Development of composite outcomes for individual patient data (IPD) meta-analysis on the effects of diet and lifestyle in pregnancy: a Delphi survey.

OBJECTIVE: To develop maternal, fetal, and neonatal composite outcomes relevant to the evaluation of diet and lifestyle interventions in pregnancy by individual patient data (IPD) meta-analysis. DESIGN: Delphi survey. SETTING: The International Weight Management in Pregnancy (i-WIP) collaborative network. Sample Twenty-six researchers from the i-WIP collaborative network from 11 countries. METHODS: A two-generational Delphi survey involving members of the i-WIP collaborative network (26 members in 11 countries) was undertaken to prioritise the individual outcomes for their importance in clinical care. The final components of the composite outcomes were identified using pre-specified criteria. MAIN OUTCOME MEASURES: Composite outcomes considered to be important for the evaluation of the effect of diet and lifestyle in pregnancy. RESULTS: Of the 36 maternal outcomes, nine were prioritised and the following were included in the final composite: pre-eclampsia or pregnancy-induced hypertension, gestational diabetes mellitus (GDM), elective or emergency caesarean section, and preterm delivery. Of the 27 fetal and neonatal outcomes, nine were further evaluated, with the final composite consisting of intrauterine death, small for gestational age, large for gestational age, and admission to a neonatal intensive care unit (NICU). CONCLUSIONS: Our work has identified the components of maternal, fetal, and neonatal composite outcomes required for the assessment of diet and lifestyle interventions in pregnancy by IPD meta-analysis.

Reshaping the gut microbiota at an early age: functional impact on obesity risk?

Overweight and obesity can currently be considered a major threat to human health and well-being. Recent scientific advances point to an aberrant compositional development of the gut microbiota and low-grade inflammation as contributing factors, in conjunction with excessive energy intake. A high-fat/energy diet alters the gut microbiota composition, which reciprocally engenders excessive energy harvesting and storage. Further, microbial imbalance increases gut permeability, leading to metabolic endotoxemia, inflammation and insulin resistance. Local intestinal immunologic homeostasis is achieved by tolerogenic immune responses to microbial antigens. In the context of amelioration of insulin sensitivity and decreased adiposity, the potential of gut microbiota modulation with specific probiotics and prebiotics lies in the normalization of aberrant microbiota, improved gut barrier function and creation of an anti-inflammatory milieu. This would suggest a role for probiotic/prebiotic interventions in the search for preventive and therapeutic applications in weight management.

Cancer morbidity in a cohort of 9175 Finnish women treated for infertility.

BACKGROUND: Results of earlier studies on cancer risk in infertile women are inconsistent for many cancer types. Our goal was to study cancer incidence among a cohort of women treated with IVF, including ICSI and frozen embryo transfer (FET), compared with that of a control population. METHODS: A cohort of women who purchased drugs for IVF (including ICSI and FET treatments, n= 9175) in the period 1996-1998 in Finland (later called IVF women) and their age and residence-matched controls further adjusted for socio-economic position and marital status were linked to the Finnish Cancer Registry 1996-2004. RESULTS: The overall cancer incidence and combined incidence of hormonal-related breast, uterine and invasive ovarian cancers were similar among IVF women and controls. IVF women had statistically significantly less cervical cancer [odds ratio (OR): 0.51, 95% confidence interval (CI): 0.30-0.85], but more skin cancers other than melanoma (OR: 3.11, 95% CI: 1.02-9.6). IVF women had three times more invasive ovarian cancers than controls, but this difference was not statistically significant, possibly due to the small number of cases. IVF women had slightly fewer breast cancers but difference was likewise not statistically significant. All cases of pulmonary cancer were diagnosed among controls (P= 0.03). CONCLUSIONS: General cancer risk or risk of hormonal-related cancers in women was not increased by IVF. The differences in certain cancers suggest a healthy patient effect or may be partly caused by residual socio-economic differences. More large studies and reanalysis of existing studies are needed to evaluate cancer risk among infertile women by subgroups regarding the cause of infertility. When evaluating risk of cancer after drug exposure, dosage and the use of different medicaments should be taken into consideration.

