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1.  Factors Affecting Sexual Activity in Midlife Women: Results from the Midlife Health Study 
Journal of Women's Health  2017;26(2):103-108.
Background: The objective of this study was to identify (1) the importance of a number of potential factors affecting the likelihood of sexual activity in perimenopausal women and (2) the likelihood of a number of barriers to sexual activity.
Methods: A cohort of 780 women undergoing menopausal transition was surveyed annually for up to 7 years. Data were collected on sexual activity and, if not sexually active, reasons for no sexual activity, as well as a number of potential risk factors. Height and weight were measured at an annual clinic visit; serum hormone concentrations were assayed using blood samples donated annually. Data were examined with logistic regression models using the individual as a random effect, with subset analysis of nonsexually active women to determine the likelihood of each barrier. All factors with univariate associations of p < 0.1 were considered in multivariate model building with stepwise addition.
Results: A total of 2440 woman-years were included in the analysis of sexual activity. The likelihood of sexual activity increased for women living with a partner, with perceived quality of life, and with less frequent hot flashes. Among 513 woman-years reporting no sexual activity, women living with a partner and women reporting frequent fatigue were less likely to lack a sexual partner, but were more likely to have sexual difficulties. Women with more physical work than average and women with higher serum estradiol levels were less likely to have sexual difficulties.
Conclusions: The factors associated with sexual activity in menopausal women are complex, indicating that an individualized approach to improving sexual activity is required.
PMCID: PMC5312621  PMID: 27653205
sexual activity; menopause; cohort study
2.  Relationship of Physical Intimate Partner Violence with Mental Health Diagnoses in the Nationwide Emergency Department Sample 
Journal of Women's Health  2017;26(2):141-151.
Objectives: We examined associations of physical intimate partner violence (PIPV) with selected mental health disorders using a nationally representative sample of emergency department (ED) discharges corresponding to men and women (18–64 years) from the 2010 Nationwide Emergency Department Sample.
Methods: PIPV was determined using International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) external cause of injury code E967.3 (battering by spouse or partner). ICD-9-CM clinical classification of discharge diagnoses was used to identify mental health disorders. Multivariable logistic regression models were constructed to estimate adjusted odds ratios (ORadj) and their 95% confidence intervals (CIs).
Results: PIPV prevalence was estimated at 0.36 per 1000 ED discharges. The strongest correlates of PIPV were alcohol-related (ORadj = 3.02, 95% CI: 2.62–3.50), adjustment (ORadj = 2.37, 95% CI: 1.56–3.58), intentional self-harm (ORadj = 1.41, 95% CI: 1.05–1.89), anxiety (ORadj = 1.23, 95% CI: 1.07–1.40), drug-related (ORadj = 1.22, 95% CI: 1.01–1.47), and mood (ORadj = 1.16, 95% CI: 1.04–1.31) disorders. PIPV's association with alcohol-related disorders was stronger among women (ORadj = 3.22, 95% CI: 2.79–3.72) versus men (ORadj = 1.98, 95% CI: 1.42–2.77). Similarly, drug-related disorders were stronger correlates of PIPV among women (ORadj = 1.32, 95% CI: 1.09–1.60) versus men (ORadj = 0.59, 95% CI: 0.31–1.16).
Conclusions: In EDs, PIPV was linked to several mental health disorders, with women experiencing comorbid PIPV and substance use more frequently than men.
PMCID: PMC5349220  PMID: 27509203
intimate partner violence; mental health; emergency department; surveillance
4.  Detrimental Effects of Higher Body Mass Index and Smoking Habits on Menstrual Cycles in Korean Women 
Journal of Women's Health  2017;26(1):83-90.
Background: Alteration of menstrual cycle by individual lifestyles and unfavorable habits may cause menstrual irregularity. We aimed to investigate the relationship between lifestyle factors and menstrual irregularity in Korean women using data from the Fifth Korea National Health and Nutrition Examination Survey (KNHANES) 2010–2012.
Materials and Methods: This cross-sectional study included 3779 nondiabetic Korean women aged 19–49 years who did not take any oral contraceptives or sex hormonal compounds. We examined the association of menstrual irregularity with age, body mass index (BMI), drinking experience, and smoking habits.
Results: Age, Asian BMI, marriage status, age at menarche, and smoking habits were significantly associated with menstrual cycle irregularity (p < 0.01). The prevalence of menstrual irregularity was significantly increased at younger ages: 18.4%, 10.3%, and 10.5% at 19–29, 30–39, and 40–49 years, respectively. Moreover, obesity groups, defined as per Asian BMI using modified WHO criteria, were strongly associated with menstrual irregularity. BMI 25.0–29.9 [obesity class I] (adjusted odds ratios [OR], 1.94; 95% confidence intervals [CI], 1.37–2.74) and ≥30.0 [obesity class II] (adjusted OR, 2.18; 95% CI, 1.22–3.91) presented significantly higher risk of menstrual irregularity compared with BMI 18.5–22.9 [normal weight]. Multivariable analysis revealed that high BMI in younger women aged 19–29 years (p < 0.001) and smoking habits in middle-aged women aged 30–39 years (p < 0.005) significantly predicted menstrual irregularity.
Conclusion: This study substantiated that menstrual irregularity was closely associated with higher BMI and smoking habits in nondiabetic Korean women. Weight loss and smoking cessation should be recommended to promote women's reproductive health.
