Per- and polyfluoroalkyl substances (PFAS), perceived stress, and depressive symptoms in a prospective cohort study of black women

BACKGROUND

Per- and polyfluoroalkyl substances (PFAS) are endocrine-disrupting chemicals with neurotoxic properties. PFAS have been associated with depressive symptoms among women in some studies, but little research has evaluated the effects of PFAS mixtures. Further, no study has investigated interactions of PFAS-depression associations by perceived stress, which has been shown to modify the effects of PFAS on other health outcomes.

OBJECTIVE

In a prospective cohort study of reproductive-aged Black women, we investigated associations between PFAS and depressive symptoms and the extent to which perceived stress modified these associations.

METHODS

We analyzed data from 1499 participants (23-35 years) in the Study of Environment, Lifestyle, and Fibroids. We quantified concentrations of nine PFAS in baseline plasma samples using online solid-phase extraction-liquid chromatography-isotope dilution tandem mass spectrometry. Participants reported perceived stress via the Perceived Stress Scale (PSS-4; range = 0-16) at baseline and depressive symptoms via the Center for Epidemiologic Studies Depression Scale (CESD; range = 0-44) at the 20-month follow-up visit. We used Bayesian Kernel Machine Regression to estimate associations between PFAS concentrations, individually and as a mixture, and depressive symptoms, and to assess effect modification by PSS-4 scores, adjusting for confounders.

RESULTS

Baseline perfluorodecanoic acid concentrations were associated with greater depressive symptoms at the 20-month follow-up, but associations for other PFAS were null. The PFAS were not associated with depressive symptoms when evaluated as a mixture. The association between the 90th percentile (vs. 50th percentile) of the PFAS mixture with CES-D scores was null at the 10th (β = 0.03; 95 % CrI = 0.20, 0.25), 50th (β = 0.02; 95 % CrI = -0.16, 0.19), and 90th (β = 0.01; 95 % CrI = 0.18, 0.20) percentiles of PSS-4 scores, suggesting perceived stress did not modify the PFAS mixture.

CONCLUSION

In this prospective cohort study, PFAS concentrations-assessed individually or as a mixture-were not appreciably associated with depressive symptoms, and there was no evidence of effect modification by perceived stress.

Health literacy needs and preferences for a technology-based intervention to improve college students' sexual and reproductive health

Objective: To explore health literacy needs and preferences for a technology-based intervention (app) to improve sexual and reproductive health (SRH) among college students. Participants: In Spring 2019, in-depth interviews were conducted with 20 participants (10 male, 10 female) from a large, public university. Methods: Interview guide was developed based on Integrated Model of Health Literacy domains and Diffusion of Innovation constructs. Data were analyzed in MaxQDA using applied thematic analysis. Results: Dominant themes included accessing health information and services, evaluating options to make decisions, intervention utility and characteristics, and the emergent theme of credibility. Specific topics included accessing STI testing, contraceptive decision making, information on human papillomavirus (HPV) and the HPV vaccine, patient-provider communication, app design and function elements, and modifying the app to meet the SRH needs of diverse college students. Conclusions: Findings identified areas where an app could address college students' SRH literacy, ultimately improving SRH outcomes among this population.

A prospective ultrasound study of cigarette smoking and uterine leiomyomata incidence and growth

BACKGROUND

Uterine leiomyomata (fibroids) are common, benign neoplasms that contribute substantially to gynecologic morbidity. Some existing epidemiologic studies indicate that cigarette smoking is associated with lower uterine leiomyomata risk. However, no prospective studies have systematically screened an entire study population for uterine leiomyomata using transvaginal ultrasound or evaluated the association between cigarette smoking and uterine leiomyomata growth.

OBJECTIVE

This study aimed to examine the association between cigarette smoking and uterine leiomyomata incidence and growth in a prospective ultrasound study.

