Showing papers in "Womens Health Issues in 2004"

Prevalence of intimate partner violence and health implications for women using emergency departments and primary care clinics.

Abstract: Objectives To determine prevalence of intimate partner violence (IPV) among women accessing health care, factors that influence rates of abuse, barriers to disclosure, and associated health problems and perceptions of safety. Methods A convenience sample of women seeking health care completed 1268 anonymous surveys (75 in Spanish) while at 1 of 24 urban, suburban, or rural emergency departments or primary care clinics. Results Of women in this study, 50–57% had experienced physical and/or emotional abuse and 26% reported sexual abuse in their lifetime. In the past year, 28% reported emotional abuse, 12% physical abuse, 6% severe physical abuse, and 4% sexual abuse. Logistic regression models found that younger, less-educated, less-affluent women presenting to urban emergency departments reported the highest rates of physical abuse. Although 83% welcomed abuse screening, only 25% ever had been asked and 86% would disclose abuse if asked directly, respectfully, and confidentially. Abused women reported significantly lower health status ratings than nonabused women ( p Conclusions Women experience many forms of abuse and present to a wide range of health care settings. The striking prevalence of IPV and associated emotional/physical health problems challenges providers to routinely assess for abuse in ways that minimize barriers to disclosure and enhance the development of an effective plan of care based on a patient's abuse experience.

Comparing breast cancer risk between lesbians and their heterosexual sisters.

Abstract: Purpose The purpose of this study was to explore the similarities and differences between lesbians and their heterosexual sisters in the established risks for developing breast cancer. Methods The design for this study was a matched (lesbian with heterosexual sister) cross-sectional, mail-back, anonymous survey. We distributed the surveys throughout the state of California to English-speaking women who identified themselves as lesbians, age 40 and older, and their sisters. Using the modified Gail Breast Cancer Risk model as well as other well-established factors associated with the development of breast cancer, we compared the breast cancer risk potential for 324 sister pairs ( N = 648). Data were analyzed using paired t -tests, analysis of covariance (ANCOVA), McNemar's χ 2 , or the Bowker statistic, as appropriate for the level of data. Main findings The lesbians had significantly higher 5-year ( p p = .001) risk for developing breast cancer. The reasons for lesbians' predicted rate of breast cancer were most likely their higher scores on all pregnancy-related variables and the relatively high number of breast biopsies they reported. The lesbians had used birth control pills less ( p p p p p p = .02) than did their heterosexual sisters. Conclusions A lesbian who comes out to her clinician is relying on the clinician to be informed and be open to discuss her life. When a lesbian has a lump or a suspicious mammogram, she needs her clinician to advocate for her within the health care system because she is at higher risk for having cancer than a heterosexual woman.

Menstruation across time : Menarche, menstrual attitudes, experiences, and behaviors

Abstract: This study explored the relationship between early and current menstrual experiences The primary hypothesis was that women who reported positive menarcheal experiences (including menstrual education and menarche) would tend to report positive current menstrual attitudes, experiences, and/or behaviors, and vice versa for women who reported negative menarcheal experiences In this survey-based study, college-aged women (n = 327) were screened by completing a questionnaire concerning their menarcheal experiences Women who had extremely negative ("negative group," n = 46) or extremely positive ("positive group," n = 38) early menstrual experiences returned to complete questionnaires concerning current menstrual attitudes, experiences, and behaviors Early and current menstrual experiences were most strongly associated in the domain of menstrual attitudes Women in the negative group reported more negative menstrual attitudes than did women in the positive group There were additional associations between early menstrual experiences and measures of body image and health behaviors Positive group participants reported more positive body image and better general health behaviors Results suggest that early menstrual experiences may be related to menstrual experiences later in life This study invites further investigation of the psychology of menstruation and suggests connecting menstruation with other women's health issues

Associations between forced sex, sexual and protective practices, and sexually transmitted diseases among a national sample of adolescent girls

