Identification of Approaches to Improve Patient Trust in Health Systems: A Group Concept Mapping Study.

EXECUTIVE SUMMARY: Higher levels of institutional trust have been associated with increased preventive healthcare use, greater adherence to treatment plans, and improved overall self-rated health status. However, little attention has been paid to understanding approaches to improve patient institutional trust. This study used group concept mapping to elicit patient perspectives on ways to improve patient trust. Eighteen insured individuals living in Delaware County, Pennsylvania, participated in the concept mapping sessions. Participants first brainstormed in a group setting to develop a list of ideas about how systems could improve trust, then each participant sorted the ideas into thematic domains and rated the statements based on both importance and feasibility. Four primary domains for improving institutional trust emerged: privacy, patient-provider relationship, respect for patients, and health system guidelines. Multiple action items to improve patient trust of the system were provided for each domain, and participants rated the "privacy" domain as the most feasible and important to address.We suggest that future local efforts to build institutional trust implement processes to improve the protection of patient privacy, support patient-provider relationships, and engender respect for patients, and that institutions develop system-level guidelines to support these principles. Next steps involve exploring the importance of these domains across other populations and developing and testing targeted interventions.

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.

DEVELOPMENT AND VALIDATION OF A NOVEL TOOL TO PREDICT HOSPITAL READMISSION RISK AMONG PATIENTS WITH DIABETES.

OBJECTIVE: To develop and validate a tool to predict the risk of all-cause readmission within 30 days (30-d readmission) among hospitalized patients with diabetes. METHODS: A cohort of 44,203 discharges was retrospectively selected from the electronic records of adult patients with diabetes hospitalized at an urban academic medical center. Discharges of 60% of the patients (n = 26,402) were randomly selected as a training sample to develop the index. The remaining 40% (n = 17,801) were selected as a validation sample. Multivariable logistic regression with generalized estimating equations was used to develop the Diabetes Early Readmission Risk Indicator (DERRI™). RESULTS: Ten statistically significant predictors were identified: employment status; living within 5 miles of the hospital; preadmission insulin use; burden of macrovascular diabetes complications; admission serum hematocrit, creatinine, and sodium; having a hospital discharge within 90 days before admission; most recent discharge status up to 1 year before admission; and a diagnosis of anemia. Discrimination of the model was acceptable (C statistic 0.70), and calibration was good. Characteristics of the validation and training samples were similar. Performance of the DERRI™ in the validation sample was essentially unchanged (C statistic 0.69). Mean predicted 30-d readmission risks were also similar between the training and validation samples (39.3% and 38.7% in the highest quintiles). CONCLUSION: The DERRI™ was found to be a valid tool to predict all-cause 30-d readmission risk of individual patients with diabetes. The identification of high-risk patients may encourage the use of interventions targeting those at greatest risk, potentially leading to better outcomes and lower healthcare costs. ABBREVIATIONS: DERRI™ = Diabetes Early Readmission Risk Indicator ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification GEE = generalized estimating equations ROC = receiver operating characteristic.

The Gestational Vaginal Microbiome and Spontaneous Preterm Birth among Nulliparous African American Women.

Introduction Early markers to identify pregnant women at high risk for spontaneous preterm birth (SPTB) have not been established and preventive options are limited. Recent attention has focused on examining the importance of characterizing the vaginal microbiome to predict SPTB. Results We examined the diversity and structure of the vaginal microbiome in nulliparous African American women during early pregnancy and compared 13 women who delivered preterm and 27 women who delivered at term. Samples were taken at one of two points in gestation, before 16 weeks or between 20 and 24 weeks. Among women who delivered preterm, we found lower bacterial diversity with lower abundance of Coriobacteriaceae, Sneathia, Prevotella, and Aerococcus compared with women delivering at term (linear discriminant analysis score > 3.0). The Shannon diversity index was not significantly different between the groups (p-value = 0.239). Phylogenetic diversity and Chao1 suggested a lower diversity in the vaginal microbiota of women who delivered preterm compared with term, but these findings were not significantly different (p = 0.077 and p = 0.066, respectively). Conclusion These data suggest that the vaginal microbiome of women delivering preterm had lower diversity than women delivering after 37 weeks, although these findings need to be explored in a larger sample of nulliparous African American women.

The role of the bacterial microbiota on reproductive and pregnancy health.