Effect of supervised and home exercise training on bone mineral density among breast cancer patients. A 12-month randomised controlled trial.

UNLABELLED: The ability of combined step aerobic- and circuit-training to prevent bone loss after breast cancer treatments was related to skeletal site and patients' menopausal status. Among premenopausal breast cancer survivors, a 12-month exercise intervention completely prevented bone loss at the femoral neck, whereas no exercise effect was seen at lumbar spine or at neither site in postmenopausal women. INTRODUCTION: The primary objective of this randomised clinical trial was to determine the preventive effect of supervised weight-bearing jumping exercises and circuit training on bone loss among breast cancer patients. METHODS: Of 573 breast cancer survivors aged 35-68 years randomly allocated into exercise or control group after adjuvant treatments, 498 (87%) were included in the final analysis. The 12-month exercise intervention comprised weekly supervised step aerobic- and circuit-exercises and similar home training. Bone mineral density (BMD) at lumbar spine and femoral neck were measured by dual-energy X-ray absorptiometry. Physical performance was assessed by 2-km walking and figure-8 running tests, and the amount of physical activity was estimated in metabolic equivalent-hours/week. RESULTS: In premenopausal women, bone loss at the femoral neck was prevented by exercise, the mean BMD changes being -0.2% among the trainees vs. -1.4% among the controls (p = 0.01). Lumbar bone loss could not be prevented (-1.9% vs. -2.2%). In postmenopausal women, no significant exercise-effect on BMD was found either at the lumbar spine (-1.6% vs. -2.1%) or femoral neck (-1.1% vs. -1.1%). CONCLUSIONS: This 12-month aerobic jumping and circuit training intervention completely prevented femoral neck bone loss in premenopausal breast cancer patients, whereas no effect on BMD was seen in postmenopausal women.

Effect of exercise on bone structural traits, physical performance and body composition in breast cancer patients--a 12-month RCT.

In this 12-month RCT, we examined whether aerobic impact exercise training (3x/week) could facilitate breast cancer survivors' recovery by enhancing their bone structural strength, physical performance and body composition. After the adjuvant chemo- and/ or radiotherapy, 86 patients were randomly assigned into the training or control group. Structural bone traits were assessed with pQCT at the tibia and with DXA at the femoral neck. Agility (figure-8 running), jump force and power (force platform), grip strength and cardiovascular fitness (2-km walk test) were also assessed. Training effects on outcome variables were estimated by two-way factorial ANCOVA using the study group and menopausal status as fixed factors. Bone structural strength was better maintained among the trainees. At the femoral neck, there was a small but significant 2% training effect in the bone mass distribution (p=0.05). At the tibial diaphysis, slight 1% to 2% training effects (p=0.03) in total cross-sectional area and bone structural strength were observed (p=0.03) among the postmenopausal trainees. Also, 3% to 4% training effects were observed in the figure-8 running time (p=0.03) and grip strength (p=0.01). In conclusion, vigorous aerobic impact exercise training has potential to maintain bone structural strength and improve physical performance among breast cancer survivors.

Hormonal contraception and mental health: results of a population-based study.

