Maura K. Whiteman

U.S. Medical Eligibility Criteria for Contraceptive Use, 2016

The 2016 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) comprises recommendations for the use of specific contraceptive methods by women and men who have certain characteristics or medical conditions. These recommendations for health care providers were updated by CDC after review of the scientific evidence and consultation with national experts who met in Atlanta, Georgia, during August 26-28, 2015. The information in this report updates the 2010 U.S. MEC (CDC. U.S. medical eligibility criteria for contraceptive use, 2010. MMWR 2010:59 [No. RR-4]). Notable updates include the addition of recommendations for women with cystic fibrosis, women with multiple sclerosis, and women receiving certain psychotropic drugs or St. Johns wort; revisions to the recommendations for emergency contraception, including the addition of ulipristal acetate; and revisions to the recommendations for postpartum women; women who are breastfeeding; women with known dyslipidemias, migraine headaches, superficial venous disease, gestational trophoblastic disease, sexually transmitted diseases, and human immunodeficiency virus; and women who are receiving antiretroviral therapy. The recommendations in this report are intended to assist health care providers when they counsel women, men, and couples about contraceptive method choice. Although these recommendations are meant to serve as a source of clinical guidance, health care providers should always consider the individual clinical circumstances of each person seeking family planning services. This report is not intended to be a substitute for professional medical advice for individual patients. Persons should seek advice from their health care providers when considering family planning options.

Smoking, body mass, and hot flashes in midlife women☆

OBJECTIVE To assess whether lifestyle factors, specifically smoking and body mass index (BMI), are associated with the occurrence of any, moderate to severe, or daily hot flashes. METHODS A cross-sectional study was conducted among women aged 40–60 years residing in the Baltimore metropolitan area who reported their history of hot flashes through a mailed survey. Logistic regression was used to assess the associations between smoking and BMI with any, moderate to severe, and daily hot flashes. RESULTS Of the 1087 women included in the study, 56% reported having hot flashes. Compared with never-smokers, current smokers were at an increased risk for both moderate to severe hot flashes (adjusted odds ratio [OR] = 1.9, 95% confidence interval [CI] 1.3, 2.9) and daily hot flashes (adjusted OR = 2.2, 95% CI 1.4, 3.7). Among current smokers, risk for hot flashes increased with greater amount smoked. High BMI (more than 30 kg/m2) was associated with an increased risk for moderate to severe hot flashes compared with low BMI (less than 24.9 kg/m2) (adjusted OR = 2.1, 95% CI 1.5, 3.0). An increased risk for any or daily hot flashes with high BMI was present only among premenopausal or perimenopausal women. CONCLUSION Potentially modifiable factors, such as current smoking and high BMI, may predispose a woman to more severe or frequent hot flashes. This information may be valuable for identifying women at risk for hot flashes and for developing appropriate prevention strategies that may include lifestyle modifications.

Body mass and mortality after breast cancer diagnosis

Obesity is an established risk factor for some breast cancers, but less is known about its effect on breast cancer prognosis. Understanding this relationship is important, given the increasing number of women diagnosed with breast cancer and the growing prevalence of obesity. We conducted a cohort analysis of 3,924 women ages 20 to 54 with incident breast cancer enrolled between 1980 and 1982 in the Cancer and Steroid Hormone study, a case-control study. Interview data were linked to survival information from the Surveillance, Epidemiology, and End Results Program. We used proportional hazards models to examine the relationship between breast cancer mortality and adult body mass index (BMI; calculated using usual adult weight), BMI at age 18, and weight change from age 18 to adulthood. Hazard ratios (HR) were adjusted for cancer stage and other factors. During a median follow-up of 14.6 years, 1,347 women died of breast cancer. Obese women (adult BMI ≥30.00) were significantly more likely than lean women (BMI ≤22.99) to die of breast cancer [HR, 1.34; 95% confidence interval (CI), 1.09-1.65]. Women with BMIs of 25.00-29.99 (HR, 1.25; 95% CI, 1.08-1.44) or 23.00-24.99 (HR, 1.20; 95% CI, 1.04-1.39) also had higher breast cancer mortality (P for trend <0.0001). BMI at age 18 and weight change were not associated with breast cancer mortality independently of other factors. Obesity could be a preventable risk factor for death among breast cancer patients. Further study is needed to determine how these findings might affect recommendations to reduce breast cancer mortality.

