Predictors of decreased libido in women during the late reproductive years.

OBJECTIVE: To identify risk factors for decreased libido among women in the late reproductive years. DESIGN: Prospective cohort. Women aged 35 to 47 years identified through random digit dialing were prospectively followed for 4 years with serial hormone assays and standardized questionnaires. Mean hormone values, hormone trends over 4 years, and fluctuation in hormone levels were compared among women with and without a decrease in libido at the last assessment period. Total testosterone, dihydroepiandrosterone sulfate, estradiol, follicle-stimulating hormone, luteinizing hormone, body mass index, psychosocial, and socioeconomic variables were evaluated using multivariable logistic regression. RESULTS: Of 326 women, 87 (27%) reported a decreased libido, whereas 239 (73%) did not. Participant-specific means for all hormone levels over the study period were similar among both groups. However, total testosterone fluctuation over the study was significantly different between groups. Women whose testosterone levels fluctuated from 3.8 to 21.5 ng/dL around a mean value of 9 ng/dL were four times more likely to report decreased libido compared with women with little fluctuation in testosterone [odds ratio (OR) 4.0; 95% CI, 1.6-10.0]. Depression (OR 3.4; 95%CI, 1.9-6.1), vaginal dryness (OR 3.5; 95%CI, 1.8-6.6), and children living at home (OR 1.4; 95%CI, 1.1-1.7) were also independently associated with decreased libido. CONCLUSIONS: Decreased libido in the late reproductive years is associated with a pronounced fluctuation in total testosterone over time. Other independent risk factors for decreased libido include vaginal dryness, depression, and living with children. Sexual dysfunction is a complex disorder, related to physiological and psychosocial factors, requiring further investigation.

Smoking during pregnancy in the United States, 2005-2014: The role of depression.

BACKGROUND: Despite success of public health-oriented tobacco control programs in lowering the smoking prevalence over the past several decades, it is unclear whether similar reductions in smoking have been experienced among pregnant women, especially in vulnerable groups such as those with major depression and/or lower socioeconomic status. OBJECTIVES: The purpose of this study is to examine the relationship between major depressive episode (MDE) and smoking among pregnant women overall, and by demographics and to estimate changes in the prevalence of cigarette smoking among pregnant women with and without MDE from 2005 to 2014. STUDY DESIGN: Cigarette use among pregnant women with and without MDE was examined using logistic regression models in the National Survey on Drug Use and Health. RESULTS: Prenatal smoking is more common among pregnant women with, compared to without, MDE (32.5% vs. 13.0%; (adjusted OR=2.50 (1.85, 3.40)), and greater disparities were revealed when also considering income, education and race. Over time, smoking during pregnancy increased significantly among women with MDE (35.9% to 38.4%; p=0.02)) and showed a decreasing trend among women without MDE (12.5% to 9.1%; p=0.07) from 2005 to 2014. CONCLUSIONS: Over the past decade, smoking during pregnancy has increased among women experiencing a major depressive episode and is over four times more common among pregnant women with, than without, MDE. Disparities in smoking during pregnancy by MDE status and socioeconomic subgroups appear substantial. Given the multitude of risks associated with both MDE and smoking during the prenatal period, more work targeting this vulnerable and high-risk group is needed.

Serious Psychological Distress and Smoking During Pregnancy in the United States: 2008-2014.

INTRODUCTION: The current study examined the relationship between acute (past 30 day) and recent (past year but not past 30 day) serious psychological distress (SPD) and smoking during pregnancy among women in the United States overall, stratified by demographic characteristics, and described the change in the prevalence of prenatal smoking among women with and without SPD, from 2008 to 2014. METHODS: Data were drawn from the National Survey on Drug Use and Health (NSDUH), an annual cross-sectional study of US persons aged 12 and over. SPD and smoking in the past 30 days among pregnant women, aged 18 and older, were examined using logistic regression models. Heterogeneity in this association by demographic characteristics, trends over time, and level of cigarette consumption was also examined. RESULTS: Prenatal smoking was common. Almost 40% of pregnant women with acute SPD reported smoking, 23% of pregnant women with recent SPD smoked, and 11.7% of pregnant women without recent SPD smoked. No significant change was found in the prevalence of prenatal smoking from 2008 to 2014 in any of these groups. Robust relationships were found between acute (OR = 5.05 [3.64-6.99]) and recent SPD (OR = 2.37 [1.74-3.24]) and smoking; these findings remained after adjusting for demographics. CONCLUSIONS: SPD and smoking during pregnancy are strongly associated; this relationship is present across all sociodemographic groups and the prevalence of smoking in pregnancy has remained relatively unchanged over the past decade both in the presence and absence of SPD. IMPLICATIONS: SPD and smoking in pregnancy are robustly linked; the prevalence of smoking in pregnancy is extremely high in women with SPD. Screening women with mental health problems for prenatal smoking, as well as screening pregnant smokers for mental health problems, seems warranted and may assist more women in seeking and utilizing treatment options. Efforts to reduce the prevalence of smoking during pregnancy might specifically target women with SPD, where the potential for impact is substantial.

