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issn:1931-843
1.  Pregnancy Test Taking Is a Correlate of Unsafe Sex, Contraceptive Nonadherence, Pregnancy, and Sexually Transmitted Infections in Adolescent and Young Adult Women 
Journal of Women's Health  2013;22(4):339-343.
Abstract
Objectives
This study was conducted to examine the hypotheses that adolescent and young adult pregnancy test takers are at increased risk for unsafe sex, oral contraception (OC) nonadherence, and higher pregnancy and sexually transmitted infection (STI) rates.
Methods
We conducted secondary analyses using data collected for a study on OC adherence among 1155 women 16–24 years of age. Data collected at baseline and 3, 6, and 12 months were used for the analyses.
Results
At baseline, 33% of women reported having undergone ≥1 pregnancy test at home or a clinic during the past 3 months. Pregnancy test takers were more likely to have ≥3 sexual partners (odds ratio [OR] 2.12; 95% confidence interval [CI] 1.49–3.02) in the past year, report unprotected oral (OR 1.48; 95% CI 1.28–1.72) or anal sex (OR 1.78; 95% CI 1.32–2.39), be diagnosed with an STI (OR 1.76; 95% CI 1.23–2.51), become pregnant (hazards ratio 1.52; 95% CI 1.10–2.10), or not use any birth control method (OR 2.11; 95% CI 1.66–2.60). Moreover, they were less likely to continue using OC that was prescribed at baseline (OR 0.38; 95% CI 0.31–0.47) and to report being ambivalent about pregnancy (OR 0.73; 95% CI 0.60–0.90) compared to non–test takers.
Conclusions
Pregnancy test taking is an important correlate of high-risk sexual behaviors, OC nonadherence, and risk of subsequent pregnancy and STIs among adolescent and young adult women. Future interventions should target these women to decrease the risk of unintended pregnancies and STIs.
doi:10.1089/jwh.2012.4029
PMCID: PMC3627403  PMID: 23531050
2.  Obesity and Risk of Breast Cancer Mortality in Hispanic and Non-Hispanic White Women: The New Mexico Women's Health Study 
Journal of Women's Health  2013;22(4):368-377.
Abstract
Obesity is reported to be associated with poorer survival in women with breast cancer, regardless of menopausal status. Our purpose was to determine if the associations of obesity with breast cancer–specific, all-cause, and non–breast cancer mortality differ between Hispanic and non-Hispanic white (NHW) women with breast cancer. Data on lifestyle and medical history were collected for incident primary breast cancer cases (298 NHW, 279 Hispanic) in the New Mexico Women's Health Study. Mortality was ascertained through the National Death Index and New Mexico Tumor Registry over 13 years of follow-up. Adjusted Cox regression models indicated a trend towards increased risk for breast cancer–specific mortality in obese NHW women (hazard ratio [HR] 2.07; 95% confidence interval [CI] 0.98–4.35) but not in Hispanic women (HR 1.32; 95% CI 0.64–2.74). Obese NHW women had a statistically significant increased risk for all-cause mortality (HR 2.12; 95% CI 1.15–3.90) while Hispanic women did not (HR 1.23; 95% CI 0.71–2.12). Results were similar for non–breast cancer mortality: NHW (HR 2.65; 95% CI 0.90–7.81); Hispanic (HR 2.18; 95% CI 0.77–6.10). Our results suggest that obesity is associated with increased risk for breast cancer–specific mortality in NHW women; however, this association is attenuated in Hispanic women.
doi:10.1089/jwh.2012.4191
PMCID: PMC3627406  PMID: 23531051
3.  Mild Depressive Symptoms Are Associated with Elevated C-Reactive Protein and Proinflammatory Cytokine Levels During Early to Midgestation: A Prospective Pilot Study 
Journal of Women's Health  2013;22(4):385-389.
Abstract
Background
We examined depressive symptoms, C-reactive protein (CRP), interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) levels during early to-midgestation.
Methods
We measured depressive symptoms on the Patient Health Questionnaire-9 (PHQ-9), and serum CRP, IL-6, and TNF-α levels twice in 27 pregnant women.
Results
After adjustment, depressive symptoms prospectively (β=0.42, p<0.05 at 16–20 weeks of gestation) and concurrently (β=0.54, p<0.01 at 7–10 weeks of gestation) predicted elevated CRP [F (2, 14)=9.20, p=0.003, R2=0.57 and F (3, 15)=9.08, p=0.001, R2=0.64, respectively]. There were similar patterns of results for TNF-α (β=0.72, p<0.01) and IL-6 levels (β=0.39, p<0.05) at 7–10 weeks of gestation [F (2,19)=8.84, p=0.002, R2=0.48]. Furthermore, the association between depressive symptoms at 7–10 weeks of gestation and increased IL-6 levels at 16–20 weeks of gestation approached statistical significance. We confirmed the findings with the Wilcoxon signed rank test (IL-6: Z=2.44, p=0.015; TNF-α: Z=1.94, p=0.05; CRP: approached statistical significance).
Conclusions
These pilot data suggest that depressive symptoms may be associated with inflammatory markers during early to-midgestation.
doi:10.1089/jwh.2012.3785
PMCID: PMC3627429  PMID: 23046044
4.  Association Between Maternal Mood and Oxytocin Response to Breastfeeding 
Journal of Women's Health  2013;22(4):352-361.
