Long-Term Risk of Reintervention After Surgical Leiomyoma Treatment in an Integrated Health Care System

OBJECTIVE

To compare long-term risk of reintervention across four uterus-preserving surgical treatments for leiomyomas and to assess effect modification by sociodemographic factors in a prospective cohort study in an integrated health care delivery system.

METHODS

We studied a cohort of 10,324 patients aged 18-50 (19.9% Asian, 21.2% Black, 21.3% Hispanic, 32.5% White, 5.2% additional races and ethnicities) who had a first uterus-preserving procedure (abdominal, laparoscopic, or vaginal myomectomy [referred to as myomectomy]; hysteroscopic myomectomy; endometrial ablation; uterine artery embolization) after leiomyoma diagnosis in the 2009-2021 electronic health records of Kaiser Permanente Northern California. We followed up patients until reintervention (second uterus-preserving procedure or hysterectomy) or censoring. We used a Kaplan-Meier estimator to calculate the cumulative incidence of reintervention and Cox regression models to estimate hazard ratios and 95% CIs comparing rates of reintervention across procedures, adjusting for age, parity, race and ethnicity, body mass index (BMI), Neighborhood Deprivation Index, and year. We also assessed effect modification by demographic characteristics.

RESULTS

Median follow-up was 3.8 years (interquartile range 1.8-7.4 years). Index procedures were 18.0% (1,857) hysteroscopic myomectomies, 16.2% (1,669) uterine artery embolizations, 21.4% (2,211) endometrial ablations, and 44.4% (4,587) myomectomies. Accounting for censoring, the 7-year reintervention risk was 20.6% for myomectomy, 26.0% for uterine artery embolization, 35.5% for endometrial ablation, and 37.0% for hysteroscopic myomectomy; 63.2% of reinterventions were hysterectomies. Within each procedure type, reintervention rates did not vary by BMI, race and ethnicity, or Neighborhood Deprivation Index. However, rates of reintervention after uterine artery embolization, endometrial ablation, and hysteroscopic myomectomy decreased with age, and reintervention rates for hysteroscopic myomectomy were higher for parous than nulliparous patients.

CONCLUSION

Long-term reintervention risks for uterine artery embolization, endometrial ablation, and hysteroscopic myomectomy are greater than for myomectomy, with potential variation by patient age and parity but not BMI, race and ethnicity, or Neighborhood Deprivation Index.

Pregnancy Outcomes After Laparoscopic Radiofrequency Ablation of Uterine Leiomyomas Compared With Myomectomy

OBJECTIVE

To compare pregnancy outcomes after laparoscopic radiofrequency ablation and myomectomy.

METHODS

The ULTRA (Uterine Leiomyoma Treatment With Radiofrequency Ablation) study is an ongoing multicenter prospective cohort study with longitudinal follow-up up to 5 years comparing outcomes of radiofrequency ablation with myomectomy in premenopausal women older than age 21 years with symptomatic uterine leiomyomas. Participants were queried every 6 months after surgery to assess the incidence of pregnancy and pregnancy outcomes.

RESULTS

Among 539 women enrolled in ULTRA, a total of 37 participants (mean age at first pregnancy 35.0±4.7 years) conceived 43 times as of March 2023 (22 radiofrequency ablation, 21 myomectomy). The average length of follow-up time after all procedures was 2.5±1.0 years. The baseline miscarriage rate in the study population was 33.3%. In participants who underwent radiofrequency ablation, 9 of 22 pregnancies (40.9%, 95% CI, 20.3-61.5%) ended in first-trimester miscarriage, 11 resulted in live births (50.0%, 95% CI, 29.1-70.9%), one resulted fetal death at 30 weeks of gestation, and one resulted in uterine rupture during miscarriage treatment with misoprostol 10 weeks after radiofrequency ablation. Among the live births in the radiofrequency ablation group, 45.5% were by vaginal delivery. In the myomectomy group, 9 of 21 pregnancies (42.9%, 95% CI, 21.7-64.0%) ended in first-trimester miscarriage and 12 resulted in live births (57.1%, 95% CI, 36.0-78.3%). There were no significant differences in the likelihood of live birth or miscarriage between the study groups.

CONCLUSION

Full-term pregnancy and vaginal delivery are achievable after radiofrequency ablation of leiomyomas. However, in this interim analysis, the miscarriage rate in both radiofrequency ablation and myomectomy groups was higher than expected for women in this age group. Long-term data collection in the ongoing ULTRA study aims to further understand pregnancy outcomes after radiofrequency ablation compared with myomectomy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT0210094.

Hypertension, Cardiovascular Risk Factors, and Uterine Fibroid Diagnosis in Midlife

Importance

Fibroids are benign neoplasms associated with severe gynecologic morbidity. There are no strategies to prevent fibroid development.

