Breastfeeding history and adenomyosis risk using a novel case-control study design.

OBJECTIVE: To evaluate the association between breastfeeding history, including lifetime exclusive breastfeeding, and risk of adenomyosis. DESIGN: We used data from a case-control study designed with 2 control groups to address the challenge of selecting noncases for a valid epidemiologic study when cases are identified by hysterectomy. The case-control study was conducted among premenopausal and postmenopausal enrollees aged 18-59 years in a large, integrated health care system in western Washington state. PATIENT(S): Cases were enrollees with incident, pathology-confirmed adenomyosis diagnosed during 2001-2006 (n = 386). The 2 control groups were as follows: (1) randomly selected age-matched enrollees with intact uteri ("population controls," n = 323) and (2) hysterectomy controls (n = 233). INTERVENTION(S): Data on breastfeeding history were collected by in-person interviews. For each reported live birth, participants were asked whether they breastfed, along with infant age at supplemental feeding introduction and breastfeeding discontinuation. MAIN OUTCOME MEASURE(S): Among participants with at least 1 live birth (330 cases, 246 population controls, and 198 hysterectomy controls), we used unconditional logistic regression to estimate adjusted odds ratios and 95% confidence intervals (CIs) for the associations between the following: (1) ever breastfeeding, (2) ever breastfeeding for ≥8 weeks, (3) lifetime breastfeeding, and (4) lifetime exclusive breastfeeding and risk of adenomyosis. Analyses were adjusted for age, reference year, smoking, education, and parity. RESULT(S): In analyses comparing cases with population controls, we observed a 40% decreased odds of adenomyosis with a history of ever breastfeeding (adjusted odds ratio, 0.6; 95% CI, 0.3-1.0) and breastfeeding for ≥8 weeks (adjusted odds ratio, 0.6; 95% CI, 0.4-0.8). The strongest associations, 60%-70% decreased odds of adenomyosis, were observed with ≥12 months of lifetime breastfeeding (vs. <3 months) (adjusted odds ratio, 0.4; 95% CI, 0.2-0.6) and 9 to <12 months of lifetime exclusive breastfeeding (vs. <3 months) (adjusted odds ratio, 0.3; 95% CI, 0.2-0.6), comparing cases to population controls. In analyses using hysterectomy controls, we observed similar patterns of associations slightly attenuated in magnitude. CONCLUSION(S): Breastfeeding history was associated with a 40% decreased odds of adenomyosis, a condition that can confer substantial morbidity and requires hysterectomy for definitive treatment. The consistency of our findings with that of a previous study lends support that breastfeeding may modify risk of adenomyosis.

Early-life factors and endometriosis risk.

OBJECTIVE: To study early-life factors in relation to endometriosis risk in adulthood. DESIGN: Population-based case-control study. SETTING: Integrated healthcare system. PATIENT(S): Cases (n = 310) were women diagnosed for the first time with endometriosis between the years 1996 and 2001, and controls (n = 727) were women without a diagnosis of endometriosis randomly selected from the healthcare system population. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for the associations between intrauterine diethylstilbestrol (DES) exposure, maternal smoking, mother's age at delivery, firstborn status, birth weight, fetal number, prematurity, and regular soy formula feeding during infancy and endometriosis were estimated using unconditional logistic regression, adjusting for frequency matching and confounding variables. Information on early-life factors was ascertained retrospectively by in-person interview, with information on maternal DES use and regular soy formula feeding directly gathered from the participant's mother or other family member. RESULT(S): We observed that women who were regularly fed soy formula as infants had more than twice the risk of endometriosis compared with unexposed women (aOR 2.4, 95% CI 1.2-4.9). Our data also suggested increased endometriosis risk with prematurity (aOR 1.7, 95% CI 0.9-3.1) and maternal use of DES (OR 2.0, 95% CI 0.8-4.9, adjusting only for frequency matching variables), although these confidence intervals included the null. CONCLUSION(S): Our results support the hypothesis that disruption of development during fetal and infant periods may increase the risk of endometriosis in adulthood.

A population-based case-control study of urinary bisphenol A concentrations and risk of endometriosis.