PMCID: PMC5278833  PMID: 27603944
menstrual cycle; KNHANES; body mass index; smoking; reproductive health
6.  Which Abortion Patients Have Had a Prior Abortion? Findings from the 2014 U.S. Abortion Patient Survey 
Journal of Women's Health  2018;27(1):58-63.
Background: Updated information about abortion patients who have had a prior abortion could inform patient-centered practices that help women avoid unintended pregnancies in the future.
Materials and Methods: Data come from a national sample of 8,380 nonhospital U.S. abortion patients accessing services at 87 facilities. The dependent variable was a self-reported measure of prior abortion. Bivariate and multivariable analyses were used to assess associations between a range of demographic and circumstantial characteristics and reports of obtaining a prior abortion.
Results: We found that 45% of patients reported having one or more prior abortions. Age was most strongly associated with this outcome, and patients aged 30 and older had more than two times the odds of having had a prior abortion compared with those aged 20–24. Other characteristics associated with an increased likelihood of prior abortion included having one or more children, being black, relying on insurance or financial assistance to pay for the procedure, and exposure to disruptive events in the last 12 months. Characteristics associated with a decreased likelihood of having a prior abortion included having a college degree and living 25 or more miles from the facility where the current abortion was obtained.
Conclusions: Age is the biggest risk factor for having had a prior abortion; the longer a woman has been alive, the longer she is at risk of unintended pregnancy. Some characteristics associated with prior abortion were beyond the control of the individuals experiencing them.
PMCID: PMC5771530  PMID: 28832238
abortion; repeat abortion; unintended pregnancy
7.  Overall Safety of Ospemifene in Postmenopausal Women from Placebo-Controlled Phase 2 and 3 Trials 
Journal of Women's Health  2018;27(1):14-23.
Objective: To evaluate the safety of daily oral ospemifene 60 mg, estrogen agonist/antagonist, used to treat moderate-to-severe dyspareunia due to postmenopausal vulvovaginal atrophy, which is part of genitourinary syndrome of menopause.
Methods: Post hoc analysis of safety data (treatment-emergent adverse events [TEAEs]) pooled from six phase 2 and 3 randomized, double-blind, multicenter placebo-controlled studies, evaluating the effects of ospemifene 60 mg on the breast, cardiovascular system, and bone in postmenopausal women.
Results: At least one TEAE was reported by 67.6% (840/1242) and 54.1% (518/958) of women taking ospemifene 60 mg and placebo, respectively. Most TEAEs were mild or moderate and occurred within 4 to 12 weeks. The most commonly reported TEAEs with ospemifene were hot flush (8.5% vs. 3.3% for placebo) and urinary tract infection (6.5% vs. 4.8%). Discontinuation due to TEAEs was 7.6% with ospemifene and 3.8% with placebo. Most women discontinued treatment due to adverse events (AEs): hot flushes, muscle spasms, headache, and vaginal discharge. Serious AEs occurred infrequently (ospemifene, 2.6%; placebo, 1.8%); most were not considered related to treatment. Breast cancer and other breast-related TEAE incidences were comparable between ospemifene (2.5%) and placebo (2.2%), and cardiovascular TEAE incidence, including deep vein thrombosis, was low with ospemifene (0.3%) and placebo (0.1%).
Conclusion: No unexpected safety signals were reported, and discontinuation due to TEAEs was low, with use of ospemifene 60 mg versus placebo in six phase 2 and 3 trials, suggesting a lack of detrimental effects on the breast, bone, and cardiovascular health of postmenopausal women when ospemifene is used to effectively treat moderate-to-severe postmenopausal dyspareunia.
PMCID: PMC5771532  PMID: 29064335
dyspareunia; ospemifene; estrogen receptor agonist and antagonist; selective estrogen receptor modulator; vulvar and vaginal atrophy
8.  Suicidal Ideation During the Postpartum Period 
Journal of Women's Health  2016;25(12):1219-1224.
Objective: To examine the association between suicidal ideation (SI), 3 weeks, 3 months, and 6 months postpartum with demographic, psychosocial, clinical factors, and depressive/anxiety symptoms (measured 24–48 hours after delivery), among a cohort of postpartum women.
Methods: This study included 1,073 mothers who gave birth in a large tertiary New York City hospital (2009–2010). Later, self-report SI was assessed using the suicide measure from the Edinburgh Postnatal Depression Scale and from the Patient Health Questionnaire.
Results: Two percent of participants presented with SI during the first 6 months postpartum. In bivariate analyses, race/ethnicity, nativity, insurance, and language were significantly correlated with SI 3 weeks, 3 months, and 6 months postpartum. Screening positive for depression (p = 0.0245) and anxiety (0.0454), assessed 1–2 days postpartum, was significantly correlated with later SI in bivariate analyses, as were antepartum complications (p = 0.001), depressive history (0.001), and self-efficacy (0.045). In adjusted models, antepartum complications (OR = 4.681, 95% CI = 1.99–10.99) and depressive history (OR-3.780, 95% CI = 1.514–9.441) were significantly associated with later postpartum SI. Heightened self-efficacy reduced the odds of later SI (p = 0.050).
Conclusion: Findings suggest that SI among a relatively healthy group of new mothers occurs with some frequency. Mothers with a history of depression and antepartum complications may be at increased risk.
