Lisa Iversen

Mortality among contraceptive pill users: cohort evidence from Royal College of General Practitioners’ Oral Contraception Study

Objective To see if the mortality risk among women who have used oral contraceptives differs from that of never users. Design Prospective cohort study started in 1968 with mortality data supplied by participating general practitioners, National Health Service central registries, or both. Setting 1400 general practices throughout the United Kingdom. Participants 46 112 women observed for up to 39 years, resulting in 378 006 woman years of observation among never users of oral contraception and 819 175 among ever users. Main outcome measures Directly standardised adjusted relative risks between never and ever users for all cause and cause specific mortality. Results 1747 deaths occurred in never users of oral contraception and 2864 in ever users. Compared with never users, ever users of oral contraception had a significantly lower rate of death from any cause (adjusted relative risk 0.88, 95% confidence interval 0.82 to 0.93). They also had significantly lower rates of death from all cancers; large bowel/rectum, uterine body, and ovarian cancer; main gynaecological cancers combined; all circulatory disease; ischaemic heart disease; and all other diseases. They had higher rates of violent deaths. No association between overall mortality and duration of oral contraceptive use was observed, although some disease specific relations were apparent. An increased relative risk of death from any cause between ever users and never users was observed in women aged under 45 years who had stopped using oral contraceptives 5-9 years previously but not in those with more distant use. The estimated absolute reduction in all cause mortality among ever users of oral contraception was 52 per 100 000 woman years. Conclusion Oral contraception was not associated with an increased long term risk of death in this large UK cohort; indeed, a net benefit was apparent. The balance of risks and benefits, however, may vary globally, depending on patterns of oral contraception usage and background risk of disease.

Long term outcomes in men screened for abdominal aortic aneurysm: prospective cohort study

Objective To determine whether there is a relation between aortic diameter and morbidity and mortality in men screened for abdominal aortic aneurysm. Design Prospective cohort study. Setting Highland and Western Isles (a large, sparsely populated area of Scotland). Participants 8146 men aged 65-74. Main outcome measures Morbidity and mortality in relation to presence of abdominal aortic aneurysm and three categories of aortic diameter (≤24 mm, 25-29 mm, and ≥30 mm). Results When screened, 414 men (5.1%) had an aneurysm (diameter ≥30 mm), 669 (8.2%) an aortic diameter of 25-29 mm, and 7063 (86.7%) an aortic diameter of ≤24 mm. The cohort was followed up for a median of 7.4 (interquartile range 6.9-8.2) years. Mortality was significantly associated with aortic diameter: 512 (7.2%) men in the ≤24 mm group died compared with 69 (10.3%) in the 25-29 mm group and 73 (17.6%) in the ≥30 mm group. The mortality risk in men with an aneurysm or with an aorta measuring 25-29 mm was significantly higher than in men with an aorta of ≤24 mm. The increased mortality risk in the 25-29 mm group was reduced when taking confounders such as smoking and known heart disease into account. After adjustment, compared with men with an aortic diameter of ≤24 mm, the risk of hospital admission for cardiovascular disease and chronic obstructive pulmonary disease was significantly higher in men with aneurysm and those with aortas measuring 25-29 mm. Men with an aneurysm also had an increased risk of hospital admission for cerebrovascular disease, atherosclerosis, peripheral arterial disease, and respiratory disease. In men with aortas measuring 25-29 mm, the risk of hospital admission with abdominal aortic aneurysm was significantly higher than in men with an aorta of ≤24 mm (adjusted hazard ratio 6.7, 99% confidence interval 3.4 to 13.2) and this increased risk became apparent two years after screening. Conclusions Men with abdominal aortic aneurysm and those with aortic diameters measuring 25-29 mm have an increased risk of mortality and subsequent hospital admissions compared with men with an aorta diameter of ≤24 mm. Consideration should be given to control of risk factors and to rescreening men with aortas measuring 25-29 mm at index scanning.