STUDY DESIGN

We enrolled 1693 residents from the Detroit metropolitan area into the Study of Environment, Lifestyle, and Fibroids during 2010 to 2012. Eligible participants were aged 23 to 34 years, had an intact uterus but no previous diagnosis of uterine leiomyomata, and self-identified as Black or African American. We invited participants to complete a baseline visit and 4 follow-up visits over approximately 10 years. At each visit, we used transvaginal ultrasound to assess uterine leiomyomata incidence and growth. Participants provided extensive self-reported data throughout follow-up including exposures to active and passive cigarette smoking in adulthood. We excluded participants who did not return for any follow-up visits (n=76; 4%). We fit Cox proportional hazards regression models to estimate hazard ratios and 95% confidence intervals for the association between time-varying smoking history and incidence rates of uterine leiomyomata. We fit linear mixed models to estimate the percentage difference and 95% confidence intervals for the association between smoking history and uterine leiomyomata growth. We adjusted for sociodemographic, lifestyle, and reproductive factors. We interpreted our results based on magnitude and precision rather than binary significance testing.

RESULTS

Among 1252 participants without ultrasound evidence of uterine leiomyomata at baseline, uterine leiomyomata were detected in 394 participants (31%) during follow-up. Current cigarette smoking was associated with a lower uterine leiomyomata incidence rate (hazard ratio, 0.67; 95% confidence interval, 0.49-0.92). Associations were stronger among participants who had smoked for longer durations (≥15 years vs never: hazard ratio, 0.49; 95% confidence interval, 0.25-0.95). The hazard ratio for former smokers was 0.78 (95% confidence interval, 0.50-1.20). Among never smokers, the hazard ratio for current passive smoke exposure was 0.84 (95% confidence interval, 0.65-1.07). Uterine leiomyomata growth was not appreciably associated with current (percent difference, -3%; 95% confidence interval, -13% to 8%) or former (percent difference, -9%; 95% confidence interval, -22% to 6%) smoking.

CONCLUSION

We provide evidence from a prospective ultrasound study that cigarette smoking is associated with lower uterine leiomyomata incidence.

Use of Chemical Hair Straighteners and Fecundability in a North American Preconception Cohort

Chemical hair straighteners ("relaxers") are used by millions of North Americans, particularly women of color. Hair relaxers may contain endocrine-disrupting compounds, which can harm fertility. We evaluated the association between hair relaxer use and fecundability among 11,274 participants from Pregnancy Study Online (PRESTO), a North American preconception cohort study. During 2014-2022, participants completed a baseline questionnaire in which they reported their history of relaxer use and completed follow-up questionnaires every 8 weeks for 12 months or until pregnancy, whichever came first. We used multivariable-adjusted proportional probabilities regression models to estimate fecundability ratios (FRs) and 95% confidence intervals (CIs). Relative to never use, fecundability was lower among current (FR = 0.81, 95% CI: 0.64, 1.03) and former (FR = 0.89, 95% CI: 0.81, 0.98) users of hair relaxers. FRs for first use of hair relaxers at ages <10, 10-19, and ≥20 years were 0.73 (95% CI: 0.55, 0.96), 0.93 (95% CI: 0.83, 1.04), and 0.85 (95% CI: 0.74, 0.98), respectively. Fecundability was lowest among those with longer durations of use (≥10 years vs. never: FR = 0.71, 95% CI: 0.54, 0.91) and more frequent use (≥5 times/year vs. never: FR = 0.82, 95% CI: 0.60, 1.11), but associations were nonmonotonic. In this preconception cohort study, use of chemical hair straighteners was associated with slightly reduced fecundability.

