The effect of childhood stunting and wasting on adolescent cardiovascular diseases risk and educational achievement in rural Uganda: a retrospective cohort study.

Background: Little is known about the long-term effects of early childhood undernutrition on adolescent cardiovascular disease risk and educational performance in low-income countries. We examined this in a rural Ugandan population. Objective: To investigate if stunting or wasting among children aged 2-5 years is associated with cardiovascular disease risk or educational achievement during adolescence. Methods: We conducted analyses using data from a cohort of children followed from early childhood to adolescence. Weight and height were measured in 1999-2000 when the children were 2-5 years of age and repeated in 2004/2005 and 2011. We compared cardiovascular disease risk parameters (mean blood pressure, lipids, HbA1c) and schooling years achieved in 2011 among 1054 adolescents categorised into four groups: those who experienced stunting or wasting throughout follow-up; those who recovered from stunting or wasting; those who were normal but later became stunted or wasted; and those who never experienced stunting or wasting from childhood up to adolescence. We controlled for possible confounding using multiple generalised linear regression models along with Generalised Estimating Equations to account for clustering of children within households. Results: Wasting was negatively associated with systolic blood pressure (-7.90 95%CI [-14.52,-1.28], p = 0.02) and diastolic blood pressure (-3.92, 95%CI [-7.42, -0.38], p = 0.03). Stunting had borderline negative association with systolic blood pressure (-2.90, 95%CI [-6.41, 0.61] p = 0.10). Recovery from wasting was positively associated with diastolic blood pressure (1.93, 95%CI [0.11, 3.74] p = 0.04). Stunting or wasting was associated with fewer schooling years. Conclusion: Recovery from wasting rather than just an episode in early childhood is associated with a rise in blood pressure while educational achievement is compromised regardless of whether recovery from undernutrition happens. These findings are relevant to children exposed to undernutrition in low-income settings.

Temporal trends in incidence and outcome of hydatidiform mole: a retrospective cohort study.

BACKGROUND: Reported incidence rates of hydatidiform mole (HM) show wide geographic and temporal variations, making reliable international comparisons difficult. The aim of the current study was to examine temporal trends in the incidence of HM and post-molar gestational trophoblastic neoplasia (GTN) in Stockholm County. MATERIAL AND METHODS: Data of all women with a diagnosis of HM in Stockholm County 1991-2010 was collected. The incidence of HM was assessed both in relation to number of births and viable conceptions (births and pregnancy terminations). The risk of post-molar GTN was analysed for all HM, as well as for the subtypes complete (CHM) and partial hydatidiform mole (PHM). Temporal trends were analysed by stratifying the study period into five-year intervals. RESULTS: The overall incidence rate of HM was 2.08/1000 deliveries and 1.48/1000 viable conceptions. A significant temporal increase in the incidence rate of HM, as well as in the total number and proportion of PHM, was seen. Among 956 women with HM, 77 (8%) progressed into post-molar GTN. There was evidence of a slight, but non-significant increase in the risk of malignancy in the two last five-year periods under study. CONCLUSIONS: We found evidence of a significant temporal increase in the incidence rate of HM, which could not fully be explained by an increase in maternal age over time. Changes in diagnostic methods probably contributed to the increased incidence rate of PHM. The risk of post-molar GTN remained constant over time.

Ongoing or previous mental disorders predispose to adverse mood reporting during combined oral contraceptive use.