Contemporary Hormonal Contraception and the Risk of Breast Cancer

Background Little is known about whether contemporary hormonal contraception is associated with an increased risk of breast cancer. Methods We assessed associations between the use of hormonal contraception and the risk of invasive breast cancer in a nationwide prospective cohort study involving all women in Denmark between 15 and 49 years of age who had not had cancer or venous thromboembolism and who had not received treatment for infertility. Nationwide registries provided individually updated information about the use of hormonal contraception, breast‐cancer diagnoses, and potential confounders. Results Among 1.8 million women who were followed on average for 10.9 years (a total of 19.6 million person‐years), 11,517 cases of breast cancer occurred. As compared with women who had never used hormonal contraception, the relative risk of breast cancer among all current and recent users of hormonal contraception was 1.20 (95% confidence interval [CI], 1.14 to 1.26). This risk increased from 1.09 (95% CI, 0.96 to 1.23) with less than 1 year of use to 1.38 (95% CI, 1.26 to 1.51) with more than 10 years of use (P=0.002). After discontinuation of hormonal contraception, the risk of breast cancer was still higher among the women who had used hormonal contraceptives for 5 years or more than among women who had not used hormonal contraceptives. Risk estimates associated with current or recent use of various oral combination (estrogen–progestin) contraceptives varied between 1.0 and 1.6. Women who currently or recently used the progestin‐only intrauterine system also had a higher risk of breast cancer than women who had never used hormonal contraceptives (relative risk, 1.21; 95% CI, 1.11 to 1.33). The overall absolute increase in breast cancers diagnosed among current and recent users of any hormonal contraceptive was 13 (95% CI, 10 to 16) per 100,000 person‐years, or approximately 1 extra breast cancer for every 7690 women using hormonal contraception for 1 year. Conclusions The risk of breast cancer was higher among women who currently or recently used contemporary hormonal contraceptives than among women who had never used hormonal contraceptives, and this risk increased with longer durations of use; however, absolute increases in risk were small. (Funded by the Novo Nordisk Foundation.)

Physical Disease and Resilient Outcomes: A Systematic Review of Resilience Definitions and Study Methods

Background Findings from physical disease resilience research may be used to develop approaches to reduce the burden of disease. However, there is no consensus on the definition and measurement of resilience in the context of physical disease. Objective The aim was to summarize the range of definitions of physical disease resilience and the approaches taken to study it in studies examining physical disease and its relationship to resilient outcomes. Methods Electronic databases were searched from inception to March 2013 for studies in which physical disease was assessed for its association with resilient outcomes. Article screening, data extraction, and quality assessment were carried out independently by 2 reviewers, with disagreements being resolved by a third reviewer. The results were combined using a narrative technique. Results Of 2280 articles, 12 met the inclusion criteria. Of these studies, 1 was of high quality, 9 were of moderate quality, and 2 were low quality. The common findings were that resilience involves maintaining healthy levels of functioning following adversity and that it is a dynamic process not a personality trait. Studies either assessed resilience based on observed outcomes or via resilience measurement scales. They either considered physical disease as an adversity leading to resilience or as a variable modifying the relationship between adversity and resilience. Conclusion This work begins building consensus as to the approach to take when defining and measuring physical disease resilience. Resilience should be considered as a dynamic process that varies across the life-course and across different domains, therefore the choice of a resilience measure should reflect this.

Factors associated with resilience or vulnerability to hot flushes and night sweats during the menopausal transition.