Abstract: Objective The main objective of this study is to better understand the associations between forced sex history and history of sexually transmitted disease (STD) infection. Three research questions are investigated. Is history of forced sex associated with risk-taking behaviors? Are these risk-taking behaviors associated with history of STD? Is history of forced sex independently associated with history of STD? Methods Information on the sexual and STD histories is obtained from 3,579 sexually active adolescent girls using data from the National Longitudinal Study of Adolescent Health. Weighted logistic and OLS regressions are employed, using techniques that account for the complex sampling design. Results Girls with a history of forced sex are significantly more likely to have a greater number of sexual partners, be younger at first sex, and be more likely to use alcohol or drugs at last sex; there is no difference in condom use at last sex. These factors, in turn, are significantly associated with a positive STD history. Condom use at last sex is negatively associated with ever having had an STD. When all five sexual and protective practices are investigated simultaneously, history of forced sex remains significantly associated with STD history (odds ratio [OR] = 1.39, p = .014); number of sexual partners and early onset of sex remain significant. Condom use and substance use at last sex reduce to marginal significance. Conclusions These results suggest that a history of forced sex is independently associated with a history of STD among sexually active adolescent girls. Programmatic strategies aimed at reducing STDs through encouraging responsible sexual behavior would potentially benefit from also including a component that addresses sexual victimization.

Physical violence against impoverished women: a longitudinal analysis of risk and protective factors.

Abstract: Violence represents a significant threat to the health of impoverished women. Few studies have examined what characteristics might be associated with increased risk of violence or protection from physical violence directed at such women, although this information is important in informing violence prevention and intervention efforts. This is the first study to our knowledge that has prospectively examined, in representative probability samples of impoverished women, multiple risk and protective factors to understand their relative importance to physical victimization. Study participants were 810 women in Los Angeles County, 402 in shelters and 408 in Section 8 low-income housing, who completed structured interviews at baseline and 6-month follow-up. Significant ( p

Correlates of body mass index and waist-to-hip ratio among Mexican women in the United States: implications for intervention development.

Abstract: Introduction This study contributes to our understanding of acculturation and obesity by examining the association between several measures of acculturation, including a bidimensional scale of acculturation, body mass index (BMI), and waist-to-hip ratio (WHR). Methods Exploratory analyses were performed using baseline data from 357 Mexican women recruited into a Spanish-language randomized community trial. The women were randomly sampled by telephone and interviewed in their homes. Women’s height, weight, waist, and hip were measured to obtain estimates of their BMI and WHR. A face-to-face interview collected data on dietary intake, physical activity, acculturation, and other demographic and psychosocial variables. Results Less than a quarter of the women were normal weight (39% overweight and 41% obese). Univariate analyses revealed that more years living in the United States and less integration into the Anglo culture were associated with a larger BMI and WHR. However, in the multivariate analyses, significant correlates of a larger BMI were less moderate physical activity and unemployment. There were trends linking a larger BMI with older age, no vigorous physical activity, more energy intake, and less integration into the Anglo culture. These same variables plus less household income were associated with a higher WHR. Exploratory analyses on acculturation revealed that bicultural Mexican-American women were more educated, more likely to be employed, reported a higher household income, and perceived fewer barriers to a healthy diet compared with traditional Mexican women. Conclusions Intervention designed to prevent overweight/obesity should consider promoting maintenance of Mexican cultural practices, as well as teach women how to effectively integrate into the Anglo culture.

Consumer assessment of the quality of interpersonal processes of prenatal care among ethnically diverse low-income women: development of a new measure.

Abstract: Purpose Consumer assessments of interpersonal processes of care during prenatal care provide important information about how well clinicians satisfy the perceived needs of the women they serve, but few measures are available that tap the various components of these processes. The purpose of this study is to develop a multidimensional measure of prenatal interpersonal processes of care (PIPC) that demonstrates reliability and validity in ethnically diverse women in Medicaid managed care plans. Methods A telephone survey of African American, Latino (U.S. and foreign born) and Caucasian pregnant women in four Medicaid managed care plans in California was conducted in English and Spanish in 2001. Factor analytic methods were used to test the PIPC measures. A psychometric evaluation, including reliability, variability, and construct validity, was conducted with the final scales for the total sample and for each racial/ethnic group. Results Three dimensions, Communication, Patient-Centered Decision Making, and Interpersonal Style, with seven scales were supported with 30 items. The scales for each dimension exhibit acceptable reliability for the total sample (Internal Consistency Reliability ranged from 0.66 to 0.85) and for all racial/ethnic groups. All scales had significant associations with satisfaction with prenatal care and explained considerable variation in satisfaction (19–43%). The scale qualities and validity associations held for all scales and ethnic groups except some scales for U.S.-born Latinas. Conclusions The multidimensional PIPC measure for assessing what actually happens between providers and low-income pregnant women of diverse ethnic groups demonstrates acceptable reliability and construct validity.

