Examining the relationship between uterine fibroids and dyspareunia among premenopausal women in the United States.

INTRODUCTION: Despite estimates of a high prevalence of deep dyspareunia (DD) among women in the United States, risk factors for this important area of sexual dysfunction have been largely understudied. AIMS: The purpose of this study was to examine the relationship between uterine fibroids and the prevalence of DD. METHODS: We used data from the Uterine Fibroid Study (enrollment 1996-1999 in a U.S. metropolitan area). Participating women were ages 35-49 and were randomly selected from the membership rolls of a prepaid health plan. Women were asked to provide detailed health information including a symptom questionnaire with questions about DD and to have a study ultrasound to screen for fibroids ≥ 0.5 cm in diameter. The analysis included 827 women, after restriction to participants who were premenopausal with an intact uterus, sexually active, completed the symptom questionnaire, and had fibroid status adequately assessed. Logistic regression was conducted to estimate the adjusted prevalence odds ratio (aPOR) for the association of DD with presence of fibroids after adjusting for age, ethnicity, education, depression, physical activity, parity, and pelvic pathology. MAIN OUTCOME MEASURE: Our main outcome measures were the presence and severity of DD. RESULTS: The presence of fibroids was significantly associated with DD (aPOR = 1.7 95% confidence interval [CI] 1.1, 2.5). The aPOR was stronger for severe DD, DD that interfered with normal activity "some" or "a lot" (aPOR = 3.1 95% CI 1.2, 8.2). However, there was not a significant dose response relationship between fibroid burden (measured by uterine volume) and DD. Fundal fibroids were more strongly associated with DD than other fibroids. Additional factors associated with significantly elevated odds of DD were parity, depression, younger age, and pelvic pathology. CONCLUSION: Our results suggest that fibroids are associated with DD. The association may not be causal but may reflect shared etiology and/or pathologic pathways.

Intraobserver variability in fibroid size measurements: estimated effects on assessing fibroid growth.

OBJECTIVES: To evaluate intraobserver variability of fibroid sonographic measurements and apply this factor to fibroid growth assessment. METHODS: Study participants were African American women aged 23 to 34 years who had never had a diagnosis of uterine fibroids. All participants underwent transvaginal sonography to screen for the presence of previously undiagnosed fibroids (≥0.5 cm in diameter). The diameters of up to 6 fibroids were measured in 3 perpendicular planes at 3 separate times during the examinations by experienced sonographers. Intraobserver variability as measured by the coefficient of variation (CV) for fibroid diameter and volume was calculated for each fibroid, and factors associated with the CV were assessed by regression models. The impact of variability on growth assessment was determined. RESULTS: Ninety-six of 300 women screened were found to have at least 1 fibroid, yielding a total of 174 fibroids for this analysis. The mean CV for the 3 measurements of fibroid maximum diameter was 5.9%. The mean CV for fibroid volume was 12.7%. Fibroid size contributed significantly to intraobserver variability (P = .04), with greater variability for smaller fibroids. Fibroid type (submucosal, intramural, or subserosal) was not important. Fibroids from the same woman tended to have similar measurement variability when assessed for volume but not for maximum diameter. Calculations showed that when following up fibroids, as much as a 20% increase in diameter could be due to measurement error, not "true growth." CONCLUSIONS: A small fibroid must have a greater change in size than a large fibroid to conclude that it is growing, but even for small fibroids an increase in diameter of greater than 20% is likely to indicate true growth, not measurement variability.

Factors associated with low-lying intrauterine devices: a cross-sectional ultrasound study in a cohort of African-American women.

OBJECTIVE: The object of this study is to examine factors and symptoms associated with low-lying IUDs as defined by ultrasound. STUDY DESIGN: This is a cross-sectional sub-study of participants in the Study of Environment, Life-style, and Fibroids (SELF). SELF participants had screening ultrasounds for fibroids at study enrollment; those with an IUD in place are included in this sub-study. Low-lying IUDs were identified and localized. Logistic regression was used to identify factors and symptoms associated with low-lying IUDs. RESULTS: Among 168 women with IUDs at ultrasound, 28 (17%) had a low-lying IUD. Having a low-lying IUD was associated with low education level (≤high school: aOR 3.1 95% CI 1.14-8.55) and with increased BMI (p=.002). Women with a low-lying IUD were more likely to report a "big problem" with dysmenorrhea (the highest option of the Likert scale) as compared to women with a normally-positioned IUD (OR 3.2 95% CI 1.07-9.54). CONCLUSION: Our study found that women with a low-lying IUD are more likely to be of lower education and higher BMI, and to report more dysmenorrhea. IMPLICATIONS: Women who are obese may benefit from additional counseling and closer follow-up after IUD placement. Future research is warranted to investigate IUD placement and possible IUD migration among women who are obese.