BACKGROUND: The effects of oral contraceptives (OCs) on mental health are not clear, and no study has been focused on the effects of the levonorgestrel-releasing intrauterine system (LNG-IUS) on mental health. The aim of this study was to analyse the association between the use of OCs and the LNG-IUS and psychological well-being and psychopathology. METHODS: The associations between the current use of OCs and the LNG-IUS, and their duration versus mood symptoms [Beck Depression Inventory (BDI)], psychological well-being [(General Health Questionnaire-12 (GHQ-12)] and recent psychiatric diagnoses [(Composite International Diagnostic Interview (CIDI)] were examined among women who participated in the Finnish-population-based Health 2000 study. Analyses were performed on the 30- to 54-year-old sample (n = 2310); some of the analyses were extended to include the younger age group (18- to 54-year-old sample; n = 3223). RESULTS: Overall, hormonal contraception was well tolerated with few significant effects on psychological well-being. The length of OC use was inversely associated with some BDI items ('dissatisfaction, irritability, lost interest in people, earlier waking and lost interest in sex'), and directly associated with 'worries about one's health' (BDI) and with a current diagnosis of 'alcohol dependence' (CIDI). The current use of the LNG-IUS was inversely associated with 'earlier waking' (BDI) and with 'impaired concentration' (GHQ), while the length of LNG-IUS use was inversely associated with 'strain' (GHQ). CONCLUSIONS: The influence of hormonal birth control on mental health is modest and mainly favourable. The length of current OC use seems to have some beneficial effects on mood although the longer the duration of use, the greater the association with a diagnosis of alcohol dependence. Knowledge of the use of hormonal contraception might be of value when assessing psychopathology in women. The cross-sectional design, with partly retrospective data collection, precludes any causal conclusions.

Quality of life and physical performance and activity of breast cancer patients after adjuvant treatments.

OBJECTIVE: The study aimed at investigating the quality of life (QoL) and physical performance and activity, and their interrelations, in Finnish female breast cancer patients shortly after adjuvant treatments. METHODS: A total of 537 disease-free breast cancer survivors aged 35-68 years were surveyed at the beginning of a one year randomized exercise intervention. The patients were interviewed using EORTC QLQ-C30, FACIT-F, RBDI, and WHQ (for vasomotor symptoms) questionnaires. Physical performance was tested by a 2 km walking test. Physical activity was measured by a questionnaire and a prospective two-week diary. Multivariate analysis was used to study the factors associated with QoL. RESULTS: About 26% of the patients were rated as depressed, 20.4% as fatigued, and 82% suffered from menopausal symptoms. The global QoL was lower than in general population (69.4 vs 74.7, p<0.001). About 62% of the walking test results were below the population average. Fatigue (p<0.001), depression (p<0.001), body mass index (p = 0.016) and comorbidity (p = 0.032) impaired, and physical activity (p = 0.003) improved QoL. Physical activity level correlated positively to physical performance (r = -0.274, p<0.0001). CONCLUSIONS: The QoL of the patients shortly after adjuvant treatments was impaired and the physical performance poor as compared to general population. In particular, depression and fatigue were related to impaired QoL. Physical performance and activity level were the only factors that correlated positively to QoL. Thus, physical exercise could be useful in rehabilitation of cancer survivors, especially for depressed and fatigued patients.

The impact of perinatal probiotic intervention on the development of overweight and obesity: follow-up study from birth to 10 years.

BACKGROUND: The achievements in combating the increasing trend of overweight and obesity have thus far been inadequate. The recently discovered instrumental role of the gut microbiota in host metabolism may offer a novel target in the prevention and management of obesity. OBJECTIVE: To evaluate the impact of perinatal probiotic intervention on childhood growth patterns and the development of overweight during a 10-year follow-up. PATIENTS AND METHODS: Altogether 159 women were randomized and double-blinded to receive probiotics (1 × 10(10) colony-forming units of Lactobacillus rhamnosus GG, ATCC 53103) or placebo 4 weeks before expected delivery; the intervention extending for 6 months postnatally. Anthropometric measurements of the children were taken at the ages of 3, 6, 12 and 24 months and at 4, 7 and 10 years in 113 (72%) children. RESULTS: The excessive weight gain was detected to be two-parted; the initial phase of excessive weight gain initiating during fetal period and continuing until 24-48 months of age and a second phase of excessive weight gain starting after the age of 24-48 months. The perinatal probiotic intervention appeared to moderate the initial phase of excessive weight gain, especially among children who later became overweight, but not the second phase of excessive weight gain, the impact being most pronounced at the age of 4 years (P=0.063, analysis of variance for repeated measures). The effect of intervention was also shown as a tendency to reduce the birth-weight-adjusted mean body mass index at the age of 4 years (P=0.080, analysis of covariance). CONCLUSIONS: Early gut microbiota modulation with probiotics may modify the growth pattern of the child by restraining excessive weight gain during the first years of life. This novel observation calls for further epidemiological and clinical trials, with precise data on early growth patterns and on confounding factors influencing weight development.

