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1.  Obesity and Human Papillomavirus Infection in Perimenopausal Women 
The Journal of Infectious Diseases  2013;208(7):1071-1080.
Introduction. Obesity is known to increase susceptibility to certain infections in men. It is unclear whether obesity increases women's risk for human papillomavirus (HPV) infection.
Methods. In a prospective cohort of 696 perimenopausal women enrolled in 2008–2012, we sought to determine whether obesity predicted incident HPV detection or nondetection. Obesity was defined as body mass index (BMI) ≥ 30 kg/m2.
Results. Baseline any type HPV prevalence was comparable between obese and nonobese women (18.7% vs 19.1%; P > .05). Over a median follow-up period of 17.9 months (interquartile range: 12.1–24.5), 187 new HPV detections occurred among 123 women, 60 of whom subsequently lost 76 detectable infections. When compared with nonobese participants, obese women had a similar rate of new HPV detection (7.1 vs 7.8 infections per 1000 infection-years; P > .05) or loss of detection (100.3 vs 85.8 infections per 100 infection-years; P > .05). Similar results were found after adjusting for age, menopausal status, smoking habit, and sexual exposure history.
Conclusions. Results from the current analysis suggest little effect of obesity on HPV detection and loss of detection in mid-adult women. More research is needed to determine whether adipokines or cytokines better capture the potential immune modulating effects of obesity on HPV infection.
PMCID: PMC3762384  PMID: 23840046
adipokine; body mass index; discrete-time survival analysis; frailty model; human papillomavirus; obesity; waist circumference
2.  Obesity and hormonal contraceptive efficacy 
Women's health (London, England)  2013;9(5):453-466.
Obesity is a major public health concern affecting an increasing proportion of reproductive-aged women. Avoiding unintended pregnancy is of major importance, given the increased risks associated with pregnancy, but obesity may affect the efficacy of hormonal contraceptives by altering how these drugs are absorbed, distributed, metabolized or eliminated. Limited data suggest that long-acting, reversible contraceptives maintain excellent efficacy in obese women. Some studies demonstrating altered pharmacokinetic parameters and increased failure rates with combined oral contraceptives, the contraceptive patch and emergency contraceptive pills suggest decreased efficacy of these methods. It is unclear whether bariatric surgery affects hormonal contraceptive efficacy. Obese women should be offered the full range of contraceptive options, with counseling that balances the risks and benefits of each method, including the risk of unintended pregnancy.
PMCID: PMC4079263  PMID: 24007251
birth control; hormonal contraception; obesity; pharmacodynamics; pharmacokinetics
3.  A Cohort Effect of the Sexual Revolution May Be Masking an Increase in Human Papillomavirus Detection at Menopause in the United States 
The Journal of Infectious Diseases  2013;207(2):272-280.
Background. Cohort effects, new sex partnerships, and human papillomavirus (HPV) reactivation have been posited as explanations for the bimodal age-specific HPV prevalence observed in some populations; no studies have systematically evaluated the reasons for the lack of a second peak in the United States.
Methods. A cohort of 843 women aged 35–60 years were enrolled into a 2-year, semiannual follow-up study. Age-specific HPV prevalence was estimated in strata defined by a lower risk of prior infection (<5 self-reported lifetime sex partners) and a higher risk of prior infection (≥5 lifetime sex partners). The interaction between age and lifetime sex partners was tested using likelihood ratio statistics. Population attributable risk (PAR) was estimated using Levin's formula.
Results. The age-specific prevalence of 14 high-risk HPV genotypes (HR-HPV) declined with age among women with <5 lifetime sex partners but not among women with ≥5 lifetime sex partners (P = .01 for interaction). The PAR for HR-HPV due to ≥5 lifetime sex partners was higher among older women (87.2%), compared with younger women (28.0%). In contrast, the PAR associated with a new sex partner was 28% among women aged 35–49 years and 7.7% among women aged 50–60 years.
Conclusions. A lower cumulative probability of HPV infection among women with a sexual debut before the sexual revolution may be masking an age-related increase in HPV reactivation in the United States.