PURPOSE: Previous studies have emphasised that women with pre-existing mood disorders are more inclined to discontinue hormonal contraceptive use. However, few studies have examined the effects of combined oral contraceptives (COC) on mood in women with previous or ongoing mental disorders. MATERIALS AND METHODS: This is a supplementary analysis of an investigator-initiated, double-blinded, randomised clinical trial during which 202 women were treated with either a COC (1.5 mg estradiol and 2.5 mg nomegestrolacetate) or placebo during three treatment cycles. The Mini International Neuropsychiatric Interview was used to collect information on previous or ongoing mental disorders. The primary outcome measure was the total change score in five mood symptoms on the Daily Record of Severity of Problems (DRSP) scale in the intermenstrual phase of the treatment cycle. RESULTS: Women with ongoing or previous mood, anxiety or eating disorders allocated to COC had higher total DRSP Δ-scores during the intermenstrual phase of the treatment cycle in comparison with corresponding women randomised to placebo, mean difference 1.3 (95% CI 0.3-2.3). In contrast, among women without mental health problems, no difference in total DRSP Δ-scores between COC- and placebo users was noted. Women with a risk use of alcohol who were randomised to the COC had higher total DRSP Δ-scores than women randomised to placebo, mean difference 2.1 (CI 95% 1.0-3.2). CONCLUSIONS: Women with ongoing or previous mental disorders or risk use of alcohol have greater risk of COC-induced mood symptoms. This may be worth noting during family planning and contraceptive counselling.

Knowledge of cervical cancer and HPV vaccine in Bangladeshi women: a population based, cross-sectional study.

BACKGROUND: The objective of this study was to assess the level of knowledge of cervical cancer among Bangladeshi women and to assess their willingness to receive the human papillomavirus (HPV) vaccine. METHODS: A population-based, cross-sectional survey was conducted from July to December 2011 in one urban and one rural area of Bangladesh. A total of 2037 ever-married women, aged 14 to 64 years, were interviewed using a structured questionnaire. Data on socio-demographic characteristics and knowledge of cervical cancer were collected. Willingness to receive the HPV vaccine was assessed. Univariate analyses were completed using quantitative data collected. Multivariable logistic regression models were developed to identify factors associated with having heard of cervical cancer and the HPV vaccine. RESULTS: The majority of study participants reported to have heard of cervical cancer (urban: 89.7%, rural 93.4%; P = 0.003). The odds of having heard of cervical cancer were significantly higher in urban women aged 35-44 years (aOR: 2.92 (1.34-6.33) and rural women aged 25-34 years (aOR: 2.90 (1.24-6.73) compared to those aged less than 24 years. Very few women reported to have detailed knowledge on risk factors (urban:9.1%, rural: 8.8%) and prevention (urban: 6.4%, rural: 4.4%) of cervical cancer. In our sample, one in five urban women and one in twenty rural women heard about a vaccine that can prevent cervical cancer. Among urban women, secondary education or higher (aOR: 3.48, 95% CI: 1.67-7.25), age of 20 years and above at marriage (aOR: 2.83, 95% CI: 1.61-5.00), and high socioeconomic status (aOR: 2.25, 95% CI: 1.28-3.95) were factors associated with having heard of the HPV vaccine. Willingness to receive the HPV vaccine among study participants either for themselves (urban: 93.9%, rural: 99.4%) or for their daughters (urban: 91.8%, rural: 99.2%) was high. CONCLUSIONS: Detailed knowledge of cervical cancer among Bangladeshi women was found to be poor. Education on cervical cancer must include information on symptoms, risk factors, and preventive methods. Despite poor knowledge, the study population was willing to receive the HPV vaccine.

Reproductive and Lifestyle Factors Associated with Endometriosis in a Large Cross-Sectional Population Sample.

OBJECTIVES: Despite the high prevalence of endometriosis among women of reproductive age, risk factors or markers for developing the condition remain largely unknown. Many of the published studies are based on small selected samples. We therefore investigated the relationships of reproductive and lifestyle factors with endometriosis in a large sample of Swedish female twins. MATERIAL AND METHODS: This cross-sectional study included 28,822 women. Among these, endometriosis was reported by 1,228 women and the self-reported diagnosis was confirmed by medical records. Potential risk factors or markers for risk considered were age at menarche, level of education, body mass index (BMI), parity, oral contraceptive (OC) use, infertility, coffee consumption, smoking, and alcohol intake, which were investigated using logistic regression with crude and adjusted analyses. We performed within-pair analysis to examine the sensitivity of the results. RESULTS: Late age at menarche and higher parity showed an inverse association and infertility showed a strong association with endometriosis. We observed positive associations with coffee consumption and smoking and an inverse association with OC use in crude analysis but not in adjusted analysis. There were no significant associations between level of education, BMI, or alcohol intake and endometriosis. Within-pair analysis showed persistent inverse association of parity and association of infertility with endometriosis. CONCLUSIONS: Our study suggests that late age at menarche and higher parity are inversely associated and infertility is strongly associated with endometriosis. Future studies are needed to explore the significance of these factors in the diagnosis of endometriosis and understanding of its etiology.

