Journal of Women's Health

Using data from HIV Prevention Trials Network 064, a multisite, observational cohort study conducted to estimate HIV incidence rates among women living in areas of high poverty and HIV prevalence in the United States, we examined the use of HIV risk characteristics to predict emotional abuse, physical violence, and forced sex.

Participants included 2099 women, 18–44 years of age, who reported unprotected vaginal or anal sex with a male partner and an additional personal or perceived male partner HIV risk characteristic in the past 6 months. Adjusting for time-varying covariates, generalized estimating equations were used to assess the ability of HIV risk characteristics to predict violence 6 months later.

Reported analyses were limited to the 1980 study participants who reported having a male sex partner at that assessment. Exchanging sex, perceived partner concurrency, and perceived partner incarceration were significantly predictive of emotional abuse 6 months later (adjusted odds ratio [AOR]: 1.60; 1.59; 1.34, respectively). Prior sexually transmitted infection diagnosis, exchanging sex, and binge drinking were significantly predictive of physical violence 6 months later (AOR: 1.62; 1.71; 1.47, respectively). None of the variables measured was significantly predictive of forced sex.

Strategies that address reducing violence against women should be studied further in the context of HIV prevention programs.

Elevated cardiac troponin (cTn), with signs/symptoms of ischemia, is a key element in a diagnosis of myocardial infarction (MI). Underdiagnosis of MI in women has been attributed to atypical symptoms, inconsistent ECG findings, and less diagnostic testing. We sought to determine if there are sex differences in cTn testing following presentation to the emergency department (ED) with a chief complaint of ischemic chest pain (CP) and if presentation affects diagnostic assessment.

All adults presenting to six hospital EDs in the Vancouver, Canada with a chief complaint of ischemic CP from 2009 to 2013 were included. The highest cTn level within 24 hours of ED presentation was used. CP was classified into cardiac- or respiratory dominant based on standard Canadian Emergency Department Triage and Acuity Scale coding. Chi-square testing was used to test for sex differences in CP categories and cTn testing within 24 hours. Logistic regression models were used to examine the association between sex, cTn testing, and CP categories.

Of 27,063 patients with ischemic CP, cardiac presentation was more common in men than women, irrespective of age. Among cardiac CP, 24.7% of men were <50 years compared to 18.2% of women; however, more women (19.9%) than men (11.6%) were >80 years. Overall, women were 1.8% less likely to have cTn testing; in patients <50 years, testing was markedly lower in women compared to men [odds ratio, OR (95% confidence intervals, CI) 0.78 (0.70–0.87)]. The odds of cardiac catheterization within 90 days of ED presentation were lower in women [OR, (95% CI) 0.52 (0.44–0.63)]. Even with cardiac CP, 17.7% of women versus 32.7% of men had cardiac catheterization.

In men and women presenting to the ED with ischemic CP, cTn testing overall is similar except among young women under 50 years old, where it is markedly lower. Women undergo less cardiac catheterization, irrespective of CP type.

Routine ovarian cancer screening is ineffective; therefore, no professional organization recommends this screening in asymptomatic patients. However, many physicians have recommended screening, exposing patients to unnecessary risk. Little research exists on how nonprofessional experience with cancer influences physicians' screening practices. This study examines the association between physicians' nonprofessional experience with cancer and reported adherence to ovarian cancer screening guidelines.

A mail questionnaire with an annual examination vignette and questions about cancer screening recommendations was sent to a random sample of 3,200 U.S. family physicians, general internists, and obstetrician-gynecologists. This analysis included 497 physicians who received a vignette of a woman at average ovarian cancer risk and weighted results to represent these physician groups nationally. The outcome measure was adherence to ovarian cancer screening guidelines. Stepwise multivariate logistic regression estimated adjusted risk ratios for guideline adherence.

In unadjusted analyses, 86.0% of physicians without nonprofessional cancer experience reported adherence to ovarian cancer screening guidelines compared with 69.2% of physicians with their own history of cancer, or a family member or close friend/coworker with cancer (p = 0.0045). In adjusted analyses, physicians with cancer themselves or in a family member or close friend/coworker were 0.82 times less likely (CI: 0.73–0.92) to report adhering to ovarian cancer screening recommendations than those without nonprofessional cancer experience.

Despite recommendations to the contrary, many physicians reported recommending ovarian cancer screening in low-risk women. Physicians with nonprofessional cancer experience were more likely to report offering or ordering nonrecommended screening than physicians without this experience.