Objective

To examine associations of hypertension, antihypertensive treatment, anthropometry, and blood biomarkers with incidence of reported fibroid diagnosis in midlife.

Design, Setting, and Participants

The Study of Women's Health Across the Nation is a prospective, multisite cohort study in the US. Participants were followed-up from enrollment (1996-1997) through 13 semiannual visits (1998-2013). Participants had a menstrual period in the last 3 months, were not pregnant or lactating, were aged 42 to 52 years, were not using hormones, and had a uterus and at least 1 ovary. Participants with prior fibroid diagnoses were excluded. Data analysis was performed from November 2022 to February 2024.

Exposures

Blood pressure, anthropometry, biomarkers (cholesterol, triglycerides, and C-reactive protein), and self-reported antihypertensive treatment at baseline and follow-up visits were measured. Hypertension status (new-onset, preexisting, or never [reference]) and hypertension treatment (untreated, treated, or no hypertension [reference]) were categorized.

Main Outcomes and Measures

Participants reported fibroid diagnosis at each visit. Discrete-time survival models estimated hazard ratios (HRs) and 95% CIs for associations of time-varying hypertension status, antihypertensive treatment, anthropometry, and biomarkers with incident reported fibroid diagnoses.

Results

Among 2570 participants without a history of diagnosed fibroids (median [IQR] age at screening, 45 [43-48] years; 1079 [42.1%] college educated), 526 (20%) reported a new fibroid diagnosis during follow-up. Risk varied by category of hypertension treatment: compared with those with no hypertension, participants with untreated hypertension had a 19% greater risk of newly diagnosed fibroids (HR, 1.19; 95% CI, 0.91-1.57), whereas those with treated hypertension had a 20% lower risk (HR, 0.80; 95% CI, 0.56-1.15). Among eligible participants with hypertension, those taking antihypertensive treatment had a 37% lower risk of newly diagnosed fibroids (HR, 0.63; 95% CI, 0.38-1.05). Risk also varied by hypertension status: compared with never-hypertensive participants, participants with new-onset hypertension had 45% greater risk of newly diagnosed fibroids (HR, 1.45; 95% CI, 0.96-2.20). Anthropometric factors and blood biomarkers were not associated with fibroid risk.

Conclusions and Relevance

Participants with untreated and new-onset hypertension had increased risk of newly diagnosed fibroids, whereas those taking antihypertensive treatment had lower risk, suggesting that blood pressure control may provide new strategies for fibroid prevention.

The Role of Sexual Function in Quality of Life Among Midlife and Older Women: The Study of Women's Health Across the Nation

Objective: To examine how (1) partnered sexual activity, and (2) sexual functioning, contribute to global quality of life (QOL) and health-related quality of life (HRQL) among midlife and older women, and whether importance of sex modifies these associations. Materials and Methods: Women in the Study of Women's Health Across the Nation (SWAN), a multiethnic/racial cohort study, aged 42-52 at recruitment, were followed for ∼20 years. The Ladder of Life and Short Form-36 physical component summary (PCS) and mental component summary (MCS) assessed Global QOL (N = 3,263) and HRQL (N = 2,576), respectively. Primary predictors were (1) having partnered sexual activity (yes/no), and (2) sexual functioning among those with partnered sexual activity. Sociodemographic, health, lifestyle, and psychosocial covariates were included. Results: Importance of sex modified covariate-adjusted association of having partnered sexual activity with global QOL. Adjusted associations of partnered sexual activity with PCS and MCS were not statistically significant. Sexual functioning, among women with partnered sexual activity, was positively associated with global QOL (adjusted p = 0.03), regardless of importance of sex; unrelated to PCS; but positively associated with MCS (adjusted p = 0.03), particularly when sex was "very/quite important." Conclusions: Partnered sexual activity and better sexual functioning are related to QOL for mid-aged and older women, and are stronger when sex is considered important. Partnered sexual activity and sexual functioning are less consistently related to HRQL when adjusted for covariates, and importance modifies only the association between sexual functioning and MCS. Understanding the importance of sex to midlife and older women contextualizes the impact of sex on QOL.

The association of urinary incontinence and disability among a diverse sample of midlife Study of Women's Health Across the Nation women

OBJECTIVE

The aim of the study is to examine whether urinary incontinence (UI) type, frequency, and amount are associated with self-reported disability in a racially/ethnically diverse cohort of community-dwelling midlife women.

METHODS

Data were from longitudinal analyses of questionnaires from the multicenter, prospective cohort Study of Women's Health Across the Nation (SWAN). We used multivariable ordinal logistic regression to examine whether urinary incontinence type, frequency, and amount at the 13th follow-up were associated with the World Health Organization Disability Assessment Schedule at the 15th follow-up controlling for other factors (menopause status, body mass index, lifestyle and psychosocial factors, and disability at follow-up 13).