PMCID: PMC3532829  PMID: 23242540
Human Papillomavirus; menopause; perimenopause; sexual revolution; cervical cancer; reactivation; cohort effect; age
4.  Contributions of recent and past sexual partnerships on incident human papillomavirus detection: acquisition and reactivation in older women 
Cancer research  2012;72(23):6183-6190.
Understanding the fraction of newly detected human papillomavirus (HPV) infections due to acquisition and reactivation has important implications on screening strategies and prevention of HPV-associated neoplasia. Information on sexual activity and cervical samples for HPV DNA detection using Roche Linear Array were collected semi-annually for two years from 700 women age 35–60 years. Incidence and potential fraction of HPV infections associated with new and lifetime sexual partnerships were estimated using Poisson models. Cox frailty models were used to estimate hazard ratios (HR) for potential risk factors of incident HPV detection. Recent and lifetime numbers of sexual partners were both strongly associated with incident HPV detection. However, only 13% of incident detections were attributed to new sexual partners whereas 72% were attributed to ≥5 lifetime sexual partners. Furthermore, 155 out of 183 (85%) incident HPV detections occurred during periods of sexual abstinence or monogamy, and were strongly associated with cumulative lifetime sexual exposure (HR: 4.1, 95% CI: 2.0, 8.4). This association increased with increasing age. These data challenge the 20 paradigm that incident HPV detection is driven by current sexual behavior and new viral acquisition in older women. Our observation that most incident HPV infection was attributable to past, not current, sexual behavior at older ages supports a natural history model of viral latency and reactivation. As the highly exposed baby-boomer generation of women with sexual debut after the sexual revolution transition to menopause, the implications of HPV reactivation at older ages on cervical cancer risk and screening recommendations should be carefully evaluated.
PMCID: PMC3513486  PMID: 23019223
human papillomavirus; HPV; sexual behavior; older women; reactivation; incidence; acquisition; perimenopause; aging
5.  Contraception for the HIV-Positive Woman: A Review of Interactions between Hormonal Contraception and Antiretroviral Therapy 
Background. Preventing unintended pregnancy in HIV-positive women can significantly reduce maternal-to-child HIV transmission as well as improve the woman's overall health. Hormonal contraceptives are safe and effective means to avoid unintended pregnancy, but there is concern that coadministration of antiretroviral drugs may alter contraceptive efficacy. Materials and Methods. We performed a literature search of PubMed and Ovid databases of articles published between January 1980 and February 2012 to identify English-language reports of drug-drug interactions between hormonal contraceptives (HCs) and antiretroviral drugs (ARVs). We also reviewed the FDA prescribing information of contraceptive hormone preparations and antiretrovirals for additional data and recommendations. Results. Twenty peer-reviewed publications and 42 pharmaceutical package labels were reviewed. Several studies of combined oral contraceptive pills (COCs) identified decreased serum estrogen and progestin levels when coadministered with certain ARVs. The contraceptive efficacy of injectable depot medroxyprogesterone acetate (DMPA) and the levonorgestrel intrauterine system (LNG-IUS) were largely unaffected by ARVs, while data on the contraceptive patch, ring, and implant were lacking. Conclusions. HIV-positive women should be offered a full range of hormonal contraceptive options, with conscientious counseling about possible reduced efficacy of COCs and the contraceptive implant when taken with ARVs. DMPA and the LNG-IUS maintain their contraceptive efficacy when taken with ARVs.
PMCID: PMC3426212  PMID: 22927715
6.  A randomized trial of the contraceptive efficacy, acceptability, and safety of C31G and nonoxynol-9 spermicidal gels 
Obstetrics and Gynecology  2010;116(6):1265-1273.
To compare contraceptive efficacy, safety, and acceptability of C31G and nonoxynol-9 spermicidal gels.
