Pulmonary embolism in menopausal hormone therapy: a population-based register study.

OBJECTIVE: Oral but not transdermal menopausal hormone therapy (MHT) increases the risk of venous thromboembolism. There is no evidence regarding the risk of the serious complication pulmonary embolism (PE). The aim was to investigate the risk of PE in women using MHT depending on administration route, type of progestin and treatment duration. METHOD: The population-based case-control study covered 1,771,253 women aged 40-69 years, during 2006-2015. Diagnoses of PE (n = 13,974) and drug dispensations were received from national validated registers. RESULTS: Current MHT users had a higher risk of PE than non-users (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.05-1.26). First ever users had the highest risk (OR 2.07, 95% CI 1.23-3.50). Transdermal administration was not associated with increased risk of PE. The OR was slightly but non-significantly higher with estrogen combined with medroxyprogesterone acetate than with norethisterone acetate. DISCUSSION: The risk of PE was significantly increased in users of oral but not transdermal MHT, with the highest risk in first ever users of oral estrogen combined with medroxyprogesterone acetate. The risk was considerably lower in women with recurrent treatment, probably because of the healthy user effect. CONCLUSION: PE was most common close to initiation of oral treatment. Transdermal MHT did not increase the risk of PE.

Plasma concentrations of etonogestrel in women using oral desogestrel before and after Roux-en-Y gastric bypass surgery: a pharmacokinetic study.

OBJECTIVE: To investigate whether Roux-en-Y gastric bypass (RYGB) affects oral desogestrel (etonogestrel) pharmacokinetics. DESIGN: Single centre, open label, phase-2 pharmacokinetic study. SETTING: University hospital of Linköping, Sweden. POPULATION: Fourteen women with planned RYGB surgery were included; nine women aged 18-45 years using 75 micrograms desogestrel completed the study. METHODS: Steady-state etonogestrel pharmacokinetic (PK) parameters were measured on three occasions for each individual (at 8 ± 6 weeks before surgery, and at 12 ± 2 and 52 ± 2 weeks after surgery). Each patient served as her own control. On each occasion, serum samples were collected during a 24-hour period and etonogestrel concentrations were determined with ultra-performance liquid chromatography/tandem mass spectrometry. MAIN OUTCOME MEASURES: Area under the plasma concentration time curve of etonogestrel (AUC0-24 hours ). RESULTS: All women had significant postoperative weight loss. There were no significant differences in AUC0-24 hours , terminal half-lives (t½ ), time to peak serum concentrations (Tmax ), or apparent oral clearances of etonogestrel (CLoral ) before and after gastric bypass surgery on any occasion. Peak serum concentrations (Cmax ) increased after 52 ± 2 weeks compared with preoperative values (0.817 ng/ml versus 0.590 ng/ml, P = 0.024). CONCLUSION: To our knowledge, this is the first study to investigate the effects on desogestrel pharmacokinetics after RYGB. This study did not reveal any clinically significant changes in etonogestrel pharmacokinetics, suggesting that oral desogestrel may be used by women after RYGB surgery. The sample size was limited, however, and therefore the results should be interpreted cautiously. TWEETABLE ABSTRACT: The pharmacokinetics of oral desogestrel does not appear to change after gastric bypass surgery.

Pelvic organ prolapse after subtotal and total hysterectomy: a long-term follow-up of an open randomised controlled multicentre study.

