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1.  Prevalence of Symptoms Consistent with a Diagnosis of Vulvodynia: Population-based estimates from two geographical regions 
American journal of obstetrics and gynecology  2013;210(1):10.1016/j.ajog.2013.09.033.
We used validated sensitive and specific questions associated with clinically-confirmed diagnoses of unexplained vulvar pain (Vulvodynia) to compare the cumulative incidence of vulvar pain and prevalence of care seeking behavior in Boston, Massachusetts metropolitan area (BMA) and in Minneapolis/St. Paul (MSP), Minnesota, between 2001–2005 using census-based data, and 2010–2012, using outpatient community-clinic data, respectively.
We received self-administered questionnaires from 5,440 women in BMA and 13,681 in MSP, 18–40 years of age, describing their history of vulvar burning or pain on contact that persisted >3 months that limited/prevented intercourse.
By age 40, 7–8% in BMA and MSP reported vulvar pain consistent with Vulvodynia. Women of Hispanic/Latina origin compared to Caucasians were 1.4 times more likely to develop vulvar pain symptoms (95%CI: 1.1–1.8). Many women in MSP (48%) and BMA (30%) never sought treatment, and >50% who sought care with known health care access received no diagnosis.
Using identical screening methods, we report high prevalence of vulvar pain in two geographical regions, and that access to health care does not increase the likelihood of seeking care for chronic vulvar pain.
PMCID: PMC3885163  PMID: 24080300
Ethnic groups; Health services accessibility; Prevalence; Vulvodynia
2.  Disparate Rates of New-Onset Depression During the Menopausal Transition in 2 Community-based Populations: Real, or Really Wrong? 
American Journal of Epidemiology  2013;177(10):1148-1156.
This study took place in eastern Massachusetts and included respondents from the Harvard Study of Moods and Cycles Cohort 1, enrolled between 1995 and 1997, and the Harvard Study of Moods and Cycles Cohort 2, enrolled between 2005 and 2009. In prospectively assessing rates of new-onset depression in 2 populations of late-reproductive–aged women with no Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) lifetime history of depression, we were surprised to find far lower rates of depression in the population with greater racial diversity and lower socioeconomic status, contrary to what had been reported in the scientific literature. To better understand why these disparate results occurred, we assessed confounding and outcome misclassification as potential explanations for the discrepancy. After determining that these were unlikely explanations for the findings, we explored 2 potential sources of selection bias: one induced by self-referral of healthy participants into the study and the other induced by the design of the study itself. We concluded that both types of selection bias were likely to have occurred in this study and could account for the observed difference in rates.
PMCID: PMC3649637  PMID: 23589585
bias; depression; prospective studies
3.  Perceived Stereotyping and Seeking Care for Chronic Vulvar Pain 
Pain medicine (Malden, Mass.)  2013;14(10):1461-1467.
We examined stereotyping of chronic pain sufferers among women aged 18 – 40 years and determined whether perceived stereotyping affects seeking care for women with chronic vulvar pain.
Cross-sectional study using a community-based survey of vulvodynia asking if “Doctors think that people with chronic pain exaggerate their pain”, and if “People believe that vulvar pain is used as an excuse to avoid having sex”.
Setting and Participants
12,834 women aged 18 – 40 years in metropolitan Minneapolis/St. Paul, Minnesota. Paul, Minnesota.
Outcome Measures
Women were considered to have a history of chronic vulvar pain if they reported vulvar burning lasting more than 3 months or vulvar pain on contact.
4,987 (38.9%) women reported a chronic pain condition; 1,651 had chronic vulvar pain. Women experiencing chronic pain were more likely than those without to perceive stereotyping from both doctors and others; a dose-response with the number of pain conditions existed. Women with chronic vulvar pain were more likely to believe that people think vulvar pain is an excuse to avoid intercourse. Half of the women with chronic vulvar pain did not seek medical care for it; of these, 40.4% perceived stereotyping from doctors. However, it was women who actually sought care (45.1%) who were more likely to feel stigmatized by doctors (adj. relative risk=1.11, 95% CI: 1.01-1.23).
Perceived negative stereotyping among chronic pain sufferers is common, particularly negative perceptions about physicians. In fact, chronic vulvar pain sufferers who felt stigmatized were more likely to have sought care than those who didn't feel stigmatized.
PMCID: PMC4036065  PMID: 23742116
Vulvodynia; stigma; stereotype; chronic pain; seeking care
4.  The Influence of Depression and Anxiety on Risk of Adult Onset Vulvodynia 
Journal of Women's Health  2011;20(10):1445-1451.
