Infertility and risk of postmenopausal breast cancer in the women's health initiative

PURPOSE

Although infertility (i.e., failure to conceive after ≥ 12 months of trying) is strongly correlated with established breast cancer risk factors (e.g., nulliparity, number of pregnancies, and age at first pregnancy), its association with breast cancer incidence is not fully understood. Previous studies were primarily small clinic-based or registry studies with short follow-up and predominantly focused on premenopausal breast cancer. The objective of this study was to assess the relationship between infertility and postmenopausal breast cancer risk among participants in the Women's Health Initiative (analytic sample = 131,784; > 25 years of follow-up).

METHODS

At study entry, participants were asked about their pregnancy history, infertility history, and diagnosed reasons for infertility. Incident breast cancers were self-reported with adjudication by trained physicians reviewing medical records. Cox proportional hazards models were used to estimate risk of incident postmenopausal breast cancer for women with infertility (overall and specific infertility diagnoses) compared to parous women with no history of infertility. We examined mediation of these associations by parity, age at first term pregnancy, postmenopausal hormone therapy use at baseline, age at menopause, breastfeeding, and oophorectomy.

RESULTS

We observed a modest association between infertility (n = 23,406) and risk of postmenopausal breast cancer (HR = 1.07; 95% CI 1.02-1.13). The association was largely mediated by age at first term pregnancy (natural indirect effect: 46.4% mediated, CI 12.2-84.3%).

CONCLUSION

These findings suggest that infertility may be modestly associated with future risk of postmenopausal breast cancer due to age at first pregnancy and highlight the importance of incorporating reproductive history across the life course into breast cancer analyses.

Risk of Adverse Cardiovascular Outcomes in Postmenopausal Women with Inflammatory Bowel Disease

BACKGROUND

Individuals with inflammatory bowel disease (IBD) who lack traditional cardiovascular disease (CVD) risk factors, such as young females, are observed to experience adverse CVD outcomes. Whether women with IBD have increased CVD risk after the menopause transition is unclear.

METHODS

We conducted a survival analysis of Women's Health Initiative (WHI) participants and excluded those with missing IBD diagnosis, model covariate data, follow-up data, or a baseline history of the following CVD outcomes: coronary heart disease (CHD), ischemic stroke, venous thromboembolism (VTE), peripheral arterial disease (PAD). Risk of outcomes between IBD and non-IBD women was performed using Cox proportional hazard models, stratified by WHI trial and follow-up. Models were adjusted for age, socio-demographics, comorbidities (e.g., hypertension, diabetes, hypercholesterolemia, etc.), family history, and lifestyle factors (e.g., smoking, alcohol, physical activity, body mass index, etc.).

RESULTS

Of 134,022 WHI participants meeting inclusion criteria, 1367 (1.0%) reported IBD at baseline. Mean baseline age was 63.4 years. After adjusting for age and other confounders, no significant difference was observed between IBD and non-IBD women for the risk of CHD (HR 0.96, 95% CI 0.73-1.24), VTE (HR 1.11, 95% CI 0.81-1.52) or PAD (HR 0.64, 95% CI 0.28-1.42). After adjusting for age, risk of ischemic stroke was significantly higher (HR 1.41, 95% CI 1.06-1.88) in IBD than non-IBD women. With further adjustment, the excess risk of ischemic stroke among IBD women was attenuated and no longer statistically significant (HR 1.31, 95% CI 0.98-1.76).

CONCLUSIONS

Among postmenopausal women with IBD, risk of ischemic stroke may be higher than in non-IBD women.

Hysterectomy, oophorectomy and risk of non-Hodgkin's lymphoma

Hysterectomy is associated with an increased risk for adverse health outcomes. However, its connection to the risk of non-Hodgkin's lymphoma (NHL) remains unclear. The aims of our study were to investigate the associations between hysterectomy, oophorectomy and risk of NHL and its major subtypes (eg, diffuse large B-cell lymphoma [DLBCL]), and whether these associations were modified by exogenous hormone use. Postmenopausal women (n = 141,621) aged 50-79 years at enrollment (1993-1998) from the Women's Health Initiative were followed for an average of 17.2 years. Hysterectomy and oophorectomy were self-reported at baseline. Incident NHL cases were confirmed by central review of medical records and pathology reports. During the follow-up period, a total of 1719 women were diagnosed with NHL. Hysterectomy, regardless of oophorectomy status, was associated with an increased risk of NHL (hazard ratio [HR] = 1.23, 95% confidence interval [CI]: 1.05-1.44). Oophorectomy was not independently associated with NHL risk after adjusting for hysterectomy. When stratified by hormone use, the association between hysterectomy and NHL risk was confined to women who had never used hormone therapy (HR = 1.35, 95% CI: 1.06-1.71), especially for DLBCL subtype (P for interaction = .01), and to those who had undergone hysterectomy before the age of 55. Our large prospective study showed that hysterectomy was a risk factor of NHL. Findings varied by hormone use. Future studies incorporating detailed information on the types and indications of hysterectomy may deepen our understanding of the mechanisms underlying DLBCL development and its potential interactions with hormone use.

Menopausal hormone therapy and coronary heart disease: the roller-coaster history

In the USA it is estimated that more than one million women become menopausal each year. Coronary heart disease (CHD) is the leading cause of mortality in menopausal woman globally. The majority of perimenopausal to postmenopausal women experience bothersome symptoms including hot flashes, night sweats, mood liability, sleep disturbances, irregular bleeding and sexual dysfunction. While menopausal hormone therapy (HT) effectively treats most of these symptoms, use of HT has become confusing, especially related to CHD risk. Despite years of observational and retrospective studies supporting a CHD benefit and improved survival among HT users, the Heart and Estrogen/Progestin Replacement Study (HERS) and the Women's Health Initiative (WHI) raised doubts about this long-held premise. The timing hypothesis has since emerged and states that when HT is initiated in younger women, soon after menopause onset, there may be cardiovascular benefit. The following review discusses the roller-coaster history of HT use as it pertains to CHD in postmenopausal women. Studies that highlight HT's CHD benefit are reviewed and provide reassurance that HT utilized in appropriately selected younger postmenopausal women close to the onset of menopause is safe from a cardiovascular perspective, in line with consensus recommendations.

Adverse pregnancy outcomes and risk of type 2 diabetes in postmenopausal women

BACKGROUND

Although gestational diabetes mellitus and delivering high-birthweight infants are known to predict a higher risk of future type 2 diabetes mellitus, the association of hypertensive disorders of pregnancy and other adverse pregnancy outcomes with type 2 diabetes mellitus is not well established.

OBJECTIVE

This study aimed to examine the associations between different types of adverse pregnancy outcomes and incident type 2 diabetes mellitus among postmenopausal women.

STUDY DESIGN

The Women's Health Initiative, a nationwide cohort of postmenopausal women, collected self-reported history of adverse pregnancy outcomes, including gestational diabetes mellitus, hypertensive disorders of pregnancy, preterm birth, and delivering low- birthweight (<2500 g) or high-birthweight (>4500 g) infants. Participants were followed up annually for self-reported incident type 2 diabetes mellitus treated with medication from baseline (1993-1998) to March 2021. This study used logistic regression to examine the associations of any and individual adverse pregnancy outcomes with diabetes mellitus. Stratified analyses were performed to assess effect modification by body mass index, race and ethnicity, education, parity, breastfeeding, and age at first birth.

RESULTS

This analysis included 49,717 women without a history of diabetes mellitus at enrollment who had a least 1 pregnancy and responded to the questionnaire about adverse pregnancy outcomes. After adjusting for body mass index, demographic, lifestyle, and reproductive factors, gestational diabetes mellitus (odds ratio, 2.26; 95% confidence interval, 1.94-2.63), high birthweight (odds ratio, 1.30; 95% confidence interval, 1.18-1.44), and hypertensive disorders of pregnancy (odds ratio, 1.18; 95% confidence interval, 1.08-1.30) were independently associated with higher odds of type 2 diabetes mellitus, whereas preterm birth and low birthweight were not associated with diabetes mellitus risk. A history of ≥2 adverse pregnancy outcomes was associated with higher odds of type 2 diabetes mellitus (odds ratio, 1.55; 95% confidence interval, 1.28-1.88). This study further observed higher odds of type 2 diabetes mellitus (odds ratio, 3.69; 95% confidence interval, 2.38-5.70) among women with a history of both gestational diabetes mellitus and hypertensive disorders of pregnancy than those without any adverse pregnancy outcomes.

CONCLUSION

Postmenopausal women with a history of gestational diabetes mellitus, those delivering high-birthweight infants, or those with hypertensive disorders of pregnancy are at risk of future type 2 diabetes mellitus. In addition, women with ≥2 conditions had an augmented risk and might be prioritized for screening and prevention efforts for type 2 diabetes mellitus.

Association of Later-Life Weight Changes With Survival to Ages 90, 95, and 100: The Women's Health Initiative

BACKGROUND

Associations of weight changes and intentionality of weight loss with longevity are not well described.