OBJECTIVE: To analyse the development of pelvic organ prolapse (POP) after subtotal (SH) and total hysterectomy (TH) in the long-term, and to assess patient-reported symptoms regarding pelvic floor dysfunction (PFD). DESIGN: Long-term follow-up study of a randomised controlled multicentre study. SETTING: Seven hospitals and one private clinic in the south-east of Sweden. POPULATION: Of the 184 women who were eligible from the original trial, 151 (82%) responded to a postal questionnaire and 128 (70%) were clinically examined. METHODS: Postal questionnaire using the short-form version of the Pelvic Floor Distress Inventory (PFDI-20) and clinical examination using the POP-Q system. Multivariate analyses were used. MAIN OUTCOME MEASURES: POP-Q measurements and symptoms of PFD. RESULTS: Follow-up time was a median of 11.3 years. Less than 3% had stage-3 prolapse. No significant difference was found in the presence of stage-2 or higher stage prolapse between the two hysterectomy groups (39% in SH versus 37% in TH; OR 1.28, 95% CI 0.59-2.80). Nor was there any significant difference in the quality-of-life measurement between the SH and TH groups [summary score PFDI-20: median 93 (range 60-201) versus 87 (range 60-186); Fisher's protected least significant difference post hoc test, P = 0.78 ). None of the symptoms of PFD revealed statistically significant differences between the hysterectomy groups. CONCLUSIONS: This long-term follow-up study of PFD showed basically no significant differences in subjective or objective measurements of POP, or in specific pelvic floor quality-of-life aspects after SH and TH. However, because of the low statistical power the results are inconclusive. Larger trials, and probably also a longer follow-up period, are necessary.

Short-term recovery after subtotal and total abdominal hysterectomy--a randomised clinical trial.

OBJECTIVE: To determine whether the day-by-day postoperative recovery differs between women undergoing subtotal and total abdominal hysterectomy, and to analyse factors associated with postoperative recovery and sick leave. DESIGN: A prospective, open, randomised multicentre trial. SETTING: Seven hospitals and one private clinic in the south-east of Sweden. POPULATION: Two-hundred women scheduled for hysterectomy for benign conditions were enrolled in the study, and 178 women completed the study. Ninety-four women were randomised to subtotal abdominal hysterectomy; 84 women were randomised to total abdominal hysterectomy. METHODS: The day-by-day recovery of general wellbeing was measured on a visual analogue scale in a diary 7 days preoperatively and 35 days postoperatively. Psychometric measurements included depression, anxiety and general psychological wellbeing. MAIN OUTCOME MEASURES: Effects of operating method and preoperative wellbeing on the day-by-day recovery and duration of sick leave. RESULTS: No significant difference was found in the day-by-day recovery between operating methods. The day-by-day recovery of general wellbeing and duration of sick leave was strongly associated with the occurrence of minor complications, but not with major complications. The level of psychological wellbeing preoperatively was strongly associated with the day-by-day recovery of general wellbeing and duration of sick leave. CONCLUSIONS: Day-by-day recovery of general wellbeing is no faster in subtotal versus total abdominal hysterectomy. Independent of operation method there is an interaction between preoperative psychological wellbeing, postoperative recovery of general wellbeing and the duration of sick leave. Postoperative complications and preoperative psychological wellbeing are strong determinants for the duration of sick leave. There is a need for intervention studies with a focus on complications and preoperative wellbeing.

A 1-year follow up of psychological wellbeing after subtotal and total hysterectomy--a randomised study.

OBJECTIVE: To compare subtotal abdominal hysterectomy (SH) and total abdominal hysterectomy (TH) regarding influence on postoperative psychological wellbeing and surgical outcome measurements. DESIGN: A prospective, open, randomised multicentre trial. SETTING: Seven hospitals and one private clinic in the south-east of Sweden. POPULATION: Two-hundred women scheduled for abdominal hysterectomy for benign conditions were enrolled in the study; 179 women completed the study (94 SH and 85 TH). METHODS: Four different psychometric tests were used to measure general wellbeing, depression and anxiety preoperatively, and at 6 and 12 months postoperatively. Statistical analysis of variance and covariance were used. MAIN OUTCOME MEASURES: Effects of operating method on psychological wellbeing postoperatively. Analysis of demographic, clinical and surgical data, including peri- and postoperative complications and complaints at follow up. RESULTS: No significant differences were observed between the two groups in any of the psychometric tests. Both surgical methods were associated with a significantly higher degree of psychological wellbeing at 6 and 12 months postoperatively, compared with preoperatively. No significant differences were found in the clinical measures including complications. A substantial number of women experienced persistent cyclic vaginal bleedings after SH. Neither minor or major postoperative complications, nor serum concentration of sex hormones, were associated with general psychological wellbeing 12 months after the operation. CONCLUSIONS: General psychological wellbeing is equally improved after both SH and TH within 12 months of the operation, and does not seem to be associated with the occurrence of peroperative complications or serum concentration of sex hormones.