Studies have shown that women with vulvodynia are more psychologically distressed than women without vulvodynia. These studies, however, have not effectively established temporal associations between diagnosed psychiatric disorders and vulvodynia.
The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) was administered to 240 case-control pairs of women with and without vulvodynia. Interviews established age at first onset of diagnosed mood and anxiety disorder. Age information was used to determine whether the first episode of mood and/or anxiety was antecedent or subsequent to the first onset of vulvodynia symptoms. Conditional logistic regressions tested whether antecedent depression or anxiety was more likely among women with or without vulvodynia. Cox proportional hazards modeling was then used to estimate risk of subsequent new or recurrent onset of mood or anxiety disorder.
After adjusting for education, race, age at menarche, age at first tampon use, and age at first sexual intercourse, odds of vulvodynia were four-times more likely among women with antecedent mood or anxiety compared to women without (95% confidence interval [CI] 2.1-7.5). Vulvodynia was associated with new or recurrent onset of mood or anxiety disorder after adjustment (hazard ratio [HR] 1.7, 95% CI 1.1-2.6) and did not significantly change after including history of mood or anxiety disorder before the onset of vulvodynia or reference age of controls in the models.
This is the first community-based epidemiologic study demonstrating that DSM-IV-diagnosed antecedent depression and anxiety disorders influence the risk of vulvodynia and that vulvodynia increases the risk of both new and recurrent onset of psychopathology.
PMCID: PMC3186444  PMID: 21823918
5.  Assessing the Utility of Methods for Menopausal Transition Classification in a Population-Based Cohort: The CARDIA Study 
Maturitas  2013;75(3):289-293.
Perimenopause significantly impacts women’s health, but is under-researched due to challenges in assessing perimenopause status. Using CARDIA data, we compared the validity of six approaches for classifying perimenopause status in order to better understand the performance of classification techniques which can be applied to general cohort data. Specifically, we examined the validity of a self-reported question concerning changes in menstrual cycle length and two full prediction models using all available data concerning menstrual cycles as potential indicators of perimenopause. The validity of these three novel methods of perimenopause classification were compared to three previously established classification methods.
For each method, women were classified as pre- or peri-menopausal at Year 15 of follow-up (ages 32–46). Year 15 perimenopause status was then used to predict Year 20 post-menopausal status (yes/no) to estimate measures of validity and area under the curve.
The validity of the methods varied greatly, with four having an area under the curve greater than 0.8.
When designing studies, researchers should collect the data required to construct a prediction model for classifying perimenopause status that includes age, smoking status, vasomotor symptoms, and cycle irregularities as predictors. The inclusion of additional data regarding menstrual cycles can be used to construct a full prediction model which may offer improved validity. Valid classification methods that use readily available data are needed to improve the scientific accuracy of research regarding perimenopause, promote research on this topic, and inform clinical practices.
PMCID: PMC3767146  PMID: 23707105
menopause; perimenopause; sensitivity; specificity; validity
6.  Feasibility of Collecting Vulvar Pain Variability and Its Correlates Using Prospective Collection with Smartphones 
Pain Research and Treatment  2014;2014:659863.
Context. Vulvar pain level may fluctuate in women with vulvodynia even in the absence of therapy; however, there is little evidence suggesting which factors may be associated with variability. Objective. Determine the feasibility of using smartphones to collect prospective data on vulvar pain and factors that may influence vulvar pain level. Methods. 24 clinically confirmed women were enrolled from a population-based study and asked to answer five questions using their smartphones each week for one month. Questions assessed vulvar pain level (0–10), presence of pain upon wakening, pain elsewhere in their body, treatment use, and intercourse. Results. Women completed 100% of their scheduled surveys, with acceptability measures highly endorsed. Vulvar pain ratings had a standard deviation within women of 1.6, with greater variation on average among those with higher average pain levels (P < 0.001). On the weeks when a woman reported waking with pain, her vulvar pain level was higher by 1.82 on average (P < 0.001). Overall, average vulvar pain level was not significantly associated with the frequency of reporting other body pains (P = 0.64). Conclusion. Our smartphone tracking system promoted excellent compliance with weekly tracking of factors that are otherwise difficult to recall, some of which were highly associated with vulvar pain level.
PMCID: PMC4071965  PMID: 25006458
7.  Allergic Reactions and Risk of Vulvodynia 
Annals of epidemiology  2009;19(11):771-777.