Oral human papillomavirus (HPV) prevalence in youth and cervical HPV prevalence in women attending a youth clinic in Sweden, a follow up-study 2013-2014 after gradual introduction of public HPV vaccination.

During 2009-2011, we reported that the oral and cervical prevalence of human papillomavirus (HPV) was high by international standards at 9.3% and 74%, respectively, in youth aged 15-23 years attending a youth clinic in Stockholm. After gradual introduction of public HPV vaccination during 2007-2012, between 2013 and 2014, when 73% of the women were HPV-vaccinated, but not necessarily before their sexual debut, oral HPV prevalence had dropped to 1.4% as compared with 9.3% in 2009-2011 (p < 0.00001). Cervical HPV prevalence was high and common cervical high-risk types were HPV51, 56, 59, 73, 16, 39, 52, and 53. However, it was shown that HPV16, 31, and 70 were significantly less common among HPV-vaccinated women than among those who had not received the vaccine.

Genital human papillomavirus infection among women in Bangladesh: findings from a population-based survey.

BACKGROUND: There has been no population-based study on human papillomavirus (HPV) prevalence or its genotypes in Bangladesh; a country eligible for GAVI funding for HPV vaccine. METHODS: We used baseline survey data of a prospective cohort study that was conducted in one urban and one rural area of Bangladesh. A total of 997 urban and 905 rural married women, aged 13 to 64 years, were enrolled in the baseline during July-December, 2011. Information was collected on socio-demographic characteristics and potential risk factors for HPV infection followed by gynecological examination and collection of endocervical samples using the cervical cytobrush (Digene cervical sampler). HPV DNA testing was done by Polymerase Chain Reaction (PCR) using a consensus primer set. RESULTS: Prevalence of any HPV infection was 7.7% with no significant difference between urban and rural women. Most common high-risk genotypes were HPV16, HPV66, HPV18, HPV45, HPV31 and HPV53. Urban women working as housemaids or garment workers were at higher risk of any HPV infection (OR = 2.15, 95% CI: 1.13-4.11) compared to housewives. Rural women whose husband lived overseas were almost two times more likely to have any HPV infection (OR = 1.93; 95% CI 1.05-3.55) compared to women whose husbands lived with them. CONCLUSION: The prevalence of HPV infection among Bangladeshi women is similar to other regions of Asia. However, type-specific patterns are different. The study findings will inform the formulation of HPV vaccination policies in Bangladesh, monitoring the impact of vaccination programmes, and the identification of target populations for screening.

Hydatidiform mole and subsequent pregnancy outcome: a population-based cohort study.

OBJECTIVE: The objective of the study was to investigate whether a history of hydatidiform mole (HM) is associated with an increased risk of adverse outcomes in subsequent pregnancies. STUDY DESIGN: This was a nationwide cohort study with data from population-based registers. The study population consisted of all children registered in the Swedish Medical Birth Register 1973-2009 (n = 3,730,825). Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated for adverse maternal and offspring pregnancy outcomes by maternal history of HM prior to the delivery, with children to women with no maternal history of HM as the reference. Risk estimates were adjusted for maternal age at delivery and maternal country of birth. RESULTS: A history of HM was not associated with an increased risk of adverse maternal outcomes in subsequent pregnancies (n = 5186). Women exposed to a molar pregnancy prior to the index birth were at an almost 25% increased risk of preterm birth (OR, 1.23; 95% CI, 1.06-1.43), whereas women with at least 1 birth between the HM and the index birth were at an increased risk of a large-for-gestational-age birth and stillbirth (OR, 1.35; 95% CI, 1.10-1.67 and OR, 1.81; 95% CI, 1.11-2.96, respectively). The risk of repeat mole was 0.4%. CONCLUSION: Women with a history of HM are at no increased risk of adverse maternal outcomes in subsequent pregnancies but have an increased risk of large-for-gestational-age birth, stillbirth, and preterm birth. However, in absolute terms, the risk of subsequent adverse offspring outcomes is very low.