Associations between vaginal bacteria and levels of vaginal defensins in pregnant women.

OBJECTIVE: We evaluated vaginal defensin concentrations and levels of bacterial vaginosis-associated bacterial species in pregnant women. STUDY DESIGN: Self-collected vaginal swabs from 2 visits during pregnancy were tested with quantitative polymerase chain reaction for 9 bacterial species. Beta defensins 2-3 and alpha defensins 1-3 were measured by enzyme-linked immunosorbent assay. RESULTS: Our 126 participants were primarily African American (60%), had a mean gestational age at enrollment of 10 ± 3 weeks and at follow-up visit of 25 ± 6 weeks. At enrollment, the prevalence of bacterial vaginosis was 74% (94/126 women), which decreased to 60% (75/126 specimens) at follow-up visit. At enrollment, beta defensin 3 concentrations were significantly lower in women with bacterial vaginosis (2.64 ± 0.91 vs 3.25 ± 0.99 log(10) pg/mL; P = .003). Higher concentrations of Atopobium vaginae, bacterial vaginosis-associated bacteria1 and 2 were associated with significantly lower concentrations of beta defensin 3 (P < .01). CONCLUSION: Bacterial vaginosis was associated with lower vaginal concentrations of beta defensin 3, but not beta defensin 2 or alpha defensins 1-3, in pregnant women.

Neighborhood safety as a correlate of tobacco use in a sample of urban, pregnant women.

OBJECTIVES: Environmental context has been increasingly recognized as an important determinant of health behavior. This study examined the effects of self-reported neighborhood violence and perceived safety on tobacco use in a sample of low-income, pregnant women. METHODS: Pregnant women (N=1521) being treated at an urban emergency room completed a baseline interview where neighborhood safety (self-reported neighborhood violence and perceived safety) as well as individual (demographics, depression symptoms, stress, tobacco use, substance abuse) and social variables (prenatal social environment and number of close friends) were evaluated cross-sectionally. Tobacco use was measured again in a telephone interview at 22 weeks gestation. RESULTS: In a logistic regression model of baseline smoking status, self-reported neighborhood violence was significantly associated with being a smoker independent of age, education status, attendance to prenatal care, gestational age and lifetime use of cocaine and marijuana. In a regression model estimating the relationship between these baseline variables and continued prenatal smoking, baseline smoking emerged as the strongest correlate of continued smoking during pregnancy. CONCLUSIONS: These findings suggest that self-reported neighborhood violence had a stronger association with early pregnancy cigarette use compared to ongoing cigarette use in a sample of low-income, pregnant women. Prospective trials are needed to fully elucidate the relationship between individual and social-environmental determinants of tobacco use in this high-risk population.

The association between maternal alcohol use and smoking in early pregnancy and congenital cardiac defects.

BACKGROUND: Alcohol use is an extremely prevalent but preventable risk factor among women seeking to become pregnant. Many women continue to use alcohol in the early stages of pregnancy before they are aware they are pregnant. Research is unclear about the role of maternal alcohol use during pregnancy and congenital cardiac defects, one of the leading types of birth defects in the United States. METHODS: Data from the Pregnancy Risk Assessment Monitoring Survey (PRAMS) were used to examine maternal alcohol use and its association with congenital cardiac defects. Various measures of alcohol use in the 3 months prior to pregnancy, as well as smoking and other risk factors for congenital cardiac defects, were linked to birth certificate data for nine states over a 10-year period (1996-2005). In this case-control study, cases included infants with a congenital cardiac defect indicated on the birth certificate, and the control group consisted of healthy, normal weight infants with no indication of a congenital abnormality on their birth certificate. Complex samples logistic regression models were used to study the relationships between several measures of alcohol use, including binge drinking and binge drinking on more than once occasion, and the interaction between alcohol use and smoking with the odds of congenital cardiac defects. RESULTS: A significant increase in congenital cardiac defects was found among mothers who reported binge drinking more than once in the 3 months prior to pregnancy compared to mothers who did not report binge drinking (adjusted odds ratio [aOR] 2.99, 95% confidence interval [CI] 1.19-7.51). There was a significant interaction between any binge drinking or binge drinking more than once and cigarette use, which corresponded to a substancial increase in congenital cardiac defects (aOR 12.65, 95% CI 3.54-45.25 and aOR 9.45, 95% CI 2.53-35.31, respectively). CONCLUSIONS: Multiple episodes of maternal binge drinking in early pregnancy may increase the odds of congenital cardiac defects, and we found this relationship was more dramatic when combined with maternal smoking.