The Use of Complementary and Alternative Medications by Menopausal Women in South East Queensland.

Abstract: This study aimed to identify the prevalence and types of complementary and alternative medications (CAMs) used by women during menopause and explore potential associations between CAM use and menopausal symptoms. Analysis was undertaken with 886 randomly selected menopausal women aged 47-67 years who participated in a postal questionnaire on the menopause experience. The prevalence of CAM use was relatively high (82.5%), with nutrition most commonly cited (67%), followed by phytoestrogens (56%), herbal therapies (41%), and CAM medications (25%). Multivariate analysis adjusted for confounders revealed that women who consumed CAM medications were 17-23% more likely to report anxiety (p = .019) or vasomotor symptoms (p = .013). Women who used herbal therapies (p = .009) or phytoestrogens (p = .030) were 13-16% more likely to experience vasomotor symptoms. Women who used nutrition were 18% more likely to experience anxiety (p = .049). These results highlight the importance for health professionals to incorporate CAMs into their practice to better inform menopausal women of their treatment choices.

Validating a pencil-and-paper measure of perimenopausal menstrual blood loss.

Abstract: In the study presented here, we describe our efforts to develop and validate a new measurement tool for perimenopausal menstrual blood loss. We validate this simple-to-use, subjective pencil-and-paper scale, the Mansfield-Voda-Jorgensen Menstrual Bleeding Scale (MVJ), against an objective measure, the weight of used menstrual products. Thirty-one women from the Minneapolis-St. Paul, MN region saved all their used products over three menstrual cycles, storing them in airtight zip bags, and rated their menstrual fluid volume loss using the MVJ. The overall correlation between MVJ scores and log discharge rate was quite high (r = 0.683); all MVJ categories were statistically unique with the exception of categories "1" and "2." The overall fit, then, was particularly good at the heavy bleeding end of the scale. When five women with poor performance were removed, the correlations ranged from 0.480-0.894. The MVJ is a promising tool for identifying women with excessive menstrual bleeding. It is a simple-to-use, pencil-and-paper scale that offers an inexpensive and practical method to clinicians who work with perimenopausal women, the group most vulnerable to unnecessary worry and/or interventions when menorrhagia is incorrectly diagnosed.

Staging the menopausal transition: data from the TREMIN Research Program on Women's Health.

Abstract: The present study was conducted to test the assumptions of a staging system of reproductive aging that was proposed at the Stages of Reproductive Aging Workshop (STRAW) in 2001. Using longitudinal data provided by 100 women over a period of 3–12 years, we asked whether midlife women move in a uniform progression from pre- to peri- to postmenopause, as refuted by earlier studies but proposed by the STRAW model, or whether they differ from this assumed pattern. Participants were recruited from the TREMIN Research Program on Women’s Health, the oldest ongoing study of menstruation and women’s health in the world. Eligibility criteria included reaching menopause during the course of the study and not using exogenous hormones. Participants provided annual self-reports of menopausal stage based on observations of their menstrual cycles (“regular,” “changing,” and “menopausal”). Findings revealed a lack of uniformity as women progressed toward menopause. From 8 to over 20 different perimenopausal stage patterns were observed, depending on the analysis. While the most common pattern was to progress from regular to changing to menopause, some women experienced menstrual bleeding after a year or more of amenorrhea, others flip-flopped between stages, and still others skipped directly from regular bleeding to menopause. We conclude that there is considerable variation in women’s movement across menopausal status categories and urge researchers to accommodate such findings in their model building.

The development and validation of the primary care satisfaction survey for women

Abstract: Assessing patient satisfaction with health care is becoming an integral component of quality monitoring in health care systems, but existing tools typically were developed to minimize differences related to gender. This paper reports the development and psychometric properties of a new survey instrument to measure women's satisfaction with their primary care. A multisite, cross-sectional validation survey of 1,202 women receiving care in primary care settings in Michigan, North Carolina, and Pennsylvania was conducted. Item response theory (IRT) and factor analysis methods were used to identify three scales in the Primary Care Satisfaction Survey for Women (PCSSW): Communication, Administration and Office Procedures, and Care Coordination and Comprehensiveness. Internal consistency reliability is reported, as well as convergent validity in relation to two generic measures (Medical Outcomes Study [MOS] Visit Satisfaction and Consumer Assessment of Health Plans Survey [CAHPS] overall quality rating); discriminant validity in relation to groups expected to have differing satisfaction levels based on previous literature; predictive validity in relation to behavioral intentions; and explanatory power in overall satisfaction ratings. The 24-item PCSSW may be self-administered or conducted by telephone and may be used in studies to evaluate or improve the quality of primary care for women.