Recent assessments have examined the composition of bacterial communities influencing reproductive, pregnancy and infant health. The Microbiome Project has made great strides in sequencing the microbiome and identifying the vast communities of microorganisms that inhabit our bodies and much work continues to examine the individual contribution of bacteria on health and disease to inform future therapies. This review explores the current literature outlining the contribution of important bacteria on reproductive health among sexually active men and women, outlines gaps in current research to determine causal and interventional relationships, and suggests future research initiatives. Novel treatments options to reduce adverse outcomes must recognize the heterogeneity of the bacteria within the microbiome and adequately assess long-term benefits in reducing disease burden and re-establishing a healthy Lactobacillus-dominant state. Recognizing other reservoirs outside of the lower genital track and within sexual partners as well as genetic and individual moderators may be most important for long-term cure and reduction of disease. It will be important to develop useful screening tools and comprehensively examine novel therapeutic options to promote the long-term reduction of high-risk bacteria and the re-establishment of healthy bacterial levels to considerably improve outcomes among pregnant women and sexually active men and women.

First Trimester Levels of BV-Associated Bacteria and Risk of Miscarriage Among Women Early in Pregnancy.

OBJECTIVES: Prior studies have examined the role of bacterial vaginosis (BV) and increased risk of miscarriage; however the risk has been modest and many BV positive pregnant women deliver at term. BV is microbiologically heterogeneous, and thus the identification of specific BV-associated bacteria associated with miscarriage is warranted. METHODS: We measured the presence and level of seven BV-associated bacteria prior to 14 weeks gestation among urban pregnant women seeking routine prenatal care at five urban obstetric practices at Temple University Hospital in Philadelphia PA from July 2008 through September 2011. 418 Pregnant women were included in this assessment and 74 experienced a miscarriage. RESULTS: Mean log concentration of BVAB3 was significantly higher among women experiencing a miscarriage (4.27 vs. 3.71, p value = 0.012). Younger women with high levels of BVAB3 had the greatest risk of miscarriage. In addition, we found a significant decreased risk of miscarriage among women with higher log concentrations of Leptotrichia/Sneathia species or Megasphaera phylotype 1-like species early in pregnancy. CONCLUSIONS FOR PRACTICE: The identification of selected vaginal bacteria associated with an increased risk of miscarriage could support screening programs early in pregnancy and promote early therapies to reduce early pregnancy loss.

Early pregnancy changes in bacterial vaginosis-associated bacteria and preterm delivery.

BACKGROUND: We evaluated the importance of measuring early vaginal levels of eight bacterial vaginosis (BV)-associated bacteria, at two points in pregnancy, and the risk of spontaneous preterm delivery (SPTD) among pregnant women and the subgroup of pregnant women with a history of preterm delivery (PTD). METHODS: This prospective cohort study enrolled women at five urban obstetric practices at Temple University Hospital in Philadelphia PA. Women with singleton pregnancies less than 16 weeks gestation self-collected vaginal swabs at two points in pregnancy, prior to 16 weeks gestation and between 20-24 weeks gestation, to measure the presence and level of eight BV-associated bacteria. Women were followed-up for gestational age at delivery via medical records. RESULTS: Among women reporting a prior PTD, women with higher levels of Leptotrichia/Sneathia species, BVAB1 and Mobiluncus spp., prior to 16 weeks gestation, were significantly more likely to experience a SPTD. In addition, pregnant women with a prior PTD and increasing levels of Leptotrichia/Sneathia species (aOR: 9.1, 95% CI 1.9, 42.9), BVAB1 (aOR: 16.4, 95% CI 4.3, 62.7) or Megasphaera phylotype 1 (aOR: 6.2, 95% CI 1.9, 20.6), through 24 weeks gestation, were significantly more likely to experience an SPTD. Among the overall group of pregnant women, the levels of BV-associated bacteria were not related to SPTD. CONCLUSION: Among the group of women reporting a prior PTD, increasing levels of BVAB1, Leptotrichia/Sneathia species, and Megasphaera phylotype 1, through mid-pregnancy were related to an increased risk of SPTD.

Relationship of selected bacterial vaginosis-associated bacteria to Nugent score bacterial vaginosis among urban women early in pregnancy.

Among urban, primarily African American pregnant women, 74% were identified with Nugent score bacterial vaginosis (BV). All BV-associated bacteria were more prevalent among women with Nugent score BV. Bacterial vaginosis-associated bacteria 3 (BVAB3) had the highest positive predictive value, whereas Gardnerella vaginalis and Atopobium spp. had the highest sensitivity. Atopobium spp. levels had the most significant area under the curve.

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.

Do pregnant women accurately report sleep time? A comparison between self-reported and objective measures of sleep duration in pregnancy among a sample of urban mothers.