Diabetes Trends Among Delivery Hospitalizations in the U.S., 1994–2004

OBJECTIVE To examine trends in the prevalence of diabetes among delivery hospitalizations in the U.S. and to describe the characteristics of these hospitalizations. RESEARCH DESIGN AND METHODS Hospital discharge data from 1994 through 2004 were obtained from the Nationwide Inpatient Sample. Diagnosis codes were selected for gestational diabetes mellitus (GDM), type 1 diabetes, type 2 diabetes, and unspecified diabetes. Rates of delivery hospitalization with diabetes were calculated per 100 deliveries. RESULTS Overall, an estimated 1,863,746 hospital delivery discharges contained a diabetes diagnosis, corresponding to a rate of 4.3 per 100 deliveries over the 11-year period. GDM accounted for the largest proportion of delivery hospitalizations with diabetes (84.7%), followed by type 1 (7%), type 2 (4.7%), and unspecified diabetes (3.6%). From 1994 to 2004, the rates for all diabetes, GDM, type 1 diabetes, and type 2 diabetes significantly increased overall and within each age-group (15–24, 25–34, and ≥35 years) (P < 0.05). The largest percent increase for all ages was among type 2 diabetes (367%). By age-group, the greatest percent increases for each diabetes type were among the two younger groups. Significant predictors of diabetes at delivery included age ≥35 years vs. 15–24 years (odds ratio 4.80 [95% CI 4.72–4.89]), urban versus rural location (1.14 [1.11–1.17]), and Medicaid/Medicare versus other payment sources (1.29 [1.26–1.32]). CONCLUSIONS Given the increasing prevalence of diabetes among delivery hospitalizations, particularly among younger women, it will be important to monitor trends in the pregnant population and target strategies to minimize risk for maternal/fetal complications.

Severe obstetric morbidity in the United States: 1998-2005.

OBJECTIVE: To examine trends in the rates of severe obstetric complications and the potential contribution of changes in delivery mode and maternal characteristics to these trends. METHODS: We performed a cross-sectional study of severe obstetric complications identified from the 1998–2005 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Logistic regression was used to examine the effect of changes in delivery mode and maternal characteristics on rates of severe obstetric complications. RESULTS: The prevalence of delivery hospitalizations (per 1,000) complicated by at least one severe obstetric complication increased from 0.64% (n=48,645) in 1998–1999 to 0.81% (n=68,433) in 2004–2005. Rates of complications that increased significantly during the study period included renal failure by 21% (from 0.23 to 0.28), pulmonary embolism by 52% (0.12 to 0.18), adult respiratory distress syndrome by 26% (0.36 to 0.45), shock by 24% (0.15 to 0.19), blood transfusion by 92% (2.38 to 4.58), and ventilation by 21 % (0.47 to 0.57). In logistic regression models, adjustment for maternal age had no effect on the increased risk for these complications in 2004–2005 relative to 1998–1999. However, after adjustment for mode of delivery, the increased risks for these complications in 2004–2005 relative to 1998–1999 were no longer significant, with the exception of pulmonary embolism (odds ratio 1.30) and blood transfusion (odds ratio 1.72). Further adjustment for payer, multiple births, and select comorbidities had little effect. CONCLUSION: Rates of severe obstetric complications increased from 1998–1999 to 2004–2005. For many of these complications, these increases were associated with the increasing rate of cesarean delivery. LEVEL OF EVIDENCE: III

Body mass and stage of breast cancer at diagnosis

Obesity is a well‐known risk factor for postmenopausal breast cancer. In contrast, the relationship between obesity and stage of breast cancer at diagnosis is less clear. We hypothesized that increased breast size in obese women may delay discovery of breast tumors. Thus, the purpose of our study was to examine whether there is an association between body mass and stage of breast cancer at diagnosis using hospital medical records. Newly diagnosed breast cancer cases (n = 966) in the Baltimore metropolitan area from 1991 to 1997 were included in our study. Patient information including age, ethnicity, weight, height and pathology data were obtained from hospital medical records. High body mass was significantly associated with late stage of breast cancer at diagnosis. Women who were obese (body mass index [BMI] ≥ 27.3) were more likely to be at an advanced stage at diagnosis compared with women with a BMI of < 27.3 (multivariate‐adjusted odds ratio [OR] 1.57, 95% confidence interval [CI] 1.15–2.14). The association between body mass and stage at diagnosis was stronger among women younger than 50 years (OR 2.34, 95% CI 1.34–4.08) compared with women 50 years or older (OR 1.30, 95% CI 0.89–1.91). Our study suggests that higher body mass is associated with advanced stage of breast cancer at diagnosis. This finding may be of considerable concern, given the increasing prevalence of obesity in women in the United States and the poor prognosis associated with late‐stage tumors.

Hormone replacement therapy and breast cancer: a qualitative review.

OBJECTIVE To assess whether recent epidemiologic evidence supports an association between use of estrogen replacement therapy or hormone replacement therapy and risk of breast cancer. DATA SOURCES The keywords “estrogen,” “estrogen replacement therapy,” or “hormone replacement therapy,” and “breast cancer” or “breast neoplasm,” were used to search for articles published from 1975–2000 in MEDLINE and Dialogweb. Only articles published in peer‐reviewed journals and containing original data were included in this review. METHODS Unadjusted or age‐adjusted risk estimates for breast cancer among ever users of estrogen therapy compared with never users were abstracted from published articles or calculated using the data provided in the published reports. TABULATION, INTEGRATION, AND RESULTS We found little consistency among studies that estimated the risk of breast cancer in hormone users compared with nonusers and in studies assessing the risk by duration of use. However, there was consistently a lower risk of death from breast cancer in hormone users compared with nonusers. CONCLUSION The evidence did not support the hypotheses that estrogen use increases the risk of breast cancer and that combined hormone therapy increases the risk more than estrogen only. Additional observational studies are unlikely to alter this conclusion. Although a small increase in breast cancer risk with hormone therapy or an increased risk with long duration of use (15 years or more) cannot be ruled out, the likelihood of this must be small, given the large number of studies conducted to date.