RESULTS

Urinary incontinence was associated with subsequent reports of disability in participants, particularly in the World Health Organization Disability Assessment Schedule domains of mobility ( P < 0.0001), communication ( P = 0.0057), and life activities ( P = 0.0407). Associations were strongest for mixed UI type compared with stress UI or urgency UI (odds ratio [OR] = 1.66, 95% confidence interval [CI] = 1.26-2.17, P < 0.001), daily frequency of UI compared with monthly or less than weekly frequency of UI (OR = 1.61, 95% CI = 1.04-2.47, P < 0.001), and larger amounts of urine leakage compared with drops of leakage (OR = 2.98, 95% CI = 1.58-5.62, P < 0.0001) for mobility/getting around domain.

CONCLUSIONS

Urinary incontinence seems to have a strong association with multiple domains of disability, including mobility and interacting with others, after approximately 3.7 years. Thus, UI may be an important factor limiting social engagement among women. Screening for mixed UI and UI that occurs greater than weekly and in amounts requiring pads may yield better information regarding an individual's future disability risk and may preserve social interaction.

Relationships between the vaginal microbiota and genitourinary syndrome of menopause symptoms in postmenopausal women: the Study of Women's Health Across the Nation

OBJECTIVE

To describe vaginal microbiota classified by community state types (CST) in a diverse cohort of postmenopausal women and evaluate relationships among genitourinary syndrome of menopause (GSM) symptoms (vaginal dryness, vulvovaginal irritation, sexual pain, dysuria, urinary urgency), CSTs, estrogen, vaginal maturation index (VMI), and vaginal pH.

METHODS

In the Study of Women's Health Across the Nation, 1,320 women aged 60.4 to 72.5 years self-collected (2015-2017) vaginal samples analyzed for microbiota composition and structure (CSTs) using 16S rRNA gene amplicon sequencing, VMI, and pH. GSM symptoms were collected with self-administered questionnaires; interviewers elicited estrogen use and measured body mass index. Serum E2 and E1 were measured using high-performance liquid chromatography. We analyzed data using Pearson χ2 tests, analysis of variance, Kruskal-Wallis tests, and binomial logistic regression.

RESULTS

The most frequently occurring CST was low Lactobacillus species IV-C (49.8%); 36.4% of women had CSTs dominated by Lactobacillus species. More than half of the women with vaginal atrophy biomarkers (VMI <50 and pH >5) had CST IV-C0, whereas women using estrogen or with higher E1 and E2 levels had a higher prevalence of Lactobacillus crispatus -dominated CST I ( P values < 0.001). Sexual pain was associated with atrophy biomarkers and independently associated with Streptococcus species-dominated CST IV-C1 (odds ratio, 2.26; 95% confidence intervals, 1.20-4.23). For all other GSM symptoms, we found no consistent associations with E1 or E2 levels, atrophy biomarkers, or any CST.

CONCLUSIONS

Although close relationships exist among estrogen, CSTs, VMI, and pH, sexual pain was the only GSM symptom associated with the structure of vaginal microbiota and atrophy biomarkers.

Complementary and Alternative Medicine Use Among Women with Symptomatic Uterine Fibroids

Objective: The aim of this study is to examine complementary and alternative medicine (CAM) use among women with symptomatic uterine fibroids in the United States. Materials and Methods: In this cross-sectional analysis of baseline data from a multicenter, prospective cohort study of premenopausal women undergoing surgery for symptomatic fibroids and who enrolled in the Uterine Leiomyoma Treatment with Radiofrequency Ablation study from 2017 to 2019, we contrast women indicating use of at least one CAM modality specifically for fibroid symptoms against women using CAM for other reasons and CAM nonusers. Multivariable logistic regression models were performed to identify participant characteristics independently associated with CAM use for fibroids. Results: Among 204 women, 55% were Black/African American and the mean age was 42 (standard deviation 6.6) years. CAM use was common (67%), with 42% (95% confidence interval [CI]: 35%-49%) reporting use of CAM specifically to treat fibroid symptoms. Most commonly, CAM treatments used for fibroids were diet (62%) and herbs (52%), while CAM treatments for other reasons were exercise (80%) and massage (43%). On average, each participant who reported CAM use utilized three different types of CAM modalities. In a multivariable model, participants were more likely to use CAM for fibroids if they had pelvic pressure (odds ratio [OR] 2.50, 95% CI: 1.07-5.87, p = 0.04), a body-mass index lower than average (OR 0.76, 95% CI: 0.60-0.97, p = 0.03), and a lower health-related quality of life score (OR 0.61, 95% CI: 0.46-0.81, p = 0.001). Conclusions: In this diverse sample of women with symptomatic fibroids, CAM use was highly prevalent. Our findings highlight the need for providers to query patients about CAM use and understand the role of CAM in fibroid management. ClinicalTrials.gov Identifier: NCT02100904.