STUDY QUESTION: Is bisphenol A (BPA) exposure associated with the risk of endometriosis, an estrogen-driven disease of women of reproductive age? SUMMARY ANSWER: Our study suggests that increased urinary BPA is associated with an increased risk of non-ovarian pelvic endometriosis, but not ovarian endometriosis. WHAT IS KNOWN ALREADY: BPA, a high-volume chemical used in the polymer industry, has been the focus of public and scientific concern given its demonstrated estrogenic effects in vivo and in vitro and widespread human exposure. Prior studies of BPA and endometriosis have yielded inconsistent results and were limited by the participant sampling framework, small sample size or use of serum (which has very low/transient concentrations) instead of urine to measure BPA concentrations. STUDY DESIGN, SIZE, DURATION: We used data from the Women's Risk of Endometriosis study, a population-based case-control study of endometriosis, conducted among female enrollees of a large healthcare system in the US Pacific Northwest. Cases were women with incident, surgically confirmed endometriosis diagnosed between 1996 and 2001 and controls were women randomly selected from the defined population that gave rise to the cases, without a current or prior diagnosis of endometriosis. PARTICIPANTS/MATERIALS, SETTINGS, METHODS: Total urinary BPA concentrations were measured in 143 cases and 287 population-based controls using single, spot urine samples collected after disease diagnosis in cases. Total urinary BPA concentration (free and conjugated species) was quantified using a high-performance liquid chromatography-mass spectrometry method. We estimated odds ratios (ORs) and 95% confidence intervals (CIs) using unconditional logistic regression, adjusting for urinary creatinine concentrations, age and reference year. We also evaluated the association by disease subtypes, ovarian and non-ovarian pelvic endometriosis, that may be etiologically distinct. MAIN RESULTS AND THE ROLE OF CHANCE: We did not observe a statistically significant association between total urinary BPA concentrations and endometriosis overall. We did observe statistically significant positive associations when evaluating total urinary BPA concentrations in relation to non-ovarian pelvic endometriosis (second versus lowest quartile: OR 3.0; 95% CI: 1.2, 7.3; third versus lowest quartile: OR 3.0; 95% CI: 1.1, 7.6), but not in relation to ovarian endometriosis. LIMITATIONS, REASONS FOR CAUTION: Given the short elimination half-life of BPA, our study was limited by the timing of collection of the single urine sample, that occurred after case diagnosis. Thus, our BPA measurements may not accurately represent the participants' levels during the etiologically relevant time period for endometriosis development. In addition, since it was not feasible in this population-based study to surgically confirm the absence of disease, it is possible that some controls may have had undiagnosed endometriosis. WIDER IMPLICATIONS OF THE FINDINGS: By using population-based data, it is more likely that the controls represented the underlying frequency of BPA exposure in contrast to prior studies that used for comparison control women undergoing surgical evaluation, where the indication for surgery may be associated with BPA exposure. The significant associations observed in this study suggest that BPA may affect the normal dynamic structural changes of hormonally responsive endometrial tissue during the menstrual cycle, promoting the establishment and persistence of refluxed endometrial tissue in cases with non-ovarian pelvic endometriosis. Further research is warranted to confirm our novel findings in endometriosis subtypes that may be etiologically distinct. STUDY FUNDING/COMPETING INTERESTS: This work was supported by the National Institutes of Health, National Institute of Environmental Health Sciences (grant number R03 ES019976), the Eunice Kennedy Shriver National Institute of Child Health and Human Development (grant number R01 HD033792); US Environmental Protection Agency, Science to Achieve Results (STAR) (grant number R82943-01-0) and National Institute of Nursing Research (grant number F31NR013092) to KU for training support. This work was supported in part by the Intramural Research Program of the National Institutes of Health, National Institute of Environmental Health Sciences. The content is solely the responsibility of the authors and does not necessarily represent the official view of the National Institute of Child Health and Human Development, National Institute of Environmental Health Sciences, National Institute of Nursing Research or the National Institutes of Health. The authors have no actual or potential competing financial interests. TRIAL REGISTRATION NUMBER: Not applicable.