Psychiatric disorders leading to hospitalization before and after infertility treatments.

BACKGROUND: This study aimed at determining the psychiatric morbidity of women undergoing infertility treatments, before and after treatment as compared with control women. METHODS: The number of women hospitalized because of psychiatric disorders was obtained from the Hospital Discharge Register (1969-2006) in a cohort of women who purchased drugs for in vitro fertilization, intra-cytoplasmic sperm injection or frozen embryo transfer treatments (n = 9175) in 1996-1998 in Finland and their controls (n = 9175). The age- and residence-matched controls were further adjusted in the analysis for socio-economic position and marital status. RESULTS: Women with infertility treatments had fewer hospitalizations due to depression, psychotic disorders, personality disorders, anxiety disorders, bipolar disorder or mania, eating disorders, adjustment disorders and alcohol or other intoxicant abuse before their treatments than did controls. However, the difference was statistically significant only for psychotic disorders [Odds ratios (OR) 0.38, 95% confidence intervals (CI) 0.20-0.72]. Differences in hospitalization remained similar also during the 10-year post-treatment follow-up. The exceptions were increased risk of hospitalizations due to adjustment disorders (OR 3.43, 95% CI 1.03-11.4) and decreased risk of alcohol or other intoxicant abuse (OR 0.44, 95% CI 0.25-0.75) among the women with infertility treatments. The infertile women who gave birth had fewer hospitalizations for all psychiatric diagnoses than did infertile women who did not have a baby. The difference was statistically significant for anxiety disorders (OR 0.38, 95% CI 0.18-0.81), depression (OR 0.63, 95% CI 0.41-0.96) and alcohol or other intoxicant abuse (OR 0.38, 95% CI 0.18-0.80). Hospitalizations among infertile women who did not have a baby and controls were similar, with the exception of significantly more hospitalizations for psychotic disorders among controls (OR 0.38, 95% CI 0.19-0.77). CONCLUSIONS: Women treated for infertility had less serious psychiatric morbidity leading to hospitalization than did the controls, both before and after treatments, suggesting a healthy patient effect. After treatments, the risk of hospitalization due to adjustment disorders was increased among the infertile women. Having a baby after infertility treatments was associated with fewer hospitalizations following psychiatric diagnosis.

Incidence of necrotizing enterocolitis in very-low-birth-weight infants related to the use of Lactobacillus GG.

BACKGROUND: One of the five level III neonatal intensive care units (NICU) in Finland has used prophylactic Lactobacillus GG (LGG) for very-low-birth-weight (VLBW) infants since 1997. AIM: To examine retrospectively the incidence of necrotizing enterocolitis (NEC) in all five university hospital NICUs in Finland in relation to the use of LGG during the years each unit has belonged to the Vermont Oxford Network (VON). METHODS: The incidence of NEC was analysed from the national database and from the VON databases separately in all five level III NICUs and additionally in three groups according to the probiotic practice in the hospitals: prophylactic LGG group, probiotics 'on demand' group and no probiotics group. RESULTS: The incidence of NEC was 4.6% vs. 3.3% vs. 1.8% in the prophylactic LGG group, the no probiotics group and the probiotics 'on demand' group [corrected] respectively; p = 0.0090, chi-square. LGG had no influence on the clinical course of NEC. CONCLUSIONS: The results of this retrospective report failed to show that LGG prophylaxis protects VLBW infants from the occurrence of NEC, in contrast to previously published results. Our results call for more research regarding effective ways to administer probiotics, including data on appropriate bacteria, strain, dose and timing of administration to achieve clinically robust effects.

Pre-eclampsia is a risk factor of carotid artery atherosclerosis.