Perinatal outcomes among Asian American and Pacific Islander women.

OBJECTIVE: The purpose of this study was to examine perinatal outcomes between Asian American and Pacific Islander subgroups. STUDY DESIGN: This is a retrospective study of all Asian American/Pacific Islander women who were delivered at Stanford University Medical Center from 1998 to 2003. Asian American women were subdivided into the following groups: Indian/Pakistani, Chinese, Filipino, Japanese, Korean, Pacific Islanders (individuals from Tonga, Samoa, Guam, or Polynesia), and Vietnamese. Perinatal outcomes included gestational hypertension/preeclampsia, gestational diabetes mellitus, preterm delivery, cesarean delivery, birthweight <2500 g, and birthweight >4000 g. RESULTS: In the study population of 3779 Asian American women, there were statistically significant differences (P < .01) between most of the outcomes that were examined. Filipina women had the highest risk of gestational hypertension/preeclampsia (adjusted odds ratio, 2.21); Indian/Pakistani women had the highest risk of preterm delivery (adjusted odds ratio, 1.67), gestational diabetes mellitus (adjusted odds ratio, 1.39), and low birthweight at term (adjusted odds ratio, 2.30); and Pacific Islander women had the highest risk of macrosomia (adjusted odds ratio, 3.67). CONCLUSION: Significant differences in perinatal outcomes exist between subgroups of the Asian American and Pacific Islander community. Future research on race/ethnicity and perinatal outcomes should examine heterogeneity among these groups before collapsing these individual subgroups into the larger group "Asian." Individuals should be counseled regarding perinatal risk according to their specific Asian subgroup.

Is grandmultiparity an independent risk factor for adverse perinatal outcomes?

OBJECTIVE: To compare maternal and neonatal outcomes among grandmultiparous women to those of multiparous women 30 years or older. METHODS: A database of the vast majority of maternal and newborn hospital discharge records linked to birth/death certificates was queried to obtain information on all multiparous women with a singleton delivery in the state of California from January 1, 1997 through December 31, 1998. Maternal and neonatal pregnancy outcomes of grandmultiparous women were compared to multiparous women who were 30 years or older at the time of their last birth. RESULTS: The study population included 25,512 grandmultiparous and 265,060 multiparous women 30 years or older as controls. Grandmultiparous women were predominantly Hispanic (56%). After controlling for potential confounding factors, grandmultiparous women were at significantly higher risk for abruptio placentae (odds ratio OR: 1.3; 95% confidence intervals CI: 1.2-1.5), preterm delivery (OR: 1.3; 95% CI: 1.2-1.4), fetal macrosomia (OR: 1.5; 95% CI: 1.4-1.6), neonatal death (OR: 1.5; 95% CI: 1.3-1.8), postpartum hemorrhage (OR: 1.2; 95% CI: 1.1-1.3) and blood transfusion (OR: 1.5; 95% CI: 1.3-1.8). CONCLUSION: Grandmultiparous women had increased maternal and neonatal morbidity, and neonatal mortality even after controlling for confounders, suggesting a need for closer observation than regular multiparous patients during labor and delivery.

Self-reported family history of leiomyoma: not a reliable marker of high risk.

PURPOSE: To examine the importance of self-reported family history of uterine leiomyoma (fibroids) as a marker of risk. METHODS: Women, aged 35 to 49, were randomly selected from the membership of a large, urban health plan. Participants completed a self-administered questionnaire about family history of fibroids. Ultrasound screening for fibroids followed, regardless of whether participants had been previously diagnosed (660 black, 412 white). Data for each ethnic group were analyzed separately using Poisson regression. RESULTS: In both ethnic groups, women who reported a family history of fibroids had an elevated risk of fibroids compared with those without family history. However, no elevated risk was apparent for cases who did not know they had fibroids when they reported the family history information. CONCLUSIONS: Many women may first learn about their family history of fibroids when discussing their own clinical diagnosis with family members. Such bias would invalidate self-reported family history as a predictor of fibroid risk. As new pharmacologic treatments for fibroids are developed, women at high risk of fibroids would benefit from early screening and pharmacologic treatment to delay development of large fibroids and reduce the need for invasive treatments. Self-reported family history is not useful for identifying high-risk women.