A recent histological study of vestibular tissue from women with localized vulvodynia found universal presence of mast cells compared to no presence in vestibular tissue among controls. Since histamine is generated by mast cells, and mast cells contribute to the production of cytokines during chronic inflammation, we assessed the association between conditions that elicit a clinically-relevant histamine response and vulvodynia.
We studied 239 women with and 239 women without vulvodynia to assess the influence of self-reported allergic reactions antecedent to first development of vulvar pain symptoms among cases, and a matched reference age among controls.
Women with self-reported hives prior to first report of vulvar pain or reference age among controls were 2.5 times more likely to develop vulvodynia (95%CI 1.7–4.4). Those reporting a history of allergic reactions to insect bites were 2.1 times more likely (95%CI 1.1–4.0), and those reporting a history of seasonal allergies were 2.0 times (95%CI 1.3–3.2) more likely to develop vulvodynia. Findings were similar in a restricted subset of clinically-confirmed cases and matched controls.
An altered immuno-inflammatory response to environmentally-induced allergic reactions may predispose women to the development of vulvodynia or may be markers of an already heightened immuno-inflammatory response.
PMCID: PMC2773800  PMID: 19825458
8.  Self-Reported Vulvar Pain Characteristics and Their Association with Clinically Confirmed Vestibulodynia 
Journal of Women's Health  2009;18(9):1333-1340.
We evaluated a series of questions pertaining to vulvar pain symptoms to determine their association with a localized vulvodynia (vestibulodynia) diagnosis in women from the general population.
A sample of 12,435 women completed a self-administered screening questionnaire for the presence of specific types and characteristics of vulvar pain lasting 3 months or longer. Sensitivity, specificity, and predictive values were calculated for each cross-classification of vulvar pain type and characteristic, using as the gold standard 121 subjects with a clinically confirmed vestibulodynia diagnosis.
Relative to women with clinically confirmed vestibulodynia, 83% reported >10 episodes of pain on contact at the time of tampon insertion, intercourse, or pelvic examination, and 83% also reported pain on contact that limited or prevented sexual intercourse. These strong associations with a vestibulodynia diagnosis were not observed with respect to women who reported vulvar pain symptoms of burning or knifelike pain, or vulvar pain characteristics of continuous versus intermittent pain, or provoked versus spontaneous pain.
Our findings suggest that a small number of symptoms may be suitable for identifying a large proportion of women suffering from vestibulodynia which may be ideal for the development of an effective screening test in the future. However, we also recognize that a large proportion of women experiencing vulvar pain symptoms will not meet the diagnostic criteria for vestibulodynia. Thus, implementing such a screening procedure as part of a routine examination or testing would require a subsequent pelvic examination to confirm a vestibulodynia diagnosis and to rule out other known explanations for vulvar pain.
PMCID: PMC2825727  PMID: 19743906
9.  A Population-Based Study of Pregnancy and Delivery Characteristics Among Women with Vulvodynia 
Pain and Therapy  2012;1(1):2.
To examine pregnancy and delivery characteristics of women with and without vulvodynia.
The authors analyzed 227 vulvodynia cases that were less than 45 years old at pain onset; controls were age matched 1:1 to cases and had no history of vulvar pain. Pregnancy and delivery events were assessed after age at first vulvar pain onset (the reference age) in cases and a matched age in controls.
The authors observed no significant difference between cases and controls in achieving pregnancy after reference age. Also, no difference in pregnancy outcome was observed between cases and controls (P = 0.87). There was an indication that cases were more likely to receive a Cesarean section delivery (P = 0.07). In addition, 37.1% of cases who had vaginal delivery versus 11.3% of controls (P < 0.01) reported pain at 2 months postpartum. Comparing only women with vulvodynia, women who had intermittent pain versus constant pain were more than twice as likely to have a pregnancy (adjusted odds ratio 2.26, 95% CI 1.10–4.60).
Women with vulvodynia may be as likely as other women to carry their pregnancy to birth; however, they may experience higher rates of Cesarean section delivery and could reflect a selection towards those women with vulvodynia who have inconsistent pain.
PMCID: PMC4107863  PMID: 25134931
Cesarean; Fertility; Pain; Pregnancy; Vaginal delivery; Vulvodynia
10.  Psychosocial predictors of the onset of anxiety disorders in women: Results from a prospective 3-year longitudinal study 
Journal of anxiety disorders  2009;23(8):1165-1169.