BACKGROUND: A history of pre-eclampsia has been shown to be associated with an increased risk of subsequent coronary artery disease. The intima-media thickness of carotid arteries and the detection of plaques are useful measures as regards preclinical atherosclerosis. The aim of this study was to examine whether women with a history of pre-eclampsia more often show signs of atherosclerosis compared with 2 control groups. METHODS: We used data from a large Finnish cross-sectional health examination survey. We had women with previous pre-eclampsia (n = 35) or pregnancy-induced hypertension (n = 61) and 2 control groups. Laboratory tests and physical examination were performed. Information on reproductive and medical history was obtained at the home interview. Carotid atherosclerosis was assessed by ultrasonography. RESULTS: The women with previous pre-eclampsia had significantly (p = 0.008) more atherosclerotic plaques than the healthy parous controls. The intima-media thickness in the women with previous pre-eclampsia also tended to be higher than in the other groups, although the differences did not reach statistical significance. In logistic regression analysis, advanced age (OR: 1.08; 95% CI: 1.04-1.13; p < 0.001) and pre-eclampsia (OR: 3.63; 95% CI: 1.50-8.79; p = 0.004) were independent risk factors as regards plaque, and in linear regression analysis advanced age (estimate: 0.012; 95% CI: 0.010-0.014; p < 0.001), HDL cholesterol (estimate: -0.049; 95% CI: -0.088 to -0.010; p = 0.013), systolic blood pressure, BMI (estimate: 0.005; 95% CI: 0.000-0.009; p = 0.043) and high-sensitivity C-reactive protein (estimate: -0.003; 95% CI: -0.007 to -0.000; p = 0.048) were independent risk factors with respect to intima-media thickness. CONCLUSIONS: Our data suggest that pre-eclampsia is an independent risk factor as regards developing plaque later in life.

Preventing excessive weight gain during pregnancy - a controlled trial in primary health care.

OBJECTIVE: To investigate whether individual counselling on diet and physical activity during pregnancy can have positive effects on diet and leisure time physical activity (LTPA) and prevent excessive gestational weight gain. DESIGN: A controlled trial. SETTING: Six maternity clinics in primary health care in Finland. The clinics were selected into three intervention and three control clinics. SUBJECTS: Of the 132 pregnant primiparas, recruited by 15 public health nurses (PHN), 105 completed the study. INTERVENTIONS: The intervention included individual counselling on diet and LTPA during five routine visits to a PHN until 37 weeks' gestation; the controls received the standard maternity care. RESULTS: The counselling did not affect the proportion of primiparas exceeding the weight gain recommendations or total LTPA when adjusted for confounders. The adjusted proportion of high-fibre bread of the total weekly amount of bread decreased more in the control group than in the intervention group (difference 11.8%-units, 95% confidence interval (CI) 0.6-23.1, P=0.04). The adjusted intake of vegetables, fruit and berries increased by 0.8 portions/day (95% CI 0.3-1.4, P=0.004) and dietary fibre by 3.6 g/day (95% CI 1.0-6.1, P=0.007) more in the intervention group than in the control group. There were no high birth weight babies (>or=4000 g) in the intervention group, but eight (15%) of them in the control group (P=0.006). CONCLUSIONS: The counselling helped pregnant women to maintain the proportion of high-fibre bread and to increase vegetable, fruit and fibre intakes, but was unable to prevent excessive gestational weight gain.

Blood pressure and menopausal transition: the Atherosclerosis Risk in Communities study (1987-95).