PMCID: PMC5175420  PMID: 27227751
postpartum suicide; postpartum suicidal ideation; postpartum depression; maternal mortality; maternal mental health; antepartum complications
9.  Body Mass Index as a Measure of Obesity: Racial Differences in Predictive Value for Health Parameters During Pregnancy 
Journal of Women's Health  2016;25(12):1210-1218.
Background: As a measure of obesity, body mass index (BMI; kg/m2) is an imperfect predictor of health outcomes, particularly among African Americans. However, BMI is used to guide prenatal care. We examined racial differences in the predictive value of maternal BMI for physiologic correlates of obesity, serum interleukin (IL)-6 and C-reactive protein (CRP), as well as cesarean section and infant birth weight.
Methods: One hundred five pregnant women (40 European American, 65 African American) were assessed during the second trimester. BMI was defined as per prepregnancy weight. Electrochemiluminescence and enzyme-linked immunosorbent assays were used to quantify IL-6 and CRP, respectively. Birth outcomes were determined by medical record review.
Results: Women of both races classified as obese had higher serum IL-6 and CRP than their normal-weight counterparts (ps ≤ 0.01). However, among women with overweight, elevations in IL-6 (p < 0.01) and CRP (p = 0.06) were observed among European Americans, but not African Americans (ps ≥ 0.61). Maternal obesity was a significantly better predictor of cesarean section among European Americans versus African Americans (p = 0.03) and BMI was associated with infant birth weight among European Americans (p < 0.01), but not African Americans (p = 0.94). Effects remained after controlling for gestational age at delivery, gestational diabetes, and gestational weight gain as appropriate.
Conclusions: BMI may be a less valid predictor of correlates of overweight/obesity among African Americans versus European Americans during pregnancy. This should be considered in epidemiological studies of maternal–child health. In addition, studies examining the comparative validity of alternative/complementary measures to define obesity in pregnancy are warranted to inform clinical care.
PMCID: PMC5175427  PMID: 27487272
health status disparities; obesity; inflammation; pregnancy; birth weight; cesarean section
10.  Health Literacy and Women's Reproductive Health: A Systematic Review 
Journal of Women's Health  2016;25(12):1237-1255.
Background: Health literacy is thought to impact women's reproductive health, yet no comprehensive systematic reviews have been conducted on the topic. Our objective was to systematically identify, investigate, and summarize research on the relationship between health literacy and women's reproductive health knowledge, behaviors, and outcomes.
Methods: PRISMA guidelines were used to guide this review. English language, peer-reviewed research articles indexed in MEDLINE as of February 2015 were searched, along with study results posted on Articles were included if they (1) described original data-driven research conducted in developed countries, (2) were published in a peer-reviewed journal, (3) measured health literacy using a validated assessment, (4) reported on the relationship between health literacy and reproductive health outcomes, related knowledge, or behaviors, and (5) consisted of a study population that included reproductive age women.
Results: A total of 34 articles met eligibility criteria and were included in this review. Data were abstracted from articles by two study authors using a standardized form. Abstracted data were then reviewed and summarized in table format. Overall, health literacy was associated with reproductive health knowledge across a spectrum of topics. It was also related to certain health behaviors, such as prenatal vitamin use and breastfeeding. Its relationship with other reproductive behaviors and outcomes remains unclear.
Conclusions: Health literacy plays an important role in reproductive knowledge and may impact behaviors and outcomes. While further research is necessary, healthcare providers should utilize health literacy best practices now to promote high-quality care for patients.
PMCID: PMC5175428  PMID: 27564780
health literacy; reproductive health; contraception; obstetrics; cancer screening; sexual behavior
11.  Hot Flash Frequency and Blood Pressure: Data from the Study of Women's Health Across the Nation 
Journal of Women's Health  2016;25(12):1204-1209.
Background: Vasomotor symptoms (VMS) are highly prevalent among midlife women and have been associated with subclinical cardiovascular disease (CVD). However, the association between VMS frequency and risk factors such as hypertension (HTN) remains unclear.
Materials and Methods: We examined VMS frequency and blood pressure (BP) among 2839 participants of the Study of Women's Health Across the Nation (SWAN), a multiethnic, prospective, study of women enrolled from seven U.S. sites between November 1995 and October 1997. Women were age 42–52, with no history of CVD, and not postmenopausal at baseline. VMS was defined by the number of days a woman reported VMS over the 2-week period before each annual visit. Frequent VMS was defined as ≥6 days of VMS; less frequent VMS was defined 1–5 days of symptoms with asymptomatic women the reference group. BP was measured at each visit in addition to demographic and clinic factors.
Results: At baseline, 298 women reported frequent VMS, 794 less frequent VMS and 1747 no VMS. More frequent baseline VMS was associated with higher BP. Compared to no VMS, baseline VMS was associated with HTN (odds ratio [OR] 1.47, 95% confidence interval [CI]; 1.14–1.88 for infrequent VMS, and OR 1.40, (95% CI; 0.97–2.02 for frequent VMS). Risk for incident pre-HTN or HTN during follow-up was increased among women with frequent VMS (hazard ratio of 1.39, 95% CI; 1.09–1.79) after adjustment for multiple covariates.
Conclusion: Women with VMS may be more likely to develop HTN compared to women without VMS. Further research related to VMS including frequency of symptoms is warranted.