Risk factors for hot flashes in midlife women

OBJECTIVE To review the scientific literature pertaining to potential risk factors for hot flashes in midlife women. METHODS Scientific publications reporting on risk factors for hot flashes were identified through a systematic Medline search and are summarized in this review paper. RESULTS Although few studies have investigated risk factors for hot flashes in midlife women, consistent evidence suggests that smoking is associated with an increased risk for hot flashes. In addition, some studies suggest that other factors, such as hormone levels, body size, tubal ligation, surgical menopause, and race/ethnicity, may be associated with the occurrence of hot flashes. CONCLUSIONS Future studies are needed to confirm previous findings and to identify additional risk factors for hot flashes. Such studies will increase our understanding of the etiology of hot flashes and may lead to better treatments and preventive measures for this condition.

Health Care Provider Attitudes and Practices Related to Intrauterine Devices for Nulliparous Women

OBJECTIVE: To examine predictors of health care providers perceiving intrauterine devices (IUDs) as unsafe for nulliparous women and of infrequent provision of IUDs to nulliparous women. METHODS: We analyzed questionnaire data obtained during December 2009 to March 2010 from 635 office-based providers (physicians) and 1,323 Title X clinic providers (physicians, physician assistants, certified nurse midwives, nurse practitioners, and nurses). Using multivariable logistic regression, we estimated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of the associations between patient, health care provider, and clinic and practice variables and provider misconceptions about the safety of IUDs for nulliparous women and with infrequent IUD provision. RESULTS: Approximately 30% of respondents had misconceptions about the safety of IUDs for nulliparous women. Factors associated with increased odds of misconceptions about the copper IUD and levonorgestrel-releasing IUD included: being an office-based family medicine physician (copper IUD adjusted OR 3.20, 95% CI 1.73–5.89; levonorgestrel-releasing IUD adjusted OR 2.03, 95% CI 1.10–3.76); not being trained in IUD insertion (copper IUD adjusted OR 4.72, 95% CI 2.32–9.61; levonorgestrel-releasing IUD adjusted OR 2.64, 95% CI 1.34–5.22); and nonavailability of IUDs on-site at their practice or clinic (copper IUD adjusted OR 2.18, 95% CI 1.20–3.95; levonorgestrel-releasing IUD adjusted OR 3.45, 95% CI 1.95–6.08). More than 60% of providers infrequently provided IUDs to nulliparous women. Nonavailability of IUDs on-site (copper IUD adjusted OR 1.78, 95% CI 1.01–3.14; levonorgestrel-releasing IUD adjusted OR 2.10, 95% CI 1.22–3.62) and provider misconceptions about safety (copper IUD adjusted OR 6.04, 95% CI 2.00–18.31; levonorgestrel-releasing IUD adjusted OR 6.91, 95% CI 3.01–15.85) were associated with infrequent IUD provision. CONCLUSION: Health care provider misconceptions about the safety of IUDs for nulliparous women are prevalent and are associated with infrequent provision. Improved health care provider education and IUD availability are needed to increase IUD use among nulliparous women. LEVEL OF EVIDENCE: III

Incidence and determinants of peripartum hysterectomy.

OBJECTIVE: Most studies of peripartum hysterectomy are conducted in single institutions, limiting the ability to provide national incidence estimates and examine risk factors. The objective of this study was to provide a national estimate of the incidence of peripartum hysterectomy and to examine factors associated with the procedure. METHODS: We used data for 1998–2003 from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, an annual nationally representative survey of inpatient hospitalizations. Peripartum hysterectomy was defined as a hysterectomy and delivery occurring during the same hospitalization. Odds ratios (ORs) and 95% confidence intervals (CIs) were adjusted for maternal and hospital characteristics using logistic regression. RESULTS: During 1998–2003, an estimated 18,339 peripartum hysterectomies occurred in the United States (0.77 per 1,000 deliveries). Compared with vaginal delivery without a previous cesarean delivery, the ORs of peripartum hysterectomy for other delivery types were as follows: repeat cesarean, 8.90 (95% CI 8.09–9.79); primary cesarean, 6.54 (95% CI 5.95–7.18); and vaginal birth after cesarean, 2.70 (95% CI 2.23–3.26). Multiple births were associated with an increased risk compared with singleton births (OR 1.41, 95% CI 1.16–1.71). CONCLUSION: Our results suggest that vaginal birth after cesarean, primary and repeat cesarean deliveries, and multiple births are independently associated with an increased risk for peripartum hysterectomy. These findings may be of concern, given the increasing rate of both cesarean deliveries and multiple births in the United States. LEVEL OF EVIDENCE: III