Nestor Correia

Mortality and causes of death in schizophrenia in Stockholm County, Sweden

A study of mortality for all patients with a first hospital diagnosis of schizophrenia in Stockholm County, Sweden, during 1973 to 1995 was performed, by linking the in-patient register with the national cause-of-death register. Overall and cause-specific standardized mortality ratios (SMR) were calculated by 5-year age classes and 5-year calendar time periods. The number of excess deaths was calculated by reducing the observed number of deaths by those expected. Our results confirmed a marked increase in mortality in schizophrenia both in males and females. Natural (somatic) causes of death was the main cause of excess deaths, with more than half of the excess deaths in females, and almost half of the excess deaths in males. Suicide was the specific cause of the largest number of excess deaths in males, while in females it was cardiovascular disease. SMRs were increased in both natural and unnatural causes of death, with 2.8 for males and 2.4 for females for all deaths, but were highest in suicide with 15.7 for males and 19.7 for females, and in unspecified violence with 11.7 for males and 9.9 for females. SMRs in suicide were especially high in young patients in the first year after the first diagnosis.

Breast-cancer risk following long-term oestrogen-and oestrogen-progestin-replacement therapy

While use of hormone‐replacement therapy (HRT) effectively alleviates menopausal symptoms and prevents osteoporosis and possibly cardiovascular disease, there is concern of a detrimental impact on breast‐cancer risk. There is a particular lack of data regarding the effect of long‐term use of oestrogen‐progestin combinations on breast‐cancer risk. We conducted a large epidemiological study in Sweden, where combined oestrogen‐progestin treatment has been predominant, to examine the influence of different regimens of menopausal hormone therapy on breast‐cancer risk. In this population‐based case‐control study, 3,345 women aged 50 to 74 years with invasive breast cancer (84% of all eligible) and 3,454 controls of similar age (82% of all selected) were included. Mailed questionnaires and telephone interviews were used to collect detailed information on use of hormone replacement and on potential confounding factors. Odds ratios (OR) and 95% confidence intervals (CI) were estimated through multiple logistic regression. There was a trend of increasing breast‐cancer risk with duration of oestrogen/oestrogen‐progestin use (OR for women treated at least 10 years, 2.43; 95% CI, 1.79–3.30, as compared to never‐users), with statistically significant estimates only for women with BMI < 27 kg/m2. Excess risks were observed to current use and use that ceased more than 10 years ago (OR for women treated at least 5 years, OR was 2.68, 95% CI, 2.09–3.42, and OR 2.57, 95% CI, 1.28–5.15, as compared with never‐users, respectively). A positive association which was noted for use of oestrogen combined with testosterone‐derived progestins appeared especially pronounced with continuously combined regimens. Long‐term use of replacement oestrogens with or without progestins may substantially increase the incidence of post‐menopausal breast cancer, particularly among non‐obese women. Int. J. Cancer 81:339–344, 1999.

Low-potency oestrogen and risk of endometrial cancer: a case-control study

BACKGROUND Urogenital symptoms are common among postmenopausal women. Such symptoms may be alleviated by low-potency oestrogen formulations administered orally or vaginally. Although low-potency oestrogen formulations are assumed to have few, if any, adverse effects on the endometrium, risk of endometrial neoplasia has not been quantified. METHODS In a nationwide population-based case-control study in Sweden of endometrial cancer among postmenopausal women, we obtained detailed information on hormone replacement from 789 cases of endometrial cancer and 3368 population controls. In a histopathological review, 80 cases were reclassified as having endometrial atypical hyperplasia. Odds ratios and 95% CI were calculated with unconditional logistic regression. FINDINGS After multivariate adjustment, oral use of oestriol 1-2 mg daily increased the relative risk of endometrial cancer and endometrial atypical hyperplasia: the odds ratios for at least 5 years of use compared with never use were 3.0 (95% CI 2.0-4.4) and 8.3 (4.0-17.4), respectively. The association was stronger for well-differentiated cancers and those with limited invasion. The excess relative risk was lost rapidly after cessation of treatment. Only weak associations were observed between vaginal application of low-potency oestrogen formulations and relative risk of endometrial neoplasia. INTERPRETATION Oral, but not vaginal, treatment with low-potency oestrogen formulations increases the relative risk of endometrial neoplasia. Thus close surveillance of patients is needed, and addition of a progestagen should be considered.

Abortion rate and contraceptive practices in immigrant and native women in Sweden

Aim: The aim of this study was to analyse whether immigrant women request induced abortion more frequently than Swedish-born women and, if so, to study possible explanations, including contraceptive practices and attitudes. Methods: All women who requested induced abortion during a period of one year were included in the study. The 1,289 women, of whom 36% were born outside Sweden, were interviewed by a nurse-midwife who, using a structured protocol, gathered information on socioeconomic factors, reasons for abortion, experience of contraceptive methods, and family planning counselling. The proportion of women with non-Swedish origin in the study population was compared with the official demographic statistics of the corresponding area. Results: The number of women born outside Sweden who requested induced abortion was larger than expected from their proportion in the population. The immigrant women originated from 77 countries and four continents, the largest subgroup, 11%, coming from Iran. Immigrant women had less experience of contraceptive use, more previous pregnancies and more induced abortions than women born in Sweden. In a multivariate analysis, immigrant status and educational level were found to be independent risk factors for repeat abortion. Conclusion: Immigrant status seems to be an independent risk factor for induced abortion. The immigrant women originated from a wide range of cultures. There is no reason to believe that the women in this heterogeneous group should have any cultural factor in common that could explain their higher proneness to seek induced abortion. The most probable cause is that immigrant status is associated more often with low education, weak social network, poverty, unemployment, and being outside common pathways to healthcare.

The Risk of Post-menopausal Breast Cancer After Estrogen and Estrogen-Progestin Replacement

Hormone replacement therapy (HRT) in post-menopausal women is widely used for symptom relief and disease prevention. As sex hormones are involved in the etiology of breast cancer (BC), there is concern that hormone substitution after the menopause may increase BC risk. Accumulated epidemiological evidence shows that many years of recent or current HRT use leads to moderate excess risk of early stage BC, particularly in non-obese women. Results from our recently completed population-based study, including 3,345 cases of BC and 3,454 controls, aged 50–74 years, reveal clear and strong relationships between long-term intake of both estrogens (Es) and Es combined with progestins, seemingly confined to women with normal or lean body build. The results also suggest that the duration-dependent excess risk remains a long time after treatment cessation and that continuously/combined E-progestin treatment may be more adverse than those cyclically/combined. Our observations raise additional concern about the long-term safety of HRT and call for research efforts to define the safest possible HRT- regimens.