Abstract
Background
Postpartum depression is associated with reduced breastfeeding duration. We previously hypothesized that shared neuroendocrine mechanisms underlie this association. We sought to measure the association between maternal mood and neuroendocrine response to breastfeeding.
Methods
We conducted a longitudinal cohort study of women recruited during pregnancy who intended to breastfeed. Baseline depression and anxiety history were assessed with a structured clinical interview. We measured mood symptoms using validated psychometric instruments, and we quantified affect and neuroendocrine responses to breastfeeding during laboratory visits at 2 and 8 weeks postpartum.
Results
We recruited 52 women who intended to breastfeed, among whom 47 completed 8-week follow-up. Duration and intensity of breastfeeding through 8 weeks were similar among mothers with lower versus higher anxiety and depression scores. In the third trimester, oxytocin was inversely correlated with Edinburgh Postnatal Depression Scale (EPDS) score (p=0.03). We did not find differences in neuroendocrine profile during breastfeeding at 2 weeks postpartum. Among the 39 women who breastfed at 8 weeks postpartum, oxytocin area under the curve during breastfeeding was inversely correlated with maternal EPDS and STAI-State and STAI-Trait anxiety scores (all p≤0.01). Higher anxiety and depression scores was further associated with lower oxytocin (group p<0.05) during feeding. During feeding at both visits, higher anxiety and depression scores were also associated with more negative affect: mothers reported feeling less happy and more depressed, overwhelmed, and stressed during feeding than women with lower scores.
Conclusion
Symptoms of depression and anxiety were associated with differences in oxytocin response and affect during breastfeeding.
doi:10.1089/jwh.2012.3768
PMCID: PMC3627433  PMID: 23586800
5.  The Lipid Accumulation Product for the Early Prediction of Gestational Insulin Resistance and Glucose Dysregulation 
Journal of Women's Health  2013;22(4):362-367.
Abstract
Background
Recent insights linking insulin resistance and lipid overaccumulation suggest a novel approach for the early identification of women who may soon experience glucose dysregulation. Among women without a history of gestational diabetes, we tested the association between the lipid accumulation product (LAP) obtained in early pregnancy and glucose dysregulation or insulin resistance in the second trimester.
Methods
A total of 180 white pregnant women of French-Canadian origin were included in this study. At 11–14 weeks' gestation, fasting insulin, glucose, C-peptide concentrations, and estimated insulin resistance (HOMA-IR) were obtained. The waist circumference (WC) and fasting triglycerides (TG) were measured to calculate LAP as (WC[cm] − 58)×TG[mmol/L]. At 24–28 weeks' gestation, glucose was measured 2 hours after a 75-g oral glucose challenge and other fasting variables were repeated.
Results
Among the nulliparous women tested at the end of the second trimester, fasting insulin, C-peptide, insulin resistance (HOMA-IR index), fasting glucose, and 2-hour glucose progressively increased (p≤0.002) according to their first-trimester LAP tertiles. Similar results were observed in parous women except for the glucose variables. The first-trimester LAP tended to show a stronger correlation to the second-trimester HOMA-IR index (r=0.56) than fasting triglyceride levels alone (r=0.40) or waist circumference alone (r=0.44) among nulliparous women. Similar associations were observed for parous women. Adjustment for body mass index weakened these associations, especially among parous women.
Conclusions
An increased value of LAP at the beginning of a pregnancy could be associated with an increased risk of insulin resistance or hyperglycemia later in gestation.
doi:10.1089/jwh.2012.3807
PMCID: PMC3627434  PMID: 23717842
6.  Persistent Genital Tract HIV-1 RNA Shedding After Change in Treatment Regimens in Antiretroviral-Experienced Women with Detectable Plasma Viral Load 
Journal of Women's Health  2013;22(4):330-338.
Abstract
Objective
To longitudinally assess the association between plasma viral load (PVL) and genital tract human immunodeficiency virus (GT HIV) RNA among HIV-1 infected women changing highly active antiretroviral therapy (HAART) because of detectable PVL on current treatment.
Methods
Women were eligible for the study if they had detectable PVL (defined as two consecutive samples with PVL>1000 copies/mL) and intended to change their current HAART regimen at the time of enrollment. Paired plasma and GT HIV-1 RNA were measured prospectively over 3 years. Longitudinal analyses examined rates of GT HIV-1 RNA shedding and the association with PVL.
Results
Sixteen women were followed for a median of 11 visits contributing a total of 205 study visits. At study enrollment, all had detectable PVL and 69% had detectable GT HIV-1 RNA. Half of the women changed to a new HAART regimen with ≥3 active antiretroviral drugs. The probability of having detectable PVL ≥30 days after changing HAART was 0.56 (95% CI: 0.37 to 0.74). Fourteen women (88%) had detectable PVL on a follow-up visit ≥30 or 60 days after changing HAART; and 12 women (75%) had detectable GT HIV-1 RNA on a follow-up visit ≥30 or 60 days after changing HAART. When PVL was undetectable, GT shedding occurred at 11% of visits, and when PVL was detectable, GT shedding occurred at 47% of visits.
Conclusions
Some treatment-experienced HIV-infected women continue to have detectable virus in both the plasma and GT following a change in HAART, highlighting the difficulty of viral suppression in this patient population.
doi:10.1089/jwh.2012.3849
PMCID: PMC3627435  PMID: 23531097
8.  High Levels of Education and Employment Among Women with Turner Syndrome 
Journal of Women's Health  2013;22(3):230-235.