Placenta accreta and maternal morbidity in the Republic of Ireland, 2005-2010.

OBJECTIVE: To describe the nationwide prevalence of placenta accreta and to quantify its impact on maternal morbidity. METHODS: Using discharge data for public hospitals in Ireland, years 2005-2010, deliveries with placenta accreta were identified using ICD-10-AM code for morbidly adherent placenta and compared with deliveries without the condition. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were estimated using logistic regression. RESULTS: Placenta accreta prevalence increased 34% from 2005 to 2010 (7.9/10 000 deliveries versus 10.6/10 000 deliveries). This condition was associated with a substantial increased risk of hemorrhage (aOR: 16.6, 95% CI: 13.4-20.5), hysterectomy (aOR: 950.6, 95% CI: 632.9-1427.9), procedures to reduce uterine blood flow (aOR: 72.4, 95% CI: 35.1-149.4), transfusion (aOR: 41.8, 95% CI: 33.4-52.2), anemia (aOR 15.1, 95% CI: 10.8-21.0), abdominal organ injury (aOR: 8.2, 95% CI: 5.2-13.1), bladder surgery (aOR: 38.5, 95% CI: 21.8-68.1), mechanical ventilation (aOR: 63.2, 95% CI: 28.4-140.6), intensive care unit admission (aOR: 41.3, 95% CI: 30.0-56.9), and co-existing placenta previa (aOR: 23.2, 95% CI: 16.8-31.8) as well as increased risk of cesarean section, longer hospitalization and stillbirth. CONCLUSIONS: To our knowledge, this is the first study to use a comparison group of deliveries without placenta accreta and quantitatively illustrate with odds ratios the profound adverse health effects of this condition on the mother.

Organochlorine pesticides and risk of endometriosis: findings from a population-based case-control study.

BACKGROUND: Endometriosis is considered an estrogen-dependent disease. Persistent environmental chemicals that exhibit hormonal properties, such as organochlorine pesticides (OCPs), may affect endometriosis risk. OBJECTIVE: We investigated endometriosis risk in relation to environmental exposure to OCPs. METHODS: We conducted the present analyses using data from the Women's Risk of Endometriosis (WREN) study, a population-based case-control study of endometriosis conducted among 18- to 49-year-old female enrollees of a large health care system in western Washington State. OCP concentrations were measured in sera from surgically confirmed endometriosis cases (n = 248) first diagnosed between 1996 and 2001 and from population-based controls (n = 538). We estimated odds ratios (OR) and 95% CIs using unconditional logistic regression, adjusting for age, reference date year, serum lipids, education, race/ethnicity, smoking, and alcohol intake. RESULTS: Our data suggested increased endometriosis risk associated with serum concentrations of ß-hexachlorocyclohexane (HCH) (third vs. lowest quartile: OR = 1.7; 95% CI: 1.0, 2.8; highest vs. lowest quartile OR = 1.3; 95% CI: 0.8, 2.4) and mirex (highest vs. lowest category: OR = 1.5; 95% CI: 1.0, 2.2). The association between serum ß-HCH concentrations and endometriosis was stronger in analyses restricting cases to those with ovarian endometriosis (third vs. lowest quartile: OR = 2.5; 95% CI: 1.5, 5.2; highest vs. lowest quartile: OR = 2.5; 95% CI: 1.1, 5.3). CONCLUSIONS: In our case-control study of women enrolled in a large health care system in the U.S. Pacific Northwest, serum concentrations of ß-HCH and mirex were positively associated with endometriosis. Extensive past use of environmentally persistent OCPs in the United States or present use in other countries may affect the health of reproductive-age women.

Genetic variation in the sex hormone metabolic pathway and endometriosis risk: an evaluation of candidate genes.