PMCID: PMC5175429  PMID: 27404767
12.  Low Uptake of Human Papillomavirus Vaccine Among Postpartum Women, 2006–2012 
Journal of Women's Health  2016;25(12):1256-1261.
Background: Young adult women find it acceptable to be offered the human papillomavirus (HPV) vaccine postpartum. Little is known about the practice of administering the HPV vaccine during the postpartum period.
Materials and Methods: The Truven Health Analytics MarketScan Commercial Claims and Encounters database was used to develop a cohort of privately insured 18 to 26–year-old women with uncomplicated live-born pregnancies. Eligibility required no previous doses of HPV vaccine before delivery and continuous insurance enrollment from June 2006 through 1 year postpartum. Descriptive statistics were performed.
Results: A total of 51,913 women meet age and enrollment criteria, with 3912 (7.5%) having received any doses of vaccine before their delivery, leaving 48,001 women in this cohort. In the year postpartum, 861 women (1.8%) received any HPV vaccine. Of the women initiating the vaccine, only 337 (39%) completed the three-vaccine series. Women who received the vaccine, compared with women who did not, were younger (21 vs. 23 years old), more often the dependent to the insurance beneficiary (56% vs. 30%), and were more likely to have had an abnormal pap smear in the year prior (19.6% vs. 9.1%) or postdelivery (16.4% vs. 4.9). More women completed the HPV vaccine series when initiated within 2 months postpartum compared with women initiating the vaccine series >2 months postpartum (44% vs. 38%).
Conclusions: Postpartum women are eligible for the HPV vaccine, yet very few are receiving it. The postpartum period is a missed opportunity for administration of this cancer-preventing vaccine.
PMCID: PMC5175430  PMID: 27447054
13.  Risk Factors for Smoking in Rural Women: The Role of Gender-Based Sexual and Intimate Partner Violence 
Journal of Women's Health  2016;25(12):1282-1291.
Background: Women living in Ohio Appalachia experience cervical cancer at disproportionately high rates. Intimate partner and sexual gender-based violence (GBV) and smoking are independent risk factors for cervical cancer and interact to heighten risk. Appalachian women smoke at higher rates than other Ohio women, but little is known about GBV exposure in the region. The purpose of this study was to establish prevalence of women's exposure to GBV in Ohio Appalachia and examine the association between GBV and smoking among women in the region.
Methods: A two-phase address-based random sampling approach was used in three purposefully selected Ohio Appalachian counties to identify women to complete an interviewer administered cross-sectional survey (n = 398). The primary exposure variable was GBV Index Score, a 4 level indices representing increasing exposure to eight abuse types. Correlation analysis and logistic regression were used to examine smoking correlations and risk.
Results: Almost 57% of women in the three selected Ohio Appalachian counties experienced GBV, with rate increasing to 77.5% among current smokers. The distribution of the GBV Exposure Index Score was significantly different across smoking status (p < = 0.0001), with exposure of GBV increasing when moving from never, to former, to current smokers. When controlling for depression, age, and adult socioeconomic position, GBV Exposure Index was significantly associated with current smoking behavior (OR:1.62, 95% CI [1.21–2.17]).
Discussion: Professionals working to reduce disparate disease burden among women in Ohio Appalachia should consider the role GBV plays in health behavior and behavioral change interventions, including smoking and smoking cessation.
PMCID: PMC5175431  PMID: 27548468
14.  Distribution of Vaccine-Type Human Papillomavirus Does Not Differ by Race or Ethnicity Among Unvaccinated Young Women 
Journal of Women's Health  2016;25(11):1153-1158.
Background: Previous studies have demonstrated racial and ethnic differences in the distribution of human papillomavirus (HPV) types among adult women with cervical precancers. The aim of this study was to determine whether the distribution of vaccine-targeted HPV types varies by race/ethnicity among unvaccinated young women.
Materials and Methods: A secondary analysis was performed using data from four studies of sexually experienced, unvaccinated, 13–26-year-old women. Participants completed surveys and provided a cervicovaginal swab for HPV DNA testing. Multivariable logistic regression analyses were performed to examine whether race, ethnicity, and other factors were associated with type-specific HPV infection among the overall sample and among HPV-infected participants. Models controlled for age, HPV knowledge, sexual behaviors, substance use, and random study effect.
Results: The mean age of participants (N = 841) was 19.3 years; 64.4% were black and 8.9% Hispanic. Black women were more likely than white women to be positive for ≥1 HPV type (odds ratio [OR] 1.83, 95% CI 1.30–2.58) and Hispanic women were less likely than non-Hispanic women to be positive for ≥1 HPV type (OR 0.47, 95% CI 0.24–0.92). However, among all young women and HPV-infected women, neither race nor ethnicity was associated with positivity for HPV types targeted by the following vaccines: 2-valent (HPV16 and/or 18), 4-valent (HPV6, 11, 16, and/or 18), or 9-valent (HPV6, 11, 16, 18, 31, 33, 45, 52, and/or 58).
Conclusion: The prevalence of HPV types targeted by the 2-valent, 4-valent, and 9-valent vaccines did not differ by race or ethnicity among all and among HPV-infected women in this sample.