Abstract
Background
Turner Syndrome (TS) is due to X chromosome monosomy and affects ∼1 per 2500 females at birth. The major features are short stature and primary ovarian failure. Short stature and monosomy for a maternal X chromosome have been implicated in impaired functionality in adult life; however, data on adult outcomes in TS are limited. In this study we evaluated the influence of adult height and parental origin of the single X chromosome on education, employment, and marital outcomes among women with TS.
Methods
This was a cross-sectional study of 240 women (25–67 years old) with TS participating in an intramural National Institutes of Health (NIH) study. Parental origin of the single X chromosome was determined by genotyping proband and parental genomic DNA. Information on education, employment, and family status was self reported. Normative data was obtained from the U.S. Bureaus of Census and Labor and Statistics.
Results
Seventy percent of the TS group had a baccalaureate degree or higher, compared with 30% of U.S. women (p<0.0001). Eighty percent of the TS group was employed compared with 70% of the U.S. female population. Approximately 50% of the TS group had ever married, compared with 78% of the general female population (p<0.0001). Height and parental origin of the single normal X chromosome had no association with education, employment, or marital status.
Conclusion
Women with TS currently achieve education and employment levels higher than the female U.S. population but are less likely to marry. Neither adult height nor parental origin of the single X chromosome influenced outcomes in education, employment, or marriage.
doi:10.1089/jwh.2012.3931
PMCID: PMC3601627  PMID: 23421579
9.  Health Beliefs Associated with Cervical Cancer Screening Among Vietnamese Americans 
Journal of Women's Health  2013;22(3):276-288.
Abstract
Background
Vietnamese American women represent one of the ethnic subgroups at great risk for cervical cancer in the United States. The underutilization of cervical cancer screening and the vulnerability of Vietnamese American women to cervical cancer may be compounded by their health beliefs.
Objective
The objective of this study was to explore the associations between factors of the Health Belief Model (HBM) and cervical cancer screening among Vietnamese American women.
Methods
Vietnamese American women (n=1,450) were enrolled into the randomized controlled trial (RCT) study who were recruited from 30 Vietnamese community-based organizations located in Pennsylvania and New Jersey. Participants completed baseline assessments of demographic and acculturation variables, health care access factors, and constructs of the HBM, as well as health behaviors in either English or Vietnamese.
Results
The rate of those who had ever undergone cervical cancer screening was 53% (769/1450) among the participants. After adjusting for sociodemographic variables, the significant associated factors from HBM included: believing themselves at risk and more likely than average women to get cervical cancer; believing that cervical cancer changes life; believing a Pap test is important for staying healthy, not understanding what is done during a Pap test, being scared to know having cervical cancer; taking a Pap test is embarrassing; not being available by doctors at convenient times; having too much time for a test; believing no need for a Pap test when feeling well; and being confident in getting a test.
Conclusion
Understanding how health beliefs may be associated with cervical cancer screening among underserved Vietnamese American women is essential for identifying the subgroup of women who are most at risk for cervical cancer and would benefit from intervention programs to increase screening rates.
doi:10.1089/jwh.2012.3587
PMCID: PMC3601630  PMID: 23428284
10.  Intimate Partner Violence and Cardiovascular Risk in Women: A Population-Based Cohort Study 
Journal of Women's Health  2013;22(3):250-258.
Abstract
Background
A potential link between intimate partner violence (IPV) and cardiovascular disease (CVD) has been suggested, yet evidence is scarce. We assessed cardiovascular risk and incident prescription of cardiovascular medication by lifetime experiences of physical and/or sexual IPV and psychological IPV alone in women.
Methods
A population-based cohort study of women aged 30–60 years was performed using cross-sectional data and clinical measurements from the Oslo Health Study (2000–2001) linked with prospective prescription records from the Norwegian Prescription Database (January 1, 2004 to December 31, 2009). We used age-standardized chi-square analyses to compare clinical characteristics by IPV cross-sectionally, and Cox proportional hazards regression to examine cardiovascular drug prescription prospectively.
Results
Our study included 5593 women without cardiovascular disease or drug use at baseline. Altogether 751 (13.4%) women disclosed IPV experiences: 415 (7.4%) physical and/or sexual IPV and 336 (6.0 %) psychological IPV alone. Cross-sectional analyses showed that women who reported physical and/or sexual IPV and psychological IPV alone were more often smokers compared with women who reported no IPV. Physical and/or sexual violence was associated with abdominal obesity, low high-density lipoprotein cholesterol, and elevated triglycerides. The prospective analysis showed that women who reported physical and/or sexual IPV were more likely to receive antihypertensive medication: incidence rate ratios adjusted for age were 1.27 (95% confidence interval 1.02–1.58) and 1.36 (CI 1.09–1.70) after additional adjustment for education and systolic and diastolic blood pressure, respectively. No significant differences were found for cardiovascular drugs overall or lipid modifying drugs.
Conclusions
Our findings indicate that clinicians should assess the cardiovascular risk of women with a history of physical and/or sexual IPV, and consider including CVD prevention measures as part of their follow-up.
doi:10.1089/jwh.2012.3920
PMCID: PMC3601632  PMID: 23428282
11.  The Clinical Relevance of Self-Reported Premenstrual Worsening of Depressive Symptoms in the Management of Depressed Outpatients: A STAR*D Report 
Journal of Women's Health  2013;22(3):219-229.