Childhood violence and behavioral effects among urban pregnant women.

BACKGROUND: Childhood violence has been linked to a variety of health outcomes in adulthood; however, little research has focused on the impact of childhood violence on behavior and health during pregnancy. We aimed to explore the role of experiencing childhood physical and sexual violence in health status and high-risk behaviors among young, urban pregnant women. METHODS: Pregnant women seeking care in an urban emergency department were recruited. Information on demographics, prior and current violence, depressive symptoms, stress, substance use, and health conditions was collected, and multivariate analyses were used. RESULTS: Twenty-nine percent of women reported at least one episode of childhood physical violence before the age of 16, and 14% reported at least one episode of rape during childhood. Women reporting any type of childhood violence were > twice as likely to be experiencing current violence (odds ratio [OR] 2.45, 95% confidence interval [95% CI] 1.83-2.74). Pregnant women who reported childhood physical violence without current violence had a higher odds of prior sexually transmitted diseases (STDs), confirmed cigarette use (OR 1.98, 95% CI 1.44-2.74), and depressive symptoms, adjusting for age, race, and education. The group of pregnant women reporting childhood sexual violence/rape without current violence reported significantly higher levels of depressive symptoms, stress, problem drinking, and cigarette use during pregnancy (OR 4.11, 95% CI 2.24-7.55). Women who experienced any type of childhood violence and reported current violence were > five times more likely to report depressive symptoms and have confirmed, recent cocaine use compared with women without a history of prior or current violence. CONCLUSIONS: These findings underscore the importance of understanding the full impact of early childhood violence on behaviors during pregnancy and provide direction for substance use and depression prevention strategies among pregnant women.

Prevalence and risk factors for gastroesophageal reflux disease in an impoverished minority population.

BACKGROUND AND AIMS: An epidemiological link between an increased body mass index and complaints of typical heartburn symptoms has been identified. It appears that increasing waist circumference, rather than overall weight is most important. Studies to date have not included minority, impoverished communities. Our aim was to determine the impact of obesity on the prevalence of reflux disease in an impoverished community while controlling for known confounders. METHODS: DESIGN Cross-sectional survey delivered by in-home interviews, convenience sampling, and targeted mailing. Data queried include demographics, medical history, lifestyle habits, and symptoms of reflux disease. Height, weight, hip and waist circumference measured in participating subjects. PARTICIPANTS: 503 subjects living in the zip code immediately surrounding Temple University Hospital. Included only adults living in the hospital's zip code for at least 3 years. RESULTS: The highest quartile of waist circumference (≥42 in.) demonstrated a strong association with GERD (AOR = 2.15; 95% CI 1.18-3.90). Smoking increased the odds by 1.72 (95% CI 1.13-2.62). There was no relationship between body mass index, waist-hip ratio, or diet and reflux classification. CONCLUSIONS: Increasing waist circumference, but not overall body mass index or waist-hip ratio, and smoking are risk factors for prevalent GERD. No association between reflux disease and lifestyle choices such as coffee drinking and fast food dining were found. LIMITATIONS: Potential for recall bias and disease misclassification. Possible methodological errors in self-measurement of waist and hip circumference.

Prevalence and risk factors for gastroesophageal reflux disease in an impoverished minority population.