OBJECTIVE: To evaluate the relationship between common genetic variation in genes involved in the biosynthesis and signaling of estrogen and progesterone and endometriosis risk. DESIGN: Genetic polymorphism analysis. SETTING: Population-based case-control study conducted in Group Health Cooperative enrollees in western Washington. PATIENT(S): Women with newly diagnosed, surgically confirmed endometriosis between 1996 and 2001 (n = 256) and age- and reference year-matched female control subjects without a history of endometriosis (n = 567). INTERVENTIONS(S): None. MAIN OUTCOME MEASURE(S): We evaluated the relationship between common genetic variation and endometriosis risk, using gene-based tests and single-variant analysis of genetic polymorphisms in ESR1, ESR2, PGR, CYP17A1, CYP19A1, HSD17B1, HSD17B2, CYP1A1, CYP1A2, COMT, and GSTM1. RESULT(S): The most consistent gene-based association with endometriosis risk was for CYP19A1. We did not find evidence for consistent significant associations between previously reported candidate SNPs in sex hormone-related genes and endometriosis risk. CONCLUSION(S): In summary, we report increased endometriosis risk with CYP19A1 gene-based tests; replication of the association between endometriosis and this gene or gene region is necessary in a larger study population.

A case-control investigation of adenomyosis: impact of control group selection on risk factor strength.

OBJECTIVE: Using a medical record abstraction-based case-control study with two control groups, we evaluated adenomyosis risk factors and investigated differences related to comparison group selection. MATERIALS AND METHODS: Medical records of all female 18- to 49-year-old Group Health (GH) enrollees with ICD-9 code 617.0 were abstracted using a standard data collection form. Cases were enrollees diagnosed with adenomyosis (n = 174) between April 1996 and September 2001. For comparison, medical records of two control groups were selected from the GH population: An age-matched sample of female enrollees (population-based controls; n = 149) and all female 18- to 49-year-old enrollees undergoing a hysterectomy (hysterectomy controls; n = 106) during the same time without adenomyosis. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using logistic regression, adjusted for identified covariates. RESULTS: Compared with normal and underweight women, overweight and obese women had increased adenomyosis risk using hysterectomy controls (OR, 2.2, 95% CI, 1.0-4.5; obese: OR, 2.2; 95% CI, 1.1-4.3) and population controls (overweight: OR, 2.1; 95% CI, 1.2-4.0; obese: OR, 3.8; 95% CI, 2.0-7.0). Using population controls, women with at least one live birth were more likely to have adenomyosis than nulliparous women (OR, 3.4; 95% CI, 1.9-6.2). CONCLUSION: Although some risk factors persisted in analyses using either control group, divergent results in relation to other risk factors for adenomyosis suggest that results of investigations of this disease may be affected by the choice of the comparison population.

Associations between polymorphisms in glucuronidation and sulfation enzymes and sex steroid concentrations in premenopausal women in the United States.

Glucuronidation, catalyzed by UDP-glucuronosyltransferases (UGT) and sulfation, catalyzed by sulfotransferases (SULT), are pathways through which sex steroids are metabolized to less active compounds. These enzymes are highly polymorphic and genetic variants frequently result in higher or lower activity. The phenotypic effects of these polymorphisms on circulating sex steroids in premenopausal women have not yet been investigated. One hundred and seventy women aged 40-45 years had a blood sample drawn during the follicular phase of the menstrual cycle for sex steroid measures and to obtain genomic DNA. Urine was collected for 2-hydroxy (OH) estrone (E(1)) and 16α-OH E(1) measures. Generalized linear regression models were used to assess associations between sex steroids and polymorphisms in the UGT1A and UGT2B families, SULT1A1, and SULT1E1. Women with the UGT1A1(TA7/TA7) genotype had 25% lower mean estradiol (E(2)) concentrations compared to the wildtype (TA6/TA6) (p=0.02). Similar associations were observed between SULT1A1(R213/H213) and E(1) (13% lower mean E(1) concentration vs. wildtype; p-value=0.02) and UGT2B4(E458/E458) and dehydroepiandrosterone (DHEA) (20% lower mean DHEA vs. wildtype; p-value=0.03). The SULT1E1(A/C) and the UGT1A1(TA7)-UGT1A3(R11) haplotypes were associated with reduced estrogen concentrations. Further study of UGT and SULT polymorphisms and circulating sex steroid measures in larger populations of premenopausal women is warranted.

Associations between polymorphisms in glucuronidation and sulfation enzymes and mammographic breast density in premenopausal women in the United States.