Patterns of Sexual Activity and the Development of Sexual Pain Across the Menopausal Transition

OBJECTIVE

To examine whether patterns of sexual intercourse frequency and demographic, menopausal status, genitourinary, health, and psychosocial factors are associated with developing sexual pain across the menopausal transition.

METHODS

These were longitudinal analyses of questionnaire data from the multicenter, multiracial and ethnic prospective cohort SWAN (Study of Women's Health Across the Nation) (1995-2008). We used multivariable discrete-time proportional hazards models to examine whether incident sexual pain was associated with preceding long-term (up to 10 visits) or short-term (two and three visits) sexual intercourse frequency patterns or other factors (eg, menopause status, genitourinary symptoms, lifestyle factors, and mental health).

RESULTS

Of the 2,247 women with no sexual pain at baseline, 1,087 (48.4%) developed sexual pain at least "sometimes" up to 10 follow-up visits over 13 years. We found no consistent association between prior patterns of sexual intercourse frequency and development of sexual pain. For example, neither decreases in intercourse frequency from baseline (adjusted hazard ratio [aHR] 0.93, 95% CI 0.73-1.19) nor decreases in frequency over three prior visits (aHR 1.00, 95% CI 0.72-1.41) were associated with incident pain. Reasons for interruptions in intercourse activity at the prior visit, including lack of interest (aHR 1.64, 95% CI 0.74-3.65) and relationship issues (aHR 0.36, 95% CI 0.04-2.88), were not associated with developing pain. Being postmenopausal using hormone therapy (aHR 3.16, 95% CI 1.46-6.85), and reported vaginal dryness (aHR 3.73, 95% CI 2.88-4.83) were most strongly associated with incident sexual pain.

CONCLUSION

Long-term and short-term declines in sexual intercourse frequency across the menopausal transition were not associated with increased hazard of developing pain with intercourse. This empirical evidence does not support the common belief that a reduction in women's sexual frequency is responsible for their symptoms of sexual pain.

VALENCIA: a nearest centroid classification method for vaginal microbial communities based on composition

BACKGROUND

Taxonomic profiles of vaginal microbial communities can be sorted into a discrete number of categories termed community state types (CSTs). This approach is advantageous because collapsing a hyper-dimensional taxonomic profile into a single categorical variable enables efforts such as data exploration, epidemiological studies, and statistical modeling. Vaginal communities are typically assigned to CSTs based on the results of hierarchical clustering of the pairwise distances between samples. However, this approach is problematic because it complicates between-study comparisons and because the results are entirely dependent on the particular set of samples that were analyzed. We sought to standardize and advance the assignment of samples to CSTs.

RESULTS

We developed VALENCIA (VAginaL community state typE Nearest CentroId clAssifier), a nearest centroid-based tool which classifies samples based on their similarity to a set of reference centroids. The references were defined using a comprehensive set of 13,160 taxonomic profiles from 1975 women in the USA. This large dataset allowed us to comprehensively identify, define, and characterize vaginal CSTs common to reproductive age women and expand upon the CSTs that had been defined in previous studies. We validated the broad applicability of VALENCIA for the classification of vaginal microbial communities by using it to classify three test datasets which included reproductive age eastern and southern African women, adolescent girls, and a racially/ethnically and geographically diverse sample of postmenopausal women. VALENCIA performed well on all three datasets despite the substantial variations in sequencing strategies and bioinformatics pipelines, indicating its broad application to vaginal microbiota. We further describe the relationships between community characteristics (vaginal pH, Nugent score) and participant demographics (race, age) and the CSTs defined by VALENCIA.

CONCLUSION

VALENCIA provides a much-needed solution for the robust and reproducible assignment of vaginal community state types. This will allow unbiased analysis of both small and large vaginal microbiota datasets, comparisons between datasets and meta-analyses that combine multiple datasets. Video abstract.

Postoperative Opioid Prescribing and Consumption after Hysterectomy: A Prospective Cohort Study

STUDY OBJECTIVE

To examine opioid prescribing and consumption patterns after hysterectomy and identify factors associated with postoperative opioid consumption.

DESIGN

Prospective cohort study.

SETTING

Single university medical center.

PATIENTS

Women undergoing hysterectomy for benign, nonobstetric indications.

INTERVENTIONS

Participant preoperative and surgical characteristics were obtained through chart review and patient report of baseline pain score. During the third postoperative week, participants completed a telephone interview, including a direct count of remaining opioid pills and assessment of satisfaction with pain management. We assessed factors associated with opioid consumption in oral morphine equivalents (OME) using a linear regression model.

