Katherine E Hartmann

National Institutes of Health state-of-the-science conference statement: prevention of fecal and urinary incontinence in adults.

The ramifications of fecal incontinence and urinary incontinence extend well beyond their physical manifestations. To promote work that will reduce suffering and costs attributable to fecal and uri...

Vulvovaginal atrophy is strongly associated with female sexual dysfunction among sexually active postmenopausal women.

Objective:The relationship between vulvovaginal atrophy and female sexual dysfunction is unclear. We investigated this association among sexually active postmenopausal women. Design:The Menopause Epidemiology Study is a cross-sectional, population-based study of women 40 to 65 years old in the United States chosen from a source population selected by random digit dialing and probability sampling. We focused on sexually active postmenopausal women (N = 1,480) for our analyses. Vulvovaginal atrophy was defined as one or more of the following: vaginal dryness, itching, irritation; pain on urination; or pain or bleeding on intercourse. The Arizona Sexual Experience Survey was used to define female sexual dysfunction. Sexual dysfunction subtypes for desire, arousal, and orgasm difficulties were individually scored. We evaluated demographic, behavioral, reproductive history, and medication covariates for effect modification and confounding. Multivariate logistic regression was used to assess the relationship between vulvovaginal atrophy and female sexual dysfunction. Results:The prevalence of vulvovaginal atrophy (57%) and female sexual dysfunction (55%) was high. Women with female sexual dysfunction were 3.84 times more likely to have vulvovaginal atrophy than women without female sexual dysfunction (95% CI: 2.99-4.94). Hot flashes modified the association between vulvovaginal atrophy and desire difficulty. Educational level modified the association between vulvovaginal atrophy and arousal difficulty. Parity modified the association between vulvovaginal atrophy and orgasm difficulty. Conclusions:This large population-based study provides evidence of an association between vulvovaginal atrophy and overall female sexual dysfunction and its subtypes. Therapies aiming to reduce symptoms of one condition may also relieve symptoms of the other.

Self-Reported Heavy Bleeding Associated With Uterine Leiomyomata

OBJECTIVE To characterize the relationship between self reported bleeding symptoms and uterine leiomyoma size and location. METHODS The leiomyoma status of a randomly selected sample of women aged 35–49 in the Washington, DC, area was determined using abdominal and transvaginal ultrasound to measure size and location of leiomyomata found at screening. Women were asked about symptoms of heavy bleeding (gushing-type bleeding, long menses, pad/ tampon use) in a telephone interview. Using multivariable regression, we examined the relationships between leiomyoma characteristics and heavy bleeding symptoms among 910 premenopausal women. RESULTS Women with leiomyomata (n = 596) were more likely to report gushing-type bleeding than women without leiomyomata; risk increased with leiomyoma size. Adjusted relative risks with 95% confidence intervals (CI) for women in each leiomyoma size category compared with the reference category (women without leiomyomata) were as follows: adjusted relative risk of 1.4 (95% CI 1.1, 1.9) for diffuse only, adjusted relative risk of 1.4 (95% CI 1.1, 1.8) for small leiomyomata (less than 2 cm), adjusted relative risk of 1.6 (95% CI 1.3, 2.0) for medium leiomyomata (2–5 cm), and adjusted relative risk of 1.9 (95% CI 1.5, 2.5) for large leiomyomata (greater than 5 cm). Reported use of eight or more pads/tampons on the heaviest days of menstrual bleeding increased with leiomyoma size, with a nearly 2.5-fold risk for women with large leiomyomata compared with women without leiomyomata (adjusted relative risk of 2.4; 95% CI 1.8, 3.1). Nonsubmucosal leiomyomata were associated with essentially the same increase in heavy bleeding as submuscosal leiomyomata of similar size. CONCLUSION Small leiomyomata were associated with increased risk of heavy bleeding, and risk increased with size. Contrary to published articles, nonsubmucosal leiomyomata were associated with heavy bleeding to the same extent as submucosal leiomyomata.