OBJECTIVE: Blood pressure changes during menopausal transition have not been studied previously using a biracial sample. We investigated whether menopausal transition was associated with change in blood pressure in African-American or white women. DESIGN, SETTING AND PARTICIPANTS: The prospective multicenter study, the Atherosclerosis Risk In Communities (ARIC) Study (1987-95) was utilized. Included were never-users of hormone replacement therapy (3,800 women, 44% of the original sample). MAIN OUTCOME MEASURE: Changes in blood pressure were adjusted for baseline age and body mass index, baseline blood pressure, antihypertensive use, ARIC field center and weight change. The menopausal transition group was compared to the non-transition group, separately, by ethnicity. RESULTS: Women undergoing the menopausal transition did not differ significantly in regard to systolic blood pressure change [5.2, 95% confidence interval (CI) 4.0-6.4] from non-transitional women (4.6, 95% CI 4.0-5.2); adjustment for age, baseline systolic blood pressure and other factors did not alter this finding. Transitional women had significantly less diastolic blood pressure change (-0.5, 95% CI -1.1 to 0.2) than non-transitional women (-2.0, 95% CI -2.4 to -1.7, P= 0.000) but, after adjustment for other covariates, the result was not significant African-American women had significantly (P= 0.003) higher systolic blood pressure change compared to white women, but this difference became non-significant (P= 0.21) after restricting the sample to women younger than 55 years of age. Interactions between menopausal transition and ethnicity were not significant, either in systolic blood pressure or diastolic blood pressure change. CONCLUSION: Menopausal transition is not associated with significant blood pressure change in African-American or white women.

Unemployment, sociodemographic background and consumption of alcohol before and during the economic recession of the 1990s in Finland.

BACKGROUND: Some studies suggest that people's alcohol consumption increases during unemployment whereas others suggest the opposite. All studies, however, deal with situations marked by relatively low national unemployment rates. We studied alcohol use among individuals in relation to unemployment, education, marital status and sex during times of both low and high unemployment in Finland. METHODS: A group of 44391 respondents, aged 18-64 years, from nationally representative, consecutive annual samples of 5000 people from 1982 to 1995 was utilized. Overall response rate for men was 77% and for women 80%. RESULTS: Univariate analyses indicated that unemployment was associated with the amount of reported alcohol use. However, when logistic regression was used to analyse interactions between alcohol consumption, unemployment, education and marital status, the picture changed. During a low unemployment period (e.g. 1982-1990), being unemployed was not associated with the upper consumption level of alcohol use (defined as > or = 8 drinks/week for men, > or = 5 for women); nor was it during a high unemployment period (1991-1995), except among single people. During a high unemployment period poorly educated, single, unemployed men (odds ratio [OR] = 1.6, 95% confidence interval [CI] : 1.1-2.4), showed a significantly higher risk of upper level of alcohol consumption than otherwise similar but employed men (OR = 0.8, 95% CI: 0.6-1.0). The reference group consisted of highly educated, married, employed men who did not exceed the upper drinking limit. Similarly, the risk of upper consumption level drinking was significantly higher among highly educated, unemployed single women (OR = 2.4, 95% CI: 1.388-4.3) than among otherwise similar but employed women (OR = 1.1, 95% CI: 1.0-1.386). CONCLUSION: Thus, unemployment was weakly but significantly related to the upper consumption level of alcohol use among single people during the recession but not in the preceding period of economic growth.

Hysterectomy and subsequent risk of cancer.

BACKGROUND: The objective of this retrospective cohort study was to assess the effect of hysterectomy on subsequent risk of cancer among 25,382 hysterectomized and a similar number of non-hysterectomized control women, registered in 1963-1976 in the Mass Screening Registry (MSR). METHODS: Cancer cases were obtained from the Finnish Cancer Registry (FCR) and standardized incidence ratio (SIR); the expected number of cases based on cancer incidence rates of the Finnish female population in 1967-1993, was used. Relative risk (RR) was calculated as SIR among the hysterectomized relative to non-hysterectomized women, adjusted for follow-up, education and parity. RESULTS: The RR estimates of non-genital cancers among women with any hysterectomy were approximately 5% higher than in the non-hysterectomized cohort. Relative risks of rectal cancer (RR = 1.4, 95% confidence interval [CI]: 1.0-1.8) and thyroid cancer (RR = 2.1, 95% CI; 1.5-3.1) were significant and largest among women who had undergone total hysterectomy pre- or perimenopausally. Relative risk estimates of breast cancer were close to unity. CONCLUSIONS: Hysterectomy is not associated with any substantial protective or promoting effect on cancers in general. Elevated risk of papillary thyroid cancer following hysterectomy is biologically plausible, as there are reproductive and endocrinological causes of thyroid cancer.

Incidence, causes and surgical methods for hysterectomy in Finland, 1987-1989.

