Journal of Women's Health

After publication of the Women's Health Initiative study in 2002, use of menopausal hormone therapy (HT) has declined by nearly 80% worldwide and internists now play only a limited role in menopause management. Over the past decade, new data have increased our knowledge of the multiple effects and mechanisms of HT.

Existing literature was reviewed.

A consensus has emerged that the benefits of HT outweigh the risks for the relief of symptoms in women who have recently undergone menopause and are not at excess risk of breast cancer and cardiovascular disease. Non-hormonal agents, selective estrogen receptor modulators (SERMs), and tibolone are also useful in management. Factors entering into the decision-making process regarding menopause management are increasingly complex and involve consideration of effects on multiple systems and potential disease-related events. These considerations suggest that internists trained to evaluate and integrate factors influencing multiple organ systems should re-engage in menopause management. Most internists currently lack the core competencies and experience necessary to address menopausal issues and meet the needs of women who have completed their reproductive years. We believe that this situation is detrimental to women's health, leads to fragmented care, and should change.

We propose that the multidimensional expertise that characterizes the internist may provide the most comprehensive approach to menopause management. For the internist to meet this need, a set of core competencies must be attained, which will require new didactic programs to be developed for medical students, residents and practicing physicians.

Tobacco use is a major risk factor for cardiovascular disease (CVD) and is the leading preventable cause of death, disease, and disability in the United States. The CDC's Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) program addresses the heart health of low-income under- or uninsured women between the ages of 40 and 64 years. This article discusses WISEWOMAN's key approaches to smoking cessation and their impact on WISEWOMAN participants' cardiovascular health.

A longitudinal retrospective analysis was conducted using data from 21 funded CDC programs from July 2008 to June 2013. Data were collected on 149,767 women to assess CVD risk, smoking status, and utilization of programs related to tobacco cessation.

The overall prevalence of smoking among the WISEWOMAN population during this period was 28%. Increases in referrals to tobacco quitlines, tobacco-cessation counseling, lifestyle interventions, and other community-based tobacco-cessation programs contributed to a 15% smoking-cessation rate among smokers who returned for a rescreening assessment over the 5-year program period.

The WISEWOMAN program has observed a smoking-cessation rate of 15% over the 5-year program period. WISEWOMAN's key approaches include continuous technical assistance that highlights quitline referrals, motivational interviewing done by program staff, and professional-development strategies for WISEWOMAN healthcare providers. WISEWOMAN will continue its programmatic emphasis on smoking cessation by partnering with state tobacco-cessation programs to work toward a lower smoking-prevalence rate among program participants.

Several reports suggest that stroke incidence is gradually declining, possibly owing to improvements in primary and secondary prevention. The objective of our study was to assess whether the trends of stroke hospitalization rates, common risk factors, and in-hospital outcomes affected both males and females similarly.

A retrospective review was made of discharge letters of acute ischemic stroke hospitalizations during 1988, 1996, and 2006 in a tertiary referral hospital. Data regarding demographics, common risk factors, and the in-hospital outcomes were collected.

A total of 1,287 cases were recorded (mean age 68.7±11.8 years, 53.3% males). The annual age-adjusted rates of stroke hospitalizations per 1,000 persons in 1988, 1996, and 2006 were 2.31, 1.64, and 1.64, respectively (p<0.001). The age-adjusted rates decreased in males (3.0, 1.77, and 1.67; p<0.001); there was no significant trend among females (1.68, 1.53, and 1.62; p=0.864). The positive trends of age-adjusted rates of hypertension and dyslipidemia were significantly steeper in females than in males. No significant difference in the trends of adjusted in-hospital mortality rates between the sexes was found. Significant decline in the length of stay was demonstrated for both sexes, with no significant difference in the measure of decline between the groups.

Stroke hospitalization rates decreased for men but not for women. Regardless of whether the discordance in stroke-incidence trends between males and females was caused by biological factors (different risk factor profile) or disparities in healthcare provision, it seems that the challenge of stroke prevention in the next decade is in lowering the risk of stroke in females.

Migraine headaches are a significant problem for American women with many of them suffering from headaches around the time of their menstrual cycle. Women taking oral contraceptives in the standard 21/7 cycle regimen often suffer from headaches around the time of the hormone free intervals (HFIs) as well. Extended oral contraceptive regimens have been shown to decrease the frequency, but not eliminate these headaches. This study is a double-blind, randomized, placebo-controlled pilot study of participants with menstrual-related migraines (MRMs) who were initiated on extended combined oral contraceptives and given frovatriptan prophylactically during HFIs.