OBJECTIVE: Sex hormones are metabolized to less active compounds via (a) glucuronidation catalyzed by UDP-glucuronosyltransferases (UGT) and (b) sulfation catalyzed by sulfotransferases (SULT). Functional UGT and SULT polymorphisms can affect clearance of sex hormones, thereby influencing exposure in hormone-sensitive tissues, such as the breast. We assessed relationships between functional polymorphisms in the UGT and SULT genes and breast density in premenopausal women. METHODS: One hundred seventy-five women ages 40 to 45 years, who had a screening mammogram taken within the previous year, provided a genomic DNA sample. Mammograms were digitized to obtain breast density measures. Using generalized linear regression, we assessed associations between percent breast density and polymorphisms in the UGT1A and UGT2B families, SULT1A1, and SULT1E1. RESULTS: Women with the SULT1A1(H213/H213) genotype had 16% lower percent breast density compared with women with the SULT1A1(R213/R213) genotype after controlling for ethnicity (P = 0.001). Breast density was 5% lower among women carrying at least one copy of the UGT1A1(TA7)-UGT1A3(R11)-UGT1A3(A47) haplotype compared with the UGT1A1(TA6)-UGT1A3(W11R)-UGT1A3(V47A) haplotype (P = 0.07). No associations were observed between polymorphisms in the UGT2B family or SULT1E1 and breast density. CONCLUSION: Polymorphisms in SULT1A1 and the UGT1A locus may influence percent breast density in premenopausal women.

Associations between endogenous sex hormone levels and mammographic and bone densities in premenopausal women.

PURPOSE: Mammographic breast and bone mineral densities (BMD) have been associated with luteal phase hormone concentrations in premenopausal women. We assessed the associations of breast and bone densities with follicular phase hormones and sex hormone binding globulin (SHBG) in premenopausal women, given that follicular phase hormones have been shown to be positively associated with premenopausal breast cancer risk. METHODS: One hundred and ninety-two 40-45-year-old women provided a spot urine and/or blood sample during the follicular phase. Hormone and SHBG concentrations, and bone density were measured and routine mammograms were accessed and digitized to obtain breast density measures. Regression models were fit to assess the associations between hormones and SHBG, and breast and bone densities. RESULTS: Positive associations were observed between percent breast density and SHBG (p trend = 0.02), as well as estradiol (p trend = 0.08), after controlling for body mass index (BMI), number of pregnancies, and breast feeding history. In addition, a statistically significant inverse association was observed between total testosterone and head BMD (p trend = 0.01), after controlling for BMI. CONCLUSIONS: Associations were observed between breast and bone densities, and serum hormone concentrations during the follicular phase of the menstrual cycle.

Endometrial hyperplasia risk in relation to recent use of oral contraceptives and hormone therapy.

PURPOSE: We sought to examine the relationship between recent use of oral contraceptives and hormone therapy and endometrial hyperplasia (EH) risk. METHODS: Cases comprised women diagnosed with complex EH (n = 289) or atypical EH (n = 173) between 1985 and 2003. One age-matched control was selected for each case; excluded were women with a prior hysterectomy or diagnosis of EH or endometrial cancer. Hormone use in the 6 months prior to the date of the case's first symptoms was ascertained using a pharmacy database and medical records. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS: Three (1.1%) cases had used oral contraceptives, compared to 16 (6.0%) controls (OR = 0.2, 95% CI: 0.0-0.6). Fifty-one (16.8%) cases had taken estrogen-only hormone therapy, in contrast to two (0.7%) controls (OR = 37.6, 95% CI: 8.8-160.0). The risk of EH among estrogen plus progestin hormone users did not differ from that of non-users (OR = 0.7, 95% CI: 0.4-1.1). CONCLUSIONS: This study suggests that previous findings of the association of estrogen-only hormone therapy with increased risk of EH and the lack of an association between estrogen plus progestin hormone therapy and EH risk are likely to apply to both complex EH and atypical EH. Further examination of the association between oral contraceptives and EH, with greater numbers of OC users, is warranted.

Reproductive factors, age at maximum height, and risk of three histologic types of breast cancer.