COVID-19 vaccination and menstrual cycle characteristics: A prospective cohort study

We prospectively examined the association between COVID-19 vaccination and menstrual cycle characteristics in an internet-based prospective cohort study. We included a sample of 1,137 participants who enrolled in Pregnancy Study Online (PRESTO), a preconception cohort study of couples trying to conceive, during January 2021-August 2022. Eligible participants were aged 21-45 years, United States or Canadian residents, and trying to conceive without fertility treatment. At baseline and every 8 weeks for up to 12 months, participants completed questionnaires on which they provided information on COVID-19 vaccination and menstrual cycle characteristics, including cycle regularity, cycle length, bleed length, heaviness of bleed, and menstrual pain. We fit generalized estimating equation (GEE) models with a log link function and Poisson distribution to estimate the adjusted risk ratio (RR) for irregular cycles associated with COVID-19 vaccination. We used linear regression with GEE to estimate adjusted mean differences in menstrual cycle length associated with COVID-19 vaccination. We adjusted for sociodemographic, lifestyle, medical and reproductive factors. Participants had 1.1 day longer menstrual cycles after receiving the first dose of COVID-19 vaccine (95 % CI: 0.4, 1.9) and 1.3 day longer cycles after receiving the second dose (95 % CI: 0.2, 2.5). Associations were attenuated at the second cycle post-vaccination. We did not observe strong associations between COVID-19 vaccination and cycle regularity, bleed length, heaviness of bleed, or menstrual pain. In conclusion, COVID-19 vaccination was associated with a ∼1 day temporary increase in menstrual cycle length, but was not appreciably associated with other menstrual cycle characteristics.

Adverse childhood experiences and adult outcomes using a causal framework perspective: Challenges and opportunities

BACKGROUND

Research on the effect of adverse childhood experiences (ACEs) on adult outcomes has typically relied on retrospective assessment of ACEs and cumulative scores. However, this approach raises methodological challenges that can limit the validity of findings.

OBJECTIVE

The aims of this paper are 1) to present the value of directed acyclic graphs (DAGs) to identify and mitigate potential problems related to confounding and selection bias, and 2) to question the meaning of a cumulative ACE score.

RESULTS

Adjusting for variables that post-date childhood could block mediated pathways that are part of the total causal effect while conditioning on adult variables, which often serve as proxies for childhood variables, can create collider stratification bias. Because exposure to ACEs can affect the likelihood of reaching adulthood or study entry, selection bias could be introduced via restricting selection on a variable affected by ACEs in the presence of unmeasured confounding. In addition to challenges regarding causal structure, using a cumulative score of ACEs assumes that each type of adversity will have the same effect on a given outcome, which is unlikely considering differing risk across adverse experiences.

CONCLUSIONS

DAGs provide a transparent approach of the researchers' assumed causal relationships and can be used to overcome issues related to confounding and selection bias. Researchers should be explicit about their operationalization of ACEs and how it is to be interpreted in the context of the research question they are trying to answer.

Hysterectomy, bilateral oophorectomy, and breast cancer risk in a racially diverse prospective cohort study

BACKGROUND

Gynecologic surgery is hypothesized to reduce risk of breast cancer; however, associations may be modified by subsequent hormone use. Our objective was to examine the association between gynecologic surgery and breast cancer incidence considering the use of hormone therapy.

METHODS

The Sister Study is a prospective cohort of initially breast cancer-free women aged 35-74 years with a sister who had breast cancer. We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between gynecologic surgery (no surgery, hysterectomy only, bilateral oophorectomy with or without hysterectomy) and incident breast cancer among 50 701 women.

RESULTS

History of gynecologic surgery was common, with 13.8% reporting hysterectomy only and 18.1% reporting bilateral oophorectomy with or without hysterectomy. During follow-up (median = 11.4 years), 3948 cases were diagnosed. Compared with no surgery, bilateral oophorectomy was inversely associated with breast cancer (HR = 0.91, 95% CI = 0.83 to 1.00), and hysterectomy alone was positively associated (HR = 1.12, 95% CI = 1.02 to 1.23). Compared with no surgery and no hormone therapy, bilateral oophorectomy combined with estrogen only therapy (HR = 0.83, 95% CI = 0.74 to 0.94) was inversely associated with breast cancer, while hysterectomy combined with estrogen plus progestin therapy was positively associated with breast cancer (HR = 1.25, 95% CI = 1.01 to 1.55).

CONCLUSIONS

We observed an inverse association between bilateral oophorectomy and breast cancer risk. The positive association between hysterectomy and breast cancer may be due to concomitant estrogen plus progestin therapy.