Prior studies have shown that sex bias exists with subject enrollment in clinical trials, with more men being enrolled than women. The objective of this study was to identify if sex bias continues to exist in present day clinical trials entered into ClinicalTrials.gov. We hypothesize that males and females are not equally represented in recent clinical trials.

Data were abstracted from all interventional Phase I, II, and III clinical trials with adult subjects entered into ClinicalTrials.gov from January 1, 2011 to December 31, 2013 and completed by November 30, 2015. Number and sex of subjects, funding source, allocation, end point classification, interventional model, and purpose were recorded. Studies pertaining to diseases that were sex specific were excluded.

Of 1,668 studies included in the initial search, 167 were excluded due to sex-specific study topic. Of the remaining 1,501 studies, 177,656 (51.1%) male and 170,331 (49.0%) female subjects were included. There was a significant difference in the sex of the subjects included in Phase I (64.1% male/35.9% female), Phase II (48.4% male/51.6% female), and Phase III (51.0% male/49.1% female) clinical trials (p < 0.05). Similarly, there was a significant difference in the sex of the subjects included in industry (50.7% male/49.3% female), National Institutes of Health (NIH) (56.6% male/43.4% female), “Other US Federal” (62.5% male/37.5% female), and “Other” funded (53.4% male/46.6% female) clinical trials (p < 0.0001), as well as between randomized (50.5% male/49.6% female) and nonrandomized (54.8% male/45.2% female) clinical trials (p < 0.0001). Upon evaluating if the sex of the subjects included in the individual clinical trials was equally matched, we found that only 4.1% of clinical trials had 100% sex matching, 22.2% had 80% sex matching, and 56.5% had 50% sex matching. Using a liberal 50% sex-matching criteria, Phase III and II clinical trials matched the sex of the subjects more frequently compared to Phase I trials (60.8%, 57.8%, and 45.5%, respectively, p = 0.003).

These data reveal that sex bias is present in current day clinical trials. Despite legislation requiring NIH-funded clinical trials to include women, NIH-funded trials were not better than industry-funded trials at matching the inclusion of both sexes.

Human papillomavirus (HPV) vaccination, which is recommended for U.S. women and girls aged 11–26 years, effectively prevents cervical cancer. Researchers have identified HPV vaccination disparities among groups of women and girls defined in relation to sexual orientation identity or race/ethnicity. However, no study has used an intersectional approach to ascertain HPV vaccine uptake among sexual orientation identity and racial/ethnic subgroups of U.S. women and girls.

Using 2011–2015 National Survey of Family Growth data, we used multivariable logistic regression to estimate differences in the odds of HPV vaccination initiation (i.e., ≥ one dose) across sexual orientation identity and racial/ethnic subgroups of black and white U.S. women aged 15–24 years (N = 2,413), adjusting for demographic factors. We also assessed whether socioeconomic and health care factors helped explain observed disparities.

The overall prevalence of HPV vaccination initiation was 47.7%. Compared to white heterosexual women, black lesbians (odds ratio [OR] = 0.16; 95% confidence interval [95% CI]: 0.06–0.46) had the lowest adjusted odds of HPV vaccination initiation, followed by white lesbians (OR = 0.33; 95% CI: 0.13–0.82) and black heterosexual women (OR = 0.63; 0.47–0.85). Including socioeconomic factors in the model only slightly attenuated the HPV vaccination initiation odds ratios for black lesbians (OR = 0.19; 95% CI: 0.06–0.56), white lesbians (OR = 0.37; 95% CI: 0.15–0.90), and black heterosexual women (OR = 0.70; 95% CI: 0.52–0.93) compared to white heterosexual women. Adding health care factors only slightly additionally attenuated the odds ratio comparing black lesbians and white heterosexual women (OR = 0.21; 95% CI: 0.07–0.67).

Our findings identified black lesbians as a particularly underserved subgroup and suggest that sexual orientation identity and race/ethnicity may have a compounding effect on HPV vaccination initiation among black and white U.S. women and girls. Evidence-based interventions that are adapted to the specific needs and experiences of black lesbians and other multiply marginalized groups are needed to promote equity in HPV-related outcomes.

Most women will experience uterine fibroids by the age of 50, yet few data exist describing the overall patient experience with fibroids. The objective of this population-based survey was to characterize symptom burden, patient awareness, and treatment decision-making for fibroids, including a comparison among women of varying backgrounds.

Women (≥18 years) were recruited via email from GfK KnowledgePanel^®, a representative panel of US households, or identified with opt-in consumer panels. The Uterine Fibroid Symptom and Health-Related Quality of Life (UFS-QOL) questionnaire and Aberdeen Menorrhagia Severity Scale (AMSS) were included.