Prevalence of uterine leiomyomas in the first trimester of pregnancy: An ultrasound-screening study

OBJECTIVE: To estimate the proportion of pregnant women with one or more leiomyomas detected by research-quality ultrasound screening in the first trimester, to describe the size and location of leiomyomas identified, and to report variation in prevalence by race/ethnicity. METHODS: Within an ongoing prospective cohort, we conducted 4,271 first-trimester or postmiscarriage ultrasound examinations. Sonographers measured each leiomyoma three separate times, recording the maximum diameter in three perpendicular planes each time. Sonographers and investigators classified type and location. RESULTS: Among 458 women with one or more leiomyomas (prevalence 10.7%), we identified a total of 687 leiomyomas. The mean size of the largest leiomyoma was 2.3 cm (95% confidence interval [CI] 1.8–2.8). Mean gestational age at ultrasonography was 61±13 days from last menstrual period. Prevalence varied by race/ethnicity: 18% in African-American women (95% CI 13–25), 8% in white women (95% CI 7–11), and 10% in Hispanic women (95% CI 5–19). The proportion of women with leiomyomas increased with age much more steeply for African-American women than for white women. CONCLUSION: Leiomyomas are common in pregnancy and occur more often among African-American women. Given the limited research on effects of leiomyomas on reproductive outcomes, the degree to which race/ethnic disparities in prevalence of leiomyomas may contribute to disparities in events such as miscarriage and preterm birth warrants investigation. LEVEL OF EVIDENCE: II

Overnight 5% Lidocaine Ointment for Treatment of Vulvar Vestibulitis

OBJECTIVE To assess the effectiveness of nightly application of 5% lidocaine ointment for treatment of vulvar vestibulitis. METHODS Over 17 months, we assessed women presenting to our pain clinic for evaluation of introital pain; 61 women met the criteria for vulvar vestibulitis and participated in a treatment trial. We measured daily pain and intercourse-related pain using a 100-mm visual analog scale. We compared ability to have intercourse and pain ratings before and after treatment, and investigated whether prior treatment or gynecologic comorbidities predicted response to treatment. RESULTS After a mean of 7 weeks of nightly treatment, 76% of women reported ability to have intercourse, compared with 36% before treatment (P = .002). Intercourse-related pain score was 39.11 (95% confidence interval [CI] 30.39, 47.83) points lower after treatment (P < .001), with a decrease of 10.37 (95% CI 3.53, 17.21) points in daily pain score (P = .004). We found no association between response to prior episodic use of lidocaine and response to nightly therapy with lidocaine ointment. Few patient characteristics predicted response to treatment; however, women with interstitial cystitis and other vulvar conditions were least likely to benefit. CONCLUSION Long-term, nightly application of 5% lidocaine ointment shows promise as a treatment for management of vulvar vestibulitis; a randomized, double-blind, clinical trial is warranted.

Long-term physical and psychological health consequences of induced abortion: review of the evidence.

UNLABELLED Induced abortion is a prevalent response to an unintended pregnancy. The long-term health consequences are poorly investigated and conclusions must be drawn from observational studies. Using strict inclusion criteria (study population >100 subjects, follow up >60 days) we reviewed an array of conditions in womens health. Induced abortion was not associated with changes in the prevalence of subsequent subfertility, spontaneous abortion, or ectopic pregnancy. Previous abortion was a risk factor for placenta previa. Moreover, induced abortion increased the risks for both a subsequent preterm delivery and mood disorders substantial enough to provoke attempts of self-harm. Preterm delivery and depression are important conditions in womens health and avoidance of induced abortion has potential as a strategy to reduce their prevalence. Only review articles including the single published meta-analysis exploring linkages between abortion and breast cancer were relied upon to draw conclusions. Reviewers were mixed on whether subsequent breast neoplasia can be linked to induced abortion, although the sole meta-analysis found a summary odds ratio of 1.2. Whatever the effect of induced abortion on breast cancer risk, a young woman with an unintended pregnancy clearly sacrifices the protective effect of a term delivery should she decide to abort and delay childbearing. That increase in risk can be quantified using the Gail Model. Thus, we conclude that informed consent before induced abortion should include information about the subsequent risk of preterm delivery and depression. Although it remains uncertain whether elective abortion increases subsequent breast cancer, it is clear that a decision to abort and delay pregnancy culminates in a loss of protection with the net effect being an increased risk. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES After completion of this article, the reader will be able to define the terms and, to outline the epidemiologic problems in studying the long-term consequences of abortion, and to list the associated long-term consequences of abortion.