PURPOSE: Survey questions are commonly used to assess sleep duration because of their low cost and convenience. Responses to these questions correlate moderately with objectively measured sleep duration in nonpregnant individuals, but little is known about the validity of self-reported sleep measures in pregnancy. The aim of the present study was to determine the extent to which self-reported gestational sleep duration assessed by questionnaire predicted objectively measured gestational sleep duration via actigraphy. METHODS: We analyzed data from 80 mothers enrolled in an ancillary study of Project BABIES, a prospective cohort study of urban, pregnant women. Sleep measurements were collected in midpregnancy and included 7 days of wrist actigraphy, a sleep log, and survey questions about sleep time adapted from the Pittsburgh Sleep Quality Index. RESULTS: Mean measured gestational sleep duration derived from actigraphy was 6.87 h [standard deviation (SD) 0.87], and questionnaire-assessed nocturnal sleep time averaged 7.29 h (SD 1.84). While the difference between measures did not reach statistical significance (p = 0.07 for paired samples t test), over half (62 %) of participants reported a habitual average nightly sleep time that differed more than 1 h from their average actigraphically measured sleep duration (39 % overestimated by more than an hour; 23 % underestimated by more than an hour). There was no correlation between measures (r = 0.007; 95 % confidence interval -0.21, 0.23). CONCLUSION: Questionnaire-derived reports of usual sleep hours do not reflect objectively measured sleep time in urban, pregnant women. Actigraphy is preferable to accurately assess gestational sleep duration.

Treatment of localized periodontal disease in pregnancy does not reduce the occurrence of preterm birth: results from the Periodontal Infections and Prematurity Study (PIPS).

OBJECTIVE: The purpose of this study was to test whether treating periodontal disease (PD) in pregnancy will reduce the incidence of spontaneous preterm delivery (SPTD) at < or = 35 weeks of gestation. STUDY DESIGN: A multicenter, randomized clinical trial was performed. Subjects with PD were randomized to scaling and root planing (active) or tooth polishing (control). The primary outcome was the occurrence of SPTD at <35 weeks of gestation. RESULTS: We screened 3563 subjects for PD; the prevalence of PD was 50%. Seven hundred fifty-seven subjects were assigned randomly; 378 subjects were assigned to the active group, and 379 subjects were assigned to the placebo group. Active treatment did not reduce the risk of SPTD at <35 weeks of gestation (relative risk, 1.19; 95% confidence interval [CI], 0.62-2.28) or composite neonatal morbidity (relative risk, 1.30; 95% CI, 0.83-2.04). There was a suggestion of an increase in the risk of indicated SPTD at <35 weeks of gestation in those subjects who received active treatment (relative risk, 3.01; 95% CI, 0.95-4.24). CONCLUSION: Treating periodontal disease does not reduce the incidence of SPTD.

Neighborhood and individual-level violence and unintended pregnancy.

As many as half of all pregnancies are unintended, and unintended pregnancy has been linked to a variety of adverse pregnancy and infant health outcomes. Our aim was to determine if urban women who experience high levels of neighborhood and/or individual-level violence are at an increased risk of reporting an unintended pregnancy. One thousand five hundred thirty-six pregnant women seeking care in an emergency department in Philadelphia, Pennsylvania were recruited in their first or second trimester and completed in-person interviews. Information on demographic characteristics, social support, substance abuse, current experience and history of interpersonal violence, perceptions of current neighborhood-level violence, and the intendedness of their current pregnancy were gathered. Multiple logistic regression analyses were conducted to assess the relationship between violence indicators and pregnancy intendedness. Six hundred twenty-seven women (41%) reported an unintended pregnancy. Not feeling safe in one's neighborhood was significantly associated with reporting an unintended pregnancy (odds ratio (OR), 1.28; 95% confidence interval (CI), 1.02-1.61) when demographic, other neighborhood, and individual-level violence indicators were accounted for. Furthermore, history of sexual abuse (OR, 1.5; 95% CI, 1.11-2.04), violence in previous pregnancy (OR = 1.7, 95% CI, 1.15-2.51), and a high index of spousal abuse score (OR = 1.6; 95% CI, 1.32-2.04) were also associated with unintended pregnancy in multiple logistic regression models. These findings indicate that neighborhood-level violence and other individual-level violence indicators may be important when examining factors related to unintended pregnancy among young, urban women.

Trends in gastroesophageal reflux disease as measured by the National Ambulatory Medical Care Survey.

BACKGROUND: The prevalence of reflux disease is increasing. Health-care utilization including physician visits for this disorder is lacking. Our purpose was to analyze the trend in physician visits for GERD from the period 1995-2006 using the National Ambulatory Medical Care Survey. We also sought to determine health-care utilization for GERD indirectly by assessing prescription trends for proton-pump inhibitors and H2 receptor blockers during the period. METHODS: The National Ambulatory Medical Care Survey is a survey of approximately 3,000 office-based physicians that uses a three-stage probability sampling procedure to allow extrapolation to the US population. All visits between 1995 and 2006 for symptoms and/or diagnoses compatible with GERD were combined into a single categorical variable. Weighted data was utilized for descriptive and inferential statistical analysis. RESULTS: After weighting, there were N = 321,513 adult ambulatory care encounters for all diagnoses. Visits for reflux increased throughout the examined period. Using logistic regression, visits for reflux were associated with female gender, age over 40, and calcium channel blocker use. Proton-pump inhibitor use increased substantially during the study period while H2 blocker use declined. Family practitioners and internists saw the majority of reflux patients. CONCLUSIONS: The frequency of ambulatory visits in the United States for gastroesophageal reflux disease increased significantly between 1995 and 2006. The use of PPI therapy is increasing even more substantially. Older age, female gender, and use of calcium channel blockers were associated with a higher frequency of GERD visits. Health-care utilization for this disorder is increasing perhaps due to our ever-increasing epidemic of obesity.