METHODS

Using longitudinal data from the Women's Health Initiative (N = 54 437; 61-81 years), we examined associations of weight changes and intentionality of weight loss with survival to ages 90, 95, and 100. Weight was measured at baseline, year 3, and year 10, and participants were classified as having weight loss (≥5% decrease from baseline), weight gain (≥5% increase from baseline), or stable weight (<5% change from baseline). Participants reported intentionality of weight loss at year 3.

RESULTS

A total of 30 647 (56.3%) women survived to ≥90 years. After adjustment for relevant covariates, 3-year weight loss of ≥5% vs stable weight was associated with lower odds of survival to ages 90 (OR, 0.67; 95% CI, 0.64-0.71), 95 (OR, 0.65; 95% CI, 0.60-0.71), and 100 (OR, 0.62; 95% CI, 0.49-0.78). Compared to intentional weight loss, unintentional weight loss was more strongly associated with lower odds of survival to age 90 (OR, 0.83; 95% CI, 0.74-0.94 and OR, 0.49; 95% CI, 0.44-0.55, respectively). Three-year weight gain of ≥5% vs stable weight was not associated with survival to age 90, 95, or 100. The pattern of results was similar among normal weight, overweight, and obese women in body mass index (BMI)-stratified analyses.

CONCLUSIONS

Weight loss of ≥5% vs stable weight was associated with lower odds of longevity, more strongly for unintentional weight loss than for intentional weight loss. Potential inaccuracy of self-reported intentionality of weight loss and residual confounding were limitations.

Needs assessment of menopause education in United States obstetrics and gynecology residency training programs

OBJECTIVE

This study aimed to assess the variance in menopause education, educational resources, and the needs of obstetrics and gynecology (ObGyn) residency programs by conducting a national survey of program directors (PDs).

METHODS

In 2022, an institutional review board-approved Web-based Qualtrics survey was designed and distributed electronically to 145 US ObGyn residency PDs. The survey consists of 15 questions. The main outcomes are reported using descriptive statistics.

RESULTS

The survey was completed by 99 of 145 PDs (68.3%). Almost all participants (92.9%) strongly agreed that residents nationwide should have access to a standardized menopause curriculum that could be utilized in their programs. Only 31.3% reported having a menopause curriculum in their residency program. Of the programs with a menopause curriculum, 96.8% reported using lectures, 77.4% reported assigned readings, and 74.2% had either dedicated menopause clinics or other clinics with a high volume of menopausal patients. Of all programs surveyed, only 29.3% reported that trainees had dedicated time assigned to a menopause clinic. A total of 83 of 99 PDs agreed or strongly agreed that their programs needed more menopause educational resources, and most (89.7%) stated they were likely or very likely to use self-paced menopause modules that include performance feedback if available.

CONCLUSIONS

Data from the needs assessment questionnaire revealed that menopause education and resources vary across residency programs, with the majority lacking a dedicated menopause curriculum. Most PDs expressed a desire for more educational resources and standardized training materials, and preferred to access an online national menopause curriculum.

Preterm birth, birthweight, and subsequent risk for depression

An individual's birthweight, a marker of in utero exposures, was recently associated with certain psychiatric conditions. However, studies investigating the relationship between an individual's preterm birth status and/or birthweight and risk for depression during adulthood are sparse; we used data from the Women's Health Initiative (WHI) to investigate these potential associations. At study entry, 86,925 postmenopausal women reported their birthweight by category (<6 lbs., 6-7 lbs. 15 oz., 8-9 lbs. 15 oz., or ≥10 lbs.) and their preterm birth status (full-term or ≥4 weeks premature). Women also completed the Burnham screen for depression and were asked to self-report if: (a) they had ever been diagnosed with depression, or (b) if they were taking antidepressant medications. Linear and logistic regression models were used to estimate unadjusted and adjusted effect estimates. Compared to those born weighing between 6 and 7 lbs. 15 oz., individuals born weighing <6 lbs. (βadj = 0.007, P < 0.0001) and ≥10 lbs. (βadj = 0.006, P = 0.02) had significantly higher Burnam scores. Individuals born weighing <6 lbs. were also more likely to have depression (adjOR 1.21, 95% CI 1.11-1.31). Individuals born preterm were also more likely to have depression (adjOR 1.18, 95% CI 1.02-1.35); while attenuated, this association remained in analyses limited to only those reportedly born weighing <6 lbs. Our research supports the role of early life exposures on health risks across the life course. Individuals born at low or high birthweights and those born preterm may benefit from early evaluation and long-term follow-up for the prevention and treatment of mental health outcomes.

Association of maternal birth weight and maternal preterm birth with subsequent risk for adverse reproductive outcomes: The Women's Health Initiative

BACKGROUND

Advancements in medical technology and pharmacologic interventions have drastically improved survival of infants born preterm and low birth weight, but knowledge regarding the long-term health impacts of these individuals is limited and inconsistent.

AIM

To investigate whether an individual's birthweight or history of being born preterm increases the risk of an adverse reproductive outcome.

STUDY DESIGN

Nested case-control study within the Women's Health Initiative.

SUBJECTS

79,934 individuals who self-reported their personal birthweight category and/or preterm birth status.

OUTCOMES MEASURES

Self-reported pregnancy outcomes: subfertility, miscarriage, stillbirth, preeclampsia, gestational diabetes, gestational hypertension, preterm birth, low birthweight infant, high birthweight infant. Logistic regression models were used to estimate unadjusted and adjusted odds ratios (OR).

RESULTS

After adjustments, individuals reporting their birthweight <6lbs. were 20 % more likely to have a stillbirth or 70 % more likely to have a low birthweight infant and were less likely to have a full-term birth or high birthweight infant during their pregnancy. Individuals reporting a birthweight ≥10 lbs. were more likely to have a high birthweight infant (OR 3.49, 95 % CI 2.73-4.39) and less likely to have a low birthweight infant (OR 0.64, 95 % CI 0.47-0.82). Individuals born preterm were at increased risk for infertility, miscarriage, preeclampsia, gestational diabetes, and delivering a preterm or low birthweight infant.

CONCLUSIONS

As more individuals born preterm and/or low birthweight survive to adulthood, the incidence and prevalence of poor reproductive outcomes may increase. Women born at extremes of birthweight and prematurity may need to be monitored more closely during their own pregnancies.

The co-occurrence and cumulative prevalence of hypertension, rheumatoid arthritis, and hypothyroidism in preterm-born women in the Women's Health Initiative

Emerging evidence suggests that preterm-born individuals (<37 weeks gestation) are at increased risk of developing chronic health conditions in adulthood. This study compared the prevalence, co-occurrence, and cumulative prevalence of three female predominant chronic health conditions - hypertension, rheumatoid arthritis [RA], and hypothyroidism - alone and concurrently. Of 82,514 U.S. women aged 50-79 years enrolled in the Women's Health Initiative, 2,303 self-reported being born preterm. Logistic regression was used to analyze the prevalence of each condition at enrollment with birth status (preterm, full term). Multinomial logistic regression models analyzed the association between birth status and each condition alone and concurrently. Outcome variables using the 3 conditions were created to give 8 categories ranging from no disease, each condition alone, two-way combinations, to having all three conditions. The models adjusted for age, race/ethnicity, and sociodemographic, lifestyle, and other health-related risk factors. Women born preterm were significantly more likely to have any one or a combination of the selected conditions. In fully adjusted models for individual conditions, the adjusted odds ratios (aORs) were 1.14 (95% CI, 1.04, 1.26) for hypertension, 1.28 (1.12, 1.47) for RA, and 1.12 (1.01, 1.24) for hypothyroidism. Hypothyroidism and RA were the strongest coexisting conditions [aOR 1.69, 95% CI (1.14, 2.51)], followed by hypertension and RA [aOR 1.48, 95% CI (1.20, 1.82)]. The aOR for all three conditions was 1.69 (1.22, 2.35). Perinatal history is pertinent across the life course. Preventive measures and early identification of risk factors and disease in preterm-born individuals are essential to mitigating adverse health outcomes in adulthood.

Associations of maternal preterm birth with subsequent risk for type 2 diabetes in women from the women's health initiative

Preterm birth has been associated with insulin resistance and beta-cell dysfunction, a hallmark characteristic of type 2 diabetes. However, studies investigating the relationship between a personal history of being born preterm and type 2 diabetes are sparse. We sought to investigate the potential association between a personal history of being born preterm and risk for type 2 diabetes in a racially and ethnically diverse population. Baseline and incident data (>16 years of follow-up) from the Women's Health Initiative (n = 85,356) were used to examine the association between personal history of being born preterm (born 1910-1940s) and prevalent (baseline enrollment; cross-sectional) or incident (prospective cohort) cases of type 2 diabetes. Logistic and Cox proportional hazards regression models were used to estimate odds and hazards ratios. Being born preterm was significantly, positively associated with odds for prevalent type 2 diabetes at enrollment (adjOR = 1.79, 95% CI 1.43-2.24; P < 0.0001). Stratified regression models suggested the positive associations at baseline were consistent across race and ethnicity groups. However, being born preterm was not significantly associated with risk for incident type 2 diabetes. Regression models stratified by age at enrollment suggest the relationship between being born preterm and type 2 diabetes persists only among younger age groups. Preterm birth was associated with higher risk of type 2 diabetes but only in those diagnosed with type 2 diabetes prior to study enrollment, suggesting the association between preterm birth and type 2 diabetes may exist at earlier age of diagnosis but wane over time.

