Kate M. Brett

Breast and Cervical Cancer Screening: Sociodemographic Predictors Among White, Black, and Hispanic Women

OBJECTIVES We evaluated the relationship between breast and cervical cancer screening and a variety of variables across race/ethnicity groups. METHODS Using logistic regression models, we analyzed data from the 1998 National Health Interview Survey to assess the relative importance of the independent variables in predicting use of cancer screening services. RESULTS Having a usual source of care was the most important predictor of cancer screening use for all race/ethnicity groups. Health insurance was associated with an increased likelihood of cancer screening. Smoking was associated with a decreased likelihood of cancer screening. CONCLUSIONS Regardless of race/ethnicity, most women follow mammography and cervical cancer screening guidelines. The identification of specific factors associated with adherence to cancer screening guidelines may help inform screening campaigns.

Visits to emergency departments for gynecologic disorders in the United States, 1992-1994.

Objective To assess rates of visits to emergency departments for gynecologic disorders among women of reproductive age in the United States. Methods Data from the National Hospital Ambulatory Medical Care Survey for 1992-1994 were analyzed to determine rates of visits to emergency departments among women, ages 15-44 years. Average annual rates per 1000 women were calculated using age, race, and region-specific population estimates. Rate ratios were used to compare rates among subgroups. Results Approximately 1.4 million gynecologic visits were made to emergency departments annually, for an average annual rate of 24.3 visits per 1000 women, ages 15–44 years (95% confidence interval [CI] 22.0, 26.6). The most frequent diagnoses were pelvic inflammatory disease (average annual rate 5.8, 95% CI 5.0, 6.6), lower genital tract infections including sexually transmitted diseases (average annual rate 5.7, 95% CI 4.8, 6.6), and menstrual disorders (average annual rate 2.9, 95% CI 2.3, 3.5). Nearly half of all gynecologic visits resulted in diagnoses of genital tract infections. Younger women (ages 15–24 years) were 2.3 (95% CI 2.0, 2.6) times as likely as older women (ages 25–44 years), and black women were 3.6 (95% CI 2.9, 4.3) times as likely as white women, to visit emergency departments for gynecologic disorders. Rate ratios for genital tract infections were 10–20 times higher for younger black women than for older, white women. Conclusion Almost half of gynecologic visits to emergency departments were related to genital tract infections, which largely are preventable.

Changes in U.S. prescribing patterns of menopausal hormone therapy, 2001-2003

OBJECTIVE: In 2002, the combination estrogen–progestin hormone therapy (HT) treatment arm of the Women’s Health Initiative was terminated early because cardiovascular and cancer risks were identified, while the estrogen-only therapy (ET) arm of this trial continued. We investigated hormone therapy prescription practice changes between 2001 and 2003 to explore the effects of the clinical trial results. METHODS: Data were obtained from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey for the years 2001 through 2003. These nationally representative surveys sample medical encounters in nonfederally employed physician’s offices and outpatient departments of nonfederal short-stay and general hospitals. The proportion and rate of visits with ET and HT prescriptions were calculated. Logistic regression was used to estimate change over time accounting for patient and provider characteristics. RESULTS: Between 2001 and 2003, the number of visits with menopausal hormone prescriptions fell from 26.5 million to 16.9 million. Almost three-quarters of hormone visits were for ET prescriptions. The decrease in the rate of visits was slightly larger for HT prescription visits (44%) than ET prescription visits (35%). The rate of decline was highest among women 50 years of age and over. After controlling for covariates, there was no significant difference in the decline by hormone type. CONCLUSION: These nationally representative data indicate substantial declines in menopausal hormone prescriptions coinciding with clinical trial results on HT. These declines occurred among all types of therapy and patient characteristics. LEVEL OF EVIDENCE: II-3

Associations with menopause and menopausal transition in a nationally representative US sample