Discussing HPV and oropharyngeal cancer in dental settings: gender and provider-type matter

Human papillomavirus (HPV) is the most common sexually transmitted infection in the US and the leading cause of oropharyngeal cancer (OPC), an oral cancer most often identified by dental providers. Given the rise in HPV-associated OPC and recent Food and Drug Administration (FDA) approval of the HPV vaccine to prevent OPC, dental providers have a unique role in HPV prevention. This study assessed US adults' comfort levels discussing HPV and OPC with dental providers. An online survey platform was used to recruit a nationally representative sample of US adults (n = 300). The questionnaire assessed participants' knowledge, acceptability, and comfort discussing HPV-related topics with dental providers. SPSS 24 was utilized for data analyses. In general, participants reported feeling comfortable discussing HPV and OPC with dental providers. Participants reported feeling more comfortable with dentists than dental hygienists when discussing (t = 2.85, p < .01) and receiving recommendations about the HPV vaccine (t = 2.09, p < .05). Participants were less comfortable discussing HPV as a risk factor for OPC compared to non-HPV related risk factors (t = 2.94, p < .01). Female participants preferred female providers, whereas male participants had no preference. Previous research has indicated dental providers recognize their role in HPV prevention, but research is needed to understand patients' perceptions of dental providers' role in HPV prevention. Findings demonstrate that US adults are comfortable discussing HPV and OPC with dental providers, which may be key to OPC-HPV prevention. Future research is needed to facilitate HPV communication between patients and dental providers.

Prevalence and Factors Associated With Intimate Partner Violence Among Women in Haiti: Understanding Household, Individual, Partner, and Relationship Characteristics

Intimate partner violence (IPV) is a significant public health issue with detrimental consequences for women's reproductive, mental, and physical health. In Haiti, IPV is a major obstacle to women's development. Yet, the determinants of IPV victimization are still not well understood. In this study, we utilized the 2016-2017 Haiti Demographic and Health Survey to determine the prevalence of IPV victimization and its subtypes (emotional, physical, and sexual abuse) among married or cohabiting women (N = 3,805) of reproductive age (15-49) by their current husband/partner. Logistic regression was conducted to explore the association between IPV and household, individual, husband/partner, and relationship characteristics. The prevalence of IPV victimization was 32.5% with the majority reporting emotional (24.7%) followed by physical (16.8%) and sexual (10.5%) violence. Increased odds of IPV victimization were found among women with children in the household (adjusted odds ratio [AOR] = 1.45, 95% confidence interval [CI] = [1.03, 2.02]), with attitudinal acceptance of wife-beating (AOR = 1.45, 95% CI = [1.05, 2.02]), and those who witnessed their father beating their mother (AOR = 1.49, 95% CI = [1.18, 2.67]). Higher odds of reporting IPV victimization were also found among women whose partner drank alcohol (AOR = 2.89, 95% CI = [2.29, 3.65]), who were in a polygynous relationship (AOR = 1.76, 95% CI = [1.23, 2.40]), and displayed one or more controlling behaviors (AOR = 1.92, 95% CI = [1.42, 2.59]). Women who reported being afraid of their partner had greater odds of IPV victimization (AOR = 16.22, 95% CI = [8.38, 31.39]). Decreased odds of reporting IPV were associated with women living in rural areas (AOR = 0.73, 95% CI = [0.53, 1.00]) and those unmarried, but living with their partner (AOR = 0.62, 95% CI = [0.43, 0.90]). Our findings identify subgroups of women in Haiti that may be vulnerable to IPV victimization. Thus, we recommend a differentiated approach to IPV prevention strategies and interventions that consider women's family structure in the household as well as individual, partner, and relationship characteristics.