In a prospective, longitudinal, population-based study of 643 women participating in the Harvard Study of Moods and Cycles we examined whether psychosocial variables predicted a new or recurrent onset of an anxiety disorder. Presence of anxiety disorders was assessed every six months over three years via structured clinical interviews. Among individuals who had a new episode of anxiety, we confirmed previous findings that history of anxiety, increased anxiety sensitivity (the fear of anxiety related sensations), and increased neuroticism were significant predictors. We also found trend level support for assertiveness as a predictor of anxiety onset. However, of these variables, only history of anxiety and anxiety sensitivity provided unique prediction. We did not find evidence for negative life events as a predictor of onset of anxiety either alone or in interaction with other variables in a diathesis-stress model. These findings from a prospective longitudinal study are discussed in relation to the potential role of such predictors in primary or relapse prevention efforts.
PMCID: PMC2760601  PMID: 19699609
11.  Sociodemographic predictors of antenatal and postpartum depressive symptoms among women in a medical group practice 
Data are scarce regarding the sociodemographic predictors of antenatal and postpartum depression. This study investigated whether race/ethnicity, age, finances, and partnership status were associated with antenatal and postpartum depressive symptoms.
1662 participants in Project Viva, a US cohort study.
Mothers indicated mid‐pregnancy and six month postpartum depressive symptoms on the Edinburgh postpartum depression scale (EPDS). Associations of sociodemographic factors with odds of scoring >12 on the EPDS were estimated.
Main results
The prevalence of depressive symptoms was 9% at mid‐pregnancy and 8% postpartum. Black and Hispanic mothers had a higher prevalence of depressive symptoms compared with non‐Hispanic white mothers. These associations were explained by lower income, financial hardship, and higher incidence of poor pregnancy outcome among minority women. Young maternal age was associated with greater risk of antenatal and postpartum depressive symptoms, largely attributable to the prevalence of financial hardship, unwanted pregnancy, and lack of a partner. The strongest risk factor for antenatal depressive symptoms was a history of depression (OR = 4.07; 95% CI 3.76, 4.40), and the strongest risk for postpartum depressive symptoms was depressive symptoms during pregnancy (6.78; 4.07, 11.31) or a history of depression before pregnancy (3.82; 2.31, 6.31).
Financial hardship and unwanted pregnancy are associated with antenatal and postpartum depressive symptoms. Women with a history of depression and those with poor pregnancy outcomes are especially vulnerable to depressive symptoms during the childbearing year. Once these factors are taken in account, minority mothers have the same risk of antenatal and postpartum depressive symptoms as white mothers.
PMCID: PMC2465548  PMID: 16476752
depression; pregnancy; socioeconomic factors; women; minority groups
12.  The Impact of Race as a Risk Factor for Symptom Severity and Age at Diagnosis of Uterine Leiomyomata among Affected Sisters 
To identify risk factors for uterine leiomyomata (UL) in a racially diverse population of women with a family history of UL and to evaluate their contribution to disease severity and age at diagnosis.
Study Design
We collected and analyzed epidemiological data from 285 sister pairs diagnosed with UL. Risk factors for UL-related outcomes were compared among black (n=73) and white (n=212) sister pairs using univariate and multivariate regression models.
Black women reported an average age at diagnosis of 5.3 years younger (SE 1.1, p<0.001) and were more likely to report severe disease (OR=5.22, CI 95% 1.99–13.7, p<0.001) than white women of similar socioeconomic status.
Self-reported race is a significant factor in the severity of UL among women with a family history of UL. Differences in disease presentation between races likely reflect underlying genetic heterogeneity. The affected sister-pair study design can address both epidemiological and genetic hypotheses about UL.
PMCID: PMC2265083  PMID: 18226615
Uterine leiomyomata; fibroids; family study; racial differences; symptom severity
13.  Influence of Body Size and Body Fat Distribution on Risk of Uterine Leiomyomata in U.S. Black Women 
Epidemiology (Cambridge, Mass.)  2005;16(3):346-354.
Uterine leiomyomata are a major source of morbidity in black women. We prospectively investigated the risk of self-reported uterine leiomyomata in relation to body mass index (BMI), weight change, height, waist and hip circumferences, and waist-to-hip ratio in a large cohort of U.S black women.
Data were derived from the Black Women’s Health Study, a U.S. prospective cohort study of black women who complete biannual mailed health questionnaires. From 1997 through 2001, we followed 21,506 premenopausal women with intact uteri and no prior diagnosis of uterine leiomyomata. Cox regression models were used to estimate incidence rate ratios (IRRs) and 95% confidence intervals (CIs).