Mycoplasma genitalium among young, urban pregnant women.

OBJECTIVE: As the consequences of Mycoplasma genitalium in pregnant women are unknown, we examined the relationship between prenatal M. genitalium infection and SAB. METHODS: The presence of M. genitalium was determined by PCR in urine from 82 women who subsequently experienced a SAB and 134 women who maintained their pregnancies past 22 weeks gestation. The relationships between M. genitalium and subsequent SAB, demographic, current pregnancy, and reproductive health history characteristics were evaluated. RESULTS: Compared to women without M. genitalium, women with M. genitalium were more likely to report nulliparity (41.7% versus 17.4%, P = .04), history of pelvic inflammatory disease (27.3% versus 8.8%, P = .08), prior C. trachomatis infection (63.6% versus 36.9%, P = .11,) and problems getting pregnant (18.2% versus 4.4%, P = .10). M. genitalium was not associated with SAB (AOR 0.9, 95% CI 0.2-3.8). CONCLUSIONS: Pregnant women who test positive for M. genitalium do not have an increased risk of SAB but report a history of reproductive morbidities.

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.

Acculturation process: a collaborative strategy of integration in attaining culturally congruent nursing care.

The author describes a strategic partnership effort in pursuit of culturally congruent care: the professional model of nursing practice. The organizing framework is an integrated strategy of acculturation based in cultural care theory. The professional health system's department of staff development and a vendor partnered to develop and implement the framework in acculturating Philippine nurses. The author also presents recommendations for future consideration.

Do short-term markers of treatment efficacy predict long-term sequelae of pelvic inflammatory disease?

OBJECTIVE: This study was undertaken to assess whether short-term markers, often used to measure clinical cure after treatment for pelvic inflammatory disease, predict sequelae of lack of pregnancy, recurrent pelvic inflammatory disease, and chronic pelvic pain. STUDY DESIGN: Women with mild-to-moderate pelvic inflammatory disease were assessed after treatment initiation at 5 days for tenderness (n = 713) and at 30 days for tenderness, cervical infections and endometritis (n = 298). Pregnancy, recurrent pelvic inflammatory disease, and chronic pelvic pain were evaluated after 84 months, on average. RESULTS: Pelvic tenderness at 5 and at 30 days significantly elevated the risk for developing chronic pelvic pain; tenderness at 30 days was also significantly associated with recurrent pelvic inflammatory disease. However, pelvic tenderness at 5 and at 30 days was only modestly clinically predictive of chronic pelvic pain or recurrent pelvic inflammatory disease (positive predictive values 22.1-66.9%). No short-term marker significantly influenced the likelihood of achieving a pregnancy. CONCLUSION: Tenderness at 5 or 30 days did not accurately predict the occurrence of pelvic inflammatory disease-related reproductive morbidities.

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.

Symptoms of gastroparesis: use of the gastroparesis cardinal symptom index in symptomatic patients referred for gastric emptying scintigraphy.

BACKGROUND/AIM: The Gastroparesis Cardinal Symptom Index (GCSI) was developed to assess symptoms of gastroparesis. The aim of this study was to correlate symptoms using the GCSI with delayed gastric emptying (DGE) in symptomatic patients referred for gastric emptying scintigraphy (GES). METHODS: A total of 226 consecutive symptomatic patients referred for GES completed the 9-question GCSI. GES was performed using a (99)Tc-labeled egg meal. Gastroparesis was defined as DGE at 2 h and/or 4 h. RESULTS: Using linear regression, nausea (p = 0.09), not able to finish a normal-size meal (p = 0.005), postprandial fullness subscore (p = 0.01), and total GCSI score (p = 0.06) were predictors of the gastric retention values at 2 h, but not at 4 h. Patients with gastroparesis had significant higher symptom scores for nausea (p = 0.035) and vomiting (p = 0.040) compared to patients with normal gastric emptying. The positive predictive value varied between 51 and 61% for total GCSI scores between 20 and 35, respectively. CONCLUSION: The individual symptoms of nausea, vomiting, and early satiety were associated with DGE at 2 h but not at 4 h. In contrast, the total or average GCSI score did not reliably predict the diagnosis of gastroparesis in symptomatic patients referred for GES.

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.