PMCID: PMC5116655  PMID: 27754751
race; ethnicity; human papillomavirus; epidemiology; vaccine
15.  Association of Premenstrual Syndrome with Blood Pressure in Young Adult Women 
Journal of Women's Health  2016;25(11):1122-1128.
Objective: The prevalence of hypertension in premenopausal women is increasing. There is substantial need for novel strategies to identify women who would benefit from increased screening and early interventions. Several mechanisms likely contributing to premenstrual syndrome (PMS) are also involved in hypertension, including renin–angiotensin–aldosterone system dysfunction and micronutrient deficiencies. However, it is unknown whether young women with PMS have elevated blood pressure.
Materials and Methods: We evaluated the association of blood pressure, PMS, and premenstrual symptoms in a cross-sectional study of 409 young women (mean age 21 years), conducted from 2006 to 2014. Our analysis included 78 cases (19%) who met established criteria for clinically significant PMS and 88 controls (22%) experiencing few symptoms. Blood pressure was measured during the mid-luteal phase. Lifestyle, diet, anthropometry, and other factors were measured by questionnaire and/or direct measurement.
Results: After adjustment for smoking, body mass index, and other factors, mean diastolic blood pressure in PMS cases was 72.3 versus 69.1 mm Hg in controls (p = 0.02). Diastolic blood pressure was also significantly higher in women reporting specific symptoms; for example, mean diastolic blood pressure in women reporting moderate or severe premenstrual nausea was 77.7 mm Hg compared with 71.0 mm Hg in women without nausea (p = 0.007). Systolic blood pressure did not vary by PMS status.
Conclusions: To our knowledge, this is among the first studies to suggest that diastolic blood pressure is elevated in young adult women experiencing PMS. Prospective studies are needed to determine whether PMS may be a useful sentinel for future hypertension risk in young women.
PMCID: PMC5116659  PMID: 27420549
premenstrual syndrome; menstrual cycle; blood pressure; diastolic pressure
16.  Cardiovascular Disease Risk Among Young Urban Women 
Journal of Women's Health  2016;25(11):1139-1146.
Background: Although young women are presumed to have low cardiovascular disease (CVD) risk and mortality, the mortality benefits secondary to ischemic heart disease have plateaued among young women, <50 years.
Materials and Methods: Women, 18–49 years (n = 595) among all participants (n = 1,045) in the Columbia University Heart Health in Action Study, were assessed for CVD risk burden, that is, presence of hypertension, diabetes mellitus, current tobacco use, hyperlipidemia, physical inactivity, and/or obesity. Anthropometrics (height, weight, waist circumference, and body mass index [BMI]); demographics; socioeconomic status, CVD risk factors, body size perception; knowledge and awareness of CV disease; and attitudes toward lifestyle perception were determined.
Results: Most were Hispanic (64.0%); non-Hispanic white (20.0%); or non-Hispanic black (8.7%), age = 35.9 ± 8.0 years. BMI was categorized as obese (≥30 kg/m2, 27.0%; 160/592); overweight (25.0–29.1 kg/m2, 29.1%; 172/592); normal weight (18.5–24.9, 41.7%; 247/592); and underweight (≤18.4; 2.2%; 13/592). More than half (57.9%; 337/582) had CVD risks: 45.9% (267/582) had >1 CVD risk factor exclusive of obesity, including physical inactivity (18.4%), hypertension (17.2%), hyperlipidemia (11.3%), current tobacco use (9.8%), and diabetes (5.6%). Regardless of CVD risk burden, most knew blood pressure, blood sugar, and cholesterol. Women with increased CVD risk burden, however, were less likely to correctly identify body size (53.3% vs. 66.1%, p = 0.002). Obese and overweight women with CVD risk factors exclusive of obesity were more likely to cite cost (23.4% vs. 10.7%, p = 0.003) and fatigue (32.2% vs. 18.8%, p = 0.006) as barriers to weight loss.
Conclusion: Among these young women, the majority had CVD risks and the CVD risk burden is high among young women, particularly among the overweight and obese and physically inactive. Strategies to encourage healthy lifestyles and reduce CVD risk factors among this vulnerable at-risk population are vital.
PMCID: PMC5116662  PMID: 27058670
cardiovascular health; obesity; health disparities
17.  Trajectories of Depressive Symptoms Throughout the Peri- and Postpartum Period: Results from the First Baby Study 
Journal of Women's Health  2016;25(11):1112-1121.
Background: Postpartum depression (PPD) is a common complication of childbearing, but the course of PPD is not well understood. We analyze trajectories of depression and key risk factors associated with these trajectories in the peripartum and postpartum period.
Methods: Women in The First Baby Study, a cohort of 3006 women pregnant with their first baby, completed telephone surveys measuring depression during the mother's third trimester, and at 1, 6, and 12 months postpartum. Depression was assessed using the Edinburgh Postnatal Depression Scale. A semiparametric mixture model was used to estimate distinct group-based developmental trajectories of depression and determine whether trajectory group membership varied according to maternal characteristics.
Results: A total of 2802 (93%) of mothers completed interviews through 12 months. The mixture model indicated six distinct depression trajectories. A history of anxiety or depression, unattached marital status, and inadequate social support were significantly associated with higher odds of belonging to trajectory groups with greater depression. Most of the depression trajectories were stable or slightly decreased over time, but one depression trajectory, encompassing 1.7% of the mothers, showed women who were nondepressed at the third trimester, but became depressed at 6 months postpartum and were increasingly depressed at 12 months after birth.