Annual Costs Associated With Diagnosis of Uterine Leiomyomata

OBJECTIVE: To describe the annual care, direct health care, and indirect work loss costs for women with a diagnosis of uterine leiomyomata. METHODS: We examined data from an employer claims database of 1.2 million beneficiaries (1999 to 2003). Analysis was restricted to women with at least 12 months of continuous coverage and ages 18 to 64 years with at least one diagnosis of leiomyomata (International Classification of Diseases, 9th Revision, 218.xx, 654.1x). We selected a comparison group of women without a leiomyoma diagnosis using a 1:1 match on age, employment, region, health plan type, and length of enrollment. We compared resource use, disability claims, and excess costs in the year after the index diagnosis. RESULTS: The average age of women diagnosed with leiomyomata in this study was 43.7 years. Women with leiomyomata (N=5,122) had more clinic visits (relative risk [RR] 1.2, 95% confidence interval [CI] 1.2–1.2), diagnostic tests (RR 3.1, 95% CI 2.9–3.2), and procedures (RR 34.6, 95% CI 25.8–46.5) than controls (N=5,122). Within 1 year of the diagnosis of leiomyomata, 42% of women had a complete blood count, 66% had pelvic imaging, and 30% had surgery (68% of surgical procedures involved hysterectomy). Women with leiomyomata were 3-fold more likely to have disability claims (RR 3.1, 95% CI 2.7–3.6). Estimated average annual excess cost for each woman with leiomyomata (adjusted for confounders) was

Comparison of gestational age at birth based on last menstrual period and ultrasound during the first trimester

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Timing of HAART initiation and clinical outcomes in human immunodeficiency virus type 1 seroconverters

771 in work loss costs). Total costs for women with leiomyomata were 2.6 times greater than for controls. CONCLUSION: Diagnosed uterine leiomyomata are associated with increased resource use and with substantially higher health care and work loss costs. LEVEL OF EVIDENCE: II-3

Quality of life and sexual function after hysterectomy in women with preoperative pain and depression

Reported last menstrual period (LMP) is commonly used to estimate gestational age (GA) but may be unreliable. Ultrasound in the first trimester is generally considered a highly accurate method of pregnancy dating. The authors compared first trimester report of LMP and first trimester ultrasound for estimating GA at birth and examined whether disagreement between estimates varied by maternal and infant characteristics. Analyses included 1867 singleton livebirths to women enrolled in a prospective pregnancy cohort. The authors computed the difference between LMP and ultrasound GA estimates (GA difference) and examined the proportion of births within categories of GA difference stratified by maternal and infant characteristics. The proportion of births classified as preterm, term and post-term by pregnancy dating methods was also examined. LMP-based estimates were 0.8 days (standard deviation = 8.0, median = 0) longer on average than ultrasound estimates. LMP classified more births as post-term than ultrasound (4.0% vs. 0.7%). GA difference was greater among young women, non-Hispanic Black and Hispanic women, women of non-optimal body weight and mothers of low-birthweight infants. Results indicate first trimester report of LMP reasonably approximates gestational age obtained from first trimester ultrasound, but the degree of discrepancy between estimates varies by important maternal characteristics.