Association between psychological stress and menstrual cycle characteristics in perimenopausal women

Abstract: In previous studies of the relationship between stress and menstrual cycles, stress has been found to be associated with longer cycles, to be associated with shorter cycles, and to have no association with cycle length. Some of the menstrual cycle changes that have been attributed to stress are similar to those experienced by women during perimenopause. In an effort to see whether an association between psychological stress and menstrual cycle characteristics can be detected in women approaching menopause, this study examines this relationship in perimenopausal women who are participants in the Tremin Research Program on Women's Health. The analyses used prospectively recorded bleeding data and retrospectively captured life-event data. A single-year cross-sectional analysis of data from 206 women shows no correlation between stress level, as measured by total number and severity of stressful life events, and cycle characteristics, including interval length, duration of bleed, and variability in both of these factors, nor are there significant differences in cycle characteristics between subgroups of women with different overall levels of stress. In analyzing stress levels and cycle characteristics across 2 years, however, women with marked increases in their level of stress (n = 30) are shown to have decreased length (-0.2 days/cycle) of menstrual cycle intervals and decreased duration of bleed (-0.1 day/cycle) compared with increases in these measures (+2.9 days/cycle for cycle interval; +0.3 days/cycle for duration of bleed) among women with no marked change in stress level (n = 103); t-tests indicate that these differences are significant (p < .05).

Evidence about extending the duration of oral contraceptive use to suppress menstruation.

Abstract: Introduction: For many years, individual women and doctors have experimented with extending the duration of active oral contraceptive (OC) pills between pill-free intervals (long OC) to control menstruation. The U.S. approval of an OC with 84 active days and 7 pill-free days in 2003 has attracted considerable media attention. In this review we consider the published evidence on the effectiveness, side effects, and risks of menstrual suppression with long OC. Methods: We performed a systematic review of published literature on long OC, up to April 2003. Results: Ten papers were located; two were randomized trials comparing long OC to standard OC; the remaining studies were single-group observational studies. Women on long OC schedules had fewer days of scheduled bleeding during days without pills but more days of unscheduled bleeding and spotting than those on standard OC. These problems were worse for women new to OC and diminished over time. Women on long OC were more likely to discontinue due to poor control of bleeding; women on standard OC were more likely to stop because of problems with headaches. Women on long OC and standard OC both showed increases in physiological factors related to clotting, with a nonsignificant tendency for those on long OC to be more affected. No studies considered the effects of long OC on breast tissue, breast density, endometrial safety, or adolescent maturation and reproductive development. No systematic data were available on the return to reproductive function and fertility after taking long OC. There were no placebo-controlled trials and no information on how long OC compares to normal, unmedicated menstrual cycles. Therefore we believe scientific evidence for safety of long OC use is presently lacking.

Demographic characteristics, menopausal status, and depression in midlife immigrant women

Abstract: The purpose of this cross-sectional analysis is to examine symptoms of depressed mood in relation to age, menopausal status, and length of residence in the United States in midlife women who are recent immigrants from the former Soviet Union. Data for this analysis are from a longitudinal study of the impact of acculturation on postimmigration health status and psychological well-being. The mean score for the Center for Epidemiological Studies-Depression (CES-D) scale was 23.56, with 77.3% of the women obtaining a score greater than the usual screening cutoff score for referral. Women taking antidepressant medications had a mean score of 30.52. CES-D scores varied significantly by age group. The lowest CES-D scores were reported by women aged 40–50, and women aged 55–60 had significantly higher scores than younger women and those over 65 years old. Total CES-D scores did not vary significantly by length of residence in United States or use of hormone therapy. Regression analysis indicated that even when use of antidepressant medication was held constant, age and residence in the United States were significant independent contributors to CES-D score: women who were older, had lived fewer years in the United States, and those who took antidepressants had higher CES-D scores. Cultural and immigration-related explanations for high scores on the depression scale are suggested.

Beyond treatment: lifestyle choices after breast cancer to enhance quality of life and survival.