Association of Social Support with Mild Cognitive Impairment and Dementia Among Older Women: The Women's Health Initiative Memory Study

BACKGROUND

Social support may be a modifiable risk factor for cognitive impairment. However, few long-term, large prospective studies have examined associations of various forms of social support with incident mild cognitive impairment (MCI) and dementia.

OBJECTIVE

To examine associations of perceived social support with incident MCI and dementia among community-dwelling older women.

METHODS

This prospective cohort study included 6,670 women from the Women's Health Initiative Memory Study who were cognitively unimpaired at enrollment. We used Cox proportional hazards models to assess associations between perceived social support with incident MCI, dementia, or either MCI/dementia during an average 10.7 (SD = 6.1)-year follow-up. Modelling was repeated for emotional/information support, affection support, tangible support, and positive social interaction subscales of social support.

RESULTS

Among 6,670 women (average age = 70 years [SD = 3.8]; 97.0% non-Hispanic/Latina; 89.8% White), greater perceived social support was associated with lower risk of MCI/dementia after adjustment for age, ethnicity, race, hormone therapy, education, income, diabetes, hypertension, and body mass index (Tertile [T]3 versus T1: HR = 0.85, 95% CI 0.74-0.99; ptrend = 0.08). Associations were significant for emotional/information support (T3 versus T1: HR = 0.84, 95% CI 0.72-0.97; ptrend = 0.04) and positive social interaction (T3 versus T1: HR = 0.85, 95% CI 0.73-0.99; ptrend = 0.06) subscales. Associations were attenuated and not significant after adjustment for depressive symptom severity.

OBJECTIVE

Perceived social support, emotional/information support, and positive social interaction were associated with incident MCI/dementia among older women. Results were not significant after adjustment for depressive symptom severity. Improving social support may reduce risk of MCI and dementia in older women.

The association between incidentally found breast arterial calcification on routine screening mammography and the development of coronary artery disease and stroke: results of a 10-year prospective study

OBJECTIVE

The objective of this study is to assess whether the presence of breast arterial calcifications (BACs) found on routine mammography is prospectively associated with the development of cardiovascular disease (CVD) events after 10 years of follow-up.

METHODS

Women presenting for screening mammography were enrolled in this prospective cohort. Baseline data were collected including history of CVD and CVD risk factors. Mammograms were assessed for the presence or absence of BAC. Participants completed questionnaires 10 years after baseline that assessed the development of CVD (coronary artery disease [CAD] and stroke) and CVD risk factors.

RESULTS

Of the 1,995 participants who enrolled at baseline, complete 10-year follow-up data were available for 1,039; of those, 114 (11.0%) were BAC-positive and 925 (89.0%) were BAC-negative at baseline. After controlling for age, BAC-positive women were more likely to develop CAD (odds ratio, 3.14; 95% confidence interval, 1.86-5.27; P < 0.001) compared with BAC-negative women after 10 years of follow-up. After controlling for age, BAC-positive women were more likely to have had a stroke (odds ratio, 5.10; 95% CI, 1.82-14.30) compared with BAC-negative women after 10 years.

CONCLUSIONS

The presence of BAC on routine screening mammography was associated with a significantly increased risk of developing CAD and stroke after 10 years of follow-up. Additional large prospective, population-based studies are needed to confirm BAC as a predictor of future CVD events and its utility in stratifying a woman's risk of CVD.

The severity of individual menopausal symptoms, cardiovascular disease, and all-cause mortality in the Women's Health Initiative Observational Cohort

OBJECTIVE

The aim of this study was to examine the association between common menopausal symptoms (MS) and long-term cardiovascular disease (CVD) and all-cause mortality.

METHODS

In an observational cohort of 80,278 postmenopausal women with no known CVD at baseline from the Women's Health Initiative, we assessed individual MS severity (mild vs none; moderate/severe vs none) for night sweats, hot flashes, waking up several times at night, joint pain or stiffness, headaches or migraines, vaginal or genital dryness, heart racing or skipping beats, breast tenderness, dizziness, tremors (shakes), feeling tired, forgetfulness, mood swings, restless or fidgety, and difficulty concentrating. Outcomes included total CVD events (primary) and all-cause mortality (secondary). Associations between specific MS, their severity, and outcomes were assessed during a median of 8.2 years of follow-up. All results were multivariable adjusted, and individual associations were Bonferroni corrected to adjust for multiple comparisons. A machine learning approach (least absolute shrinkage and selection operator) was used to select the most parsimonious set of MS most predictive of CVD and all-cause mortality.

RESULTS

The severity of night sweats, waking up several times at night, joint pain or stiffness, heart racing or skipping beats, dizziness, feeling tired, forgetfulness, mood swings, restless or fidgety, and difficulty concentrating were each significantly associated with total CVD. The largest hazard ratio (HR) for total CVD was found for moderate or severe heart racing or skipping beats (HR, 1.55; 95% confidence interval [CI], 1.29-1.86). The individual severities of heart racing or skipping beats, dizziness, tremors (shakes), feeling tired, forgetfulness, mood swings, restless or fidgety, and difficulty concentrating were associated with increased all-cause mortality. Moderate or severe dizziness had the largest HR (1.58; 95% CI, 1.24-2.01). Multiple symptom modeling via least absolute shrinkage and selection operator selected dizziness, heart racing, feeling tired, and joint pain as most predictive of CVD, whereas dizziness, tremors, and feeling tired were most predictive of all-cause mortality.

CONCLUSION

Among postmenopausal women with no known CVD at baseline, the severity of specific individual MS was significantly associated with incident CVD and mortality. Consideration of severe MS may enhance sex-specific CVD risk predication in future cohorts, but caution should be applied as severe MS could also indicate other health conditions.

Low Diastolic Blood Pressure and Mortality in Older Women. Results From the Women's Health Initiative Long Life Study

BACKGROUND

Recommended systolic blood pressure targets often do not consider the relationship of low diastolic blood pressure (DBP) levels with cardiovascular disease (CVD) and all-cause mortality risk, which is especially relevant for older people with concurrent comorbidities. We examined the relationship of DBP levels to CVD and all-cause mortality in older women in the Women's Health Initiative Long Life Study (WHI-LLS).

METHODS

The study sample included 7,875 women (mean age: 79 years) who underwent a blood pressure measurement at an in-person home visit conducted in 2012-2013. CVD and all-cause mortality were centrally adjudicated. Hazard ratios (HRs) were obtained from adjusted Cox proportional hazards models.

RESULTS

After 5 years follow-up, all-cause mortality occurred in 18.4% of women. Compared with a DBP of 80 mm Hg, the fully adjusted HR for mortality was 1.33 (95% confidence interval [CI]: 1.04-1.71) for a DBP of 50 mm Hg and 1.67 (95% CI: 1.29-2.16) for a DBP of 100 mm Hg. The HRs for CVD were 1.14 (95% CI: 0.78-1.67) for a DBP of 50 mm Hg and HR 1.50 (95% CI: 1.03-2.17) for a DBP of 100 mm Hg. The nadir DBP associated with lowest mortality risk was 72 mm Hg overall.

CONCLUSIONS

In older women, consideration should be given to the potential adverse effects of low and high DBP. Low DBP may serve as a risk marker. DBP target levels between 68 and 75 mm Hg may avoid higher mortality risk.

Endophenotype effect sizes support variant pathogenicity in monogenic disease susceptibility genes

Accurate and efficient classification of variant pathogenicity is critical for research and clinical care. Using data from three large studies, we demonstrate that population-based associations between rare variants and quantitative endophenotypes for three monogenic diseases (low-density-lipoprotein cholesterol for familial hypercholesterolemia, electrocardiographic QTc interval for long QT syndrome, and glycosylated hemoglobin for maturity-onset diabetes of the young) provide evidence for variant pathogenicity. Effect sizes are associated with pathogenic ClinVar assertions (P < 0.001 for each trait) and discriminate pathogenic from non-pathogenic variants (area under the curve 0.82-0.84 across endophenotypes). An effect size threshold of ≥ 0.5 times the endophenotype standard deviation nominates up to 35% of rare variants of uncertain significance or not in ClinVar in disease susceptibility genes with pathogenic potential. We propose that variant associations with quantitative endophenotypes for monogenic diseases can provide evidence supporting pathogenicity.