Participants having spontaneous menstrual cycles or taking daily combined oral contraceptives in a 21/7 regimen with MRMs were placed on a contraceptive containing levonorgestrel and ethinyl estradiol. Analyses compared headache scores during pre-study baseline cycles to those in a 168-day extended regimen with placebo versus frovatriptan treatments during HFIs.

Daily headache scores decreased (p=0.034) from 1.29±0.10 during pre-study cycles to 1.10±0.14 during extended combined oral contraceptive use. Frovatriptan blocked the increase in headache score over the placebo during HFIs. However, following the withdrawal of frovatriptan, headache scores increased (p>0.01) despite resuming combined oral contraceptive use.

Extended combined oral contraceptive regimen reduces MRM severity. Frovatriptan prevents headaches during HFIs, but is associated with new headache symptoms when withdrawn.

Awareness of the contributions of thrombophilia to thrombosis-related morbidity and mortality has been growing in the last few decades. Thrombophilia is especially concerning in females seeking contraception because some types of hormonal contraception have been associated with venous thromboembolism (VTE). Clinicians face a growing need for awareness of evidence-based contraception selection for this population.

PubMed literature searches were conducted to provide a review of the literature describing contraceptive use in patients with thrombophilia. This review also describes contraceptive selection and counseling for this population.

Studies of combined hormonal contraceptive (CHC) use demonstrate a 2- to 50-fold increase in VTE in individuals with thrombophilia, depending on the type of thrombophilia and the reference group identified. Two small studies describing VTE incidence in progesterone-only contraceptive (POC) users with thrombophilia were identified but they did not provide conclusive information regarding VTE risk in this population.

POC may be recommended for contraception in patients with most thrombophilias, but studies should be undertaken to further define the safety of POC use in this population.

Our study assessed the follow-up of gestational diabetes mellitus (GDM) in the postpartum period among a racially and ethnically diverse group of women receiving care in a major urban medical center.

We conducted cross-sectional analysis of clinical and administrative data on women aged 18–44 years who gave birth at Boston Medical Center (BMC) between 2003 and 2009, had GDM, and used BMC for regular care. We calculated the rate of glucose testing by 70 days and by 180 days after delivery and used logistic regression to assess the predictors of testing.

By 6 months postpartum, only 23.4% of GDM-affected women received any kind of glucose test. Among these, over half had been completed by 10 weeks but only 29% were the recommended oral glucose tolerance test (OGTT). After accounting for sociodemographic and health service factors, women aged ≤35 years of age and women with a family practice provider were significantly less likely to be tested than their counterparts (odds ratio [OR] 0.51; 95% confidence interval [CI] 0.32, 0.83 and OR 0.36; 95% CI 0.19, 0.71 respectively). Women who attended a primary care visit within 180 days after birth had three times higher odds of being tested than those without such a visit (OR 3.10; 95% CI 1.97, 4.87).

Despite widely disseminated clinical guidelines, postpartum glucose testing rates are exceedingly low, marking a critical missed opportunity to launch preventive care for women at high risk of type 2 DM. Failed follow-up of GDM by providers of prenatal and postpartum care also reflects a broader systems failure: the absence of a well-supported transition from pregnancy care to ongoing primary care for women.

Racial disparities in breast cancer treatment among Medicare beneficiaries have been documented. This study aimed to determine whether racial disparities exist among white and black female Medicare beneficiaries in Alabama, an economically disadvantaged U.S. state.

From a linked dataset of breast cancer cases from the Alabama Statewide Cancer Registry and fee-for-service claims from Medicare, we identified 2,097 white and black females, aged 66 years and older, who were diagnosed with stages 1–3 breast cancer from January 1, 2000, to December 31, 2002. Generalized estimating equation (GEE) models were used to determine whether there were racial differences in initiating and completing National Comprehensive Cancer Network Clinical Practice guideline-specific treatment.

Sixty-two percent of whites and 64.7% of blacks had mastectomy (p=0.27); 34.6% of whites and 30.2% of blacks had breast conserving surgery (BCS) (p=0.12). Among those who had BCS, 76.8% of whites and 83.3% of blacks started adjuvant radiation therapy (p=0.33) and they equally completed adjuvant radiation therapy (p=0.29). For women with tumors over 1 centimeter, whites and blacks were equally likely to start (16.1% of whites and 18.3% of black; p=0.34) and complete (50.6% of whites and 46.3% of black; p=0.87) adjuvant chemotherapy. There were still no differences after adjusting for confounders using GEE. However, differences were observed by area-level socioeconomic status (SES), with lower SES residents more likely to receive a mastectomy (odds ratio [OR]=1.26; 95% confidence interval [CI]: 1.01–1.57) and initiate radiation after BCS (OR=2.24; 95% CI: 1.28–3.93).