Abstract
Objective
To determine the incidence, clinical and demographic correlates, and relationship to treatment outcome of self-reported premenstrual exacerbation of depressive symptoms in premenopausal women with major depressive disorder who are receiving antidepressant medication.
Method
This post-hoc analysis used clinical trial data from treatment-seeking, premenopausal, adult female outpatients with major depression who were not using hormonal contraceptives. For this report, citalopram was used as the first treatment step. We also used data from the second step in which one of three new medications were used (bupropion-SR [sustained release], venlafaxine-XR [extended release], or sertraline). Treatment-blinded assessors obtained baseline treatment outcomes data. We hypothesized that those with reported premenstrual depressive symptom exacerbation would have more general medical conditions, longer index depressive episodes, lower response or remission rates, and shorter times-to-relapse with citalopram, and that they would have a better outcome with sertraline than with bupropion-SR.
Results
At baseline, 66% (n=545/821) of women reported premenstrual exacerbation. They had more general medical conditions, more anxious features, longer index episodes, and shorter times-to-relapse (41.3 to 47.1 weeks, respectively). Response and remission rates to citalopram, however, were unrelated to reported premenstrual exacerbation. Reported premenstrual exacerbation was also unrelated to differential benefit with sertraline and bupropion-SR.
Conclusions
Self-reported premenstrual exacerbation has moderate clinical utility in the management of depressed patients, although it is not predictive of overall treatment response. Factors that contribute to a more chronic or relapsing course may also play a role in premenstrual worsening of major depressive disorder (MDD).
doi:10.1089/jwh.2011.3186
PMCID: PMC3634137  PMID: 23480315
12.  Association Between Adiponectin and Tumor Necrosis Factor-Alpha Levels at Eight to Fourteen Weeks Gestation and Maternal Glucose Tolerance: The Parity, Inflammation, and Diabetes Study 
Journal of Women's Health  2013;22(3):259-266.
Abstract
Objective
Inflammation may influence gestational hyperglycemia, but to date, the data from observational studies is largely limited to results from the third trimester of pregnancy. Our objective was to evaluate first trimester adipocytokine levels. We sought to determine whether first trimester adiponectin and tumor necrosis factor-alpha (TNF)-alpha concentrations were independently associated and predictive of maternal glucose tolerance, as measured by the 1-hour glucose challenge test (GCT), after adjustment for maternal lifestyle behaviors and body mass index (BMI).
Material and Methods
Prospective study of pregnant women (n=211) enrolled in the Parity, Inflammation, and Diabetes Study. Nonfasting serum levels of adiponectin and TNF-r2 were measured at 8–14 weeks of pregnancy. GCT results were abstracted from electronic prenatal records. Multiple linear regression models were developed to determine the association of adiponectin and TNF-r2 levels with response to the GCT, adjusting for demographics, pregravid dietary intake and physical activity, first trimester BMI, and gestational weight gain.
Results
At baseline, higher adiponectin concentrations were inversely and statistically significantly associated with maternal response to the GCT [regression coefficient (β) −0.68; 95% confidence interval (CI): −1.29, −0.06). Adjustment for lifestyle factors did not alter the association of adiponectin with the GCT (β −0.74; 95% CI: −1.43, −0.05). After adjustment for first trimester BMI, the association of adiponectin was attenuated and no longer significant (β −0.46; 95% CI: −1.15, 0.24). TNF-r2 levels were not associated with the GCT (β −0.003; 95% CI: −0.011, 0.005).
Conclusions
First trimester adiponectin levels are not predictive of the 1-hour GCT response, but may be a marker for the effect of maternal BMI on glucose response to the GCT.
doi:10.1089/jwh.2012.3765
PMCID: PMC3634147  PMID: 23480316
13.  A Multicenter, Prospective Study to Evaluate the Use of Contrast Stress Echocardiography in Early Menopausal Women at Risk for Coronary Artery Disease: Trial Design and Baseline Findings 
Journal of Women's Health  2013;22(2):173-183.
Abstract
Aims
This multisite prospective trial, Stress Echocardiography in Menopausal Women At Risk for Coronary Artery Disease (SMART), aimed to evaluate the prognostic value of contrast stress echocardiography (CSE), coronary artery calcification (CAC), and cardiac biomarkers for prediction of cardiovascular events after 2 and 5 years in early menopausal women experiencing chest pain symptoms or risk factors. This report describes the study design, population, and initial test results at study entry.
Methods
From January 2004 through September 2007, 366 early menopausal women (age 54±5 years, Framingham risk score 6.51%±4.4 %, range 1%–27%) referred for stress echocardiography were prospectively enrolled. Image quality was enhanced with an ultrasound contrast agent. Tests for cardiac biomarkers [high-sensitivity C-reactive protein (hsCRP), atrial natriuretic protein (ANP), brain natriuretic protein (BNP), endothelin (ET-1)] and cardiac computed tomography (CT) for CAC were performed.