BACKGROUND AND AIMS: An epidemiological link between an increased body mass index and complaints of typical heartburn symptoms has been identified. It appears that increasing waist circumference, rather than overall weight is most important. Studies to date have not included minority, impoverished communities. Our aim was to determine the impact of obesity on the prevalence of reflux disease in an impoverished community while controlling for known confounders. DESIGN: Cross-sectional survey delivered by in-home interviews, convenience sampling, and targeted mailing. Data queried include demographics, medical history, lifestyle habits, and symptoms of reflux disease. Height, weight, hip and waist circumference measured in participating subjects. PARTICIPANTS: 503 subjects living in the zip code immediately surrounding Temple University Hospital. Included only adults living in the hospital's zip code for at least 3 years. RESULTS: The highest quartile of waist circumference (≥42 in.) demonstrated a strong association with GERD (AOR = 2.15; 95% CI 1.18-3.90). Smoking increased the odds by 1.72 (95% CI 1.13-2.62). There was no relationship between body mass index, waist-hip ratio, or diet and reflux classification. CONCLUSIONS: Increasing waist circumference, but not overall body mass index or waist-hip ratio, and smoking are risk factors for prevalent GERD. No association between reflux disease and lifestyle choices such as coffee drinking and fast food dining were found. LIMITATIONS: Potential for recall bias and disease misclassification. Possible methodological errors in self-measurement of waist and hip circumference.

Preterm labor and bacterial vaginosis-associated bacteria among urban women.

AIMS: Bacterial vaginosis (BV) affects millions of women, is extremely prevalent and is frequently chronic. We recognize numerous microbiologic variations among women with BV and this variability may explain the limited effectiveness of metronidazole in curing BV and/or reducing the risk of spontaneous preterm birth (SPTB) among BV-positive pregnant women. We assessed the independent role of seven common BV-associated bacteria on the risk of spontaneous preterm birth (SPTB) among urban pregnant women. METHODS: This prospective cohort study was conducted within an urban obstetrics practice at Temple University Hospital in Philadelphia, PA. Fifty pregnant women with documented singleton pregnancies between 25-36 weeks' gestation from February 2007 through June 2007 who presented to the Labor and Delivery Unit for evaluation of uterine contractions/preterm labor were enrolled. RESULTS: We found that high median levels of Gardnerella vaginalis and low median levels of Lactobacillus crispatus were significantly predictive of SPTB. Slightly higher levels of Megasphaera-like species were also found among the group of women experiencing a SPTB during the follow-up period. CONCLUSIONS: Further identification of the individual attributable risk for separate BV-associated bacteria may be most useful in developing successful treatments to prevent SPTB among BV positive women.

Racial differences in bacterial vaginosis among pregnant women: the relationship between demographic and behavioral predictors and individual BV-related microorganism levels.

OBJECTIVE: To determine predictors of bacterial vaginosis (BV) and the level of three common BV-related microorganisms by racial group. METHODS: Prospective cohort study of 1,886 pregnant women. BV was measured with Nugent's Gram Stain criteria, smoking status with urinalysis of cotinine levels, and stress with Cohen's perceived stress scale. RESULTS: 73% of the cohort were African-American and 37% were BV positive. Smoking, numerous sexual partners, and single status were related to both BV positivity as well as higher levels of Gardnerella ssp. among African-American pregnant women. Age and history of STD were associated with BV positivity, and history of STD and insurance status were associated with Gardnerella ssp. levels in non-African-American pregnant women. Contrary to prior research, perceived stress and douching were not associated with BV positivity or the level of any of the BV-related microorganisms in this cohort. CONCLUSIONS: A greater number of modifiable, behavioral-related risk factors predicted BV and the level of BV-related microorganisms among African-American compared to non-African-American pregnant women. A deeper understanding of predictors of BV and related microorganism levels by racial group may help eliminate critical disparities with respect to BV positivity and adverse pregnancy outcomes, including spontaneous preterm birth.

Effect of physical activity on menopausal symptoms among urban women.

PURPOSE: To determine whether physical activity, measured by expended kilocalories per week (kcal.wk), decreases the risk of menopausal symptoms among African American and Caucasian women. METHODS: Level of physical activity and menopausal symptoms, including hot flashes, depression, anxiety, stress, and vasomotor, physiological, and somatic symptom summaries were measured in 401 women during an 8-yr period. Tertiles of physical activity at each assessment were defined as kilocalories per week: top third (>or= 1450 kcal x wk(-1)), middle third (< 1450 to 644 kcal x wk(-1)), and bottom third (< 644 kcal x wk(-1)). Regression models were used to estimate the independent effect of physical activity at each time period on menopausal symptoms after adjusting for covariates and hormone levels. Results were also stratified by race, smoking status, and menopausal status. RESULTS: Overall, only perceived stress was related to level of physical activity, with women in both the middle and top tertiles of physical activity reporting lower mean levels of stress compared with women in the lowest tertile of activity. In the analysis by menopausal stage, active postmenopausal women continued to report lower mean levels of anxiety, stress, and depressive symptoms compared with inactive postmenopausal women. We did not find an association between level of physical activity and reports of hot flashes, even after adjusting for the variability in the hormonal changes. CONCLUSIONS: Among a cohort of community-dwelling women, high levels of physical activity were related to lower levels of stress during an 8-yr follow-up period. In addition, levels of anxiety, stress, and depression were lowest among physically active postmenopausal women compared with inactive women in the same menopausal grouping.