After 70,345 person-years of follow up, 2146 new cases of uterine leiomyomata confirmed by ultrasound (n = 1885) or hysterectomy (n = 261) were self-reported. Compared with the thinnest women (BMI <20.0 kg/m2), the multivariate IRRs for women with BMIs of 20.0–22.4, 22.5–24.9, 25.0–27.4, 27.5–29.9, 30.0–32.4, and 32.5= kg/m2 were 1.34 (95% CI = 1.02–1.75), 1.39 (1.07–1.81), 1.45 (1.12–1.89), 1.47 (1.11–1.93), 1.36 (1.02–1.80), and 1.21 (0.93–1.58), respectively. IRRs were larger among parous women. Weight gain since age 18 was positively associated with risk, but only among parous women. No other anthropometric measures were associated with risk.
BMI and weight gain exhibited a complex relation with risk of uterine leiomyomata in the Black Women’s Health Study. The BMI association was inverse J-shaped and findings were stronger in parous women. Weight gain was positively associated with risk among parous women only.
PMCID: PMC1847589  PMID: 15824551
14.  Reproductive Factors, Hormonal Contraception, and Risk of Uterine Leiomyomata in African-American Women: A Prospective Study 
American journal of epidemiology  2004;159(2):113-123.
The authors assessed the risk of uterine leiomyomata in relation to reproductive factors and hormonal contraception in a prospective cohort study of US Black women. From March 1997 through March 2001, the authors followed 22,895 premenopausal women with intact uteri and no prior self-reported diagnosis of uterine leiomyomata. The authors used age- and time-stratified Cox regression models to estimate incidence rate ratios for self-reported uterine leiomyomata, confirmed by ultrasound or hysterectomy, in association with selected reproductive and hormonal factors. During 76,711 person-years of follow-up, 2,279 new cases of ultrasound- or hysterectomy-confirmed uterine leiomyomata were self-reported. After adjustment for age, body mass index, smoking, alcohol intake, and other reproductive covariates, the risk of ultrasound- or hysterectomy-confirmed leiomyomata was inversely associated with age at menarche, parity, and age at first birth and positively associated with years since last birth. Overweight or obesity appeared to attenuate the inverse association between parity and uterine leiomyomata. Current use of progestin-only injectables was inversely associated with risk. No consistent patterns were observed for other forms of hormonal contraception. Reproductive history is an important determinant of leiomyomata risk in premenopausal US Black women. Progestin-only injectables may reduce risk.
PMCID: PMC1847588  PMID: 14718211
Blacks; contraceptives; oral; female; leiomyoma; premenopause; prospective studies; reproduction; uterine neoplasms
15.  Midline episiotomy and anal incontinence: retrospective cohort study 
BMJ : British Medical Journal  2000;320(7227):86-90.
To evaluate the relation between midline episiotomy and postpartum anal incontinence.
Retrospective cohort study with three study arms and six months of follow up.
University teaching hospital.
Primiparous women who vaginally delivered a live full term, singleton baby between 1 August 1996 and 8 February 1997: 209 who received an episiotomy; 206 who did not receive an episiotomy but experienced a second, third, or fourth degree spontaneous perineal laceration; and 211 who experienced either no laceration or a first degree perineal laceration.
Main outcome measures
Self reported faecal and flatus incontinence at three and six months postpartum.
Women who had episiotomies had a higher risk of faecal incontinence at three (odds ratio 5.5, 95% confidence interval 1.8 to 16.2) and six (3.7, 0.9 to 15.6) months postpartum compared with women with an intact perineum. Compared with women with a spontaneous laceration, episiotomy tripled the risk of faecal incontinence at three months (95% confidence interval 1.3 to 7.9) and six months (0.7 to 11.2) postpartum, and doubled the risk of flatus incontinence at three months (1.3 to 3.4) and six months (1.2 to 3.7) postpartum. A non-extending episiotomy (that is, second degree surgical incision) tripled the risk of faecal incontinence (1.1 to 9.0) and nearly doubled the risk of flatus incontinence (1.0 to 3.0) at three months postpartum compared with women who had a second degree spontaneous tear. The effect of episiotomy was independent of maternal age, infant birth weight, duration of second stage of labour, use of obstetric instrumentation during delivery, and complications of labour.
Midline episiotomy is not effective in protecting the perineum and sphincters during childbirth and may impair anal continence.
PMCID: PMC27253  PMID: 10625261

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