BACKGROUND: The objective of our study was to investigate the incidence of hysterectomy by age, indication and surgical method employed during 1987-1989 in Finland, corrected by 'uteri or cervix at risk' population. METHODS: Three years (1987-1989) of patient discharges from the Finnish Hospital Discharge Register, which covers all Finnish hospitals including the few private ones, was used. Patients represented all Finnish adult women (approximately 2,000,000). RESULTS: Approximately 9000 hysterectomies are performed annually in Finland. The annual incidence of hysterectomy was 348/100,000 women (most among women aged 45-49), and after correction for 'uteri or cervix at risk' this rose by 11% to 390/100,000. The most frequent indications were leiomyoma (50%) and endometriosis (11%). Prolapse, menstrual disorders and cancer each accounted for 7-8% of all hysterectomies. The most common surgical approach was total abdominal hysterectomy (36%), while hysterectomy with bilateral oophorectomy and partial hysterectomy each accounted for 20% of operations. Differences in the rates by indication or surgical approach between 'uteri or cervix at risk' corrected and uncorrected estimates varied between 0% and 22%. CONCLUSIONS: The incidence of, and indications for hysterectomy in Finland are approximately the same as in other European countries, but partial hysterectomy is more common in Finland. Because the correction for the 'uteri or cervix at risk' population produced changes in the rates of hysterectomy, correction should be considered when calculating hysterectomy rates or incidences of cervical or endometrial cancer.

Estrogen replacement therapy and MRI-demonstrated cerebral infarcts, white matter changes, and brain atrophy in older women: the Cardiovascular Health Study.

OBJECTIVE: We studied the relationship between the use of estrogen replacement therapy (ERT) and cerebral magnetic resonance imaging (MRI) abnormalities among older women. DESIGN: A population-based prospective study (Cardiovascular Health Study). SETTING: Four regions in the United States. PARTICIPANTS: A total of 2133 (62.9% of the eligible) women aged 65 to 95 years (mean age 74.8), on whom MRI was performed in 1992-1994. MEASUREMENTS: Presence of global brain atrophy, white matter changes, small infarct-like lesion (ILL) (<3 mm), MRI infarcts (> or =3 mm, mostly small and asymptomatic), and cognitive function as measured by Mini-Mental State Exam (MMSE), and by ERT use (current/past/never), adjusted for a number of socioeconomic, lifestyle, and reproductive covariates. RESULTS: Current use of ERT was reported by 15% and past use by another 23% of participants; 35% of all women had MRI infarcts. The prevalence of MRI infarcts did not differ in current or past users from those who had never used ERT (nonusers). Bifrontal distance, the largest distance between frontal horns, and the size of ventricles were larger among current ERT users compared to past users or nonusers (P (trend) = .01), adjusted for all other covariates, but no dose-response relationship to current or past ERT use was found. Duration of estrogen use was not associated with any atrophy measure. Cortical atrophy measure, sulcal widening, or white matter disease did not differ significantly by ERT use or duration of use. Central measures of atrophy, bifrontal distance, and ventricular size were significantly associated with cognition as measured by MMSE. CONCLUSIONS: Current ERT users had much more clinically significant central atrophy than nonusers, but the implications remained unclear.

Cardiovascular morbidity in relation to ovarian function after hysterectomy.