Characteristics and pregnancy outcomes of pregnant women asymptomatic for bacterial vaginosis.

STUDY DESIGN: To determine the clinical, behavioral or demographic factors associated with asymptomatic bacterial vaginosis (BV) and to examine if women with asymptomatic BV had a higher risk of a variety of pregnancy outcomes compared to symptomatic BV positive women. For this study, 1916 pregnant women who were 12 weeks' gestation or less were enrolled. Interviewers facilitated vaginal swab collection for BV assessment, and completed the baseline questionnaire. BV was identified by Gram stain. RESULTS: Forty percent of pregnant women screened positive for BV and a substantial proportion of BV positive pregnant women were asymptomatic (67%). Asymptomatic BV positive women reported lower stress scores (RR = 0.78, 95% CI: 0.67-0.89), slightly more prior STD's (RR = 1.03, 95% CI: 1.01-1.07), and a higher quantity of Mobiluncus (RR = 1.04 95% CI: 1.01-1.07) compared to symptomatic BV positive women. We did not find an increase in adverse pregnancy outcomes related to BV symptomatology. CONCLUSION: Among first trimester pregnant women, only stress, STD history, and quantity of Mobiluncus were associated with symptom reports among BV positive pregnant women. We also found that women with asymptomatic BV did not have an increased risk of a variety of adverse pregnancy outcomes compared to symptomatic BV positive women.

Association of physical activity with reproductive hormones: the Penn Ovarian Aging Study.

BACKGROUND: Physical activity is associated with reduced risk for breast cancer, perhaps through reductions in circulating reproductive hormones (estrogens and androgens). There may also be a role for physical activity in regulating menopausal symptoms. Few studies have examined associations of physical activity on hormone levels. None have examined the potential effect of the menopausal transition on the associations between physical activity and reproductive hormone levels. MATERIALS AND METHODS: Data from the Penn Ovarian Aging Study were used for this analysis. Self-reported physical activity was assessed in 391 women up to four times over 10 years and extending across the menopausal transition. Other assessments included reproductive hormones via RIA (estradiol, luteinizing hormone, follicle-stimulating hormone, testosterone, DHEA sulfate), body weight, and height. Multivariate repeated measures regression models were developed to compare reproductive hormone levels within physical activity tertiles, adjusting for age, follow-up time, smoking, and ethnicity. RESULTS: Activity level was inversely associated with estradiol in the subgroup in the late transition stage. Adjusted means for estradiol were 24.6 and 37.9, a relative difference of 54% in estradiol when comparing highest to lowest activity tertile (P = 0.02). Similarly, in this subgroup, there was an inverse association between physical activity and testosterone levels (means of 11.1 and 15.94 in the highest and lowest tertile, a 47% relative difference; P = 0.01). There were no significant associations of activity with any other reproductive hormone. CONCLUSIONS: These results identify a particular window of the menopausal transition during which physical activity is associated with reduced estradiol and/or testosterone levels.

Symptoms associated with menopausal transition and reproductive hormones in midlife women.