MEASUREMENTS AND MAIN RESULTS

Of the 129 participants, 113 (88%) completed the postoperative survey after hysterectomy: 16 vaginal, 43 robotic-assisted, 42 conventional laparoscopic, and 12 abdominal hysterectomies. The median amount of opioid prescribed was 150 OME (interquartile range [IQR] 113-200), while the median amount consumed was 75 (IQR 10-135), reflecting an average consumption of about 50% of the prescription. Opioid prescription size was associated with consumption; for every additional oral morphine equivalent prescribed, on average, an additional 0.5 was consumed (p <.001). If the indication for hysterectomy was related to pain, participants consumed 25.3 additional OME (p = .04). The amount of opioid prescribed was inversely correlated with pain management satisfaction; every additional point on a 1 through 5 Likert scale of increasing satisfaction was associated with 44 fewer OME prescribed (standard error 9 OME, p <.001). For the 1464 total unused pills among the 104 participants with leftover opioids, only 20% reported an Food and Drug Administration -compliant opioid disposal plan.

CONCLUSION

Gynecologic surgeons can respond to the opioid epidemic by reducing excess opioid pills after hysterectomy by providing both the smallest effective prescription size and concrete resources for safe opioid disposal. These actions may contribute to a reduction in opioid use disorder cases or overdose deaths.

The menopause transition and women's health at midlife: a progress report from the Study of Women's Health Across the Nation (SWAN)

OBJECTIVE

Our initial understanding of the menopause transition (MT) has been framed by clinical samples of women seeking treatment rather than by population-based studies. The Study of Women's Health Across the Nation (SWAN) initiated in 1996 with an overall goal to define the MT, to characterize its biological and psychosocial antecedents and sequelae in an ethnically and racially diverse sample of midlife women.

METHODS

This review summarizes the central findings of SWAN to date that can inform women and their healthcare providers about the impact of the MT and midlife aging on overall health and well-being.

RESULTS

SWAN characterized changes in reproductive axis and menstrual cycle patterns that informed the development of the reproductive aging staging system Staging of Reproductive Aging Workshop+10; MT-related symptoms and mental health (vasomotor symptoms, sleep complaints, psychological symptoms, cognitive performance, and urogenital and sexual health); and physiological systems and functions (cardiovascular and cardiometabolic health, bone health, physical function performance) that are influenced by the MT. SWAN demonstrated substantial interrelations among these changes and significant racial/ethnic differences in the rate and magnitude of change in multiple health indictors in midlife women. The findings point to midlife as a critical stage for adopting healthy behavior and preventive strategies.

CONCLUSIONS

Over the past 23 years, SWAN has advanced our understanding of the impact of the MT and midlife aging on health and well-being in women. SWAN will be instrumental to determine whether MT-related changes during midlife are related to unfavorable health and well-being in early old age.

Factors related to age at natural menopause: longitudinal analyses from SWAN

Early age at the natural final menstrual period (FMP) or menopause has been associated with numerous health outcomes and might be a marker of future ill health. However, potentially modifiable factors affecting age at menopause have not been examined longitudinally in large, diverse populations. The Study of Women's Health Across the Nation (SWAN) followed 3,302 initially premenopausal and early perimenopausal women from 7 US sites and 5 racial/ethnic groups, using annual data (1996-2007) and Cox proportional hazards models to assess the relation of time-invariant and time-varying sociodemographic, lifestyle, and health factors to age at natural FMP. Median age at the FMP was 52.54 years (n = 1,483 observed natural FMPs). Controlling for sociodemographic, lifestyle, and health factors, we found that racial/ethnic groups did not differ in age at the FMP. Higher educational level, prior oral contraceptive use, and higher weight at baseline, as well as being employed, not smoking, consuming alcohol, having less physical activity, and having better self-rated health over follow-up, were significantly associated with later age at the FMP. These results suggest that age at the natural FMP reflects a complex interrelation of health and socioeconomic factors, which could partially explain the relation of late age at FMP to reduced morbidity and mortality.

Relationship between hysterectomy and admixture in African American women

OBJECTIVE

Most studies suggest that hysterectomies are more common in African American women than in other ethnic groups. To assess this ethnic surgical disparity in a novel way, our main goal was to determine whether admixture (the proportion of sub-Saharan African or European origin in individuals) is associated with hysterectomy frequency in African American women in the Women's Health Initiative.

STUDY DESIGN

In this retrospective study, we used ancestry informative single nucleotide polymorphisms to estimate admixture proportions in >10,000 African American women from the Women's Health Initiative. Logistic regression models were used to assess the association between admixture and self-reported history of hysterectomy with and without controls for relevant covariates. Multinomial logistic regression models were used to assess the association between admixture and self-reported age of hysterectomy. We also considered other potential risk factors (adiposity, hypertension, and education) for hysterectomy accounting for admixture.