Conclusions: This trajectory study indicates that women who are depressed during pregnancy tend to remain depressed during the first year postpartum or improve slightly, but an important minority of women become newly and increasingly depressed over the course of the first year after first childbirth.
PMCID: PMC5116682  PMID: 27310295
depression; postpartum; women's health; reproductive health; social support; marital status; trajectory analysis
18.  Domestic Violence Enhanced Perinatal Home Visits: The DOVE Randomized Clinical Trial 
Journal of Women's Health  2016;25(11):1129-1138.
Background: Perinatal intimate partner violence (IPV) is common and has significant negative health outcomes for mothers and infants. This study evaluated the effectiveness of an IPV intervention in reducing violence among abused women in perinatal home visiting programs.
Materials and Methods: This assessor-blinded multisite randomized control trial of 239 women experiencing perinatal IPV was conducted from 2006 to 2012 in U.S. urban and rural settings. The Domestic Violence Enhanced Home Visitation Program (DOVE) intervention group (n = 124) received a structured abuse assessment and six home visitor-delivered empowerment sessions integrated into home visits. All participants were screened for IPV and referred appropriately. IPV was measured by the Conflicts Tactics Scale2 at baseline through 24 months postpartum.
Results: There was a significant decrease in IPV over time (F = 114.23; p < 0.001) from baseline to 1, 3, 6, 12, 18, and 24 months postpartum (all p < 0.001). Additional models examining change in IPV from baseline indicated a significant treatment effect (F = 6.45; p < 0.01). Women in the DOVE treatment group reported a larger mean decrease in IPV scores from baseline compared to women in the usual care group (mean decline 40.82 vs. 35.87). All models accounted for age and maternal depression as covariates.
Conclusions: The DOVE intervention was effective in decreasing IPV and is brief, thereby facilitating its incorporation within well-woman and well-child care visits, as well as home visiting programs, while satisfying recommendations set forth in the Affordable Care Act for IPV screening and brief counseling.
PMCID: PMC5116686  PMID: 27206047
intimate partner violence; perinatal health; home visiting; evidenced-based intervention; rural; urban
19.  Outcomes of a Clinic-Based Educational Intervention for Cardiovascular Disease Prevention by Race, Ethnicity, and Urban/Rural Status 
Journal of Women's Health  2016;25(11):1174-1186.
Background and Purpose: Heart disease is the leading killer of women and remains poorly recognized in high-risk groups. We assessed baseline knowledge gaps and efficacy of a survey-based educational intervention.
Methods: Four hundred seventy-two women in clinical settings completed pre-/post-surveys for knowledge of: heart disease as the leading killer, risk factors (general and personal levels), heart attack/stroke symptoms, and taking appropriate emergency action. They received a clinic-based educational intervention delivered by healthcare professionals in the course of their clinical care. Change score analyses tested pre-/post-differences in knowledge after the educational intervention, comparing proportions by race, ethnicity, and urban/nonurban status.
Results: Knowledge and awareness was low in all groups, especially for American Indian women (p < 0.05). Awareness was overall highest for heart disease as the leading killer, but it was the lowest for taking appropriate action (13% of Hispanic, 13% of American Indian, 29% of African American, and 18% of nonurban women; p < 0.05). For all women, knowledge of the major risk factors was low (58%) as was knowledge of their personal levels for risk factors (73% awareness for hypertension, 54% for cholesterol, and 50% for diabetes). The intervention was effective (% knowledge gain) in all groups of women, particularly for raising awareness of: (1) heart disease as the leading killer in American Indian (25%), Hispanic (18%), and nonurban (15%) women; (2) taking appropriate action for American Indian (80%), African American (64%), non-Hispanic (55%), and urban (56%) women; (3) heart disease risk factors for Hispanic (56%) and American Indian (47%) women; and (4) heart disease and stroke symptoms in American Indian women (54% and 25%, respectively).
Conclusions: Significant knowledge gaps persist for heart disease in high-risk women, suggesting that these gaps and groups should be targeted by educational programs. We specify areas of need, and we demonstrate efficacy of a clinic-based educational intervention that can be of utility to busy healthcare professionals.
PMCID: PMC5116690  PMID: 27356155
preventive cardiology; community; race; ethnicity; rurality
20.  Endometrial Cancer Associated Symptoms: A Case-Control Study 
Journal of Women's Health  2016;25(11):1187-1192.
Background: The majority of women with endometrial cancer (EC) present at an early stage with an associated 5-year survival rate of >90%. High rates of early detection are attributed to warning symptoms; however, the prevalence of such symptoms has not been well defined.
Methods: A case–control study was conducted assessing the prevalence of symptoms in EC patients at a large cancer center compared with healthy controls. Controls included patients seen for an annual gynecologic care visit (AV) or for a gynecological problem-based visit (PV). A self-administered questionnaire was given to all participants addressing EC-associated symptoms, at the time of initial clinic visit. Odds ratios (ORs) were used to compare prevalence of symptoms between EC cases and controls. Logistic regression was used to determine the impact of menopausal status and obesity on symptom prevalence.