ObjectiveThe aim of this study was to explore factors associated with “resilience” and “vulnerability” to hot flushes and night sweats. MethodsA total of 4,407 women aged 45 to 54 years who were recruited from family practices in northeast Scotland responded to a postal questionnaire. Among respondents reporting high-frequency hot flushes (n = 628) or night sweats (n = 628), we compared those with low levels of bother (“resilient”) with the rest. Similarly, among women reporting low-frequency hot flushes (n = 459) or night sweats (n = 459), those with high bother (“vulnerable”) were compared with the rest. Forward stepwise logistic regression examined social, psychological, and physical factors associated with resilience or vulnerability to each symptom. ResultsWomen resilient to hot flushes were those who had previously not been bothered by their menstrual periods; were not experiencing somatic symptoms or night sweats; and perceived their symptoms as having low consequences on their lives. Those vulnerable to hot flushes had children; had a high body mass index; reported night sweats; and perceived their symptoms as having high life consequences. Women resilient to night sweats were nonsmokers; were not experiencing sleep difficulties; were not using psychological symptom management strategies; and perceived their menopausal symptoms as having low life consequences. Those vulnerable to night sweats had low educational attainment; had previously been bothered by their menstrual periods; had below-average physical health; reported musculoskeletal symptoms and hot flushes; and perceived their menopausal symptoms as having high life consequences. ConclusionsFactors associated with resilience or vulnerability differ by symptom studied, although relationships with illness perceptions exist in all models. Our results suggest that a single approach to managing these symptoms is likely to be unsuccessful.

The impact and management of symptoms experienced at midlife: a community-based study of women in northeast Scotland

Please cite this paper as: Duffy O, Iversen L, Hannaford P. The impact and management of symptoms experienced at midlife: a community‐based study of women in northeast Scotland. BJOG 2012;119:554–564.

Factors associated with reporting classic menopausal symptoms differ.

ABSTRACT Objectives To investigate how symptoms experienced in midlife cluster and to identify factors independently associated with hot flushes, night sweats, and vaginal dryness. Methods A questionnaire was sent to 8206 women aged 45–54 years, recruited from family practices in north-east Scotland, UK. Using data collected about 23 symptoms, we conducted factor analysis for premenopausal, perimenopausal, postmenopausal and surgically menopausal women. Forward stepwise logistic regression was used to identify sociodemographic, lifestyle and psychological variables independently associated with the classic menopausal symptoms. Results Overall, 4407 women responded. Hot flushes were experienced by 46.7% (95% confidence interval (CI) 45.2–48.2) of women, night sweats by 46.4% (95% CI 44.9–47.9) and vaginal dryness by 28.2% (95% CI 26.9–29.6). Seven factors including 20 symptoms emerged from factor analysis. Hot flushes were associated with: being perimenopausal or postmenopausal; low education; obesity; low social support; reporting night sweats, musculoskeletal, bloating, menstrual and sexual symptoms; using complementary alternative medicines, lifestyle (e.g. exercising) or psychological management strategies (e.g. talking to family or friends) for menopausal symptoms. Night sweats were associated with: lower body weight; smoking; possible depression; reporting sleep difficulties, hot flushes and sexual symptoms; using lifestyle strategies for menopausal symptoms. Vaginal dryness was associated with: being postmenopausal; high education; high social support; below average physical health, reporting hot flushes, somatic symptoms and decreased sexual interest; using psychological or lifestyle strategies for menopausal symptoms. Conclusion It is important to investigate each classic menopausal symptom separately. Combining menopausal symptoms into categories such as vasomotor symptoms may lead to inaccurate conclusions about variables associated with these symptoms.

Hypertensive disorders of pregnancy and future health and mortality: A record linkage study

The objective of this register-based cohort study was to examine the relationship between hypertensive disorders of pregnancy and future hospital discharges from specified causes including cardiovascular disease, incident cancer registrations and mortality. From the Aberdeen Maternity and Neonatal Databank we identified 34,854 women who were born on or before 31st December 1967 and who had (i) preeclampsia/eclampsia, (ii) gestational hypertension or (iii) normal blood pressure in their first pregnancy. Hospital discharges from selected causes including cardiovascular disease, cancer registrations and deaths in these women were identified from the Scottish Morbidity Records. There were 2026 women who had preeclampsia, 8891 who had gestational hypertension and 23,937 who were normotensive during their first pregnancy. Compared to normotensive women, women with preeclampsia had a higher mortality from ischaemic heart disease (adj. IRR 1.38, 95% CI 1.03, 1.84) and circulatory disease (adj. IRR 1.30, 95% CI 1.06, 1.60). Similar trends were seen with gestational hypertension. There was no difference in all cause mortality in the three groups. The odds of a hypertensive episode were higher in women with preeclampsia (adj. OR 1.79, 95% CI 1.55, 2.05) and gestational hypertension (adj. OR 1.68, 95% CI 1.55, 1.82) compared to normotensives. Compared to normotensives, women with gestational hypertension (adj. IRR 0.91, 95% CI 0.85, 0.96) or preeclampsia (adj. IRR 0.86, 95% CI 0.77, 0.97) had lower incidences of cancer. Women with pregnancy induced hypertension are at a higher risk of incidence and mortality from ischaemic heart disease and a lower risk of cancer.