Current clinical features of complete and partial hydatidiform mole in Sweden.

OBJECTIVE: To describe the current clinical presentation of complete (CHM) and partial (PHM) hydatidiform mole in a Swedish setting. STUDY DESIGN: A retrospective analysis of medical charts from 331 women with hydatidiform mole (HM) between 1991 and 2010 was performed. Demographics and clinical features were analyzed, and symptoms in women with CHM were compared to those from a historic group (1988 to 1993) from the New England Trophoblastic Disease Center. RESULTS: In women with CHM, bleeding was more common than in women with PHM (57% vs. 41%, p < 0.001) but significantly less common as compared to the historic group (84%). Women with CHM and PHM were diagnosed before the onset of symptoms in 32% and 53%, respectively, compared to the previously reported 10% (p < 0.001). There was a significantly higher proportion of women 240 years of age with CHM than with PHM (23% vs. 7%). Ultrasound predicted the molar diagnosis in 73% of CHMs and 35% of PHMs (p < 0.001). CONCLUSION: In our study a large proportion of molar pregnancies were asymptomatic at the time of diagnosis. This confirms earlier reports of the changing clinical presentation of HM and shows that this trend continues. Age, ultrasound findings and hCG levels can add valuable information.

Detection of human papillomavirus among women in Laos: feasibility of using filter paper card and prevalence of high-risk types.

BACKGROUND: Persistent infection with high-risk (HR) human papillomavirus (HPV) is a well-recognized cause of cervical cancer, but little is known about the situation in Laos. The aims of the study were to determine the prevalence of HR-HPV among Lao women and to evaluate the use of a filter paper card (FTA Elute Micro Card) for collection of cervical cells in the humid tropical climate. METHODS: This is a cross-sectional study including 1922 women from 3 provinces in Laos. During a gynecological examination, cervical cells were collected and applied to the FTA card followed by HPV typing using a real-time polymerase chain reaction (PCR)-based assay. RESULTS: Overall, 213 of the 1922 women were positive for HR-HPV (11%). The most common type was the group HPV33/52/58 (3%), followed by the single type 16 (2%) and the group 18/45 (1%), respectively. Only 11 cards (0.6%) did not contain a sufficient amount of genomic DNA for polymerase chain reaction-based analysis. CONCLUSIONS: The prevalence of HR-HPV infections in Laos is similar to other Asian countries, and 40% of the women with an HR-HPV infection will be target of the present HPV vaccines. The FTA card is suitable for collection of cervical cells for HR-HPV typing in tropical conditions. This information is important for planning and establishing primary and secondary prevention of cervical cancer in Laos.

Choriocarcinoma following ovarian hydatidiform mole: a case report.

BACKGROUND: Ovarian ectopic pregnancies are uncommon, and a hydatidiform mole in this location is extremely rare but may later develop into a choriocarcinoma. CASE: A 49-year-old woman with a history of an ectopic pregnancy, lost to follow-up in spite of rising human chorionic gonadotropin (hCG) levels, presented three years later at the emergency ward with hemoptysis, vaginal bleeding and elevated serum hCG. Pulmonary and vaginal metastasis was found, and the diagnosis of a choriocarcinoma was confirmed. She received chemotherapy during a 6-month period and recovered successfully. Seven years later she is free of disease. Reevaluation of the histological specimen from the previous ectopic pregnancy confirmed an ovarian hydatidiform mole and the later development of choriocarcinoma which probably originated from this mole. CONCLUSION: The diagnosis of hydatidiform mole can be difficult, however, it may be crucial to the patient. Whenever a histopathologic examination of products of conception is performed, it is important that a hydatidiform mole can be ruled out, and that may require additional analysis such as immunohistochemistry and DNA ploidy. In cases in which a gestational trophoblastic disease is suspected, it is necessary to monitor serum hCG until values are negative.

Safety, feasibility, and acceptability of visual inspection with acetic acid and immediate treatment with cryotherapy in rural Laos.