OBJECTIVES The purpose of this study was to assess sociodemographic and behavioral factors in relation to menopausal status in a representative sample of the United States population. METHODS Data were taken from the 1999 National Health Interview Survey (NHIS), limited to women aged 40-54 years who had not undergone surgical menopause. Menopausal transition was defined as absence of menstrual cycles for at least 3 but no more than 11 months or cycles that had become irregular in the past 12 months. Postmenopause was defined as absence of a menstrual cycle for 12 or more months. We used age-adjusted three-level logistic regression to examine the association between menopausal status and smoking, race/ethnicity, education, body mass index, exercise, and alcohol use. RESULTS Twenty percent of women in this sample had experienced natural menopause, 18% were in the menopausal transition and 61% were premenopausal. Using premenopause as the reference group, current cigarette smoking was strongly associated with being postmenopausal (odds ratio (OR) 2.2, 95% confidence interval (CI) 1.7, 3.0) and weakly associated with being in the menopausal transition (OR 1.4, 95% CI 1.1, 1.8). Education level was associated with being postmenopausal (OR 0.4, 95% CI 0.3, 0.6 comparing women with a college degree to women who had not completed high school), and alcohol use was weakly associated with being postmenopausal, with no evidence of a dose-response. CONCLUSIONS The associations with smoking were stronger for postmenopause than for the transition phase, suggesting that the effect of smoking may be to shorten the transition period. Education level may be a marker for other exposures that affect ovarian senescence.

Long-term survival after coronary heart disease. Comparisons between men and women in a national sample.

This study examined the sex differential in long-term survival after incident coronary heart disease (CHD) in the Epidemiologic Followup Study to the First National Health and Nutrition Examination Survey. This cohort was first contacted in 1971 to 1975 with follow-up through 1987. Of the 1407 white participants for whom CHD was identified at some point during the study, 56% of men and 46% of women died during the follow-up period. After adjustment for age at incidence, traditional heart disease risk factors, and initial coronary disease diagnosis, the relative risk of death among women compared to men was 0.70. Womens survival advantage after myocardial infarction was 0.81. Women who had ever taken post-menopausal estrogens were most likely to survive after CHD or myocardial infarction compared to men (relative risks [RRs] = 0.42 and 0.57, respectively), although women who did not take estrogen were also significantly more likely than men to survive after CHD (RR = 0.79) but not after myocardial infarction (RR = 0.88).

Complementary and alternative medicine use among midlife women for reasons including menopause in the United States: 2002

Objective: The use of complementary and alternative medicine (CAM) has been examined previously for midlife women only in regional studies. The purpose of this study was to obtain national estimates of CAM use. Design: Data were obtained from the 2002 National Health Interview Survey, which included a CAM supplementary questionnaire. The response rate was 74%. The analysis included 3,621 female respondents between 45 and 57 years of age who had answered all of the relevant questions. SUDAAN software was used to account for the complex sampling design. Results: Forty-five percent of women 45 to 57 years of age had used some form of CAM within the last 12 months. Approximately 25% used biologics (e.g., herbs) or mind-body (e.g., biofeedback) modalities, whereas only 15% used body work (massage and chiropractic medicine). Use did not vary by age, but white race, higher education, and residence in the West were associated with increased use. Only 45% of CAM users mentioned its use to a medical provider. The most cited reason for using CAM involved treatment of pain, with only 3% mentioning menopause. However, the odds for use of CAM were almost twice as high for women with menopausal symptoms in the past year compared with women with no symptoms (odds ratio: 1.9, 95% CI: 1.6-2.2). Conclusions: CAM use among midlife U.S. women is high, although CAM is not used specifically for menopausal concerns. These data will be useful as a benchmark of the use of CAM as use of conventional menopause therapies are influenced by the Womens Health Initiative results.

Hysterectomy Prevalence by Hispanic Ethnicity: Evidence From a National Survey

OBJECTIVES We investigated hysterectomy prevalence among Hispanic women. METHODS We obtained data from 4684 Hispanic women and 20 604 non-Hispanic White women from the 1998-1999 National Health Interview Survey. We calculated nationally representative odds ratios of previous hysterectomy, controlling for confounders. RESULTS Compared with non-Hispanic White women, the odds ratio for hysterectomy was 0.36 (95% confidence interval [CI] = 0.30, 0.44) for Hispanic women with no high school diploma, 0.57 (95% CI = 0.44, 0.74) for high school graduates, and 0.67 (95% CI = 0.42, 0.87) for college attenders. Country of origin had little influence on hysterectomy prevalence. Hysterectomy was positively associated with acculturation. CONCLUSIONS Hispanic women undergo fewer hysterectomies than do non-Hispanic White women. The reasons for this, as well as information on ethnicity-specific appropriateness of hysterectomy, should be explored.