Infertility and Risk of Heart Failure in the Women's Health Initiative

BACKGROUND

There is growing recognition that reproductive factors are associated with increased risk of future cardiovascular disease. Infertility has been less well studied, although emerging data support its association with increased risk of cardiovascular disease. Whether infertility is associated with future risk of heart failure (HF) is not known.

OBJECTIVES

This study sought to examine the development of HF and HF subtypes in women with and without history of infertility.

METHODS

We followed postmenopausal women from the Women's Health Initiative prospectively for the development of HF. Infertility was self-reported at study baseline. Multivariable cause-specific Cox models were used to evaluate the association of infertility with incident overall HF and HF subtypes (heart failure with preserved ejection fraction [HFpEF]: left ventricular ejection fraction of ≥50% vs heart failure with reduced ejection fraction [HFrEF]: left ventricular ejection fraction of <50%]).

RESULTS

Among 38,528 postmenopausal women (mean age: 63 ± 7 years), 5,399 (14%) participants reported a history of infertility. Over a median follow-up of 15 years, 2,373 developed incident HF, including 807 with HFrEF and 1,133 with HFpEF. Infertility was independently associated with future risk of overall HF (HR: 1.16; 95% CI: 1.04-1.30; P = 0.006). Notably, when examining HF subtypes, infertility was associated with future risk of HFpEF (HR: 1.27; 95% CI: 1.09-1.48; P = 0.002) but not HFrEF (HR: 0.97; 95% CI: 0.80-1.18).

CONCLUSIONS

Infertility was significantly associated with incident HF. This was driven by increased risk of HFpEF, but not HFrEF, and appeared independent of traditional cardiovascular risk factors and other infertility-related conditions. Future research should investigate mechanisms that underlie the link between infertility and HFpEF.

The impact of weight change and measures of physical functioning on mortality

INTRODUCTION

Lower grip strength and measures of physical functioning are associated with all-cause mortality. Relationships among long-term weight loss, physical functioning, and mortality in older women are understudied.

METHODS

Participants were 5039 women who were part of the Long Life Study (LLS) ancillary study to the Woman's Health Initiative (WHI). Average age was 78.76 ± 6.92. We defined long-term weight loss or gain as a decrease or increase of 5% or more of baseline body weight. Our primary outcome was all-cause mortality and our secondary outcomes were vascular death, and coronary heart disease (CHD). The mean follow-up time was 5.4 years. Cox regression modeling was performed for each outcome of interest. Variables of interest were weight change, grip strength, and functional status as measured by the Short Physical Performance Battery (SPPB) controlling for multiple potential confounders.

RESULTS

Weight loss of 5% or more percent body weight was associated with a hazard ratio of 1.66 (1.37-2.01) for all-cause mortality. Weight gain was not related to mortality or cardiovascular outcomes. Those in the highest grip strength quartile had a hazard ratio of 0.51 (0.39-0.66) for all-cause mortality. For the SPPB the hazard ratio was 0.29 (0.21-0.40), adjusting for changes in weight, race, smoking, history CHD, smoking, and diabetes. Higher grip strength and SPPB were associated with lower risks for vascular death, and CHD, independently of weight change.

CONCLUSIONS

Weight loss was associated with increased mortality. Stronger grip strength and higher SPPB scores were associated with lower mortality risk independent of weight change.

Association between coronary artery vitamin D receptor expression and select systemic risks factors for coronary artery atherosclerosis

OBJECTIVE

The aim of this study is to analyze the association between coronary artery vitamin D receptor (VDR) expression and systemic coronary artery atherosclerosis (CAA) risk factors.

METHODS

Female cynomolgus monkeys (n = 39) consumed atherogenic diets containing the women's equivalent of 1000 IU/day of vitamin D₃. After 32 months consuming the diets, each monkey underwent surgical menopause. After 32 postmenopausal months, CAA and VDR expression were quantified in the left anterior descending coronary artery. Plasma 25OHD_3, lipid profiles and serum monocyte chemotactic protein-1 (MCP-1) were measured.

RESULTS

In postmenopausal monkeys receiving atherogenic diets, serum MCP-1 was significantly elevated compared with baseline (482.2 ± 174.2 pg/ml vs. 349.1 ± 163.2 pg/ml, respectively; p < 0.001; d = 0.79) and at the start of menopause (363.4 ± 117.2 pg/ml; p < 0.001; d = 0.80). Coronary VDR expression was inversely correlated with serum MCP-1 (p = 0.042). Additionally, the change of postmenopausal MCP-1 (from baseline to necropsy) was significantly reduced in the group with higher, compared to below the median, VDR expression (p = 0.038). The combination of plasma 25OHD₃ and total plasma cholesterol/high-density lipoprotein cholesterol was subsequently broken into low-risk, moderate-risk and high-risk groups; as the risk increased, the VDR quantity decreased (p = 0.04). CAA was not associated with various atherogenic diets.

CONCLUSION

Coronary artery VDR expression was inversely correlated with markers of CAA risk and inflammation, including MCP-1, suggesting that systemic and perhaps local inflammation in the artery may be associated with reduced arterial VDR expression.

Safety assessment of compounded non-FDA-approved hormonal therapy versus FDA-approved hormonal therapy in treating postmenopausal women

OBJECTIVE

To assess the safety and serum estradiol (E2) and total testosterone (T) concentrations in postmenopausal women treated with Pellet Hormonal Therapy (PHT) and Food and Drug Administration approved Hormonal Therapy (FHT).

METHODS

A total of 539 postmenopausal women were identified, including 384 on PHT and 155 on FHT. Data extracted from medical records include demographics, indication for hormone therapy, treatment duration, side effects, serum E2 and T levels, and frequency of laboratory follow-up.

RESULTS

The incidence of overall side effects was significantly higher in PHT compared with FHT (221 [57.6%] vs 23 [14.8%], P < 0.00001, odds ratio [95% CI] =8.0[4.5-14.2]). When examining women with an intact uterus prior to hormone therapy initiation, 55.3% (136/246) on PHT vs 15.2% (12/79) on FHT had at least one episode of abnormal uterine bleeding (P < 0.0001, odds ratio [95% CI] = 7.9[3.6-17.0]). Furthermore, a significantly higher proportion of women on PHT (20.3% [50/246]), compared with 6.3% (5/79) on FHT, had a hysterectomy (P = 0.036, odds ratio [95% CI] = 3.2[1.1-9.3]). Both mean (SD, Min-Max) peak E2 (pg/mL) and peak T (ng/dL) are significantly higher in the PHT group than those in the FHT group (E2: 237.70 [168.55, 10-1,111] vs 93.45 [130.77, 5.5-465.8], T: 194.04 [84.94, 4.3-599] vs 15.59 [19.52, 0.2-70], P < 0.00001). Of those on PHT, four women had E2 level > 1,000 pg/mL and nine women with T level > 400 ng/dL.

CONCLUSION

Women on PHT had a significantly higher incidence of side effects than FHT as well as a significantly higher supraphysiological level of peak E2 and T during the treatment.

Predictive Value of DXA Appendicular Lean Mass for Incident Fractures, Falls, and Mortality, Independent of Prior Falls, FRAX, and BMD: Findings from the Women's Health Initiative (WHI)

In the Women's Health Initiative (WHI), we investigated associations between baseline dual-energy X-ray absorptiometry (DXA) appendicular lean mass (ALM) and risk of incident fractures, falls, and mortality (separately for each outcome) among older postmenopausal women, accounting for bone mineral density (BMD), prior falls, and Fracture Risk Assessment Tool (FRAX® ) probability. The WHI is a prospective study of postmenopausal women undertaken at 40 US sites. We used an extension of Poisson regression to investigate the relationship between baseline ALM (corrected for height2 ) and incident fracture outcomes, presented here for major osteoporotic fracture (MOF: hip, clinical vertebral, forearm, or proximal humerus), falls, and death. Associations were adjusted for age, time since baseline and randomization group, or additionally for femoral neck (FN) BMD, prior falls, or FRAX probability (MOF without BMD) and are reported as gradient of risk (GR: hazard ratio for first incident fracture per SD increment) in ALM/height2 (GR). Data were available for 11,187 women (mean [SD] age 63.3 [7.4] years). In the base models (adjusted for age, follow-up time, and randomization group), greater ALM/height2 was associated with lower risk of incident MOF (GR = 0.88; 95% confidence interval [CI] 0.83-0.94). The association was independent of prior falls but was attenuated by FRAX probability. Adjustment for FN BMD T-score led to attenuation and inversion of the risk relationship (GR = 1.06; 95% CI 0.98-1.14). There were no associations between ALM/height2 and incident falls. However, there was a 7% to 15% increase in risk of death during follow-up for each SD greater ALM/height2 , depending on specific adjustment. In WHI, and consistent with our findings in older men (Osteoporotic Fractures in Men [MrOS] study cohorts), the predictive value of DXA-ALM for future clinical fracture is attenuated (and potentially inverted) after adjustment for femoral neck BMD T-score. However, intriguing positive, but modest, associations between ALM/height2 and mortality remain robust. © 2021 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Menopause Management Knowledge in Postgraduate Family Medicine, Internal Medicine, and Obstetrics and Gynecology Residents: A Cross-Sectional Survey

OBJECTIVE

To evaluate the knowledge of and nature of training for menopause management in postgraduate residents.