Numerous studies have evaluated the association between factors related to maturation and reproduction and breast cancer risk, but few have assessed how these factors are related to different histologic types of breast cancer among postmenopausal women. We used polytomous logistic regression to assess the effect of age at maximum height and reproductive factors on risk of invasive breast cancer by histologic type in three case groups (524 ductal, 324 lobular, and 196 ductal-lobular) and 469 controls enrolled in a population-based case-control study of women ages 55 to 74 years residing in the Seattle-Puget Sound region of Washington State (2000-2004). Histologic type was determined by a centralized tissue review for 83% of cases. Age at menarche and age at maximum height were inversely associated with risk of ductal-lobular carcinoma (P(trend) = 0.04 for both exposures) but not ductal or lobular carcinoma. Relative to nulliparous women, parous women had a 50% reduced risk of all histologic types of breast cancer. We observed similar increases in risk across histologic types associated with having a first live birth at ages > or = 30 years compared with ages < or = 19 years. Compared with parous women who never breast-fed, those who breast-fed had a reduced risk of ductal carcinoma (odds ratio, 0.7; 95% confidence interval, 0.5-0.9) but not lobular or ductal-lobular carcinoma. Further exploration of breast cancer risk by histology is merited to understand differences in the etiology of ductal, lobular, and ductal-lobular carcinoma.

Risk of complex and atypical endometrial hyperplasia in relation to anthropometric measures and reproductive history.

The authors sought to test the hypothesis that characteristics and exposures which influence the balance of estrogen and progesterone bear on the incidence of endometrial hyperplasia (EH), a noninvasive proliferation of the lining of the uterus. Cases included all female members of Group Health (Washington State) who were diagnosed with complex EH or EH with atypia during the period 1985-2003 and whose diagnoses were confirmed in a pathology review (n = 446). Controls were selected randomly from Group Health membership files and were matched to the cases by age and enrollment status at the reference date. An increased risk of EH was associated with increasing body mass index and nulliparity. There was a suggestion of a decreased risk of EH with atypia among current smokers. No association with diabetes or hypertension was found. The risk factors observed to be associated with EH in this study are similar to those associated with endometrial cancer. Whether these risk factors predispose women to cancer simply by increasing EH incidence or continue to augment cancer risk even after EH is present is currently unknown.

Shift work, hCLOCK T3111C polymorphism, and endometriosis risk.

BACKGROUND: Endometriosis, a dysplastic disease affecting approximately 5%-10% of US reproductive-age women, has been linked to exposures indicating high circulating estrogen levels. One such exposure may be night shift work, which has been associated with menstrual disruption and increased risk of 2 other estrogen-influenced diseases, breast cancer and adverse coronary events. METHODS: In this population-based case-control study, cases were 235 women aged 18 to 49 years who were enrolled in a large health-maintenance organization in the state of Washington, and who were first diagnosed with surgically-confirmed endometriotic disease between April 1, 1996 and March 31, 2001. Controls were 545 randomly selected women enrolled in the same program who did not have a history of endometriosis. Study participants were asked about night shift work in all paid full-time or part-time jobs they had worked from age 18 to the reference date. Genotypes for T3111C hCLOCK were determined for a subset of 218 cases and 456 controls. RESULTS: Any night shift work was associated with a 50% increase in risk of endometriosis (odds ratio = 1.48 [95% confidence interval = 0.96-2.29]), and working more than half of shifts on a job at night was associated with a nearly doubled disease risk (1.98 [1.01-3.85]). Changing sleep patterns on days off was associated with further increases in disease risk. T3111C hCLOCK polymorphism was unrelated to endometriosis status and did not modify the effect of shift work on endometriosis. CONCLUSIONS: These findings suggest that some aspects of night shift work may influence the development of endometriosis.

Ovarian cysts and breast cancer: results from the Women's Contraceptive and Reproductive Experiences Study.