Results: The cases (n = 75) were significantly older than the AV (n = 203) and PV (n = 151) controls (59.7 vs. 49.8 vs. 51.0 years, p < 0.01), had a higher body mass index (35.5 vs. 29.4 vs. 30.9 kg/m2, p < 0.01), and were more likely to be postmenopausal (76% vs. 53.7% vs. 52.0%, p < 0.01). The cases were more likely to report postmenopausal bleeding (OR = 32.99 and 5.83, p < 0.01) and abnormal vaginal discharge (OR = 8.8 and 3.3, p < 0.01) compared with the AV and PV groups. Overall, 55.4% of cases reported abnormal vaginal discharge.
Conclusions: Symptoms of both postmenopausal bleeding and abnormal vaginal discharge were significantly higher in EC compared with controls. The presence of such symptoms should raise concern for malignant disease and prompt immediate gynecological evaluation.
PMCID: PMC5116765  PMID: 27254529
endometrial cancer; cancer symptoms; postmenopausal bleeding
21.  Obstetrician/Gynecologists' Knowledge, Attitudes, and Practices Regarding Weight Gain During Pregnancy 
Journal of Women's Health  2017;26(11):1169-1175.
Objective: Assess obstetrician–gynecologists' knowledge and counseling practices regarding gestational weight gain (GWG).
Materials and Methods: Questionnaire studies were conducted in 2012 and 2014 sent to practicing obstetrician–gynecologists.
Results: Response rates were 111/236 (47%) and 206/474 (43.5%). The majority of respondents agreed (50.0%) or strongly agreed (26.6%) that excessive GWG is a major health concern, often or always calculate the body mass index (BMI) of their patients (79.1%), and use BMI to modify their weight gain recommendations (78.5%). The physicians reported that, on average, 7.8% of pregnant patients gained too little weight, 47.3% gained an appropriate amount, and 45.1% gained too much. A greater proportion of patients with private insurance was associated with physician perception of fewer gaining excessive weight (r = −0.205, n = 198, p = 0.004), whereas high proportions with Medicaid or uninsured were positively correlated with a perception of excessive GWG (r = 0.206 and 0.187, n = 198, p = 0.004 and 0.008, respectively). A majority of physicians (55.1%) were not confident in their ability to affect their patients' prenatal weight gain. Confident physicians exhibited more appropriate practice efforts (e.g., use prepregnancy BMI; 83.6% vs. 74.8%, p = 0.009) and were more likely to inform their patients about the increased risk of pregnancy complications (90.8% vs. 69.7%, p = 0.001) and possible harms to their baby (76.9% vs. 61.0%, p = 0.001) from excessive GWG.
Conclusions: Study participants perceived excessive GWG to be a significant problem, but had low confidence in their ability to address it.
PMCID: PMC5695727  PMID: 28604154
gestational weight gain; body mass index; guidelines
22.  Effect of Flibanserin Treatment on Body Weight in Premenopausal and Postmenopausal Women with Hypoactive Sexual Desire Disorder: A Post Hoc Analysis 
Journal of Women's Health  2017;26(11):1161-1168.
Background: Flibanserin, a 5-HT1A agonist and 5-HT2A antagonist, is indicated for the treatment of acquired, generalized hypoactive sexual desire disorder (HSDD) in premenopausal women. This post hoc analysis evaluated the effect of flibanserin treatment on body weight in premenopausal and postmenopausal women with HSDD.
Materials and Methods: This analysis included three 24-week, double-blind, placebo-controlled studies of flibanserin 100 mg each bedtime (qhs) in premenopausal women, a similarly designed study in postmenopausal women, and a 52-week, open-label extension study in premenopausal women.
Results: In a pooled analysis of premenopausal women, mean baseline body mass index (BMI) was 27.0 kg/m2 in the flibanserin group (n = 1227) and 26.8 kg/m2 in the placebo group (n = 1238). Among patients who completed 24 weeks of treatment, least squares (LS) mean weight change was −1.4 kg in the flibanserin group (n = 1010) and −0.1 kg in the placebo group (n = 1066; p < 0.0001). Weight loss ≥5% from baseline was reported in 21.0% of patients who received flibanserin and 7.8% of patients who received placebo; weight loss ≥10% was reported in 3.8% and 2.0% of patients, respectively. In postmenopausal women, mean baseline BMI was 27.7 kg/m2 in the flibanserin group (n = 467) and 27.3 kg/m2 in the placebo group (n = 480). LS mean weight change at week 24 was −1.8 kg in the flibanserin group (n = 385) and −0.1 kg in the placebo group (n = 425; p < 0.0001), with weight loss ≥5% reported in 24.7% and 7.3% of patients, respectively, and weight loss ≥10% reported in 5.2% and 1.7%, respectively. In HSDD patients with >12 months (n = 880) and >18 months (n = 637) of exposure to flibanserin, mean weight change was −1.0 and −1.2 kg, respectively; 25.4% and 26.9% of patients, respectively, experienced weight loss ≥5% from baseline, and 7.8% and 8.4%, respectively, experienced weight loss ≥10%.
Conclusions: Women treated with flibanserin for HSDD may experience weight loss.
PMCID: PMC5695746  PMID: 28817365
body weight; flibanserin; reproductive health; sexuality; weight loss
23.  Lifetime Exposure to Intimate Partner Violence and Proinflammatory Cytokine Levels Across the Perinatal Period 
Journal of Women's Health  2016;25(10):1004-1013.