Eligible women were grouped into three cohorts: “at-risk” (symptoms suggestive of fibroids without clinical diagnosis, n = 300), “diagnosed” (n = 871), and fibroid-related “hysterectomy” (n = 272). Cohort and intracohort race/ethnicity and income analyses revealed differences in symptom burden, awareness/perception, and treatment history. Based on UFS-QOL scores, at-risk women reported significantly greater symptom severity and decreased health-related QOL versus diagnosed women; Hispanic women reported greater symptom severity versus white and black women. At-risk women also reported heavy menstrual bleeding and significant impact on work productivity. Among diagnosed women, 71% used pharmacologic therapy for symptom relief, and 30% underwent surgical or procedural treatment. Initial discussions with healthcare providers significantly impacted treatment outcomes; the hysterectomy cohort was most likely to first discuss hysterectomy.

Women with fibroids or symptoms suggestive of fibroids experience significant distress that reduces QOL, particularly racial minorities and women in lower income brackets. Survey results suggest that many women are likely undiagnosed, underscoring the need for improved awareness and education.

Alzheimer's disease (AD) is characterized by progressive cognitive decline, often associated with Behavioral and Psychological Symptoms of Dementia (BPSD). Acetylcholinesterase inhibitors (ChEi) may attenuate cognitive decline and mitigate BPSD. The EVOLUTION group found that the switch from oral ChEi to transdermal rivastigmine patch formulation resulted in improvement/stabilization in the frequency of clinically relevant BPSD, but gender-specific subgroup analyses were not reported.

Participants underwent Neuropsychiatric Inventory to assess the frequency and severity of neuropsychiatric symptoms at baseline and 3 and 6 months after the switch from oral ChEi to transdermal rivastigmine patch. A descriptive post hoc analysis was conducted to assess whether there were gender-based differences in BPSD profile during the 6 months after the switch.

The entire sample consisted of 475 patients, 274 women and 201 men. Women were on average slightly older and with poorer cognitive performance (60.6% of the women had moderate-AD, defined as Mini-Mental State Examination [MMSE] score of 10–17, vs. 43.8% of men). In mild-AD patients (MMSE score 18–26), the frequency of BPSD did not change significantly over time and an association was found between gender and depression (odds ratio; OR [95% confidence interval; CI] female vs. male = 3.32 [1.44–7.67]), anxiety (2.42 [1.23–4.79]), apathy (2.25 [1.07–4.70]), nighttime behavior disturbances (3.97 [1.66–9.49]), and appetite/eating abnormalities (2.39 [1.10–5.18]). Moderate-AD female patients had euphoria more frequently than male patients (OR [95% CI] female vs. male = 3.67 [1.25–10.74]). The frequency of delusions, anxiety, and irritability decreased during the first 3 months after the switch, independently of gender.

Mild-AD women tended to suffer more frequently from BPSD than men; in the 3 months after treatment switch, moderate-AD patients showed a decrease in delusions, anxiety, and irritability, with no significant differences between genders. Ad hoc studies to investigate this potential gender effect in AD could be well worthwhile.

The purpose of this study was to evaluate the maternal outcome in women with very advanced maternal age (VAMA) at childbirth (>45 years) compared to advanced maternal age (35–39 and 40–44 years).

Retrospective cohort study using the Texas Public Use Data File, years 2013–2014. Maternal age was a three-level variable: 35–39 (referent), 40–44, and 45–59 years (VAMA). Adjusted risk ratios (aRRs) for the two older age groups for various obstetrical and nonobstetrical complications were calculated from log-binomial regression models.

The sample consisted of 96,879 deliveries. In univariate analyses, a higher frequency (p < 0.05) of gestational diabetes, pregestational diabetes, chronic hypertension, pregnancy related hypertensive disorders, multiple gestation, oligohydramnios, polyhydramnios, placenta previa, postpartum hemorrhage, small for gestational age, intrauterine fetal death, and length of stay were noted in the two older maternal age groups compared to the youngest maternal age group. Multiple gestations were noted to be more frequent in the two older groups: the VAMA group had a 336% increase in their risk (aRR = 4.36, 95% CI: 3.68–5.17), while women 40–44 years of age experienced a 17% increase in their risk (aRR = 1.17, 95% CI: 1.07–1.29) compared to women in the 35–39 year group. The risk of the following outcomes was approximately doubled in VAMA women compared to the referent (all statistically significant): small for gestational age (aRR = 1.92), stillbirth (aRR = 2.12), and intrauterine fetal death (aRR = 1.96).