A diagnosis of ovarian cysts is likely an indicator of hormonal milieu and thus may be related to breast cancer risk. Recent studies have reported an inverse relationship between prior ovarian cyst diagnosis and breast cancer risk. We evaluated this relationship in the Women's Contraceptive and Reproductive Experiences (CARE) Study, a population-based case-control study conducted in Atlanta, Detroit, Philadelphia, Los Angeles, and Seattle. Cases had first primary invasive breast cancer diagnosed between 1994 and 1998 at ages 35-64 years. African American women were over-sampled. Controls were identified through random digit dialling and were frequency matched to cases on centre, race, and five-year age group. A total of 4575 cases and 4682 controls were interviewed. We used unconditional logistic regression adjusted for age and study centre within racial groups to estimate the odds ratio (OR) and 95% confidence interval (CI) for the relationship between prior ovarian cysts and breast cancer. Ovarian cyst diagnosis was associated with a significantly reduced risk among Caucasians (OR=0.85, 95% CI 0.76-0.96) and among African Americans (OR=0.68, 95% CI 0.57-0.81). The association in Caucasians was not significant within subgroups defined by menopausal status, hormone use, or gynecological surgery while the OR estimates in African Americans were consistently lower and frequently significant. These data are consistent with the previously reported inverse association between ovarian cysts and breast cancer, but the evidence for a relationship was stronger in African Americans than Caucasians. Additional studies are required to determine the specific cyst type(s) responsible for the observed relationship.

Androgenicity of progestins in hormonal contraceptives and the risk of gestational diabetes mellitus.

OBJECTIVE: There is some evidence that use of hormonal contraceptives, particularly the more androgenic formulations, can alter a woman's glucose tolerance. We examined the association between hormonal contraceptive use, categorized by the androgenicity of the progestin component, and risk of gestational diabetes mellitus (GDM) in a nested case-control study. RESEARCH DESIGN AND METHODS: Case (n = 356) and control (n = 368) subjects were selected from a multiethnic cohort of 14,235 women who delivered a singleton live birth between 1 January 1996 and 30 June 1998, who were screened for GDM at 24-28 gestational weeks, and who were members of Kaiser Permanente for at least 5 years before pregnancy. GDM was defined using the National Diabetes Data Group plasma glucose cutoffs. Information concerning hormonal contraceptive use during the 5 years before pregnancy was obtained from medical charts and some pharmacy data. RESULTS: There was a suggestion that compared with no hormonal contraceptive use, use of a low-androgen hormonal contraceptive before pregnancy was associated with a slight reduction in risk of GDM (odds ratio 0.84 [95% CI 0.58-1.22]), whereas use of a high-androgen hormonal contraceptive was associated with a modest increase in GDM risk (1.43 [0.92-2.22]). CONCLUSIONS: The effects of hormonal contraceptive use on GDM risk may vary by the androgenicity of the progestin component.

Conversational silence, coercion, equality: the role of language in influencing who gets identified as abused.

Various methods of ascertaining self-reported exposure to intimate partner violence (IPV) in health care and research settings have been evaluated to identify women who interpret themselves as abused for clinical and research intervention. However, few interpretive frameworks have been proposed to explain factors that may influence the success of this ascertainment process, including the contribution of language in facilitating women's interpretations of situations as abusive across social, cultural and historical contexts. This omission is substantial, given that IPV is context-specific, involving interaction between individuals of diverse linguistic and cultural backgrounds and their sociocultural environment. In the first part of this paper, we outline hermeneutics, one interpretive theoretical tradition to describe approaches to interpreting IPV. Hermeneutics is a linguistic philosophy that focuses on questions of how people understand spoken language, written text, and themselves through language across sociocultural environments. Hermeneutics acknowledges conditions and situations that facilitate opportunities for broad shared understanding and vocabularies about violence between communities, professionals and abused women, which in turn may reduce harm to women and negotiate action women may want to take in response to situations they interpret as abusive. In the second and third parts of the paper, we compare and contrast the strengths and limitations of three common approaches for asking women about IPV in health care and research settings, and outline a multi-dimensional IPV ascertainment tool that incorporates the three asking approaches to facilitate professionals bringing broad definitions of and vocabularies about abuse to encounters with women. This paper provides health care researchers, clinicians and policy makers with a framework for understanding the potential influence of language on women's interpretations of IPV, including the role of community and professional conversational silence, coercion and equality in influencing women's interpretations. We look at the influence of language about intimate partner violence in the United States on women's interpretations of abuse, although the basic constructs presented here could be applied in other countries and settings.