No racial differences were found in guideline-specific breast cancer treatment or treatment completion, but there were differences by SES. Future studies should explore reasons for SES differences and whether similar results hold in other economically disadvantaged U.S. states.

The purpose of this study was to examine the association between menarcheal age and subsequent sexual partnering in women aged 21–44 years.

Data from the 2006–2010 National Survey of Family Growth were used (n=7,962). Menarcheal age was defined as ≤11, 12–14, or ≥15 years. Sexual partnering was defined as being concurrent, serially monogamous or monogamous in the previous year. Polytomous logistic regression models evaluated the association between age of menarche and sexual partnering.

Nearly 6% reported concurrent partnerships and ∼4% serial monogamy. Age of menarche was not associated with subsequent concurrent sexual partnering (adjusted odds ratio relative to ≥18 years [aOR_≤11]: 1.09; 95% confidence interval [CI]: 0.57–2.09; aOR_12–14: 1.13; 95% CI: 0.64–1.99) or serial monogamy (aOR_≤11: 0.75; 95% CI: 0.41–1.38; aOR_12–14: 0.71; 95% CI: 0.39–1.29).

Early menarche is not a risk factor for sexual partnering in adulthood. However, menarche provides an opportunity for education to aid young women to make decisions regarding sexual debut and sexual partnering that are healthy for them.

Cardiovascular disease (CVD) is the leading cause of death in women, yet significant health disparities exist for high-risk groups, including Latinas, and comprehensive, culturally relevant, and effective prevention intervention models are lacking. We used a systems approach to develop, assess, and pilot a community-based education program for improving outcomes for knowledge/awareness of CVD, cardiometabolic risk, and health behaviors in Latinas.

Latinas (n=35, mean age 50) participated in a 4-month community-based bilingual preventive cardiovascular education program. Pre/post analyses were for knowledge/awareness of CVD risk factors, symptoms, calling 911; personal risk factors (smoking, physical inactivity, family history of CVD); clinical parameters (weight, body mass index [BMI], waist, blood pressure, fasting lipids, and glucose); diagnosis of metabolic syndrome (MetS); and serum inflammatory markers (tumor necrosis factor [TNF]-α, high-sensitivity C reactive protein [hsCRP], and interleukin [IL]-12).

Baseline knowledge/awareness was relatively low, risk factors and MetS prevalent, and serum inflammatory markers elevated. Postintervention, participants demonstrated significant (p<0.05) improvements in knowledge of symptoms, risk factors for CVD, calling 911, and knowledge/adoption of heart-healthy behaviors. Clinical health status also improved, especially for serum triglycerides (p<0.05; 21% decline), prevalence of MetS (from 43% to 37% of participants), and serum levels of the proinflammatory TNF-α (from 16.9±1.11 pg/mL to 13.5±0.8 pg/mL, p<0.05).

A bilingual culturally appropriate community-based CVD-prevention program based on health education, medical screenings, and empowerment is a successful, effective, adaptable, and replicable model to significantly improve cardiometabolic risk in Latinas.

Rates of sexually transmitted infections (STIs) and unplanned pregnancy are high in Kenya, and limited reproductive health education exists in schools.

We designed and implemented a 6-week reproductive health curriculum in Laikipia District, Kenya, in 2011, which included didactic sessions, educational games, and open discussions. We applied a mixed quantitative and qualitative methods to evaluate this curriculum including a comprehensive 35-item survey to assess pre- and post-training knowledge, attitudes, and practices of female teenagers regarding STIs/HIV and family planning using paired t-test as well as complementary focus groups (n=42) and individual interviews (n=20).

Average age for 42 female teenagers was 16.5 (±1.31) years. Pre-test questionnaires revealed lack of knowledge about different types of STIs, specifically chlamydia, but adequate knowledge of basic contraception including abstinence and condom use. By the conclusion of the study, we observed improvement in following educational domains: general knowledge of HIV/AIDS (85%±7.5% to 94%±5.6%) (p<0.001); general knowledge of teen pregnancy and STIs (57%±19% to 82%±13%) (p<0.001); and overall scores of knowledge, attitude, and self-efficacy (81%±6.6% to 90%±5%) (p<0.001). Focus group discussions, however, revealed persistent misconceptions and knowledge gaps with themes regarding HIV transmission risk factors, perceived difficulty negotiating condom use, masturbation and its perceived consequences, and issues surrounding female circumcision.

Important misconceptions and gaps in reproductive practices were identified and addressed using a mixed methods approach. Despite prior basic knowledge and positive attitudes on STI prevention and family planning, complementary teaching approaches were instrumental in improving overall knowledge of STIs other than HIV as well as family planning. The curriculum was feasible, well received, and achieved its educational goals.