PARTICIPANTS AND METHODS

A cross-sectional, anonymous survey was e-mailed to trainees at all postgraduate levels in family medicine, internal medicine, and obstetrics and gynecology at US residency programs between January 11, and July 4, 2017. The survey was adapted from an existing instrument and included questions regarding knowledge of hormone therapy (HT) and other menopause management strategies, availability and type of training in menopause medicine, and demographic information.

RESULTS

Of the 703 surveys sent, a total of 183 residents representing 20 US residency programs responded (26.0% response rate). Most trainees were between 26 and 30 years of age (133 of 172 [77.3%]), female (114 of 173 [65.9%]), and believed it was important or very important to be trained to manage menopause (165 of 176 [93.8%]). Although most respondents answered some of the menopause competency questions correctly, important gaps were identified. Of 183 participants, 63 (34.4%) indicated they would not offer HT to a symptomatic, newly menopausal woman without contraindications, and only 71 (38.7%) indicated they would prescribe HT until the natural age of menopause to a prematurely menopausal woman. Of 177 respondents, 36 (20.3%) reported not receiving any menopause lectures during residency, and only 12 of 177 (6.8%) reported feeling adequately prepared to manage women experiencing menopause.

CONCLUSION

Family medicine, internal medicine, and obstetrics and gynecology residency trainees recognize the importance of training in menopause management, but important knowledge gaps exist. Investing in the education of future clinicians to provide evidence-based, comprehensive menopause management for the growing population of midlife women is a priority.

Transvaginal ultrasound training for the obstetrics and gynecology resident: A multisite randomized controlled trial of educational DVD

PURPOSE

Residents in obstetrics and gynecology are deemed to be proficient in transvaginal ultrasound (TVUS) upon graduation, although TVUS education in residency is not standardized. The objective of this study is to assess for improvement in TVUS knowledge among residents after viewing an educational DVD.

METHODS

This is a multisite prospective randomized controlled trial using an educational DVD ("Gynecology: Beginners Only"), compared to routine education. All participants completed a pretest on TVUS images and principles. The intervention group repeated the test after DVD viewing. During the trial, performing and logging TVUS examinations were encouraged. All enrolled residents repeated the test 6-10 months later.

RESULTS

Fifty-seven residents completed the study with a mean pretest score of 9.7 (1st year resident 9.8, 2nd year resident 9.6, 3rd year resident 10.1, 4th year resident 9.4, P = .763), with a mean of 31.5 TVUS examinations logged prior to intervention. The mean score in the intervention group (n = 34) improved significantly after viewing (11.2, P < 0.003). This improvement did not persist 6-10 months later on a follow-up quiz (mean 10.7, P = .894). At completion of the study, participants logged an average of 56.7 TVUS examinations.

CONCLUSION

An educational DVD is easily implemented and demonstrates short-term benefit. Exploration of different teaching modalities in development of a comprehensive training program may improve long-term retention.

Depression may be a risk factor for coronary heart disease in midlife women <65 years: A 9-year prospective cohort study

OBJECTIVE

Depression has been suggested as a risk factor for coronary heart disease (CHD). However, whether the risk may be affected by age is unknown. We seek to assess the difference in long-term CHD risk between younger (<65) and older (≥65) women with depressive symptoms.

METHODS

Between June and August 2004, 1995 women presenting for routine mammography were enrolled to the primary study on breast arterial calcification. In 2005 (year 2), each woman completed a validated depression screening questionnaire. A similar questionnaire was mailed to each participant at year 4, 5, and 10 to obtain follow-up data (demographic and CHD risk factors) and record any change in CHD status.

RESULTS

Of 1084 women who returned surveys at year 10, 998 had no history of CHD and answered depression screening questions at year 2 as well as questions about CHD events at year 10. Of 185 out of 998 (18.5%) who had positive depression screening at year 2, 24 (13.0%) developed ≥1 CHD events by year 10, which is significantly higher than the incidence of 6.5% (53/813) in control group (p < 0.001). With CHD risk factors including age adjusted in a logistic regression model, depression was the only significant predictive factor for CHD in women aged <65 (OR = 6.56, 95% CI 1.07-40.09, p = 0.042). However, in women aged ≥65, age was the only significant predictive factor for CHD.

CONCLUSION

A history of depression may increase the risk of CHD over 9 years of follow-up, and more prominently in midlife women aged <65 years.

Diagnostic accuracy of FRAX in predicting the 10-year risk of osteoporotic fractures using the USA treatment thresholds: A systematic review and meta-analysis

OBJECTIVES

The aim of this study was to conduct a systematic review and meta-analysis on the performance of the WHO's Fracture Risk Assessment (FRAX) instrument in predicting 10-year risk of Major Osteoporotic Fractures (MOF) and Hip Fractures (HF), using the USA treatment thresholds, in populations other than their derivation cohorts.

DESIGN

EMBASE and MEDLINE database were searched with search engine PubMed and OVID as well as Google Scholar for the English-language literature from July 2008 to July 2016. Limiting our search to articles that analyzed only MOF and/or HF as an outcome, 7 longitudinal cohorts from 5 countries (USA, Poland, France, Canada, New Zealand) were identified and included in the meta-analysis. SAS NLMIXED procedure (SAS v 9.3) was applied to fit the Hierarchical Summary Receiver Operating Characteristics (HSROC) model for meta-analysis. Forest plot and HSROC plot was generated by Review Manager (RevMan v 5.3).

RESULTS

Seven studies (n=57,027) were analyzed to assess diagnostic accuracy of FRAX in predicting MOF, using 20% as the 10-year fracture risk threshold for intervention, the mean sensitivity, specificity, and diagnostic odds ratio (DOR) along with their 95% confidence intervals (CI) were 10.25% (3.76%-25.06%), 97.02% (91.17%-99.03%) and 3.71 (2.73-5.05), respectively. For HF prediction, using 3% as the 10-year fracture risk threshold, six studies (n=50,944) were analyzed. The mean sensitivity, specificity, and DOR along with their 95% confidence intervals (CI) were 45.70% (24.88%-68.13%), 84.70% (76.41%-90.44%) and 4.66 (2.39-9.08), respectively.

CONCLUSIONS

Overall, using the 10year intervention thresholds of 20% for MOF and 3% for HF, FRAX performed better in identifying patients who will not have a MOF or HF within 10years, than those who will. A substantial number of patients who developed fractures, especially MOF within 10years of follow up, were missed by the baseline FRAX assessment.

Allopathic and Osteopathic Medicine Unify GME Accreditation: A Historic Convergence

In 1968, the American Medical Association resolved to accept qualified graduates of osteopathic medical schools into its accredited Graduate Medical Education (GME) programs. An equally momentous decision was arrived at in 2014 when the Accreditation Council for Graduate Medical Education (ACGME), the American Osteopathic Association (AOA), and the American Association of Colleges of Osteopathic Medicine (AACOM) resolved to institute a single unified GME accreditation system by July 1, 2020. As envisioned, the unified accreditation system will all but assure system-wide consistency of purpose and practice in anticipation of the Next Accreditation System (NAS) of the ACGME. Governance integration replete with AOA and AACOM and osteopathic representation on the ACGME Board of Directors is now well underway. What is more, osteopathic representation on current Review Committees (RCs) and in a newly established one with an osteopathic focus has been instituted. Viewed broadly, the unification of the GME accreditation system goes a long way toward recognizing the overlapping characteristics in the training and practice of allopathic and osteopathic medicine. As such, this momentous development represents the latest, indeed boldest leap toward convergence between the two historic branches of American medicine. In this Health Policy Analysis we seek to place the impending unification of the GME accreditation process in its historical context, delineate its near-term impact, and discuss the potential long-term implications thereof.

A design thinking approach to primary ovarian insufficiency

Most clinicians are not prepared to provide integrated personal care to address all the clinical needs of women with primary ovarian insufficiency. Design thinking is an engineering methodology used to develop and evaluate novel concepts for systems operation. Here we articulate the need for a seamlessly integrated mobile health system to support genomic research as well as patient care. We also review the pathophysiology and management of primary ovarian insufficiency. Molecular understanding regarding the pathogenesis is essential to developing strategies for prevention, earlier diagnosis, and appropriate management of the disorder. The syndrome is a chronic disorder characterized by oligo/amenorrhea and hypergonadotropic hypogonadism before age 40 years. There may be significant morbidity due to: 1) depression and anxiety related to the loss of reproductive hormones and infertility; 2) associated autoimmune adrenal insufficiency or hypothyroidism; and 3) reduced bone mineral density and increased risk of cardiovascular disease related to estrogen deficiency. Approximately 5% to 10% of women with primary ovarian insufficiency conceive and have a child. Women who develop primary ovarian insufficiency related to a premutation in FMR1 are at risk of having a child with fragile X syndrome, the most common cause of inherited intellectual disability. In most cases of spontaneous primary ovarian insufficiency no environmental exposure or genetic mechanism can be identified. As a rare disease, the diagnosis of primary ovarian insufficiency presents special challenges. Connecting patients and community health providers in real time with investigators who have the requisite knowledge and expertise would help solve this dilemma.