Hypertensive disorders of pregnancy and adult offspring cardiometabolic outcomes: a systematic review of the literature and meta-analysis

Hypertensive disorders of pregnancy include eclampsia, pre-eclampsia, gestational hypertension, pre-existing chronic hypertension and pre-eclampsia superimposed on chronic hypertension.1 ,2 They affect up to 8% of pregnancies and are a major cause of maternal and fetal morbidity and mortality.1 Chronic hypertension is associated with a much higher risk of pre-eclampsia and, in a subset of women, worsening of hypertension during pregnancy (without development of pre-eclampsia).3 ,4 Women with pre-eclampsia have an adverse cardiovascular risk profile in later life.5 ,6 Cardiovascular risk factors in the childhood and early adulthood of offspring of pregnancies affected by pre-eclampsia have been examined in two earlier systematic reviews. These found evidence of raised blood pressure (BP) and body mass index (BMI) in the offspring born to pre-eclamptic pregnancies.7 ,8 Less is known about the later life cardiovascular risk in offspring affected by maternal pre-eclampsia or other maternal hypertensive disorders of pregnancy, although some studies suggest a higher risk of cardiovascular disease, including hypertension9 and stroke10 in adulthood. The associations between hypertensive disorders of pregnancy and subsequent cardiovascular disease in the offspring are complex. Hypertensive disorders of pregnancy are associated with prematurity (which may be iatrogenic) and low birth weight even when corrected for gestation.11 Small for gestational age and gestation have been inversely associated with risk of cardiovascular disease.12 ,13 Furthermore, the strength of these associations varies by hypertensive disorder and severity of condition. We have systematically reviewed published papers of the association between maternal hypertensive disorders of pregnancy, and cardiovascular risk factors and disease in adult offspring. A systematic review of the published literature was undertaken. Inclusion criteria were: ### Types of study Observational epidemiological studies of offspring exposed in utero to a maternal hypertensive disorder of pregnancy. ### Types of participant Offspring aged at least 18 years at last …

Resilience of primary healthcare professionals: a systematic review

BACKGROUND Modern demands and challenges among healthcare professionals can be particularly stressful and resilience is increasingly necessary to maintain an effective, adaptable, and sustainable workforce. However, definitions of, and associations with, resilience have not been examined within the primary care context. AIM To examine definitions and measures of resilience, identify characteristics and components, and synthesise current evidence about resilience in primary healthcare professionals. DESIGN AND SETTING A systematic review was undertaken to identify studies relating to the primary care setting. METHOD Ovid(®), Embase(®), CINAHL, PsycINFO, and Scopus databases were searched in December 2014. Text selections and data extraction were conducted by paired reviewers working independently. Data were extracted on health professional resilience definitions and associated factors. RESULTS Thirteen studies met the inclusion criteria: eight were quantitative, four qualitative, and one was an intervention study. Resilience, although multifaceted, was commonly defined as involving positive adaptation to adversity. Interactions were identified between personal growth and accomplishment in resilient physicians. Resilience, high persistence, high self-directedness, and low avoidance of challenges were strongly correlated; resilience had significant associations with traits supporting high function levels associated with demanding health professional roles. Current resilience measures do not allow for these different aspects in the primary care context. CONCLUSION Health professional resilience is multifaceted, combining discrete personal traits alongside personal, social, and workplace features. A measure for health professional resilience should be developed and validated that may be used in future quantitative research to measure the effect of an intervention to promote it.