Police-reported intimate partner violence during pregnancy: who is at risk?

The objective of this retrospective cohort study was to determine risk factors for police-reported intimate partner violence (IPV) during pregnancy among Seattle residents with a registered live birth or fetal death in Washington State. Logistic regression was used to calculate adjusted odds ratios (aOR) and 95% confidence intervals for the association between demographic, behavioral, and obstetric history risk factors and any, physical, and non-physical police-reported IPV. Significant risk factors for any police-reported IPV during pregnancy included unmarried status (aOR 2.36), public health program use (aOR 1.33), smoking or alcohol use during pregnancy (aORs 1.45 and 1.80, respectively), previous live birth (aOR 1.39), and previous spontaneous or induced abortion (aORs 1.39 and 1.34, respectively). Risk factors for physical IPV varied only slightly from those for any IPV, and fewer factors were associated with nonphysical IPV. Demographic, behavioral, and obstetric history risk factors are potential markers of IPV risk during pregnancy.

Risk of functional ovarian cyst: effects of smoking and marijuana use according to body mass index.

Smoking is one of the few risk factors that have been identified for functional ovarian cysts, and results of one epidemiologic study suggest that body mass index (BMI; weight (kg)/height (m)(2)) may modify the effect of this exposure. The current study assessed the association of cigarette smoking and marijuana use with functional ovarian cyst risk by using data from a population-based 1990-1995 case-control study of 586 incident functional ovarian cyst cases and 757 age-matched controls in a large health maintenance organization in Washington State. In multivariate analyses controlling for age, education, and reference year, the authors found an increase in risk associated with current cigarette smoking among women whose BMI was <20 (odds ratio (OR) = 2.48, 95% confidence interval (CI): 1.32, 4.64) or 20-25 (OR = 1.60, 95% CI: 1.04, 2.46) but not >25 (OR = 0.85, 95% CI: 0.53, 1.37). Corresponding risks associated with current marijuana use were BMI <20, OR = 2.05 (95% CI: 0.89, 4.75); BMI 20-25, OR = 1.78 (95% CI: 1.00, 3.17); and BMI >25, OR = 0.72 (95% CI: 0.36, 1.42). Study results indicate that increased BMI may attenuate the adverse effect of smoking on the risk of functional ovarian cyst.

Mammographic density in relation to daidzein-metabolizing phenotypes in overweight, postmenopausal women.

Circulating hormones are associated with mammographic density, an intermediate marker of breast cancer risk. Differences in circulating hormones, including estrone and testosterone, have been observed in premenopausal women based on their capacity to metabolize daidzein, an isoflavone found predominantly in soybeans. Equol and O-desmethylangolensin (O-DMA) are products of intestinal bacterial metabolism of daidzein. There is interindividual variability in the capacity to produce daidzein metabolites; individuals can be equol producers or non-producers and O-DMA producers or non-producers. We tested the hypothesis that daidzein-metabolizing phenotypes are associated with mammographic density. Participants were recruited from among 92 sedentary, postmenopausal women, ages 50 to 75 years, who participated in a 1-year physical activity intervention. Pre-intervention mammographic density was determined using a computer-assisted, gray-scale thresholding technique. Fifty-five of these women consumed supplemental soy protein (>10 mg daidzein/d) for 3 days and collected a first-void urine sample on the fourth day to determine daidzein-metabolizing phenotypes. Equol and O-DMA concentrations were measured using gas chromatography-mass spectrometry. Associations between daidzein-metabolizing phenotypes and percent mammographic density were adjusted for age, maximum adult weight, gravidity, family history of breast cancer, and serum follicle-stimulating hormone and free testosterone concentrations. Mammographic density was 39% lower in equol producers compared with non-producers (P = 0.04). O-DMA producers had mammographic density 69% greater than non-producers (P = 0.05). These results suggest that particular intestinal bacterial profiles are associated with postmenopausal mammographic density, and these associations are not entirely explained by differences in reproductive or anthropometric characteristics or circulating hormones.