Results
CSE (76% exercise, 24% dobutamine) was abnormal in 42 women (11.5%), and stress electrocardiogram (ECG) was positive in 22 women (6%). Rest BNP correlated weakly with stress wall motion score index (WMSI) (r=0.189, p<0.001). Neither hsCRP, ANP, endothelin, nor CAC correlated with stress WMSI. Predictors of abnormal CSE were body mass index (BMI), diabetes mellitus, family history of premature coronary artery disease (CAD), and positive stress ECG. Twenty-four women underwent clinically indicated coronary angiography (CA); 5 had obstructive (≥50%), 15 had nonobstructive (10%–49%), and 4 had no epicardial CAD.
Conclusions
The SMART trial is designed to assess the prognostic value of CSE in early menopausal women. Independent predictors of positive CSE were BMI, diabetes mellitus, family history of premature CAD, and positive stress ECG. CAC scores and biomarkers (with the exception of rest BNP) were not correlated with CSE results. We await the follow-up data.
doi:10.1089/jwh.2012.3714
PMCID: PMC3573721  PMID: 23398128
14.  Bone Mineral Density Screening Among Women with a History of Breast Cancer Treated with Aromatase Inhibitors 
Journal of Women's Health  2013;22(2):132-140.
Abstract
Background
Understanding adherence to bone mineral density (BMD) screening after breast cancer (BC) treatment with aromatase inhibitors (AI) is an important first step in preventing or treating BC-related osteoporosis.
Methods
This retrospective cohort study assessed receipt and adherence to BMD screening among 342 women diagnosed with BC who were at high risk for osteoporosis after BC treatment with AI between 2004 and 2007. Nonadherence to baseline and annual BMD screening (recommended by 2003 American Society of Clinical Oncology Guidelines) was assessed using descriptive statistics and Poisson regression models accounting for length of AI use and follow-up.
Results
In the year before AI initiation, 16% of women received BMD screening. Fifty-six percent had no BMD screening in the14 months after a minimum of 9 months of continuous AI use, and 75% and 66% failed to have BMD screens during the second (14.1–26 month) and third (26.1–38 month) annual time periods after continuous AI use for at least 23 and 35 months, respectively. Overall, 24% had no BMD screening after 35 months of continuous AI use. Statistically significant predictors of nonadherence included predominant exemestane use, BMD screening before AI initiation, and diabetes mellitus history. Postcollege education, geographic region of primary care clinic, and never smoking were associated with a reduced risk of nonadherence.
Conclusions
A significant proportion of breast cancer patients treated with AI did not receive guideline-recommended BMD screening. Findings should raise awareness of the importance of BMD screening and targeting women at increased risk of screening nonadherence.
doi:10.1089/jwh.2012.3687
PMCID: PMC3573722  PMID: 23362883
15.  Inconsistencies Between Medical Records and Patient-Reported Recommendations for Follow-Up After Abnormal Pap Tests 
Journal of Women's Health  2013;22(2):147-152.
Abstract
Purpose
Adherence with recommended follow-up after an abnormal Pap test is a critical step in the prevention of cervical cancer. Here, we focused on identifying inconsistencies between self-reported and health department record recommendations for follow-up.
Methods
Self-reported recommendations for follow-up were collected by questionnaire from 519 women with abnormal Pap tests in rural Appalachia as part of a trial of the efficacy of patient navigation. Health department medical records were reviewed to collect healthcare provider recommendations. Measures of inconsistency (discordance) were calculated for overall recommendations and each of three particular follow-up recommendations: repeat Pap test, referral for further tests, and other gynecologist referral.
Results
The inconsistencies between the recommendation from the health department records and self-reports ranged from 15.0% (repeat Pap test) to 35.3% (gynecologist referral). Inconsistencies were most common among women with a history of abnormal Pap tests and those with more severe initial results. Recommendations for repeat Pap tests were correctly reported most often when the women recalled receiving a letter stating the results. Of greatest concern were the inconsistencies regarding recommendations for referral to a gynecologist. The more severe the Pap test result, the greater the odds of inaccurate self-reports of receiving a referral to a gynecologist for follow-up, p<0.001.
Conclusions
Clinicians should be aware that patients with a history of abnormal results and severe Pap test abnormalities are at risk of misreporting recommendations for follow up.
doi:10.1089/jwh.2011.3414
PMCID: PMC3573725  PMID: 23145889
16.  Attitudes and Practices Regarding Late Preterm Birth Among American Obstetrician-Gynecologists 
Journal of Women's Health  2013;22(2):167-172.
Abstract
Background
Late preterm birth (LPTB) accounts for most preterm births and has been increasing, associated with increases in cesarean sections and inductions at this gestational age.
Methods
A self-administered survey, consisting of questions about opinions, knowledge, and practices regarding LPTB, was mailed to 1232 American College of Obstetricians and Gynecologists (ACOG) Fellows and Junior Fellows in Practice in May–July 2010.
Results
Surveys were returned by 520 practicing obstetricians. Two thirds of respondents correctly defined LPTB (34–36 weeks completed gestation). Most responding physicians (87%) were aware of the evidence regarding morbidity and mortality of infants born at 34–36 weeks; 81% considered such evidence sufficient to make a clinical judgment. Although 84% were concerned about long-term health problems in these infants, many disagreed that LPTB infants were at increased risk of long-term neurodevelopmental outcomes. Most agreed that the increase in LPTB in the United States is due to increasing rates and complications of multifetal pregnancies and maternal disorders. Almost all responding physicians agreed that certain clinical indications (e.g., severe preeclampsia, placental abruption, premature rupture of the membranes [PROM]) were appropriate reasons for early delivery, and most disagreed with delivering late preterm infants for logistical reasons or convenience. Half of responding physicians reported that concerns about malpractice risks contribute to their decision to induce labor or perform a cesarean section at 34–36 weeks.