Weight gain restriction for obese pregnant women: a case-control intervention study.

OBJECTIVE: To minimise obese women's total weight gain during pregnancy to less than 7 kg and to investigate the delivery and neonatal outcome. DESIGN: A prospective case-control intervention study. SETTING: Antenatal care clinics in the southeast region of Sweden. POPULATION: One hundred fifty-five pregnant women in an index group and one hundred ninety-three women in a control group. METHODS: An intervention programme with weekly motivational talks and aqua aerobic classes for obese pregnant women. MAIN OUTCOME MEASURES: Weight gain in kilograms, delivery and neonatal outcome. RESULTS: The index group had a significantly lower weight gain during pregnancy compared with the control group (P < 0.001). The women in the index group weighed less at the postnatal check-up compared with the weight registered in early pregnancy (P < 0.001). The percentage of women in the index group who gained less than 7 kg was greater than that of women in the control group who gained less than 7 kg (P= 0.003). The percentage of nulliparous women in this group was greater than that in the control group (P= 0.018). In addition, the women in the index group had a significantly lower body mass index at the postnatal check-up, compared with the control group (P < 0.001). There were no differences between the index group and the control group regarding birthweight, gestational age and mode of delivery. CONCLUSION: The intervention programme was effective in controlling weight gain during pregnancy and did not affect delivery or neonatal outcome.

Follow-up of patients with low back pain during pregnancy.

OBJECTIVE: To identify the long-term risk for low back pain among women with previous severe low back pain during pregnancy. METHODS: In a previous prospective study, 79 pregnant women developed low back pain severe enough to require sick leave. Twelve years later a questionnaire was sent to 62 of these women and 84 controls who did not develop severe low back pain during pregnancy. The questionnaire asked about occupation, low back pain in general and during later pregnancies, and sick leave due to low back pain. There were also questions regarding use of oral contraceptives and its possible relation to low back pain. RESULTS: The response rate was 84% in the back pain group and 80% among controls. The two groups were similar according to the percentage of women having had another pregnancy (33 of 52 [63%] versus 39 of 67 [58%]) but ten (19%) of the women with previous low back pain stated they had refrained from another pregnancy because of their fear of low back pain compared with only one control. Almost all women (31 of 33) with previous severe low back pain experienced the same symptoms in a subsequent pregnancy, compared with 17 of 39 (44%) controls. Even when they were not pregnant, women with previous low back pain suffered more often and used more sick leave due to low back pain (44 of 52 versus 43 of 67, chi2 = 5.68, P < .05). The location (sacroiliac joint or lumbar affection) of the previous low back pain did not affect the long-term prognosis. In a logistic regression model, previous low back pain during pregnancy was the only independent risk factor for low back pain during a subsequent pregnancy, whereas an occupation involving physical demand did not affect the results. However, together with previous low back pain during pregnancy, heavy occupation increased the risk for current nonpregnant low back pain. CONCLUSION: Women with severe low back pain during pregnancy have an extremely high risk for experiencing a new episode of severe low back pain during another pregnancy and when not pregnant.

Hormone replacement therapy and previous use of oral contraceptives among Swedish women.