RESULTS

African admixture was a strong risk factor after the adjustment for multiple covariates (odds ratio, 1.85; P < .0001). The admixture risk for hysterectomy was highest for those procedures that were performed in the 35-39 age range (odds ratio, 3.08; P < .0001) and least evident in oldest ages (≥45 years old). Our analyses also suggest that adiposity, hypertension, and education were associated independently with hysterectomy in this population group.

CONCLUSION

These results suggest that higher African admixture is associated with higher frequencies of hysterectomy and that genetic studies that specifically target African American women and diseases that are associated with hysterectomy may be especially useful in understanding the pathogenesis and underlying cause of this disparity in health outcome.

Gains in body fat and vasomotor symptom reporting over the menopausal transition: the study of women's health across the nation

Although most women report vasomotor symptoms (hot flashes, night sweats) during midlife, their etiology and risk factors are incompletely understood. Body fat is positively associated with vasomotor symptoms cross-sectionally, but the longitudinal relation between changes in body fat and vasomotor symptoms is uncharacterized. The study aim was to examine whether gains in body fat were related to vasomotor symptom reporting over time. Measures of bioelectrical impedance for body fat, reproductive hormones, and reported vasomotor symptoms were assessed annually over 4 years from 2002 to 2006 among 1,659 women aged 47-59 years participating in the Study of Women's Health Across the Nation. Body fat change was examined in relation to vasomotor symptoms by using generalized estimating equations. Body fat gains were associated with greater odds of reporting hot flashes in models adjusted for age, site, race/ethnicity, education, smoking, parity, anxiety, and menopausal status (relative to stable body fat, gain: odds ratio = 1.23, 95% confidence interval: 1.02, 1.48; P = 0.03; loss: odds ratio = 1.07, 95% confidence interval: 0.89, 1.29; P = 0.45). Findings persisted controlling for estradiol, the free estradiol index, or follicle-stimulating hormone concentrations. The relations between body fat changes and night sweats were not statistically significant. Body fat gains are associated with greater hot flash reporting during the menopausal transition.

Factors associated with prevalent and incident urinary incontinence in a cohort of midlife women: a longitudinal analysis of data: study of women's health across the nation

To compare the characteristics of and baseline factors associated with prevalent and incident urinary incontinence in a diverse cohort of midlife women, the authors analyzed the baseline and first five annual follow-up visits of the Study of Women's Health Across the Nation (SWAN), 1995-2001. From responses to annual questionnaires, the authors defined prevalent incontinence as at least monthly incontinence reported at baseline and incident incontinence as at least monthly incontinence first reported over follow-up. They used multiple logistic regression for their comparison. The mean age of their cohort at baseline was 45.8 (standard deviation: 2.7) years. Prevalent incontinence was 46.7%, and the average incidence was 11.1% per year. Most women reported stress, but a higher proportion developed urge incontinence (15.9% vs. 7.6% at baseline). African Americans (29.5%) and Hispanics (27.5%) had the lowest prevalence of incontinence; African Americans (11.6%) and Caucasians (13.4%) had the highest average annual incidence. Parity, diabetes, fibroids, and poor social support were associated with prevalent incontinence, while high body mass index, high symptom sensitivity, and poor health were associated with incident incontinence. In midlife women, incident incontinence is mild with different characteristics and baseline risk factors; overweight women have a higher risk of developing incontinence.

Hospitalizations for Pelvic Inflammatory Disease and Tuboovarian Abscess

OBJECTIVE

To describe the demographic characteristics of and procedures for patients hospitalized for pelvic inflammatory disease (PID) and tuboovarian abscess in California from 1991 to 2001.

METHODS

We used the International Classification of Diseases, 9th Revision, Clinical Modification, diagnostic and procedural codes in the California Patient Discharge Database and census data to calculate hospitalization rates for PID and tuboovarian abscess by age and race/ethnicity. We estimated the proportion of PID and tuboovarian abscess hospitalizations associated with procedures and estimated average length of hospital stay, readmission rates, and mortality.

RESULTS

From 1991 to 2001, the California hospitalization rate for PID decreased by 61.5% (from 2.6 to 1.0 per 10,000 women). Tuboovarian abscess hospitalization rates declined by 33.3% during the same time period (from 0.6 to 0.4). Pelvic inflammatory disease hospitalization rates were highest among 20-39 year olds compared with other age categories. Black women aged 20-39 had the highest PID hospitalization rates compared with other racial/ethnic groups. The proportion of hospitalizations associated with hysterectomy was lowest for blacks.

CONCLUSION

In California, the hospitalization rate for PID has declined between 1991 and 2001. Black women, 20-39 years of age, had the highest PID hospitalization rates.

LEVEL OF EVIDENCE

III.

The effect of ultralow-dose transdermal estradiol on urinary incontinence in postmenopausal women

OBJECTIVE

To estimate the effect of 2 years of treatment with ultralow-dose transdermal estradiol (E2) on incontinence in postmenopausal women.