Conclusions
Many obstetricians underestimate long-term neurodevelopmental outcomes among infants born late preterm and may have a lower threshold to deliver some infants late preterm for indications that are not evidence based. Additional educational efforts regarding LPTB are needed.
doi:10.1089/jwh.2012.3814
PMCID: PMC3573726  PMID: 23350861
17.  Factors Influencing Time to Diagnosis After Abnormal Mammography in Diverse Women 
Journal of Women's Health  2013;22(2):159-166.
Abstract
Background
Abnormal mammograms are common, and the risk of false positives is high. We surveyed women in order to understand the factors influencing the efficiency of the evaluation of an abnormal mammogram.
Methods
Women aged 40–80 years, identified from lists with Breast Imaging Reporting and Data System (BIRADS) classifications of 0, 3, 4, or 5, were surveyed. Telephone surveys asked about the process of evaluation, and medical records were reviewed for tests and timing of evaluation.
Results
In this study, 970 women were surveyed, and 951 had chart reviews. Overall, 36% were college graduates, 68% were members of a group model health plan, 18% were Latinas, 25% were African Americans, 15% were Asian, and 43% were white. Of the 352 women who underwent biopsies, 151 were diagnosed with cancer (93 invasive). Median time to diagnosis was 183 days for BIRADS 3 compared to 29 days for BIRADS 4/5 and 27 days for BIRADS 0. At 60 days, 84% of BIRADS 4/5 women had a diagnosis. Being African American (hazard ratio [HR] 0.69, 95% confidence interval [CI] 0.49-0.97, p=0.03), income < $10,000 (HR 0.55, 95% CI 0.31-0.98, p<0.04), perceived discrimination (HR 0.22, 95% CI 0.09-0.52, p<0.001), not fully understanding the results of the index mammogram (HR 0.49, 95% CI 0.32-0.75, p=0.001), and being notified by letter (HR 0.66, 95% CI 0.48-0.90, p=0.01) or telephone (HR 0.62, 95% CI 0.42-0.92, p=0.02) rather than in person were all associated with significant delays in diagnosis.
Conclusions
Evaluation of BIRADS 0, 4, or 5 abnormal mammograms was completed in most women within the recommended 60 days. Even within effective systems, correctible communication factors may adversely affect time to diagnosis.
doi:10.1089/jwh.2012.3646
PMCID: PMC3573728  PMID: 23350859
18.  Gender Differences in Mortality and CD4 Count Response Among Virally Suppressed HIV-Positive Patients 
Journal of Women's Health  2013;22(2):113-120.
Abstract
Background
Treatment outcomes for antiretroviral therapy (ART) patients may vary by gender, but estimates from current evidence may be confounded by disease stage and adherence. We investigated the gender differences in treatment response among HIV-positive patients virally suppressed within 6 months of treatment initiation.
Methods
We analyzed data from 7,354 patients initiating ART between April 2004 and April 2010 at Themba Lethu Clinic, a large urban public sector treatment facility in South Africa. We estimated the relations among gender, mortality, and mean CD4 response in HIV-infected adults virally suppressed within 6 months of treatment initiation and used inverse probability of treatment weights to correct estimates for loss to follow-up.
Results
Male patients had a 20% greater risk of death at both 24 months and 36 months of follow-up compared to females. Older patients and those with a low hemoglobin level or low body mass index (BMI) were at increased risk of mortality throughout follow-up. Men gained fewer CD4 cells after treatment initiation than did women. The mean differences in CD4 count gains made by women and men between baseline and 12, 24, and 36 months were 28.2 cells/mm3 (95% confidence interval [CI] 22.2–34.3), 60.8 cells/mm3 (95% CI 71.1-50.5 cells/mm3), and 83.0 cells/mm3 (95% CI 97.1-68.8 cells/mm3), respectively. Additionally, patients with a current detectable viral load (>400 copies/mL) and older patients had a lower mean CD4 increase at the same time points.
Conclusions
In this initially virally suppressed population, women showed consistently better immune response to treatment than did men. Promoting earlier uptake of HIV treatment among men may improve their immunologic outcomes.
doi:10.1089/jwh.2012.3585
PMCID: PMC3579326  PMID: 23350862
19.  Do Menopausal Status and Use of Hormone Therapy Affect Antidepressant Treatment Response? Findings from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study 
Journal of Women's Health  2013;22(2):121-131.
Abstract
Background
Menopausal status and use of hormonal contraception or menopausal hormone therapy (HT) may affect treatment response to selective serotonin reuptake inhibitors (SSRIs). This report evaluates whether menopausal status and use of hormonal contraceptives or menopausal HT affect outcome in women treated with citalopram.
Methods
In the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study, 896 premenopausal and 544 postmenopausal women were treated with citalopram for 12–14 weeks. Baseline demographic and clinical characteristics were used in adjusted analysis of the effect of menopausal status and use of hormonal contraceptives or menopausal HT on outcomes. Remission was defined as final Hamilton Rating Scale for Depression-17 (HRSD17) ≤7 or Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR16) score ≤5 and response as ≥50% decrease from the baseline QIDS-SR16 score.