We conducted a multicenter, randomized, double-masked, controlled trial to assess whether a gel containing the spermicide C31G was non-inferior to a commercially available product containing nonoxynol-9. Participants were healthy, sexually active females ages 18–40 years. Measured outcomes included pregnancy rates, continuation rates, adverse events, and acceptability. Sample size was calculated at a 2.5% significance level using a one-sided test, based on assumed 6-month pregnancy probability of 15% in the Conceptrol group. Sample size was sufficient to reject, with 80% power, the null hypothesis that pregnancy probability in the C31G arm would be more than 5% higher.
Nine-hundred thirty-two women were randomized in the C31G group and 633 in the nonoxynol-9 group. For randomized subjects with at least one episode of coitus (modified intent-to-treat group), six-month pregnancy probabilities were 12.0% (95% confidence interval (CI) 9.3–14.7%) and 12.0% (95%CI 8.7–15.3%) for C31G and nonoxynol-9 respectively. Twelve-month pregnancy probabilities were 13.8% (95%CI 7.6–20%) for C31G and 19.8% (95%CI 10.9–28.7%) for nonoxynol-9. Two serious adverse events were deemed possibly related to study product, and neither occurred the C31G group. Three-fourths of users in either group reported that they liked their assigned study product. Approximately 40% of subjects discontinued prematurely for reasons other than pregnancy, with 11% lost to follow-up.
C31G demonstrated noninferior contraceptive efficacy compared to nonoxynol-9. Both products were safe and acceptable. C31G may provide another marketable option for women seeking spermicidal contraception.
PMCID: PMC3332092  PMID: 21099590
7.  Family Planning and the Burden of Unintended Pregnancies 
Epidemiologic Reviews  2010;32(1):152-174.
Family planning is hailed as one of the great public health achievements of the last century, and worldwide acceptance has risen to three-fifths of exposed couples. In many countries, however, uptake of modern contraception is constrained by limited access and weak service delivery, and the burden of unintended pregnancy is still large. This review focuses on family planning's efficacy in preventing unintended pregnancies and their health burden. The authors first describe an epidemiologic framework for reproductive behavior and pregnancy intendedness and use it to guide the review of 21 recent, individual-level studies of pregnancy intentions, health outcomes, and contraception. They then review population-level studies of family planning's relation to reproductive, maternal, and newborn health benefits. Family planning is documented to prevent mother-child transmission of human immunodeficiency virus, contribute to birth spacing, lower infant mortality risk, and reduce the number of abortions, especially unsafe ones. It is also shown to significantly lower maternal mortality and maternal morbidity associated with unintended pregnancy. Still, a new generation of research is needed to investigate the modest correlation between unintended pregnancy and contraceptive use rates to derive the full health benefits of a proven and cost-effective reproductive technology.
PMCID: PMC3115338  PMID: 20570955
contraception; contraceptive behavior; family planning services; pregnancy outcome; pregnancy, unplanned; reproduction
8.  Correlates of Cervicovaginal Human Papillomavirus Detection in Perimenopausal Women 
Journal of Women's Health  2009;18(9):1341-1346.
The aim of this research was to determine correlates of prevalent cervicovaginal human papillomavirus (HPV) infection in perimenopausal women.
A total of 178 women, ages 40–60, were recruited from four clinics in the metropolitan area of Baltimore, Maryland. A self-collected cervicovaginal specimen and questionnaire were completed following enrollment and consent. HPV was detected by L1 consensus polymerase chain reaction (PCR) and genotyped using a prototype line blot assay. Adjusted prevalence ratios (aPR) and 95% confidence intervals (CIs) from Poisson regression models with robust variance identified correlates of prevalent HPV infection.
Prevalence of any HPV genotype at baseline among 172 women with complete data was 20% (6% for high-risk HPV). HPV prevalence was higher among single compared to married women (aPR = 4.3 [95% CI: 2.0, 9.5]), and among women with ≥2 sex partners in the last six months compared to women who reported none (aPR = 4.9 [1.7, 13.9]) after adjustment for confounders. Menopausal stage was also associated with HPV detection, with increased prevalence among perimenopausal compared to premenopausal women (aPR 2.3 [1.1, 5.1]), after adjustment for confounders. Age was moderately correlated with menopausal staging (r = 0.57).