OBJECTIVE: To assess the safety, acceptability, and feasibility of visual inspection with acetic acid (VIA) followed by immediate treatment with cryotherapy as a single-visit approach for the prevention of cervical cancer among women in rural Laos. METHODS: In 2009, women from 2 provinces in Laos were recruited for cervical cancer screening using VIA. If the inspection of the cervix showed a well-defined acetowhite lesion close to the os, immediate cryotherapy was offered. RESULTS: Of the 1926 women who were included, 134 (7.0%) tested positive on VIA. Of these, 113 (84.3%) underwent immediate cryotherapy and none declined treatment. One year after immediate cryotherapy, 77 (68.1%) women returned for a follow-up assessment and 68 (88.3%) were now VIA-negative. There was no report of a major complication during or after treatment. The acceptance of both VIA and cryotherapy was high. CONCLUSION: Visual inspection with acetic acid is a simple test that requires minimal infrastructure and expenditure. Integration of VIA with cryotherapy at the primary care level may constitute a feasible program for the prevention of cervical cancer in Laos.

Pre-vaccination prevalence of human papillomavirus types in the genital tract of 15-23-year-old women attending a youth health clinic in Stockholm, Sweden.

Knowledge of the prevalence of different human papillomavirus (HPV) types in young girls is important for the early detection of changes in HPV prevalence, e.g. due to HPV vaccines. The purpose of this study was to obtain information on the prevalence of 24 different genital HPV types in a group of sexually active young women (aged 15-23 y) attending a major youth healthcare centre in Stockholm, before the introduction of public HPV vaccination of young women in the autumn of 2010. A total of 615 women were analyzed for 24 different, mainly high-risk HPV (HR-HPV) types using multiplex polymerase chain reaction and Luminex technology. A high HPV prevalence in this cohort was demonstrated, particularly with regard to HPV16, but also to all included HR-HPV types. Of the 544 successfully analyzed samples from non-vaccinated individuals, 70% were positive for the HPV types assayed for, and 62% were positive for HR-HPV types. Over a third (34.7%) of the women were infected with HPV16, and a high frequency of infections with HR-HPV types 51 (10.7%), 18 (10.1%), 52 (9.9%) and 73 (9.4%) was also observed. At least 9 different non-vaccine HR-HPV types were present with a prevalence of >6% in this selected group of young women.

Women's perception of cervical cancer and its prevention in rural Laos.

BACKGROUND: Cervical cancer is the second most common cancer of women in the world, and it becomes a major cause of cancer mortality in low-income countries. Currently, little is known regarding cervical cancer incidence in Laos, although it is anticipated to be high like in neighboring countries. To be able to develop a screening program in the country, it is essential to explore women's perception of the disease. The purpose of this study was therefore to describe knowledge, awareness, and attitudes regarding cervical cancer among rural women of Laos. METHODS: In a descriptive cross-sectional study, women were interviewed using a structured questionnaire covering sociodemographic factors, knowledge of the disease and its risk factors, awareness, and attitudes toward cervical cancer and its prevention. RESULTS: Eight hundred women were included in the study, and 58% claimed to know about cervical cancer. Approximately one third (38%) considered themselves to be at risk, but less than 5% had ever had a Papanicolau test. Sixty-two percent believed it was possible to prevent cervical cancer and that vaccination may be a suitable method, but only 14% know about risk factors. Another method for prevention was frequent vaginal douching, which was suggested by 70% of the women. Symptoms like bleeding and discharge were correctly identified as possible indicators of cervical cancer, but only 57 women (7%) knew that an early stage of the disease could be symptom-free. Lack of subjective symptoms was the main reason for women to refrain from gynecological examinations. CONCLUSIONS: This study indicates that rural women in Laos have limited knowledge about cervical cancer and even less about screening and prevention. There is a need to educate the general community about the disease and its prevention.

High occurrence of a new variant of Chlamydia trachomatis escaping diagnostic tests among STI clinic patients in Stockholm, Sweden.