Results
Premenopausal and postmenopausal women differed in multiple clinical and demographic baseline variables but did not differ in response or remission rates. Premenopausal women taking hormonal contraceptives had significantly greater unadjusted remission rates on the HRSD17 and the QIDS-SR16 than women not taking contraception. Response and remission rates were not different between postmenopausal women taking vs. not taking HT. Adjusted results showed no significant difference in any outcome measure across menopause status in women who were not taking contraception/HT. There were no significant differences in adjusted results across HT status in premenopausal or postmenopausal women.
Conclusions
In this study, citalopram treatment outcome was not affected by menopausal status. Hormonal contraceptives and HT also did not affect probability of good outcome.
doi:10.1089/jwh.2012.3479
PMCID: PMC3613168  PMID: 23398127
20.  The “Welcome to Medicare” Visit: A Missed Opportunity for Cancer Screening Among Women? 
Journal of Women's Health  2013;22(1):19-25.
Abstract
Background
On January 1, 2005, Medicare began covering a “Welcome to Medicare” visit (WMV) for new enrollees with fee-for-service (FFS) Medicare (Parts A and B). The new benefit was expected to increase demand for mammography and Pap tests among women transitioning onto Medicare. This study examined whether Medicare's coverage of a WMV influenced the use of mammography and Pap tests among women aged 65 and 66 years with FFS Medicare.
Methods
Medicare Current Beneficiary Survey (MCBS) data from 2001 to 2007 were linked with Medicare claims. Utilization rates for preventive visits, mammography, and Pap tests were measured among women entering Medicare. Multivariate logistic regressions were estimated to quantify the effects of the new Medicare benefit on the use of these screening tests, controlling for patient characteristics.
Results
Regression-adjusted mammography and Pap test rates did not increase after WMV coverage was introduced. The 2005 reform had nonsignificant trivial effects on the use of both tests, most likely because few of the women who were eligible for a WMV took advantage of it.
Conclusions
Medicare coverage of a WMV had no impact on mammography screenings or Pap tests among women who were eligible for the benefit.
doi:10.1089/jwh.2012.3777
PMCID: PMC3546361  PMID: 23145890
21.  Initial and Sustained Female Condom Use Among Low-Income Urban U.S. Women 
Journal of Women's Health  2013;22(1):26-36.
Abstract
Objectives
The female condom (FC), an effective barrier method for HIV/sexually transmitted infection (STI) prevention, continues to be absent from most community settings, including reproductive health and treatment clinics. Reducing or eliminating basic barriers, including lack of awareness, knowledge of proper use, and access to free samples, may significantly increase use among those who want or need them.
Methods
A prospective cohort of 461 women in Hartford, Connecticut (2005–2008), was interviewed at baseline, 1 month, and 10 months about FC use and other personal, partner, peer, and community factors. All participants received brief demonstration of FC use and four free FC1 at baseline. Pairwise longitudinal tests and structural equation modeling were used to test predictors of initial (1 month) and sustained (10 month) FC use.
Results
Although only 29% of the sample reported ever having used FC at baseline, 73% of never users (51% of the returned 1-month sample) had initiated FC use by 1 month after receiving the brief intervention. Additionally, 24% of the returned 10-month sample (30% of 10-month FC users) reported sustained use, measured as having used FC at baseline or 1 month and also in the prior 30 days. General latent variable modeling indicated that FC knowledge and attitudes predicted initiating FC use; male condom use, FC knowledge and attitudes, and network exposure to FC information predicted sustained use.
Conclusions
Findings indicated that many women will potentially initiate and continue using FC when basic barriers are removed. Brief FC education with free trial samples should be built into standard clinical practice and public health programs.
doi:10.1089/jwh.2011.3430
PMCID: PMC3546362  PMID: 23276188
22.  Impact of Reproductive Status and Age on Response of Depressed Women to Cognitive Therapy 
Journal of Women's Health  2013;22(1):58-66.
Abstract
Objective
Previous research suggests that reproductive hormones are potential affective modulators in mood disorders and may influence response to antidepressant medications. To our knowledge, there are no data on relationships between hormonal status and response to psychotherapy for recurrent major depressive disorder (MDD).
Methods
At two sites, female outpatients (n=353), aged 18–70, with recurrent MDD received 12–14 weeks of cognitive therapy (CT). Menopausal status and age were based on self-report. In the parent study, nonresponse to therapy was defined as persistence of a major depressive episode (MDE) as defined by the DSM-IV or a final Hamilton Rating Scale for Depression-17-Item (HRSD17) score of ≥ 12 or both. More traditional definitions of response (at least a 50% reduction in pretreatment HRSD17) and remission (a final HRSD17 ≤ 6) were also examined.
Results
Controlling for pretreatment HRSD17 scores, there were no significant differences found in the rates of response to CT or symptom status among premenopausal, perimenopausal, and postmenopausal women.
Conclusions
We found no support for the hypotheses that response to CT or the rates of change in depressive symptoms are moderated by reproductive status. The findings, however, are limited by the absence of early follicular phase serum sampling/analysis to estimate hormone levels and the reliance on self-report to establish menopausal status. These data motivate a full investigation of the effects of reproductive status on response to psychosocial interventions.
doi:10.1089/jwh.2011.3427
PMCID: PMC3546363  PMID: 23305218
23.  A Comparison of Mediterranean-Style and MyPyramid Diets on Weight Loss and Inflammatory Biomarkers in Postpartum Breastfeeding Women 
Journal of Women's Health  2013;22(1):48-57.