Our observations suggest the independent associations of sexual behavior and hormones on prevalent HPV in perimenopausal women. Age was not a good surrogate for menopausal stage, as it was only moderately correlated with menopausal stage.
PMCID: PMC2825723  PMID: 19702476
9.  Impact of bariatric surgery on hypertensive disorders in pregnancy: retrospective analysis of insurance claims data 
Objective To determine whether women who had a delivery after bariatric surgery have lower rates of hypertensive disorders in pregnancy compared with women who had a delivery before bariatric surgery.
Design Retrospective cohort study.
Setting Claims data for 2002-6 from seven insurance plans in the United States.
Participants 585 women aged 16-45 who had undergone bariatric surgery, had at least one pregnancy and delivery, and had continuous insurance coverage during pregnancy plus two weeks after delivery.
Main outcome measure Hypertensive disorders in pregnancy defined with ICD-9 codes. The independent variable was the timing of delivery in relation to bariatric surgery, classified as deliveries before and after surgery. We used logistic regression to calculate odds ratios and confidence intervals for each type of hypertensive disorder in pregnancy.
Results Among the 585 women who had undergone bariatric surgery and had a delivery, 269 delivered before surgery and 316 delivered after surgery. Gastric bypass was the surgery in 82% (477) of all women. Women who delivered before surgery were younger at the time of delivery (mean age 31.3 v 32.5) but had higher rates of pre-existing diabetes and gestational diabetes mellitus. Compared with women who delivered before surgery, women who delivered after surgery had substantially lower rates of pre-eclampsia and eclampsia (odds ratio 0.20, 95% confidence interval 0.09 to 0.44), chronic hypertension complicating pregnancy (0.39, 0.20 to 0.74), and gestational hypertension (0.16, 0.07 to 0.37), even after adjustment for age at delivery, multiple pregnancy (that is, twins or more), surgical procedure, pre-existing diabetes, and insurance plan.
Conclusion In this retrospective analysis of US women, bariatric surgery was associated with lower rates of hypertensive disorders in subsequent pregnancy.
PMCID: PMC2854330  PMID: 20388692
10.  Effects of switching from oral to transdermal or transvaginal contraception on markers of thrombosis 
Contraception  2008;78(6):451-458.
The study was conducted to determine the impact of switching from oral to transdermal patch or vaginal ring contraception on biomarkers of thrombosis.
Study Design
Current healthy oral contraceptive (OC) users were randomized to switch to either a contraceptive ring (CR) or patch (CP) and underwent phlebotomy to measure surrogate biomarkers of thrombosis (sex hormone binding globulin (SHBG), free protein S, and activated protein C-resistance (APC-r)) before switching, and during the 4th cycle of use of the new method.
Of 142 reproductive age women enrolled, 120 sample pairs were available for analysis. SHBG increased significantly from baseline in CP users (mean change (95% CI) +29.9 nM (9.6, 50) but not in CR users −1.6 (−16.6, 13.5). Protein S decreased significantly from baseline in CP users (mean change −7.1% (−12.1, −2.1), but increased significantly in CR users +5.3% (1.1, 9.6). The APC-r ratio did not undergo a significant change from baseline in either group [CP +0.06 (−0.06, 0.18), CR +0.02 (−0.10, 0.14)] Compared to CR users, subjects using the CP had significantly higher SHBG (187.5 (167.0, 208), 146 (132.6,159.4), p = 0.012), significantly lower protein S (81.8 (76.8, 86.8), 93.6 (89.1, 98.1), p = 0.001), and similar APC-r ratios (2.99 (2.85,3.14), 3.09 (2.96, 3.22), p = 0.3) at the cycle 4 visit.
OC users who switch to the ring exhibit beneficial changes in biomarkers of thrombosis while those switching to the patch display a shift favoring clot formation.
PMCID: PMC2628719  PMID: 19014790
Transdermal; Transvaginal; Hormonal Contraception; Thrombosis; Randomized

Results 1-10 (10)