A Mixed-methods Study to Understand Food Environments and Grocery Shopping Patterns of Community Residents in Underserved Neighborhoods in Tampa, Florida

A mixed methods study was conducted to better understand food access, food retail store environment, and perspectives of community residents on their grocery store shopping patterns and access to healthy foods in underserved, predominantly African American neighborhoods. GIS mapping, grocery store observations (n = 4), a food access and grocery store environment survey (n = 126), and focus groups (n = 48) were used. The results indicate that these neighborhoods have a low density of grocery stores, and only two out of four grocery stores meet the standard for a healthy retail store. Barriers to getting healthy foods and solutions to improve food access are discussed.

A prospective, double-blind, randomized, controlled clinical trial of ampicillin-sulbactam for preterm premature rupture of membranes in women receiving antenatal corticosteroid therapy

OBJECTIVE

Our purpose was to test the efficacy of antibiotic prophylaxis in women with preterm premature rupture of the membranes who receive antenatal corticosteroids.

STUDY DESIGN

A total of 112 women received one of three regimens in a double-blind randomized controlled trial: (1) ampicillin-sulbactam for 72 hours followed by amoxicillin-clavulanate, (2) ampicillin for 72 hours followed by amoxicillin, or (3) placebo.

RESULTS

A total of 48.6% of neonates in the placebo group either died or had sepsis or respiratory distress syndrome versus 29.3% in the pooled antibiotic group (p < 0.05) and 26.3% in the ampicillin-sulbactam/amoxicillin-clavulanate subgroup (p < 0.05). All three neonatal deaths occurred in the placebo group (p = 0.03 versus pooled antibiotics). Mean birth weight was significantly greater in the pooled antibiotic group (1773 gm, p = 0.04) and in the ampicillin-sulbactam/amoxicillin-clavulanate subgroup (1870 gm, p = 0.02) than in the placebo group (1543 gm). Antibiotic prophylaxis reduced the need for prolonged ventilation (p = 0.05).

CONCLUSIONS

Antibiotic prophylaxis in combination with corticosteroids in preterm premature rupture of membranes significantly lowered the total frequency of neonatal mortality, sepsis, and respiratory distress syndrome and significantly increased birth weight compared with corticosteroids alone.

Evaluation of the nonreactive positive contraction stress test prior to 32 weeks: the role of the biophysical profile

A nonreactive positive contraction stress test in a pregnancy near term is an indication for delivery. Such nonreassuring antepartum testing combined with severe prematurity presents a management dilemma. Ideally, prolongation of selected pregnancies would allow time for corticosteroid therapy and fetal maturation. Prior to 32 weeks' gestation, we utilized the biophysical profile to select patients for continued intrauterine management as an alternative to immediate delivery. Continued surveillance was undertaken if the fetus had a reassuring biophysical profile score; immediate delivery by cesarean section was undertaken if the biophysical profile score was nonreassuring. This approach allowed a mean gain of 13 days in utero for the continued surveillance group. There was no evidence of further fetal compromise in this group based on umbilical cord pH or 5-minute Apgar scores. These data suggest that the biophysical profile can be safely used to prolong selected preterm pregnancies with nonreactive positive contraction stress tests without adversely affecting the initial neonatal metabolic status.

Cognitive adaptation to stressful events during pregnancy and postpartum: development and testing of the CASE instrument

The purpose of this article is to describe the development and testing during pregnancy and postpartum of a new instrument, the Cognitive Adaptation to Stressful Events Scale (CASE). The conceptual framework for the CASE is based on Taylor's theory of cognitive adaptation to threatening events using the dimensions of meaning, mastery, and self-esteem. A convenience sample of 202 primigravida women completed the CASE at six assessment points: 10 to 12, 20 to 22, and 30 to 32 weeks of pregnancy and 1 to 2, 8, and 14 weeks postpartum. Regression analysis conducted with CASE scores at each of the assessment points in relation to psychological symptom distress as measured with the SCL-90R Global Severity Index (GSI) indicated a strong relationship during each time period. Although replication with multiethnic, high-risk pregnancy and clinically depressed groups is needed, the CASE is a promising tool for examining the cognitive adaptation process occurring during pregnancy and postpartum.