METHODS

Ultra Low Dose Transdermal estRogen Assessment (ULTRA) was a multicenter, randomized, double-blinded, placebo-controlled trial of unopposed ultralow-dose (0.014 mg/d) transdermal E2 for prevention of osteoporosis in 417 postmenopausal women aged 60 to 80 years. Frequency of incontinence episodes was assessed at baseline and after 4 months and 2 years of treatment using a self-reported questionnaire. We used an intention-to-treat analysis to compare change in incontinence frequency, improved (decreased 2 or more episodes per week), unchanged (increased or decreased no more than 1 episode per week), or worsened (increased 2 or more episodes per week) between the E2 and placebo groups among women with and without at least weekly incontinence at baseline.

RESULTS

At baseline, the prevalence of at least weekly incontinence was similar between E2 and placebo groups (43%). After 2 years, there was no difference between groups in the proportions of women with incontinence at baseline whose incontinence improved, worsened, or was unchanged. The odds ratio for worsening incontinence in the E2 compared with placebo group was 1.35 (95% confidence interval 0.75-2.42. In women without incontinence at baseline, the odds of developing at least weekly incontinence after 2 years in the E2 compared with placebo group was not significant (odds ratio 1.2, 95% confidence interval 0.7-2.2).

CONCLUSION

Two years of treatment with unopposed ultralow-dose transdermal E2 did not substantially change the frequency of incontinence symptoms or alter the risk of developing at least weekly incontinence.

LEVEL OF EVIDENCE

I.

Postmenopausal hormone therapy: does it cause incontinence?

OBJECTIVE

To estimate the effect of hormone therapy on risk of stress and urge urinary incontinence.

METHODS

The Heart Estrogen/progestin Replacement Study was a randomized, placebo-controlled, double-blinded trial to evaluate daily oral conjugated estrogen (0.625 mg) plus medroxyprogesterone acetate (2.5 mg) therapy for the prevention of heart disease events in women with established heart disease. The 1,208 participants in Heart Estrogen/progestin Replacement Study who reported no loss of urine in the previous 7 days at baseline are included in this analysis.

RESULTS

During 4.2 years of treatment, 64% of women randomly assigned to hormone therapy compared with 49% of those assigned to placebo reported weekly incontinence (P < .001). The higher risk of incontinence in the hormone group was evident at 4 months, persisted throughout the treatment period, and was independent of the age of the women. The odds ratios for weekly incontinence among women on hormone therapy compared with placebo were 1.5 for urge incontinence (95% confidence interval [CI] 1.2-1.8; P < .001) and 1.7 for stress incontinence (95% CI 1.5-2.1; P < .001). Four years of treatment with hormone therapy caused an excess risk of 12% for weekly urge incontinence and 16% for weekly stress incontinence; the corresponding numbers needed to harm were 8.6 (95% CI 5.8-16.6) and 6.2 (95% CI 4.6-9.4).

CONCLUSION

Estrogen plus progestin therapy increases risk of urge and stress incontinence within 4 months of beginning treatment.

LEVEL OF EVIDENCE

I.

Effect of Raloxifene on Urinary Incontinence

OBJECTIVE

To estimate the effect of 3 years of treatment with raloxifene on urinary incontinence in postmenopausal women.

METHODS

We used measures of urinary incontinence severity, frequency, and type in the Multiple Outcomes of Raloxifene trial, a multicenter randomized, controlled trial of women who were at least 2 years postmenopausal with osteoporosis. At 10 U.S. sites of this trial, 963 women randomly assigned to raloxifene or placebo completed questionnaires about incontinence at baseline and 3 years later. We analyzed the odds of worsening severity and frequency of incontinence and type of incontinence after 3 years of treatment with raloxifene.

RESULTS

The mean age of our subjects was 68.3 +/- 7 years. After 3 years of treatment, there was no significant difference between raloxifene and placebo groups in urinary incontinence severity (multivariable odds ratio [OR] 1.02; 95% [CI] 0.78, 1.34). The majority of the women (60%) had no change in urinary incontinence episodes from baseline to year 3. The odds of worsening urinary incontinence severity after 3 years of raloxifene treatment were 1.05 (95% CI 0.75, 1.48). Similarly, the odds of developing new onset incontinence were 0.95 (95% CI 0.59, 1.52). Finally, raloxifene did not effect the odds of having stress (OR 1.01; 95% CI 0.71, 1.43) or urge (OR 1.20; 95% CI 0.86, 1.68) incontinence after 3 years of use.

CONCLUSION

In postmenopausal women with osteoporosis, 3 years of treatment with raloxifene had no effect on urinary incontinence.

LEVEL OF EVIDENCE

I

Stress urinary incontinence surgery in the United States

OBJECTIVE

To describe the prevalence, regional rates and demographic characteristics, morbidity, and mortality of stress urinary incontinence surgeries in the United States.