OBJECTIVE: To test the hypothesis that prevalence of women with menopausal symptoms of hot flushes; aches, joint pain, and stiffness; depressed mood; poor sleep; decreased libido; or vaginal dryness increases with progression through the menopausal transition. METHODS: Women in the Penn Ovarian Aging Study were assessed longitudinally for 9 years. Data were obtained from structured interviews, a validated symptom questionnaire, menstrual bleeding dates and early follicular hormone measures (estradiol [E2], follicle-stimulating hormone [FSH], and inhibin b). Menopausal stages were based on menstrual bleeding patterns. Other risk factors included age, race, history of depression, current smoking, body mass index, and perceived stress. Generalized linear regression models for repeated measures were used to estimate associations among the variables with each symptom. RESULTS: The prevalence of hot flushes; aches, joint pain, and stiffness; and depressed mood increased in the menopausal transition. Menopausal stage was associated with hot flushes (P<.001); aches joint pain, and stiffness (P<.001); and depressed mood (P=.002). Within-woman fluctuations of E2 were associated with hot flushes and aches. Poor sleep, decreased libido, and vaginal dryness were not associated with menopausal stages. There was 80% power to detect an absolute difference of 11% for libido and vaginal dryness and 17% for poor sleep in the prevalence of these symptoms in the late menopausal transition compared with premenopausal status. CONCLUSION: The study highlights the role of menopausal stages for some symptoms of midlife women and indicates that stages in the transition to menopause are associated with hot flushes; aches, joint pain, and stiffness; and depressed mood. Fluctuations of E2, decreased levels of inhibin b, and increased FSH levels were associated with these symptoms. LEVEL OF EVIDENCE: II.

Associations of hormones and menopausal status with depressed mood in women with no history of depression.

CONTEXT: Whether depressed mood reported in the transition to menopause by women with no history of depression is associated with menopausal status and changes in reproductive hormones is controversial and lacks scientific information. OBJECTIVES: To identify new onset of depressive symptoms and diagnosed depressive disorders in the menopausal transition and to determine the associations of menopausal status, reproductive hormones, and other risk factors with these cases. DESIGN: A within-woman, longitudinal (8-year) study to identify risk factors of depressed mood. SETTING: A subset of a randomly identified, population-based cohort. PARTICIPANTS: Premenopausal women with no history of depression at cohort enrollment. MAIN OUTCOME MEASURES: The Center for Epidemiological Studies of Depression scale (CES-D) was used to assess depressive symptoms, and the Primary Care Evaluation of Mental Disorders (PRIME-MD) was used to identify clinical diagnoses of depressive disorders. RESULTS: High CES-D scores (> or=16) were more than 4 times more likely to occur during a woman's menopausal transition compared with when she was premenopausal (odds ratio, 4.29; 95% confidence interval, 2.39-7.72; P<.001). Within-woman change in menopausal status, increased levels of follicle-stimulating hormone and luteinizing hormone, and increased variability of estradiol, follicle-stimulating hormone, and luteinizing hormone around the woman's own mean levels were each significantly associated with high CES-D scores after adjusting for smoking, body mass index, premenstrual syndrome, hot flashes, poor sleep, health status, employment, and marital status. A diagnosis of depressive disorder was 2(1/2) times more likely to occur in the menopausal transition compared with when the woman was premenopausal (odds ratio, 2.50; 95% confidence interval, 1.25-5.02; P=.01); the hormone measures were also significantly associated with this outcome. CONCLUSION: Transition to menopause and its changing hormonal milieu are strongly associated with new onset of depressed mood among women with no history of depression.

A cost-effectiveness analysis of prenatal screening strategies for Down syndrome.

OBJECTIVE: To evaluate which Down syndrome screening strategy is the most cost-effective. METHODS: Using decision-analysis modeling, we compared the cost-effectiveness of 9 screening strategies for Down syndrome: 1) no screening, 2) first-trimester nuchal translucency (NT) only, 3) first-trimester combined NT and serum screen, 4) first-trimester serum only, 5) quadruple screen, 6) integrated screening, 7) sequential screening, 8) integrated serum only, or 9) maternal age. Costs included cost of tests and resources used for raising a child with Down syndrome. One-way and multiway sensitivity analyses were performed for all model variables. The main outcome measures were cost per Down syndrome case detected, rate of delivering a liveborn neonate with Down syndrome, and rate of diagnostic procedure-related pregnancy loss for each strategy. RESULTS: Sequential screening detected more Down syndrome cases compared with the other strategies, but it had a higher procedure-related loss rate. Integrated serum screening was the most cost-effective strategy. Sensitivity analyses revealed the model to be robust over a wide range of values for the variables. The addition of the cost of genetic sonogram to the second-trimester strategies resulted in first-trimester combined screening becoming the most cost-effective strategy. CONCLUSION: Within our baseline assumptions, integrated serum screening was the most cost-effective screening strategy for Down syndrome. If the cost of nuchal translucency is less than dollars 57 or when genetic sonogram is included in the second-trimester strategies, first-trimester combined screening became the most cost-effective strategy. LEVEL OF EVIDENCE: III.