Abstract: G r c f b i lmost 2 million women in the United States are iving with a breast cancer diagnosis (Aziz, 2002). ecent advances in treatment give new hope for a long nd healthy life (Goss et al., 2003). However, length of urvival after a breast cancer diagnosis varies greatly, ven after accounting for disease stage and treatment Harris, Lippman, Morrow, & Osborne, 2000). This uggests that other factors may also be important. People commonly change diet and lifestyle after a ancer diagnosis in an effort to maintain health and revent recurrence (Maskarinec, Murphy, Shumay, & akai, 2001) However, there are few definitive data bout nonclinical factors that influence breast cancer utcomes. We will review epidemiologic findings for everal lifestyle factors and outcomes after breast ancer, and indicate current knowledge gaps. We have ocused on lifestyle factors after diagnosis, which is hat the woman facing a breast cancer diagnosis can hange. The predominant hypothesis has been that a diet igh in fruit, vegetables, and fiber and low in fat may enefit survival (Rock & Demark-Wahnefried, 2002). here are trials currently underway to examine these ietary patterns on the risk for recurrence and surival after diagnosis of early-stage breast cancer. The omen’s Healthy Eating and Living (WHEL) Study ncludes 3,000 women where the intervention is to onsume five vegetable servings (including 16 ounces f vegetable juice), three fruit servings, 30 g of dietary iber per day, and a very low fat diet (15% to 20% of nergy). The Women’s Intervention Nutrition Study WINS), with 2,500 postmenopausal women, will evalate the impact of a reduction in dietary fat intake to

Acceptability of a self-sampling technique to collect vaginal smears for gram stain diagnosis of bacterial vaginosis.

Abstract: To diagnose asymptomatic bacterial vaginosis (BV), self-sampled vaginal smears were collected during a study of risk factors for preterm birth in African American women. More than 90% of those women who were willing to participate in the interview portion of the study were also willing to provide a self-sampled vaginal smear. The smears are an acceptable and efficient way of detecting BV in an urban minority population.

Hormones, menopause, and heart disease: making sense of the Women's Health Initiative.

Abstract: The Women’s Health Initiative (WHI) randomized clinical trial of hormone therapy (HT) and primary prevention of coronary heart disease (CHD) found overall harm rather than benefit from medication. This surprised professionals, made newspaper headlines, and changed prescription practices. However, the pre-WHI research literature was strongly supportive of a prevention role for HT only when interpreted in particular ways. This article reviews the history of research on HT and CHD prevention preceding WHI and the initial response to WHI in terms of underlying decision-making-rules and values about how to design and interpret research, especially rules and values fostering a positive view of HT’s benefits for disease prevention even in the face of neutral, ambiguous, and negative evidence.

Acceptability of an existing, female-controlled contraceptive method that could potentially protect against hiv: a comparison of diaphragm users and other method users

Abstract: Objective The diaphragm, an internal barrier contraceptive device, is a candidate for a female-controlled method for preventing human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). This study's objective was to examine how women who use the diaphragm differ from women using the pill and/or condoms with respect to factors hypothesized to influence the acceptability of contraceptive methods. Our goal was to increase understanding of who finds the diaphragm acceptable and why. Methods We conducted a cross-sectional telephone survey with selected female members of a managed care organization. For this analysis, we limited the sample to 585 women currently using the diaphragm ( n = 196), pill ( n = 200), condoms ( n = 132), or pill and condoms ( n = 57). We conducted bivariate analyses and multinomial logistic regression analyses to assess the associations between selected characteristics and diaphragm use. Results Diaphragm use was significantly associated with several variables. Of particular interest, placing less importance on hormonal method characteristics was significantly associated with diaphragm use (versus use of the pill, condoms, or both). Placing more importance on barrier method attributes was significantly associated with diaphragm use (versus pill use, alone or with condoms). In addition, lower condom use self-efficacy was significantly associated with diaphragm use (versus condom use, alone or with pill). Lack of motivation to avoid HIV/STIs was significantly associated with using the diaphragm versus condoms (only). Conclusion These results have important implications for future research, interventions, counseling strategies for providers, and product development. Our findings suggest that if the diaphragm protects against HIV, it could be a desirable option for some women.