OBJECTIVES: To assess the current and previous use of hormone replacement therapy (HRT) and alternative remedies in a postmenopausal population and to relate HRT use to previous use of oral contraceptives. MATERIAL AND METHODS: All 1323 women living in Linköping of 55 or 56 years old during 1995 were sent a questionnaire asking for data with relation to health and climacteric symptoms as well as to previous and current use of HRT, oral contraceptives and alternative remedies. RESULTS: Current use of HRT was more common among women who previously used oral contraceptives (41.3%) than among women who had never used oral contraceptives (23.1%). HRT users were also more often physically active, had undergone hysterectomy and had lighter occupation than non-users. Of all women 35% were current users of HRT, half of them for at least 2 years, whereas only 5% had tried HRT and abandoned therapy. Alternative remedies were used by 5% of the women as therapy for climacteric complaints, and about four times as many women had tried such therapy but abandoned it. The only characteristic about use of alternative medicines was that they were used less often by women who had been hysterectomized. No women treated for breast cancer used HRT and only few of them used alternative remedies. CONCLUSIONS: The prevalence of HRT use, as well as compliance, was high. Previous use of oral contraceptives probably affected the attitude towards using HRT.

Collagen metabolism markers as a reflection of bone and soft tissue turnover during the menstrual cycle and oral contraceptive use.

Two different groups of women, 23 healthy young adults and 13 women with chronic posterior pelvic pain, were studied before and during use of oral contraceptives (OC). Collagen metabolism markers-here, the amino-terminal propeptide of type I procollagen, the carboxy-terminal telopeptide of type I collagen, and the amino-terminal of procollagen type III-as well as hormones and other endocrine factors indicating the balance between androgen expression/anabolism and catabolism of the subjects (testosterone, sex-hormone binding globulin, and insulin-like growth factor I were measured. Type I procollagen, the carboxy-terminal telopeptide of type I collagen, and the amino-terminal of procollagen type III were all significantly decreased during OC use. These findings implicate OC use-induced changes in collagen type I and III turnover. A shift in the anabolic/catabolic balance was also recorded indicating a less anabolic situation during OC use.

Is hormone replacement therapy a risk factor for low back pain among postmenopausal women?

STUDY DESIGN: Cross-sectional study with two age cohorts. OBJECTIVE: To assess whether women receiving hormone replacement therapy after menopause have a higher prevalence of back problems than women who do not receive such treatment. BACKGROUND: Back pain is a common medical problem throughout life and especially during pregnancy. Hormonal factors have been proposed as a possible contributor. PATIENTS AND METHODS: A validated postal questionnaire was sent in early 1995 to all 1324 women of 55 years and 56 years of age residing in Linköping, Sweden. This questionnaire included questions about current hormone replacement treatment, previous and current back problems, medical care for back problems, parity, exercise and smoking habits, and occupation. RESULTS: The questionnaire was returned by 84.7% of the women. There was a significant, albeit weak, positive association between current use of hormone replacement treatment and low back pain. Previous back problems during pregnancy was a strong risk factor for current back pain, whereas neither current smoking nor regular physical exercise was a risk factor according to multiple logistic regression analysis. The interaction of smoking and an occupation involving heavy lifting significantly affected back pain. CONCLUSIONS: Women receiving hormone replacement treatment had a slightly, but significantly, higher prevalence of current back pain than nonusers (48% vs. 42%, respectively, P < 0.05), which could not be explained by differences in occupation, smoking habits, or current physical activity. Although the association between hormone replacement therapy and back problems is weak and probably of minor clinical importance, it is speculated that hormonal effects on joints and ligaments may be involved.

[Estrogen and natural products in the treatment of postmenopausal complaints. Oral contraceptives prepare the way for hormonal substitution]. / Ostrogen och naturmedel vid postmenopausala besvär. P-piller banar väg för hormonsubstitution.