Risk Assessment Tools for Osteoporosis-Related Fractures

Osteoporosis is a prevalent and po- tential debilitating disease. Characterized by archi- tectural modifications in bone matrix, osteoporosis ultimatelyincreases the propensity forbones to frac- ture, especially at the hip and spine. Fortunately, osteoporosis can be treated effectively if detected at an early stage. While recognizing an increased risk offracture inwomen with osteoporosis, mostcases of fracture occur in women with osteopenia orlowbone mass. A good fracture risk assessment tool would be more clinically meaningful than an accurate osteo-. porosis screening or diagnostic tool. Here we present a concise review ofthe existing modalities which may be utilized to screen for osteoporosis or predict risk of oteonorotic fractures.

CREOG In-Training Examination Results: Contemporary Use to Predict ABOG Written Examination Outcomes

BACKGROUND

The in-training examination (ITE) offers formative assessments of residents' developing medical knowledge. Identification of an ITE performance level associated with success on the specialty board examination allows identification of "at risk" residents.

OBJECTIVE

This study sought to identify a threshold score for obstetrics and gynecology residents' performance on the Council on Resident Education in Obstetrics and Gynecology (CREOG) ITE that predicts successful performance on the American Board of Obstetrics and Gynecology (ABOG) written examination.

METHODS

We analyzed ITE and ABOG results of 80 residents who completed 4 years of CREOG ITEs at 2 institutions between 2002 and 2012. We assessed the level of performance associated with successful performance on the ABOG written examination.

RESULTS

Data analyzed included scores for 71 of 80 residents (89%), with an overall pass rate of 82%. A postgraduate year (PGY) 4 score of 200 on the CREOG ITE or twice in any of the PGY training years was associated with a 100% ABOG pass rate. Scoring ≥ 205 in any PGY also was associated with a 100% pass rate. Residents who did not attain a score of 200 had a 35% to 45% chance of failing the ABOG written examination, depending on the PGY of the ITE performance.

CONCLUSIONS

Our findings suggest that a CREOG ITE score of at least 200 twice, or as a PGY-4, offers assurance of successful performance on the ABOG examination. Scores lower than this threshold may be used to identify "at risk" residents for added learning and provide program elements in need of improvement.

Association of breast arterial calcification with stroke and angiographically proven coronary artery disease: a meta-analysis

OBJECTIVE

We conducted a meta-analysis of the current literature to deduce the strength of association between breast arterial calcification (BAC) and coronary artery disease (CAD) and/or stroke.

METHODS

PubMed, Google Scholar, ClinicalTrials.gov, and Ovid were searched for English-language literature up to August 2013 using the terms "breast arterial calcification," "breast vascular calcification," "coronary artery disease," "coronary heart disease," "cardiovascular disease," "abnormal coronary angiography," and "stroke." A hand search of the reference lists of key articles was performed to supplement the literature search. Our literature search revealed 75 articles for further abstract review. Limiting our search to articles that quantitatively assessed the correlation between BAC and stroke or angiographically proven CAD, we reviewed 35 full manuscripts. Of these articles, 14 were included in the final analysis.

RESULTS

We analyzed 10 cross-sectional studies (n = 3,952) with CAD as the primary outcome (diagnosed by coronary angiography). The odds ratio (95% CI) for CAD in those with BAC versus those without BAC is 3.86 (3.25-4.59) (P < 0.0001). For stroke, six cross-sectional studies were analyzed (n = 18,888). The odds ratio (95% CI) for stroke in those with BAC versus those without BAC is 1.54 (1.25-1.90) (P < 0.0001).

CONCLUSIONS

These results suggest that BAC is significantly associated with both CAD and stroke. Although more prospective studies are warranted to clarify whether BAC is truly a predictor of the future development of CAD and stroke, the concept that BAC is a benign finding is waning.

Vitamin D heritability and effect of pregnancy status in Vervet monkeys (Chlorocebus aethiops sabaeus) under conditions of modest and high dietary supplementation

OBJECTIVES

The two objectives of the current study were to: 1) investigate the genetic contributions to variations in serum vitamin D concentrations under two dietary conditions (a standard monkey biscuit diet vs. a diet designed to model typical American consumption); and 2) explore the interaction of vitamin D with pregnancy status using a cohort of pedigreed female vervet/African green monkeys.

METHODS

This study includes 185 female (≥3.5 years) vervet/African green monkeys (Chlorocebus aethiops sabaeus) from a multi-generational, pedigreed breeding colony. The 25(OH)D3 concentrations were first measured seven to eight weeks after consuming a "typical American" diet (TAD), deriving 37, 18, and 45% of calories from fat, protein sources, and carbohydrates, and supplemented with vitamin D to a human equivalent of 1,000 IU/day. Vitamin D concentrations were assessed again when animals were switched to a low-fat, standard biscuit diet (LabDiet 5038) for 8 months, which provided a human equivalent of approximately 4,000 IU/day of vitamin D. All statistical analyses were implemented in SOLAR.

RESULTS

Pregnancy was associated with reduced 25(OH)D3 concentrations. Heritability analyses indicated a significant genetic contribution to 25(OH)D3 concentrations in the same monkeys consuming the biscuit diet (h(2) =0.66, P=0.0004) and TAD (h(2) =0.67, P=0.0078) diets, with higher 25(OH)D3 concentrations in animals consuming the biscuit diet. Additionally, there was a significant genotype-by-pregnancy status interaction on 25(OH)D3 concentrations (P<0.05) only among animals consuming the TAD diet.

DISCUSSION

These results support the existence of a genetic contribution to differences in serum 25(OH)D3 concentrations by pregnancy status and emphasize the role of diet (including vitamin D supplementation) in modifying genetic signals as well as vitamin D concentrations.

Osteoporosis screening in postmenopausal women aged 50-64 years: BMI alone compared with current screening tools

OBJECTIVES

Consensus on when to initiate DXA screening for early postmenopausal women (< 65 years of age) is lacking. Low body mass index (BMI) has been proposed as one of the major risk factors for osteoporosis. This study sought to compare the predictive performance of BMI alone with 5 screening modalities (the U.S. Preventive services task force [USPSTF] FRAX threshold of 9.3%, a risk factor based approach [≥ 1 risk factors], the osteoporosis self-assessment tool [OST < 2], the osteoporosis risk assessment instrument [ORAI ≥ 9], and the simple calculated osteoporosis risk estimation [SCORE ≥ 6]) in identifying early postmenopausal women with osteoporosis.

METHODS

Postmenopausal women aged 50-64 years presenting for a DXA test were recruited between January 1, 2007, and March 1, 2009. Demographic data and osteoporosis risk factors were obtained through a telephone survey. The performance of each screening tool in predicting osteoporosis was compared.

RESULTS

Of 445 study participants, 95% were White, 38 had osteoporosis (T-score ≤ -2.5). BMI (< 28) was associated with the highest Sensitivity (95%), the lowest Negative Likelihood Ratio (LR-) of 0.14, an AUC of 0.73, and the number needed to scan (NNS) of 8. The USPSTF approach had the lowest sensitivity (24%), highest LR- (0.91), lowest AUC (0.62), and highest NNS (9). Among 5 established modalities, SCORE (≥ 6) appears to be the best (sensitivity: 92%, LR-: 0.24, AUC: 0.75, NNS: 9).

CONCLUSION

BMI (< 28) had a comparable numerical screening performance overall to the current screening modalities. BMI (< 28) could be considered a potential indicator when screening early postmenopausal White women for osteoporosis. However, a better osteoporosis screening tool remains to be developed.

A multi-center randomized trial of two different intravenous fluids during labor

OBJECTIVE

To determine if the intrapartum use of a 5% glucose-containing intravenous solution decreases the chance of a cesarean delivery for women presenting in active labor.

METHODS

This was a multi-center, prospective, single (patient) blind, randomized study design implemented at four obstetric residency programs in Pennsylvania. Singleton, term, consenting women presenting in active spontaneous labor with a cervical dilation of <6 cm were randomized to lactated Ringer's with or without 5% glucose (LR versus D5LR) as their maintenance intravenous fluid. The primary outcome was the cesarean birth rate. Secondary outcomes included labor characteristics, as well as maternal or neonatal complications.

RESULTS

There were 309 women analyzed. Demographic variables and admitting cervical dilation were similar among study groups. There was no significant difference in the cesarean delivery rate for the D5LR group (23/153 or 15.0%) versus the LR arm (18/156 or 11.5%), [RR (95% CI) of 1.32 (0.75, 2.35), p = 0.34]. There were no differences in augmentation rates or intrapartum complications.