Hormone replacement therapy and breast cancer risk in a nationally representative cohort

BACKGROUND The relative risk of breast cancer associated with the use of postmenopausal hormone replacement therapy (HRT) continues to be debated. We used a nationally representative cohort to study the issue. METHODS This analysis utilized data from the NHANES I Epidemiologic Follow-up Study. Subjects were interviewed in 1971 through 1974 and four waves of follow-up interviews were conducted through 1992. Survival analysis of 5,761 postmenopausal women provided estimates of the relative risk of breast cancer in users of HRT when compared with non-users, controlling for potential confounders. RESULTS There were 219 incident cases of breast cancer in 73,253 person-years of follow-up. The incidence rate was 326 per 100,000 person-years in women who had never used HRT and 255 per 100,000 in women who had ever used HRT. There was no statistically significant association between the HRT use and subsequent development of breast cancer: relative risk (RR) = 0.8, 95% confidence interval 0.6, 1.1. There was no trend in RR by length of HRT use: less than 3 years HRT use, RR = 0.9; 3 to 9 years , RR = 0.5; 10 or more years, RR = 0.8. CONCLUSIONS This study, based on a nationally representative cohort followed for up to 22 years, failed to find an increased risk of breast cancer associated with the use of HRT. It provides further evidence that if there is an increased risk of breast cancer associated with HRT use, this risk is small.

Differences in Use of Postmenopausal Hormone Replacement Therapy by Black and White Women

The purpose of this study is to investigate differential use of hormone replacement therapy (HRT) by race after controlling for family income and education. Data from the Epidemiologic Followup to the First National Health and Nutrition Examination Survey (NHEFS), a nationally representative cohort followed from the mid-1970s until 1992, were analyzed to address this question. Included in the analysis are women who became menopausal during the year of their baseline examination or during follow-up, had answered questions about their HRT use, and were either black or white. After controlling for education, body mass index, and history of bilateral oophorectomy or hysterectomy, black women were 60% less likely to have ever taken HRT than white women (odds ratio [OR] = 0.41, 95% confidence interval [CI] = 0.30–0.55). Furthermore, even among the women who did take HRT at some point, black women were less than half as likely as white women to have continued use of the therapy for five or more years (OR = 0.44. 95% CI = 0.29–0.68). These data suggest that black women, regardless of educational level, are less likely to use HRT, and those that do are less likely to continue long enough to affect their probability of these diseases.

Racial differences in hormone replacement therapy prescriptions.

OBJECTIVE To examine racial differences in hormone replacement therapy (HRT) use by analyzing the relative risks and rates of HRT prescriptions for black and white women. METHODS Data on visits to hospital outpatient departments and office-based physicians by black and white women aged 45-64 years were obtained from 25,203 visits sampled in the 1993-1995 National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Surveys. The relative effect of race on the provision of an HRT prescription at an ambulatory visit was estimated by controlling confounders using logistic regression. Population-based rates of physician visits and visits with HRT prescriptions were also calculated to address issues involving access to care. RESULTS Approximately 98,787,000 annual visits were made by black and white women 45-64 years of age, 9.2% of which involved prescriptions for HRT. The percentage of visits by black women in which prescriptions for HRT were reported (4.5%) was roughly half that of white women (9.7%). The association persisted after controlling for type of physician, practice type, geographic region, payment source, and non-HRT prescription(s) (odds ratio 2.1; 95% confidence interval 1.5, 2.9). The rate of ambulatory care among black women (3.82 visits per year per woman) was virtually identical to that of white women (3.94 visits per year), whereas the rate of visits with HRT prescriptions for white women was twice as high as for black women (0.38 and 0.17 visits per year, respectively). CONCLUSION Apparent racial differences in HRT use persist after controlling for physician and visit factors not explored in previous studies.