To chart current and previous use of hormone replacement therapy (HRT) and alternative remedies in a postmenopausal population, in relation to previous oral contraceptive (OC) usage, all 1,323 55-56-year-old women living in Linköping in 1995 were sent a questionnaire concerning health status and climacteric symptoms, and previous and/or current use of HRT, OCs and alternative remedies. Current HRT was more common among previous OC users than among those who had never used OCs (41.4 vs. 23.1 percent). As compared with non-HRT users, HRT users were characterised by greater physical activity but less strenuous occupations, and a higher prevalence of hysterectomy. Of the series as a whole, 35 per cent were currently on HRT, half of them having been so for at least two years, and only 5 per cent had abandoned HRT after trying it for some time. Alternative remedies were used by 5 per cent of the women as therapy for climacteric complaints, but about four times as many women had tried such therapy and abandoned it. The sole characteristic feature of alternative remedy usage was that it was less common among hysterectomised women. Of women treated for breast cancer, none used HRT and few used alternative remedies. Thus, in this postmenopausal population, the prevalence of HRT was high, as was the level of compliance. Previous OC usage was probably a determinant of current attitudes toward HRT.

Effects of acupuncture, applied relaxation, estrogens and placebo on hot flushes in postmenopausal women: an analysis of two prospective, parallel, randomized studies.

OBJECTIVE: To assess if transdermal or oral estrogens, acupuncture and applied relaxation decrease the number of menopausal hot flushes/24 h and improve climacteric symptoms, as assessed by the Kupperman index, more than transdermal placebo treatment. SETTING: An outpatient clinic at a Swedish university hospital. METHODS: A total of 102 postmenopausal women were recruited to two studies performed in parallel. In Study I, the women were randomized between transdermal placebo or estrogen treatment and, in Study II, between oral estrogens, acupuncture or applied relaxation for 12 weeks. Climacteric symptoms were measured with daily logbooks on hot flushes. Women completed the assessment questionnaire for the Kupperman index at baseline and after 12 weeks. RESULTS: The number of flushes/24 h decreased significantly after 4 and 12 weeks in all groups except the placebo group. Both at 4 and 12 weeks, acupuncture decreased the number of flushes more (p<0.05; p<0.01, respectively) than placebo. At 12 weeks, applied relaxation decreased the number of flushes more (p<0.05) than placebo. The Kupperman index score decreased in all groups except the placebo group. The decrease in score was significantly greater in all treatment groups than in the placebo group (p<0.01). CONCLUSION: Acupuncture and applied relaxation both reduced the number of hot flushes significantly better than placebo and should be further evaluated as alternatives to hormone therapy in women with menopausal vasomotor complaints.

Influence of obesity on the use of sickness absence and social benefits among pregnant working women.

OBJECTIVE: To evaluate if obesity in early pregnancy has any possible impact on the capacity of pregnant women to engage in gainful employment. METHODS: Register data from a database on sickness absence and pregnancy benefit and parental benefit claims were combined with type of occupation and body mass index (BMI) for 693 women consecutively delivered during the course of one year at a county hospital in Sweden. RESULTS: The results showed the lowest BMI among women who had administrative jobs and the highest BMI in women who undertook more burdensome and heavy types of manual work. A significant increase in BMI was also seen among those pregnant women who were registered as unemployed. The finding that in the manual types of occupation, obese pregnant women took almost twice as many days of leave provided by the parental benefit programme as did women with a BMI of <25, indicates that obese pregnant women perhaps do not have the same physical endurance required to manage the combined demands of work and pregnancy. No differences were found with regard to sickness absence between obese women and pregnant women with normal BMI; however, differences were found between different occupational groups. CONCLUSIONS: Our study indicates that a woman's BMI at the beginning of pregnancy is associated with her occupational status. Obesity among pregnant women may well be used as a psychosocial indicator as obesity correlates with social and economic problems. Any planned weight reduction programme in antenatal care must therefore consider this important psychosocial aspect.

Trends in body mass index during early pregnancy in Swedish women 1978-2001.