CONCLUSIONS

The use of intravenous fluid containing 5% dextrose does not lower the chance of cesarean delivery for women admitted in active labor.

High-risk HPV testing in the management of atypical glandular cells: A systematic review and meta-analysis

Whereas the utility of high-risk HPV (hrHPV) testing is widely accepted in triage of women with atypical squamous lesions, its role in managing atypical glandular cells (AGC) is not fully elucidated. A systematic review and meta-analysis were performed to evaluate the accuracy of hrHPV testing in the management of women with AGC to detect underlying high-grade intraepithelial neoplasia or worse, and adenocarcinoma in situ or worse (AIS+). Additionally, the diagnosis of extra-cervical cancer was considered as an outcome in this review. A bibliographic database search (PubMed, EMBASE, CENTRAL) identified twelve eligible studies. The occurrence of cervical intraepithelial neoplasia grade two or worse including AIS+ (CIN2+/AIS+), was 19.8% among women with AGC, and 55.7% among women with AGC and concurrent squamous lesions (atypical squamous cells of undetermined significance or worse, ASC-US+). The pooled sensitivity and specificity of hrHPV-testing with Hybrid Capture 2 (HC2) to detect CIN2+/AIS+ in women with AGC was 90.0% (95% CI = 85.1-93.4%) and 75.1% (95% CI = 64.8-83.2%), respectively. Women who were hrHPV-negative, demonstrated an increased risk for extra-cervical malignancy (endometrium, fallopian tube, ovary). In women of 50y and older, a hrHPV-negative result was linked with a 18.0% chance of extra-cervical malignancy, while the chance of cervical pre-cancer and cancer was 0.4 and 0.0%, respectively. In conclusion, given the high risk of underlying CIN2+/AIS+, women with AGC should be referred directly to colposcopy. However, hrHPV test results in combination with the age, appears to improve the diagnostic process by distinguishing the risk for cervical versus non-cervical lesions.

A clinical research integration special program (CRISP) for young women with primary ovarian insufficiency

Large-scale medical sequencing provides a focal point around which to reorganize health care and health care research. Mobile health (mHealth) is also currently undergoing explosive growth and could be another innovation that will change the face of future health care. We are employing primary ovarian insufficiency (POI) as a model rare condition to explore the intersection of these potentials. As both sequencing capabilities and our ability to intepret this information improve, sequencing for medical purposes will play an increasing role in health care beyond basic research: it will help guide the delivery of care to patients. POI is a serious chronic disorder and syndrome characterized by hypergonadotrophic hypogonadism before the age of 40 years and most commonly presents with amenorrhea. It may have adverse health effects that become fully evident years after the initial diagnosis. The condition is most commonly viewed as one of infertility, however, it may also be associated with adverse long-term outcomes related to inadequate bone mineral density, increased risk of cardiovascular disease, adrenal insufficiency, hypothyroidism and, if pregnancy ensues, having a child with Fragile X Syndrome. There may also be adverse outcomes related to increased rates of anxiety and depression. POI is also a rare disease, and accordingly, presents special challenges. Too often advances in research are not effectively integrated into community care at the point of service for those with rare diseases. There is a need to connect community health providers in real time with investigators who have the requisite knowledge and expertise to help manage the rare disease and to conduct ongoing research. Here we review the pathophysiology and management of POI and propose the development of an international Clinical Research Integration Special Program (CRISP) for the condition.

Management of "Atypical Endocervical Cells" Compared to "Atypical Glandular Cells"

OBJECTIVE

To assess adherence to management guidelines based on the terminology used to describe atypical glandular cells (AGC) on cytology reports.

MATERIALS AND METHODS

We analyzed AGC pathology reports from Hartford Hospital, 2004-2007, and identified cases of AGC with the terminology atypical glandular cells or atypical endocervical cells (AEC). We calculated rates of clinical evaluations based on the terminology used to describe the AGC. Statistical analysis was performed using the χ test.

RESULTS

Seventy-eight reports contained the terminology AEC and 97 reports contained the terminology AGC. The rate of histologic sampling in women with AEC was lower than in women with AGC (52.6% vs 83.5%; p < .01). Similarly, the rate of comprehensive evaluations was lower (33.3% vs 71.1%; p < .01). Fewer endocervical curettages (47.4% vs 77.3%; p < .01) and fewer endometrial biopsies in women 35 years or older were performed (26.9% vs 69.1%; p < .01) in women with AEC than in women with AGC.

CONCLUSIONS

Women with AGC reports containing the term AEC were managed less optimally than those with AGC. These results suggest that the terminology used to describe the finding of atypical glandular cells may influence the clinical evaluation. Clinicians may not recognize AEC as AGCs. Ours results suggest that the terminology atypical endocervical cells should be avoided or accompanied by the terminology atypical glandular cells.

Postinterview communication with residency applicants: a call for clarity!

The residency match is an increasingly competitive process. Communication from medical student applicants to programs varies, and the effect this has on their rank status is unclear. We assessed how obstetrics and gynecology program directors interpret and act on postinterview communication initiated by applicants by conducting an anonymous cross-sectional web-based survey of allopathic obstetrics and gynecology program directors. One hundred thirty-seven program directors (55%) responded to the survey. Twenty-nine percent would consider ranking an applicant more favorably if the applicant expressed interest (beyond a routine thank you) or if a faculty mentor personally known to the program director stated that the applicant was ranking the program first. Fifty-two percent indicated that they would rank an applicant more favorably if a mentor known to them endorsed the applicant as outstanding. Approximately 30% responded that applicants who did not communicate with their program were disadvantaged compared with those who did. Approximately 17% stated it was desirable to create additional specialty-specific guidelines regarding postinterview contact between programs and applications. Based on the wide variation in how program directors interpret and act on postinterview communication from applicants, residency programs should formulate and communicate a clear policy about whether they request and how they respond to postinterview communication from applicants and their mentors. This will establish a more level playing field and eliminate potential inequities resulting from inconsistent communication practices.

Contraceptive use in adolescents in Sub-Saharan Africa: evidence from Demographic and Health Surveys

OBJECTIVE

Failure to use contraceptives contributes to an unacceptably high rate of undesired pregnancy in Sub-Saharan adolescents with associated maternal and neonatal mortality/morbidity. Evidence-based research is needed to understand contraceptive usage in Sub-Saharan adolescents and to enable appropriate allocation of donor resources.

DESIGN

Nationally-representative USAID (U.S. Agency for International Development) Demographic and Health Surveys from 18 least developed Sub-Saharan African nations.

POPULATION

212,819 Sub-Saharan African women (45,054 were 15-19 years old).

METHODS

The percentages of adolescents using contraception, as well as their preferred contraceptive methods and desired family size, were reported.

MAIN OUTCOME MEASURES

Contraceptive Use, Neonatal Mortality, Undesired Pregnancy, Pregnancy Terminations.

RESULTS

Most adolescents (92.4%) surveyed reported no contraceptive use, although 21.6% reported recent sexual activity. A current pregnancy was reported in 6.6% (n = 2,951) of adolescents with 29.9% of these pregnancies being unwanted. Many surveyed adolescents (18.8%) had at least one prior birth. A death of the previous child was reported in 6.6% (n = 560) with half of these deaths (n = 276) occurring within the first month of life. Many adolescents planned to delay childbearing for at least two years (37.1%) or were unsure about future timing (33.3%), and 2.2% reported a history of at least one pregnancy termination. Most adolescents (73.1%) felt it would be a problem if they became pregnant. Adolescents indicated injectable medications and contraceptive pills were the preferred future contraceptives at 39.9% and 31.4% respectively.

CONCLUSIONS

Sub-Saharan African adolescents report a mismatch between desire for contraception and use; preferred methods are oral and injectable contraceptives.

Vitamin D and cardiovascular disease: an appraisal of the evidence

BACKGROUND

Supplementation with vitamin D has received attention as a potential cardioprotective strategy. Biologically plausible mechanisms have been proposed to link vitamin D to coronary heart disease (CHD) prevention, and observational studies suggest an inverse association between serum 25-hydroxyvitamin D (25OHD) concentrations and CHD. Few randomized clinical trials of vitamin D supplementation and CHD have been conducted, however, and no trial with CHD as the primary prespecified outcome has been completed.

CONTENT

A search was conducted in PubMed to find prospective studies of the use of vitamin D supplementation and its relationship to cardiovascular risk factors (RFs) and/or cardiovascular disease (CVD). The exact search query was: ((vitamin D supplement*[Title/Abstract]) AND cardiovascular [Title/Abstract]) AND prospective [Title/Abstract]. This query yielded 42 results. "Randomized Controlled Trial" (article type) was used as a filter in a subsequent query with the same search terms. We review the evidence that vitamin D supplementation modifies coronary RFs, such as blood pressure, lipids, glucose tolerance, and/or affects the development of clinical CHD events. We address potential sources of confounding in observational epidemiologic studies of the relationship between serum 25OHD and CHD. We also address laboratory assay issues relevant to the reliable measurement of 25OHD.