METHODS

We used data from the 1998 National Hospital Discharge Survey and the 1998 National Census to calculate rates of surgeries for stress urinary incontinence by age, race, and region of the United States. From these data we estimated morbidity and mortality associated with incontinence surgery.

RESULTS

In 1998, approximately 135000 women had inpatient surgery for stress urinary incontinence in the United States. The mean age of these women was 54.0 (+/-13.3) years. The South had the highest rate of surgery (14.8 per 10000 women), whereas the Northeast had the lowest (9.8 per 10000). In the 79% of discharges for which race was stated, the surgery rate for whites (11.6 per 10000) was almost five times greater than for blacks (2.6 per 10000), whereas the perioperative complication rate for blacks was twice that for whites (20.6% compared with 9.7%). Almost 70% of incontinence surgeries were done in combination with other major gynecologic procedures. For all incontinence surgeries, approximately 18% had complications, and mortality was rare (0.01%).

CONCLUSION

Stress urinary incontinence surgery is common, especially among white women. Differences in regional and racial surgical rates may represent differences in physician practice, patient expectations, and access to or utilization of care.

Pelvic organ prolapse surgery in the United States, 1997

OBJECTIVE

Our purpose was to describe the prevalence, regional rates and demographic characteristics, morbidity, and mortality of pelvic organ prolapse surgeries in the United States.

STUDY DESIGN

We used data from the 1997 National Hospital Discharge Survey and the 1997 National Census to calculate rates of pelvic organ prolapse surgeries by age, race, and regional trends.

RESULTS

In 1997, 225,964 women underwent surgery for prolapse (22.7 per 10,000 women). The mean age of these women was 54.6 years (+/-15.2). The South had the highest rate of surgery (29.3 per 10,000) and the Northeast had the lowest (16.1 per 10,000). The surgery rate for whites (19.6 per 10,000) was 3 times greater than that for African Americans (6.4 per 10,000). Although 16% of surgeries had complications, mortality was rare (0.03%).

CONCLUSION

Pelvic organ prolapse surgery is common. Regional and racial differences in rates of surgery may reflect physician practice, patient preferences, and gynecologic care utilization.

Cost of pelvic organ prolapse surgery in the United States

OBJECTIVE

To estimate the annual direct cost to society of pelvic organ prolapse operations in the United States.

METHODS

We multiplied the number of pelvic organ prolapse operations identified in the 1997 National Hospital Discharge Survey by national average Medicare reimbursement for physician services and hospitalizations. Although this reimbursement does not estimate the actual cost, it is a proxy for cost, which estimates what society pays for the procedures.

RESULTS

In 1997, direct costs of pelvic organ prolapse surgery were 1012 million dollars (95% confidence interval [CI] 775 dollars, 1251 million), including 494 dollars million (49%) for vaginal hysterectomy, 279 million dollars (28%) for cystocele and rectocele repair, and 135 million dollars (13%) for abdominal hysterectomy. Physician services accounted for 29% (298 million dollars) of total costs, and hospitalization accounted for 71% (714 million dollars). Twenty-one percent of pelvic organ prolapse operations included urinary incontinence procedures (218 million dollars). If all operations were reimbursed by non-Medicare sources, the annual estimated cost would increase by 52% to 1543 million dollars.

CONCLUSION

The annual direct costs of operations for pelvic organ prolapse are substantial.

Oral contraceptives and primary liver cancer: temporal trends in three countries

OBJECTIVE

To determine if vital statistics support a temporal association between the introduction of oral contraceptives (OC) and the incidence of, and mortality from, primary liver cancer in three countries from different regions of the world.

METHODS

We used Cancer Incidence in Five Continents, volumes I-VI, for incidence data on primary liver cancer in the United States and Japan. The Centre for Epidemiology in Stockholm provided the incidence data for Sweden. We obtained mortality data for the U.S. from Vital Statistics of the United States, for Japan from The World Health Statistics Annual, and for Sweden from Swedish government sources. We compiled data on the prevalence of OC use in all three countries from multiple sources, including the National Survey of Family Growth, The Population Council, and original articles.

RESULTS

Despite several hundred million woman-years of exposure to OCs, primary liver cancer incidence and mortality rates among women have not changed substantially in the United States. In Sweden, another country with extensive OC use, the primary liver cancer incidence trends in women paralleled those of men. The incidence of, and mortality rate from, primary liver cancer is gradually rising in Japan, where OC use has been negligible.

CONCLUSION

Population-based data from three industrialized countries with very different patterns of oral contraceptive use provide no support for a measurable effect of OCs on primary liver cancer. Although case-control studies from developed countries have suggested an increase in risk, if such an effect does exist, the public health impact appears to be negligible.