The relationship between obesity and race on inhibin B during the menopause transition.

OBJECTIVE: Data are lacking on the effects of obesity and race on inhibin B levels during the menopause transition. The purpose of this study was to determine the relationship among inhibin B levels, body mass index (BMI), and race during the menopause transition. DESIGN: In the Penn Ovarian Aging Study, a prospective cohort study of reproductive aging, 436 women aged 35 to 47 years were followed up with serial hormones, anthropometric measures, and questionnaires for 6 years. Univariate and multivariable analyses were performed comparing mean log transformed inhibin B levels among menopause stages, age groups, BMI categories, races, and smoking groups. RESULTS: In the univariate analyses, mean inhibin B levels were negatively associated with menopause stage, age, and BMI, but not significantly with race or smoking. Interactions of menopause status and BMI were significant (P < 0.001). Premenopausal women with a BMI of 25 or higher had significantly lower inhibin B levels compared with women with a BMI of less than 25 (41.8 pg/mL vs 58.4 pg/mL, P < 0.001), whereas postmenopausal women with a BMI of 30 or higher had significantly higher inhibin B levels compared with the postmenopausal women with a BMI of less than 25 (29.1 pg/mL vs 26.7 pg/mL, P < 0.001). CONCLUSIONS: Although BMI is a significant independent predictor of inhibin B levels, the relationship between BMI and inhibin B changes with advancing menopause stage. These data provide additional evidence that obesity influences hormones during the menopause transition.

Predictors of chronic pelvic pain in an urban population of women with symptoms and signs of pelvic inflammatory disease.

OBJECTIVE: The objective of this study was to assess the risk profile for chronic pelvic pain (CPP) after pelvic inflammatory disease (PID). STUDY: Multivariate logistic regression was used to assess risk factors for CPP in a longitudinal study of 780 predominately black, urban women with clinically suspected PID: complaints of acute pain (<30 days); a clinical finding of pelvic tenderness; and leukorrhea, mucopurulent cervicitis, or untreated gonococcal or chlamydial cervicitis. CPP was defined as pain reported at >or=2 consecutive interviews conducted every 3 to 4 months for 2 to 5 years. RESULTS: Nonblack race (odds ratio [OR], 2.17; 95% confidence interval [CI], 1.31-3.58), being married (OR, 2.06; 95% CI, 1.02-4.18), a low SF-36 mental health composite score (OR, 2.71; 95% CI, 1.69-4.34), >or=2 prior PID episodes (OR, 2.84; 95% CI, 1.07-7.54), and smoking (OR, 1.65; 95% CI, 1.01-2.71) independently predicted CPP. Histologic endometritis or evidence of endometrial Neisseria gonorrhoeae or Chlamydia trachomatis infection was negatively associated with CPP (OR, 0.69; 95% CI, 0.44-1.10). CONCLUSIONS: A range of demographic, clinical, historical, and behavioral factors predict CPP after PID.

Defining menopause status: creation of a new definition to identify the early changes of the menopausal transition.

OBJECTIVE: Several menopausal staging definitions are currently being used in ongoing studies designed to identify changes occurring during menopause. The objective of this study was to determine which definition captures the earliest hormonal changes in the menopausal transition. DESIGN: In this prospective cohort study, women aged 35 to 47 years were followed for 5 years. Women were classified as premenopausal, early transition, late transition, and postmenopausal by 2 different menopausal staging systems defined by bleeding patterns. Definitions from the Study of Women Health Across the Nation (SWAN) and Stages of Reproductive Aging Workshop (STRAW) were compared. A new menopausal staging system (PENN-5) was also developed with five groups rather than four to distinguish among women with more subtle changes in cycle length. For each staging system, a linear regression model was created comparing mean hormone values (inhibin B, FSH, LH, E2) and menopausal stages at each assessment. Race, body mass index, cycle day, smoking, and follow-up time were included in the model. RESULTS: Statistically significant differences in mean inhibin B and FSH levels, but not estradiol levels, were detected between the earliest menopausal stages of each definition. Significant differences in LH values were detected among the earliest stages of the SWAN and STRAW definitions, but not the PENN-5 definition. CONCLUSIONS: Subtle changes in menstrual cycle length reflect significant changes in inhibin B and FSH levels during the menopausal transition. Therefore, it appears that subtle changes in bleeding pattern may be helpful in identifying the earliest hormonal changes during menopausal transition.