OBJECTIVE: To determine if removal of the uterus with ovarian preservation is associated with cardiovascular morbidity and risk factors. METHODS: Self-reported histories of gynecologic surgery of 3895 women from 40 regions in Finland, 30-95 years old, were collected in 1977-1980, and 78% of hysterectomies were confirmed from the hospital records. Cardiovascular risk factors (total- and high-density lipoprotein cholesterol, education, body mass index [BMI], blood glucose, and triglycerides), parity, and current use of hormone replacement therapy were used to adjust the risk of hypertension (less than 60 years old and diastolic blood pressure [BP] at least 95 mmHg, or 60 years older and diastolic BP at least 100 mmHg), coronary heart disease, and heart failure. The women with unconfirmed hysterectomies and missing information on cardiovascular risk factors were excluded. Thereafter, the final number of subjects included in the analysis was 3780. RESULTS: One or no ovary was removed in 163 hysterectomies, and in 55 cases, both ovaries were removed. Women with hysterectomy and preservation of at least one ovary had significantly higher diastolic BP and higher BMI than those who had not undergone hysterectomy. Women with hysterectomy and ovarian preservation also had a significantly increased risk of hypertension (odds ratio 2.2, 95% confidence interval 1.5-3.1). The risks of other heart diseases (angina pectoris, myocardial infarction, and heart failure) were not significantly increased. CONCLUSION: Hysterectomy with ovarian preservation is associated with increased risk of high diastolic BP, diagnosis of hypertension, and increased BMI, but not with other heart diseases. Either hysterectomy increases the risk of hypertension or the increase of BP and the development of myomas, which often lead to hysterectomy, are explained by a common pathogenetic mechanism.

Socioeconomic variations in hysterectomy: evidence from a linkage study of the Finnish hospital discharge register and population census.

STUDY OBJECTIVE: To explore variations in rates for hysterectomy in relation to social class, education, and family income. DESIGN: Retrospective analysis of the 1988 Finnish hospital discharge register linked individually to the 1987 population census. SETTING: Finland. PARTICIPANTS: All women living in Finland aged 35 and over were the denominator population. The numerators were the 8663 women who underwent hysterectomy in 1988. MAIN RESULTS: The overall rate for hysterectomy was 63.5/10,000 women aged 35 and over. There was a marked positive correlation between disposable family income and hysterectomy rates even after age, hospital catchment area, education, and occupational status were adjusted for. However, no linear trend for overall hysterectomy rates was observed in relation to social class or education. Procedures due to myomas, accounting for 48% of all hysterectomies, were more frequent among women of high socioeconomic status according to all socioeconomic indicators. Larger proportions of hysterectomies for myoma were also performed in patients in private hospitals and in pay beds in public hospitals than in women in worse off groups. CONCLUSIONS: Unlike the findings in earlier studies from other countries, there was a positive correlation between income and hysterectomy rates as a result of the high numbers of hysterectomies performed to treat myoma in the well off women. The findings are discussed in terms of socioeconomic differences in the use of private gynaecological services, and factors, such as parity and use of hormonal replacement therapy, that affect the growth of myomas.

Cardiovascular risks and socioeconomic status: differences between men and women in Finland.

STUDY OBJECTIVE: The study aimed to assess the association of different indicators of socioeconomic status with levels of cardiovascular disease risk factors in men and women aged 25-64 years. DESIGN: This was a cross sectional survey, using a community based random sample. SETTING: The provinces of North Karelia and Kuopio in eastern Finland and the cities of Turku and Loimaa and surrounding communities in southwestern Finland in 1987. PARTICIPANTS: Altogether 2164 men and 2182 women aged 25-64 years took part. MEASUREMENTS AND MAIN RESULTS: Data were collected using self administered questionnaires and the measurement of height, body weight, and blood pressure and blood sampling for lipid determinations were done at the survey site. The risk of cardiovascular disease was determined by calculating a simple risk factor score based on the observed values of HDL and total cholesterol, leisure time, physical activity, blood pressure, medication for hypertension, body mass index, and smoking. Indicators of socioeconomic position used were years of education, family income, marital status, and the person's occupation. Lower levels of education, occupation, and income were all significantly associated with an unfavorable risk factor profile in men and women. Education and occupation showed the strongest associations with the risk factor score in both men and women. The results changed little when adjusting for income and marital status. Family income was more strongly associated with the risk factor score in women than men. When adjusting for occupation and education, income was no longer significantly associated with the risk factor score in men. Marital status was not significantly associated with the risk factor score in either sex. CONCLUSIONS: Using the strength of the association with the cardiovascular risk factor score as the criterion for a good socioeconomic indicator, the present study suggests that education and occupation may be equally good indicators in both men and women. Family income may have some additional importance, especially in women.