Seasonal rhythms of menarche in the United States: Correlates to menarcheal age, birth age, and birth month

Abstract: Purpose To examine the seasonality of menarche in a large sample of women from the United States. Methods Retrospective data were collected on month of birth and menarche, age of menarche, and latitude and altitude of residence from a sample of approximately 3,000 U.S. women from the TREMIN Research Program and from a college student population. Results Monthly analyses using observed (O) to expected (E) ratios indicated a peak frequency of menarche in July (1.45) and January (1.19) and troughs in February (0.75) and May (0.79). Collapsing the data into seasons also revealed summer and winter peaks. Participants from a younger cohort (born after 1970) had an earlier age of menarche than participants from an older cohort (born before 1970). Older cohort participants also had a more pronounced December-January frequency peak and younger cohort participants had a more pronounced July frequency peak. Older cohort participants exhibited more variability in menarcheal age as a function of menarche month and birth month. Late-maturing participants (>14 years) had a larger December peak of menarche frequencies. Spring-born participants exhibited less seasonality to their menarche. Month of birth was not significantly associated with month of menarche; however, fewer cases than expected occurred 3 months after the birth month and more cases than expected occurred 6 months after the birth month. Age of menarche and monthly distribution of menarche did not vary according to latitude or altitude. Conclusions Menarche seasonality is suggested to be a multifactor process mediated by the most prominent seasonal time cue. Attention to these cues that have been hypothesized to contribute to menarche seasonality (e.g., stress or the photoperiod) may have practical implications for women's health, given some of the risks associated with early menarche.

A wake-up call to advance women's health☆

Abstract: O omen’s health has recently become a major clinical field, as well as a relevant public issue Kasper, 2002). Providing health care to women is omplex and challenging, and requires the coordiated effort of a multidisciplinary team of health care rofessionals. To succeed in this effort health care rofessionals need to practice good communication kills, have access to evidence-based information and e able to translate scientific evidence into their clinial practice. As patients, women should have easy ccess to the latest evidence-based information deigned to help them make the right decisions about heir care and the care of their family members. Recently, there has been a significant increase in epresentation of women in clinical trials (Department f Health and Human Services National Institutes of ealth, June 2003), including the Women’s Health nitiative. These trials have yielded abundant findings ith high clinical relevance to women (Cauley, et al., 003; Hays, et al., 2003; Manson, et al., 2003). Health ervices research has also shown that although omen seek more medical care, use more health care ervices, and spend more on medications than men Roe, McNamara, & Motheral, 2002), inequalities in are still limit women’s access to certain diagnostic rocedures and therapies proven to be effective for pecific conditions (Weisman, 1999; Bierman & lancy, 2001; Grady, Chaput, & Kristof, 2003). Much, herefore, still needs to be done to improve access, eceipt, and quality of care for this priority population. he challenge remains to go beyond research findings o ensure that research is used to eliminate inequalities

Early puberty in girls: the case of premature adrenarche.

Abstract: In this article we examine the issue of early puberty in girls. First, a brief overview of normal pubertal development is provided, including the two endocrine components of puberty: gonadarche and adrenarche. Second, we critically discuss the controversy regarding whether puberty truly is occurring earlier in girls. Third, we emphasize one type of early puberty, the case of premature adrenarche (PA). PA is used to illustrate the importance of identifying types of early puberty, evaluating the types to determine causality, determining whether follow-up of early puberty is necessary, and showing the potential ramifications of ignoring this variation in pubertal development. Findings from a pilot study comparing PA and on-time puberty children are used to show the importance of determining whether early puberty is normal in all cases.

The role of physician gender in the evaluation of the national centers of excellence in women's health: test of an alternate hypothesis

Abstract: A 2002 evaluation of the National Centers of Excellence in Women's Health (CoE) provided evidence that women receive higher-quality primary health care, as indicated by receipt of recommended preventive care and patient satisfaction, when they receive their care in comprehensive women's health centers. A potential rival explanation for the CoE evaluation findings, however, is that the higher quality of care in the CoE may be attributable to a predominance of female physicians in CoE settings. More women who receive health care in a CoE have a female regular physician and female physicians may provide more preventive health services. Additionally, women may self-select into the CoE because of their preference for female providers. This paper presents results of an analysis examining the role of physician gender in the CoE evaluation. Women seen in three CoE clinics and women seen in other settings in the same communities who had a female physician are compared to assess the CoE effect while controlled for physician gender. The findings confirm a positive CoE effect for many of the quality of care indicators that were observed in the original evaluation. Women seen in CoEs are more likely to receive physical breast examinations and mammograms (ages > or =50). In addition, positive CoE findings for counseling on domestic violence, sexually transmitted diseases, family or relationship concerns, and sexual function or concerns were upheld. The CoE model of care delivers advantages to women that are not explained by the greater number of female physicians in these settings.