SUMMARY

Most vitamin D supplementation trials have not demonstrated improvement in CVD, but they have tested relatively low vitamin D doses. Thus, the evidence remains inconclusive, highlighting the need for rigorous randomized trials of higher vitamin D doses with cardiovascular events as prespecified outcomes. While we await the results of ongoing trials, the recommended dietary allowances from the Institute of Medicine remain the best guidepost for nutritional requirements.

Sexual dysfunction, depression, and anxiety among patients of an inner-city menopause clinic

OBJECTIVE

The objective of this study was to identify the prevalence of female sexual dysfunction (FSD) in a sample comprising women of mostly Hispanic descent and low socioeconomic status (SES).

METHODS

Demographic data and symptoms related to sexuality were analyzed from 102 women who consecutively came to the Women's Life Center at Hartford Hospital (2004-2008). FSD was defined as decreased sexual desire, dyspareunia, or vaginal dryness; depression as one positive response to a validated three-question screening instrument; and anxiety as a positive response to whether the patient experiences anxiety sometimes or often.

RESULTS

The cohort was 52.9 ± 6.8 years of age (mean ± standard deviation [SD]) and 80.0% Hispanic, and 47.8% were unemployed. The majority (92.8%) earned < $25,000, and most (95.8%) did not have a college degree. The prevalence of FSD was 75.6%. The prevalence of depression was 80.9% vs. 52.8% (p = 0.01) and that of anxiety was 76.6% vs. 45.7% (p = 0.01) among women with vs. without a decrease in sexual desire. The prevalence of depression was 83.3% vs. 55.9% (p = 0.03) and that of anxiety was 76.7% vs. 52.9% (p = 0.07) among women who reported dyspareunia vs. those who did not. Problems sleeping was the only variable associated with a statistically higher likelihood of FSD (odds ratio [OR] 5.57, 95% confidence interval [CI] 1.22-25.33, p = 0.03). No significant differences were seen when comparing FSD between Hispanics and non-Hispanics.

CONCLUSIONS

This sample of predominantly Hispanic women of low SES had a high prevalence of FSD. These data also suggest that poor sleep is significantly associated with FSD and that women of low SES with FSD may have a significantly higher prevalence of depression and anxiety.

Coronary artery vitamin D receptor expression and plasma concentrations of 25-hydroxyvitamin D: their association with atherosclerosis

OBJECTIVE

The aim of this study was to analyze coronary artery vitamin D receptor (VDR) expression, the plasma concentrations of 25-hydroxyvitamin D3 (25OHD3), and their relationship with coronary artery atherosclerosis.

METHODS

Premenopausal cynomolgus monkeys were fed atherogenic diets containing the equivalent of 1,000 IU/day of vitamin D3. Protein was derived from casein-lactalbumin (C/L, n = 10), soy protein isolate (soy, n = 10), or a combination (n = 19). After 32 months of consuming the diets, each monkey underwent surgical menopause. After 32 postmenopausal months, coronary atherosclerosis was measured in the left circumflex (LCX) artery and left anterior descending (LAD) artery. VDR expression was determined for the LAD, and 25OHD3 concentrations were assessed.

RESULTS

Both the cross-sectional area of atherosclerotic plaques (in square millimeters) and plaque thickness (in millimeters) in the LCX as well as the LAD arteries were analyzed in these monkeys. Those with higher plasma vitamin D3 concentrations and higher VDR were compared with those with higher plasma 25OHD3 concentrations and lower VDR. Significantly smaller plaque sizes were noted with higher plasma 25OHD3 concentrations and higher VDR. For the LCX artery, there was also a significantly lower plaque size (both plaque thickness and cross-sectional area) in those with higher quantities of VDR and lower 25OHD3 concentrations versus those with lower quantities of VDR and higher plasma concentrations of 25OHD3 (P = 0.009 and P = 0.040, respectively).

CONCLUSIONS

Cynomolgus monkeys with higher quantities of VDR have significantly less atherosclerosis than do those with lower quantities of VDR and higher plasma 25OHD3 concentrations. If these findings translate to human beings, it might explain why some individuals with higher plasma concentrations of 25OHD3 have more coronary artery atherosclerosis.

25(OH)D3 and cardiovascular risk factors in female nonhuman primates

OBJECTIVE

To determine if interindividual differences in plasma concentrations of 25-hydroxyvitamin D(3) (25(OH)D(3)) have pathophysiologic significance, we evaluated a cohort of female monkeys, seeking to identify associations with clinically relevant cardiovascular risk factors, including age, abdominal obesity (waist circumference), and high-density lipoprotein cholesterol (HDL-C).

METHODS

One hundred fifty-five female vervet monkeys (Chlorocebus aethiops sabaeus) aged 3-25 years consumed a typical western diet for 7-8 weeks that provided a woman's equivalent of approximately 1000 IU/day of vitamin D(3). Measurements of vitamin D(3) and HDL-C concentrations, as well as waist circumference, were obtained.

RESULTS

Among young monkeys (aged 3-5 years), compared to older monkeys (aged 16-25 years), the mean plasma 25(OH)D(3) concentrations were 82.3±3.2 ng/mL and 58.6±2.9 ng/mL (p<0.0001), respectively. Plasma 25(OH)D(3) concentrations had a range of 19.6-142.0 ng/mL (mean±standard error [SE] 66.4±1.7 ng/mL). 25(OH)D(3) concentrations were inversely associated with age (p<0.0001) and waist circumference (p=0.016) and were positively correlated with HDL-C (p=0.01). However, when statistically controlling for age, none of these relationships remained significant.

CONCLUSIONS

Higher plasma concentrations of 25(OH)D(3) were associated with more favorable cardiovascular risk factors, with inverse associations observed between 25(OH)D(3) and abdominal obesity, HDL-C, and age. These associations were no longer significant when controlling for age.

Burnout, depression and job satisfaction in obstetrics and gynecology residents

OBJECTIVE

This study among ObGyn residents was designed to determine the relationship of burnout to job satisfaction, depression, and self-care activities.

METHODS

The link to a 64-item, anonymous, self-administered online survey was distributed to obstetrics and gynecology residents at six obstetric and gynecologic residency programs in the greater Hartford Connecticut region. We used the Maslach Burnout Inventory-Human Services Survey to assess job burnout, the Center for Epidemiological Studies-Depression Scale to identify depression, and we incorporated questions regarding job satisfaction and self care activities.

RESULTS

Of the surveyed residents, 13% satisfied all three subscale scores for high burnout and > 50% have high levels of depersonalization and emotional exhaustion. Residents with high levels of emotional exhaustion were less satisfied with their careers (P = 0.001), regretted choosing ObGyn (P < 0.001), and had higher rates of depression (P < 0.001). A high level of depersonalization was inversely correlated to job satisfaction and personal accomplishment, and strongly correlated to depression. A high level of personal accomplishment was strongly correlated with job satisfaction and satisfaction with the specialty but was inversely correlated with a sense of depersonalization. There was no correlation between burnout and self-care activities.

CONCLUSIONS

Burnout is strongly correlated with depression and inversely correlated with job satisfaction. Burnout and depression were highly prevalent among ObGyn residents. Decreasing stressors and assuring motivated, committed, and supportive educators may prove to be helpful in the enhancement of resident job satisfaction.

Adherence to practice guidelines for atypical glandular cells on cervical cytology

BACKGROUND

Atypical glandular cells (AGC) on cervical cytology are high-risk, requiring an extensive evaluation. Compliance with practice guidelines for AGC, however, has been low. Some AGC cytology reports contain cytopathologist recommendations for evaluation. This study determines whether evaluation rates for AGC have improved over time, and whether cytopathologists' recommendations correlate with the types of evaluation women receive.

METHODS

Evaluation rates from 284 women with AGC (2004-2007) were compared with findings from 1998-2001. Rates of evaluations were compared based on cytology report recommendations.

RESULTS

A total of 76.1% of the AGC cases had histologic sampling, and 58.8% had a comprehensive evaluation. These rates are higher than those from 1998-2001 (63.5% and 35.8%, respectively; P<.01). Rates of evaluations of women with AGC "favor neoplasia" did not increase between the 2 time periods. Between 2004-2005 and 2006-2007, rates of comprehensive initial evaluations and endometrial sampling in women ≥35 years of age did not increase. Of the AGC reports that did contain cytopathologist recommendations, 28% were consistent with practice guidelines, 26% recommended an incomplete histologic evaluation, and 46% recommended repeat cytology. Women whose AGC report recommended a comprehensive evaluation or any histologic evaluation were more likely to have a comprehensive work-up (79%) than those whose reports did not contain recommendations (55%, P <0.01) or recommended repeat cytology (51%, P<0.02).

CONCLUSIONS

Adherence to practice guidelines for the evaluation of women with AGC has improved but continues to be suboptimal. Our findings suggest that continuing education and including practice guidelines on AGC cytology reports may improve compliance.