on systematic identification, evaluation and consolidation of practice-changing clinical literature.

The PEMSoft Mobile app includes explicit step-by-step emergency critical care procedures, information about common pediatric signs and symptoms and content covering pediatric injuries and management approaches. More than 3,000 evidence-based pediatric topics and a similar number of medical illustrations, clinical images and videos are also available via the mobile app.

The PEMSoft Mobile App is accessible from both Apple and Android devices.

For more information and technical support, visit the PEMSoft Mobile Access page. To view the official press release, click here.

DynaMed Careers

Looking for a change? The DynaMed editorial team is expanding and looking for talented and driven individuals. Visit the links below to learn about these exciting opportunities.

Section Editor of Specialty Content

DynaMed Contribution Opportunities

DynaMed Peer Review
Editorial Policies for Reviewers
Education for Clinicians in Training

Call for Peer Reviews

We are currently seeking subspecialty reviewers for our Patient Education Resource Center (PERC). PERC provides fact sheets and discharge instructions for patients leaving the hospital or emergency room. These hand-outs fulfill the meaningful use requirements for the Medicare & Medicare Services Incentive Programs.

Click here to speak with us about becoming a peer reviewer.