Abstract
Background
Of postpartum women, 15%–20% retain≥5 kg of their gestational weight gain, increasing risk for adult weight gain. Postpartum women are also in a persistent elevated inflammatory state. Both factors could increase the risk of obesity-related chronic disease. We hypothesized that breastfeeding women randomized to a Mediterranean-style (MED) diet for 4 months would demonstrate significantly greater reductions in body weight, body fat, and inflammation than women randomized to the U.S. Department of Agriculture's (USDA) MyPyramid diet for Pregnancy and Breastfeeding (comparison diet).
Methods
A randomized, controlled dietary intervention trial was conducted in 129 overweight (body mass index [BMI] 27.2±4.9 kg/m2), mostly exclusively breastfeeding (73.6%) women who were a mean 17.5 weeks postpartum. Dietary change was assessed using a validated Food Frequency Questionnaire (FFQ) before and after intervention as well as plasma fatty acid measures (gas chromatography/flame ionization detector [GC/FID]). Anthropometric measurements and biomarkers of inflammation, tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6), also were assessed at baseline and 4 months via enzyme-linked immunosorbent assay (ELISA).
Results
Participants in both diet groups demonstrated significant (p<0.001) reductions in body weight (−2.3±3.4 kg and −3.1±3.4 kg for the MED and comparison diets, respectively) and significant (p≤0.002) reductions in all other anthropometric measurements; no significant between-group differences were shown as hypothesized. A significant decrease in TNF-α but not IL-6 was also demonstrated in both diet groups, with no significant between-group difference.
Conclusions
Both diets support the promotion of postpartum weight loss and reduction in inflammation (TNF-α) in breastfeeding women.
doi:10.1089/jwh.2012.3707
PMCID: PMC3546415  PMID: 23276189
24.  Osteoporosis Healthcare Disparities in Postmenopausal Women 
Journal of Women's Health  2012;21(12):1232-1236.
Abstract
Background
Previous studies in referral populations have shown that fewer African American women complete dual-energy x-ray absorptiometry (DXA) screening and are prescribed medications for osteoporosis. This study examines if these disparities exist in primary care practices.
Methods
Of 4748 eligible women ≥60 years of age in primary care practices, we randomly selected 500 African American and 500 Caucasian women. We compared the DXA screening referral rate and results, follow-up rate, and medication prescribing for low bone mineral density (BMD) between African American and Caucasian women and analyzed provider demographics. We used logistic regression analysis to control confounding variables, such as age and BMI.
Results
Among the initial 1000 women, only 29.8% African American Women were referred to DXA compared to 38.4% Caucasian women (p<0.05), and 20.8% African American vs. 27.0% Caucasian (p<0.05) women completed the test. Among women with a diagnosis of osteoporosis, African Americans were less likely to receive medication (79.6% vs. 89.2%, p<0.05), without a difference in follow-up visit pattern between races. Female providers were more likely to refer women for DXA (27.7%) than male providers (21.7%) (p=0.035), and this gender difference in referral was more pronounced for African American patients.
Conclusions
Not enough eligible women are being screened and treated for osteoporosis in primary care. Even fewer African American women receive DXA screenings and are treated for osteoporosis. Controlling for age and BMI attenuated but did not eliminate the difference. Female providers were more likely than male providers to refer women for DXA.
doi:10.1089/jwh.2012.3812
PMCID: PMC3518540  PMID: 23140203
25.  Gender Differences in Symptoms and Care Delivery for Chronic Obstructive Pulmonary Disease 
Journal of Women's Health  2012;21(12):1267-1274.
Abstract
Background
Morbidity and mortality for women with chronic obstructive pulmonary disease (COPD) are increasing, and little is known about gender differences in perception of COPD care.
Methods
Surveys were administered to a convenience sample of COPD patients to evaluate perceptions about symptoms, barriers to care, and sources of information about COPD.
Results
Data on 295 female and 273 male participants were analyzed. With similar frequencies, women and men reported dyspnea and rated their health as poor/very poor. Although more women than men reported annual household income <$30,000, no significant gender differences in frequency of health insurance, physician visits, or ever having had spirometry were detected. In adjusted models (1) women were more likely to report COPD diagnostic delay (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.13-2.45, p=0.01), although anxiety (OR 1.83, 95% CI 1.10-3.06, p=0.02) and history of exacerbations (OR 1.60, 95% CI 1.08-2.37, p=0.01) were also significant predictors, (2) female gender was associated with difficulty reaching one's physician (OR 2.54, 95% CI 1.33-4.86, p=0.004), as was prior history of exacerbations (OR 2.25, 95% CI 1.21-4.20, p=0.01), and (3) female gender (OR 2.15, 95% CI 1.10-4.21, p=0.02) was the only significant predictor for finding time spent with their physician as insufficient.
Conclusions
Significant gender-related differences in the perception of COPD healthcare delivery exist, revealing an opportunity to better understand what influences these attitudes and to improve care for both men and women.
doi:10.1089/jwh.2012.3650
PMCID: PMC3518541  PMID: 23210491

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