OBJECTIVE: To study the body mass index (BMI) in women seeking maternity health care during early pregnancy in Sweden, and to show trends for a period of more than 20 years. STUDY DESIGN: Register study. METHODS: Data from the maternity health programme on consecutively delivered women in two Swedish hospitals were collected for the years 1978, 1986, 1992, 1997 and 2001. All women were weighed at their first midwife visit between 8 and 10 weeks of gestation and height was also measured. RESULTS: Data on 4883 women were collected. Data on weight were available for 4490 (92%) women and data on BMI were available for 4378 (90%) women. The age-adjusted average weight increased from 59.5 kg in 1978 to 68.2 kg in 2001, and the BMI increased from 21.7 in 1978 to 24.7 in 2001. In 2001, 38.6% of the women had a BMI >25 compared with 11.2 in 1978. In 2001, 11.6% of the women were obese compared with 2.2% in 1978. CONCLUSIONS: During the last two decades, an alarming increase in weight has occurred in Swedish women of childbearing age.

Oral contraceptives and low back pain. Attitudes among physicians, midwives and physiotherapists.

BACKGROUND: Only few indications have appeared in the literature concerning a possible relationship between the use of oral contraceptives and low back pain. In our daily work we often meet women who have been recommended to abandon their use of oral contraceptives depending on coexisting low back pain. In order to assess the opinions of a possible relationship between oral contraceptives and low back pain this study was undertaken. METHODS: A validated questionnaire was sent out to physicians, physiotherapists and midwives dealing with either contraceptive counselling or low back pain. A modified questionnaire was sent to medical- and physiotherapist students to assess whether the opinions were a result of the education or the working experience. RESULTS: A total of 225 questionnaires were sent out and 206 (91%) were returned. Sixteen percent thought there was a relationship between the use of oral contraceptives and risk of low back pain. Thirty percent had seen patients with low back pain that was interpreted as being affected by use of oral contraceptives. Twenty-five percent recommended at least some patients with low back pain to change their contraceptive method. Among the students there was a difference in opinion between the first and the last year students indicating that their opinions had been influenced by their education. CONCLUSIONS: Evidently many professionals dealing with oral contraceptives and low back pain believe that there is a relationship between oral contraceptives and low back pain, despite the lack of scientific evidence. These recommendations might influence the contraceptive safety for the individual woman and the possible relationship between use of oral contraceptives and low back pain should therefore be more thoroughly investigated before general recommendations are given.

Postural corrections after standardised perturbations of single limb stance: effect of training and orthotic devices in patients with ankle instability.

OBJECTIVE: Soccer players with functional instability of the ankle joint have shown impairment of postural control in single limb stance. The aim of this study was to examine the effect of stance perturbation. METHODS: A standardised method for the study of postural corrections after perturbation (Equitest) was used. Female soccer players with and without functional instability were examined. RESULTS: The subjects showed a relative change from ankle to hip synergy at medially directed translations of the support surface. This impairment was restored after eight weeks of ankle disk training. The effect of a shoe and brace did not exceed the effect of the shoe alone. CONCLUSIONS: Functional instability seems to be related to impaired ability to retain equilibrium in single limb stance by means of ankle corrections. A positive effect of ankle disk training leading to functional restoration was confirmed.

Previous injuries and persisting symptoms in female soccer players.

One hundred and fifty players in a female senior soccer division, starting up a new season, were examined for past injuries and persisting symptoms. An incidence of 0.18 injury/player/year was found, which is not significantly different from previously reported injury rates for male soccer. Sprains to the lower extremity and shin-splints were the most common previous injuries. Forty-three percent of the players had some kind of persistent symptom as a result of a past injury. Symptoms from previous ankle and knee sprains and from overuse injuries were the most common. Players who had sustained an ankle joint injury were more prone to have persistent symptoms (p less than 0.05) if they had persistent mechanical instability. Compared to previous retrospective studies on men's soccer, the women showed a higher rate of previous patellar dislocations. These injuries often caused persistent symptoms. The women showed fewer serious knee injuries. This might depend on a real difference in incidence or is just a reflection of female players ceasing to play soccer after a severe knee injury.