Background: Intimate partner violence (IPV) is a public health concern, affecting one-third of US women. Prior research suggests an association between exposure to IPV and poor maternal perinatal health, but the underlying biological correlates are not well understood. This study examined the relationship between exposure to IPV and proinflammatory cytokine levels, a candidate mechanism accounting for poor psychiatric and obstetric outcomes, across the perinatal period.
Materials and Methods: Data were obtained from a prospective, longitudinal cohort study of 171 women receiving obstetrical care from a hospital-based practice serving a predominantly low-income minority population. Participants completed questionnaires on IPV exposure, psychiatric symptoms, and psychosocial and obstetric factors and provided blood samples at 18 and 32 weeks of gestation and 6 weeks and 6 months postpartum. Serum levels of interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α) were assayed via enzyme-linked immunosorbent assay.
Results: Thirty-five (20.5%) women reported lifetime exposure to IPV and 7 (4.1%) reported being physically hurt in the preceding 12 months (4 while pregnant). Lifetime exposure to IPV was associated with increased likelihood of experiencing perinatal depression and smoking during pregnancy. Women with a history of IPV had significantly higher levels of TNF-α at 18 weeks (z = −2.29, p < 0.05), but significantly smaller changes in levels of IL-6 (β = −0.36, p = 0.04) across time.
Conclusion: Lifetime exposure to IPV was associated with a range of adverse mental health outcomes and may affect proinflammatory cytokine levels in pregnancy.
PMCID: PMC5069724  PMID: 26744816
24.  Mortality Risk Associated With Resistant Hypertension Among Women: Analysis from Three Prospective Cohorts Encompassing the Spectrum of Women's Heart Disease 
Journal of Women's Health  2016;25(10):996-1003.
Background: Women are at greater risk of developing resistant hypertension (RH) than men, yet scarce data exist on RH-associated outcomes in women. We aimed to determine all-cause mortality risk associated with apparent RH (aRH) among women across the spectrum of underlying coronary disease.
Materials and Methods: We analyzed data from St. James Women Take Heart (WTH; women without coronary disease at baseline), Women's Ischemia Syndrome Evaluation (women with signs/symptoms of ischemia at baseline), and the INternational VErapamil-Trandolapril STudy (INVEST; women with coronary artery disease and hypertension at baseline), totaling 15,108 adult women with no hypertension, non-RH (blood pressure [BP] ≥140/90 mmHg on ≤2 drugs or BP <140/90 mmHg on 1–3 drugs), or aRH (BP ≥140/90 mmHg on ≥3 drugs or anyone on ≥4 drugs) at baseline. The primary outcome was all-cause mortality.
Results: Prevalence of aRH ranged from 0.4% (WTH) to 10.6% (INVEST). Women with aRH, compared to those without, were older, more often black, and more likely to be obese or diabetic. Pooling all cohorts, risk for all-cause death was greater in women with aRH than in women with non-RH (adjusted HR 1.40; 95% CI 1.27–1.55) and women without hypertension (adjusted HR 2.34; 95% CI 1.76–3.11) over a median follow-up of 14.3 years.
Conclusions: aRH prevalence in women varies according to underlying coronary disease, and aRH is associated with a substantial, early, and sustained increased risk of all-cause death. Additional research into early recognition and prevention strategies for RH are needed, especially in black and older women, and those with known cardiovascular risk factors.
PMCID: PMC5069707  PMID: 27224417
hypertension; resistant hypertension; women; mortality; INVEST; WISE
25.  Screening Mammography Use Among Older Women Before and After the 2009 U.S. Preventive Services Task Force Recommendations 
Journal of Women's Health  2016;25(10):1030-1037.
Background: It is uncertain how changes in the U.S. Preventive Services Task Force breast cancer screening recommendations (from annual to biennial mammography screening in women aged 50–74 and grading the evidence as insufficient for screening in women aged 75 and older) have affected mammography use among Medicare beneficiaries.
Materials and Methods: Cohort study of 12 million Medicare fee-for-service women aged 65–74 and 75 and older to measure changes in 3-year screening use, 2007–2009 (before) and 2010–2012 (after), defined by two measures—proportion screened and frequency of screening by age, race/ethnicity, and hospital referral region.
Results: Fewer women were screened, but with similar frequency after 2009 for both age groups (after vs. before: age 65–74: 60.1% vs. 60.8% screened, 2.1 vs. 2.1 mammograms per screened woman; age 75 and older: 31.7% vs. 33.6% screened, 1.9 vs. 1.9 mammograms per screened woman; all p < 0.05). Black women were the only subgroup with an increase in screening use, and for both age groups (after vs. before: age 65–74: 55.4% vs. 54.0% screened and 2.0 vs. 1.9 mammograms per screened woman; age 75 and older: 28.5% vs. 27.9% screened and 1.8 vs. 1.8 mammograms per screened woman; all p < 0.05). Regional change patterns in screening were more similar between age groups (Pearson correlation r = 0.781 for proportion screened; r = 0.840 for frequency of screening) than between black versus nonblack women (Pearson correlation r = 0.221 for proportion screened; r = 0.212 for frequency of screening).
Conclusions: Changes in screening mammography use for Medicare women are not fully aligned with the 2009 recommendations.
PMCID: PMC5069708  PMID: 27427790
change in screening; mammography; older women; USPSTF recommendations; regional variation; race/ethnicity difference

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