This population-based study detected a dose–response association between maternal age and the risk of multiple maternal and fetal complications.

There is a well-documented link between eating disorders (EDs) and adverse health outcomes, including fertility difficulties. These findings stem largely from clinical data or samples using a clinical measure (e.g., diagnosis) of EDs, which may limit our understanding of how EDs or disordered eating behaviors (DEBs) shape female fertility.

We compared reproductive outcomes from two longitudinal data sources, clinical and population-based data from the Utah Population Database (UPDB) (N = 6,046), and nonclinical community-based data from the National Longitudinal Study of Adolescent to Young Adult Health (Add Health) (N = 5,951). We examined age at first birth using Cox regression and parity using negative binomial regression.

Using the UPDB data, women with diagnosed ED experienced later ages of first birth (hazard rate ratio [HRR] = 0.38; p < 0.01) and lower parity (incidence rate ratio [IRR] = 0.38; p < 0.01) relative to women without EDs. Using the Add Health sample, women who self-reported DEB experienced earlier age of first birth (HRR = 1.16; p < 0.05) and higher parity (IRR = 1.17; p < 0.01) relative to women without DEB.

Conflicting results suggest two sets of mechanisms, physical/biological (sex specific) and social/behavioral (gender specific), may be simultaneously shaping the reproductive outcomes of women with histories of EDs or DEB. Discipline-specific methodology likely shapes Women's Health research outcomes.

Women of childbearing age (18–44 years) present an important group for understanding sleep, but few studies have focused on this population. No study has investigated the associations among sleep, overweight/obesity, and risk of type 2 diabetes among childbearing-age women in the National Health and Nutrition Examination Survey (NHANES).

Data were from NHANES, 2005–2008. The study population consisted of 18–44 year old women. Pregnant women and those diagnosed with sleep disorders were excluded. Sleep duration and quality were self-reported. Body mass index (BMI), waist circumference (WC) measurements, and a 2-hour 75 g oral glucose tolerance test (OGTT) were performed by trained NHANES staff. An unadjusted linear regression analysis; a second adjusted for demographics only (partially adjusted model); and a third adjusted for demographics and variables associated with overweight/obesity and diabetes (fully adjusted model) were computed to assess associations among sleep duration/quality and BMI, WC, and 2-hour OGTT.

Total sample consisted of 2388 childbearing-age women. Only sleep duration was significantly associated with BMI and WC in the unadjusted and partially adjusted models, but was no longer significant in the fully adjusted model. Neither sleep duration nor quality was significantly associated with 2-hour OGTT in any of the models.

Targeting sleep duration and sleep quality alone would not likely contribute to significantly lower BMI, WC, or risk of type 2 diabetes in US childbearing-age women. Additional studies, especially longitudinal ones using objective measures of sleep, are needed to confirm these findings.

Despite high prevalence rates among women of mood disorders and of infertility, there is a paucity of systematic data to inform the treatment of women at risk for psychiatric morbidity in the context of assisted reproductive technologies (ART). The objective was to delineate predictors of depressive relapse in women with histories of mood disorders during ART, including the role of psychotropic medication continuation.

This was a prospective observational study of women undergoing ART with past diagnoses of major depressive disorder (MDD) or bipolar depression. For 6-months, follow-up included assessments of mood, perceived stress, and partner support. A subsample participated in biomarker collection. Depressive relapse was confirmed using Mini-International Neuropsychiatric Interview.

N = 38 were evaluable. Participants with MDD (N = 25) experienced a depressive relapse rate of 44.0%. Relapse rates among antidepressant maintainers (N = 15; relapse rate = 40.0%) and antidepressant discontinuers (N = 10; relapse rate = 50.0%) were not significantly different. Among participants with bipolar disorder (N = 13), the overall relapse rate was 30.8%. Among psychotropic medication maintainers (N = 10), 40.0% relapsed, and among discontinuers (N = 3), none relapsed. Scores on the Perceived Stress Scale correlated with relapse risk (odds ratio [OR] = 1.17, 95% confidence interval [CI]: 1.08–1.26, p = 0.0065). C-reactive protein was associated with relapse (OR = 1.92, 95% CI: 1.43–2.55, p < 0.0001); blood cortisol and interleukin-6 were not.

Risk of depressive relapse among women undergoing ART is considerable. Medication continuation does not adequately confer relapse prevention. Stress and inflammation appear to contribute to risk of relapse. Additional strategies to mitigate depressive relapse in at-risk women undergoing ART are needed.