Tracking the course of menstrual life: contributions from the Society for Menstrual Cycle Research.

Abstract: Menstrual experience is often conceptualized primarily as a physiological event. Physiologically the obvious beginning of menstrual life is menarche or the first menstruation which occurs on average at age 13 when activation of the reproductive (hypothalamus-pituitary- adrenal) axis takes place and estradiol and other hormones increase. Menarche occurs mid to late puberty after other developmental events (breast bud development secondary sex characteristics) have occurred. There has been a secular trend toward earlier menarche thought to reflect improved environmental and economic conditions but this trend is believed to have leveled off since the mid-20th century because industrialization is complete. Menopause the date of the final menstrual bleed occurs when the complex regulatory system involving the hypothalamic-pituitary-ovarian axis changes as the ovarian follicles decrease in number. The age at menopause has been relatively constant at least over several decades at just over 51 years for natural menopause with over 90% of women experiencing menopause by age 55. (excerpt)

Context of care and contraceptive method use.

Abstract: Objectives We assessed the relationship between context of care (incorporates insurance status with clinical setting) on contraceptive use among a national sample of reproductive-aged women. Our hypothesis is that compared to privately insured women who receive their health care in private doctors' offices, women who are publicly insured or self-pay and/or receive their health care in a clinic are more likely to use permanent or long-acting contraceptive methods. Methods The study population, consisting of 4,358 women surveyed as part of the 1995 National Survey of Family Growth (NSFG) who were both at risk of unintended pregnancy and currently sexually active, was analyzed using polytomous logistic regression. Results Following adjustment for age, race/ethnicity, marital status, education, income, parity and smoking, there was a trend toward long-acting contraceptive use among women with public insurance or who were self-pay, regardless of clinical setting compared to privately insured women seen in private clinics. Self-pay and publicly insured women of low parity tended to use long-acting contraception, as did privately insured women seen in clinics. Conclusions Insurance information, as well as clinical setting, may guide clinicians' contraceptive decision-making.

The relationship of health care delivery system characteristics and legal factors to mode of delivery in women with prior cesarean section: a systematic review.

Abstract: Objective To evaluate the relationship of health care delivery system characteristics and legal factors to mode of delivery in women with prior cesarean section. Methods We identified relevant studies by searching MEDLINE and HealthSTAR (1980 to May 2002), reference lists of pertinent articles, and recommendations of local and national experts. We also searched the online Cochrane systematic reviews and controlled trials registries, Database of Abstracts and Reviews on Effectiveness, and EMBASE databases. Results Studies of guidelines suggested that opinion leaders influence provider behavior regarding repeat cesarean delivery versus trial of labor decisions. Studies of hospital and insurance characteristics provided inconsistent results. There was insufficient evidence to evaluate the relationship between provider characteristics and delivery outcomes. Legislation and liability-related factors effected limited change. Conclusion Studies of health care system characteristics and other factors focused primarily on rates of delivery modes (vaginal birth after cesarean or repeat cesarean delivery) rather than patient safety or health outcomes. Future studies must account for case mix, time trends, and other potential confounders, especially concerning associations of provider characteristics.

Women's cognitive health: postmenopausal dementia and the women's health initiative memory study.

Abstract: t d a c f S y 2050, it is estimated that 13 million Americans will have Alzheimer disease (AD) (Hebert, Scherr, ienias, Bennett, & Evans, 2003). Milder cognitive mpairment affects between one fifth and one third of lder adults (Lopez, Jagust, DeKosky, et al., 2003) and redicts dementia and subsequent institutionalization Fisk, Merry, & Rockwood, 2003). Medications have een developed specifically for the treatment of cogitive decline, but their benefit has been more modest han hoped for. A better understanding of risk factors or cognitive impairment, as well as treatments to meliorate the condition, is an important public health riority. Postmenopausal women appear to have a greater isk of developing AD than men (Payami, Montee, rimlid, Shattuc, & Kaye, 1996). One explanation elates to women’s lower endogenous estrogen levels fter menopause (Paganini-Hill & Henderson, 1994). nitially, a positive association between exogenous strogen and cognitive performance in nondemented lder women was consistently reported (e.g., Kawas et l., 1997; Maki & Resnick, 2000; Phillips & Sherwin, 991). In addition, meta-analyses of estrogen’s potenial protective effects against dementia found risk eductions of 29% (Yaffe, Sawaya, Lieberburg, &