BACKGROUND: In 2006, a genetic variant of Chlamydia trachomatis not detectable with the most commonly used diagnostic tests was identified. Initial reports suggested that as many as 10% to 13% of all chlamydia cases would have remained undiagnosed. The aim of the study was to find the occurrence and clinical findings of this genetic variant among a high-risk population in Stockholm, Sweden. METHODS: Samples were analyzed using the Cobas TaqMan CT test (Roche Diagnostics). To detect the new variant, an additional PCR-analysis, artus C. trachomatis LC MOMP PCR Kit (Qiagen) was performed on all negative samples. Positive results in the artus test were confirmed by a mutant specific PCR. Clinical data were retrospectively collected from medical records. RESULTS: Among 1009 samples analyzed, 115 were positive for C. trachomatis and among those, 27 were found to belong to the genetic altered strain. This variant constituted 23% of all chlamydia cases diagnosed, and 29% were found in the age group 20 to 29 years. Women with the new variant were younger and had more often performed another chlamydia test within the previous 6 months compared with those infected with the wild type. CONCLUSION: These results indicate that a large number of sexually active individuals might be infected despite a negative chlamydia test, thus facilitating a rapid transmission of the new variant. Accordingly, it is of great importance to be aware of limitations of the diagnostic methods used.

Effects of mifepristone on endometrial receptivity.

At the development of receptivity the endometrium undergoes specific changes. Several factors have been suggested as markers of endometrial receptivity. A common feature for most of these factors is that they are directly, or indirectly, regulated by progesterone. The effect of various doses and regimens of mifepristone on endometrial development and markers of receptivity has been studied. Timed endometrial biopsies were assessed by immunhistochemistry, reverse transcriptase polymerase chain reaction (RT-PCR) and electron microscopy. In addition the contraceptive efficacy of these regimens was investigated. Administration of 200 mg of mifepristone immediately post ovulation has a pronounced effect on endometrial development and on suggested markers of receptivity. This regimen has been shown to be an effective contraceptive method. When 10 mg is given pre or post ovulation, only minor effects on the endometrium are observed. Our studies show that mifepristone, when administered in low doses that do not affect ovulation, significantly affects some of the studied markers of endometrial receptivity and reduces pregnancy rates; however, these activities are more pronounced with the higher dose, which is more effective. Our findings provide insight into the regulation of progesterone receptors of various suggested markers of endometrial receptivity and the possibility of using mifepristone for endometrial contraception.

Mechanisms of action of mifepristone when used for emergency contraception.

An emergency contraceptive method is used after coitus but before pregnancy occurs. The use of emergency contraception is largely underutilized worldwide. Recently, treatment with 10 mg mifepristone as a single dose has emerged as one of the most effective hormonal methods for emergency contraception, with very low side effects. However, the mechanism of action of mifepristone in humans when used for contraceptive purposes and especially for emergency contraception remains largely unknown. The objective of this review is to summarize available data on the effect of mifepristone on female reproductive functions relevant to emergency use of the compound. Taken together, available data from studies in humans indicate that the contraceptive effect of mifepristone used as a single low dose for emergency contraception is mainly due to impairment of ovarian function, either by blocking or postponing the luteinizing hormone surge, rather than to inhibiting of implantation.

Progesterone receptor isoform B in the human fallopian tube and endometrium following mifepristone.

The distribution of progesterone receptor isoform B may have important clinical significance. The aim of this study was to compare the expression, localization and regulation of progesterone receptor isoform B in the human Fallopian tube and endometrium following mifepristone in a dose effective for contraception. Fertile women were treated with a single dose of 200 mg mifepristone on day luteinizing hormone (LH)+2. Biopsies were obtained from the Fallopian tube on day LH+4 to LH+6 and from the endometrium on day LH+6 to LH+8. Progesterone receptor isoform B expression was analyzed by immunohistochemistry and reverse transcriptase polymerase chain reaction. Treatment with mifepristone increased progesterone receptor isoform B concentration in epithelial and stromal cells in the Fallopian tube and also increased progesterone receptor isoform B concentration in the glandular cells of the endometrium. These results further support the hypothesis that the contraceptive effect of mifepristone when given postovulatory is primarily due to alteration of the peri-implantation milieu influencing endometrial receptivity.