Making evidence-based decisions in medicine: (or more importantly) using evidence when the case doesn't quite fit

Abstract: e p 1 b m n T m d v c i w v n trying to establish evidence of an impact on health utcomes associated with a new treatment, a randomzed clinical trial (RCT) is undisputedly called the gold tandard—the best evidence you can get from a single tudy. Better yet, a structured meta-analysis of the vidence from several RCTs evaluating the same therpy, such as those conducted under the aegis of the ochrane groups, (cf The Cochrane Collaboration, 003; O’Connor et al., 1999b; O’Connor et al., 2001; lsen et al., 1998) provide the most widely respected cientific basis for estimating the likelihood of achievng any impact on health outcomes (its potential to mprove health or at least avoid the untoward conseuences of untreated disease) as well as estimating armful side effects of the treatment (its potential to arm). There are some standards to assess the helpfulness nd harmfulness of a therapy that take into account he seriousness of the harms and benefits from the reatment as well as their likelihood, and compare it to lternative treatment choices—including no treatent. For example, the Federal Drug Agency has everal explicit standards it uses to evaluate new rugs or to change the status of a drug’s availability rom prescription to over the counter. Various expert anels, such as the Task Force on Preventive Mediine, professional organizations, and consensus roups also attempt to set criteria to help weigh the vidence to arrive at a recommended therapy or

Health care reform and women's interests: present, past, and future.

Abstract: S m i w e o h e t p t t w w nce again the United States may be preparing to take nother serious look at reforming the country’s health are system. News stories recount the plight of those ithout health insurance, reports are issued tabulatng the numbers of the uninsured and the societal osts, and the presidential candidates proffer legislaive successes or plans for covering millions of uninured Americans. Should women be concerned about hether, how, and when the system is changed? And hould they play a part in the changes that are made? he answer to both questions is a resounding yes. We hear a great deal about the uninsured. Many are amiliar with the fact that today 43 million Americans 17% of the under-65 population) are currently uninured (Institute of Medicine, 2004). In 2002, due to conomic woes, we witnessed the largest yearly inrease among the uninsured in a decade. Many lost mployer-based coverage and public forms of health overage were unable to mitigate that loss. Two-thirds f those who are uninsured are from low-income amilies, yet four of five (81%) are in families where dults are working. Coverage at the workplace is often ot available to these individuals who work in lowage jobs. In addition, health insurance is increasngly unavailable and more costly to others whose obs and income are less marginal than those of the orking poor (Kaiser Commission on Medicaid and he Uninsured, December 2003). One of the most common misconceptions about our ealth care system is that those without insurance will omehow find the care they need. Indeed, many do, lthough that care may be delayed and inadequate, utting their health and lives at risk. The federal law that rohibits hospitals from turning away uninsured pa-

Emergency contraception: do we have the political will to increase access?

Abstract: Will the Food and Drug Administration (FDA) ever fully approve emergency contraception for over-the-counter access? And if so will this approval have practical implications for our nation’s health? The answer to these questions is “yes” only if our nation’s political will is available and engaged. On December 16 2003 the FDA’s Reproductive Health Drugs Advisory and Nonprescription Drugs Panel supported (by a 27–4 vote) making Plan B (a type of emergency contraception) available over-the-counter —a major success for public health and reproductive rights advocates in the United States. However on May 6 2004 the FDA struck down the recommendation from its own committee and scientific advisors. Despite empirical evidence that supports the safe use of emergency contraception among women the FDA’s rejection was based on its conclusion that there is not enough research to support the safe use of Plan B by women under 16 years of age without provider supervision. And whereas the FDA rejected the over-the-counter recommendation it left the door open for future work towards the approval of an over-the-counter application. Because women younger than 18 years old have the highest percentage (82–83%) of unintended pregnancy in the United States and because the United States has a higher teen pregnancy rate than other industrialized nations it is imperative that this population has access to safe contraception options and that it is not excluded from future emergency contraception over-the-counter policies. (excerpt)