Levonorgestrel intrauterine device and depression: A Swedish register-based cohort study.

BACKGROUND: The levonorgestrel intrauterine device (LNG-IUD) is traditionally viewed as a safe contraceptive with limited systemic effects. However, three recent studies have indicated an increased risk of depression subsequent to LNG-IUD use. This study aimed to examine the potential associated risk between LNG-IUDs and depression, and determine which women are at risk. METHODS: This longitudinal cohort study was based on data from seven Swedish national population-based registers. All Nordic-born women aged 15-24 years residing in Sweden between 2010 and 2017 were included. Cox regression was implemented to estimate the adjusted hazard ratio (AHR) for developing depression, defined as first depression diagnosis or redeemed prescription for antidepressant treatment. We adjusted for age, education level, parental country of origin, parental psychiatric health, previous hormonal contraceptive use and medical indications for contraceptive use. FINDINGS: 703,157 women were included in the analysis. The LNG-IUD was associated with 57 % increased risk of depression [AHR 1.57 (95 % CI 1.51-1.64)]. The greatest risk increase was seen in adolescent women [AHR 2.57, (95 % CI 2.36-2.80)] and women who used the LNG-IUD as their first hormonal contraceptive method [AHR 1.63, (95 % CI 1.50-1.78)]. The risk of depression decreased at the end of study period [AHR 1.43, (95 % CI 1.36-1.51)], once the LNG-IUD became more widely accessible among nulliparous women. CONCLUSIONS: Adolescent women who use the LNG-IUD as their first-ever hormonal contraceptive are at increased risk of developing depression. However, additional impact from confounding factors is likely as risk estimates decreased over the study period. Further research needs to determine if there is a causal relationship between LNG-IUDs and depression.

Demographic and clinical characteristics determining patient-centeredness in endometriosis care.

PURPOSE: The primary aim of this study was to assess patient-centeredness of endometriosis care in a national sample of Swedish women with endometriosis. The secondary aims were to assess the importance of different dimensions of endometriosis care and to analyze demographic and clinical determinants associated with the experience of patient-centeredness. METHODS: This cross-sectional study included 476 women with confirmed endometriosis. An invitation to participate was sent to 1000 randomly selected women aged ≥ 18 years having any endometriosis diagnosis and who had visited a gynecological clinic due to endometriosis problems any time during the past five years. Participants were recruited from ten different-sized gynecology clinics all over Sweden. The invitation letter had a link to the digital survey, which consisted of demographic and clinical questions, and the ENDOCARE questionnaire (ECQ). ECQ measures experiences, importance and patient-centeredness of ten dimensions of endometriosis care. Univariate and multiple regression analyses were used to analyze which patient-specific demographic and clinical determinants were associated with the experience of patient-centeredness. RESULTS: The response rate was 48%. The results indicate that Swedish women with endometriosis experience low patient-centeredness and rate relational aspects with healthcare professionals as the most important aspects of care. Having a gynecologist with patient responsibility was an independent predictor for high patient-centeredness. CONCLUSION: Women with endometriosis in Sweden experience low patient-centeredness, reflecting the urgent need for improvement. More effort should be given to develop the relational aspects of care. Women with endometriosis should have a responsible gynecologist to care for treatment and follow-up.

Hormonal Contraceptive Use and Risk of Depression Among Young Women With Attention-Deficit/Hyperactivity Disorder.

OBJECTIVE: Women with attention-deficit/hyperactivity disorder (ADHD) have an increased risk of becoming teenage mothers. Adverse effects of hormonal contraception (HC), including depression, may affect adherence to user-dependent contraception and increase the risk for unplanned pregnancies and teenage births in women with ADHD. The current study analyzed whether girls and young women with ADHD are at increased risk for depression during HC use compared with women without ADHD. METHOD: A linkage of Swedish national registers covering 29,767 girls and young women with ADHD aged 15 to 24 years and 763,146 without ADHD provided measures of ADHD and depression diagnoses (International Classification of Diseases [ICD] code) and prescription of stimulant medication, HC, and antidepressant medication (Anatomical Therapeutic Chemical [ATC] code). Cox regression models applying an interaction term (ADHD diagnosis × HC use) evaluated the excess risk of HC-induced depression in women with ADHD. RESULTS: Women with ADHD had a 3-fold higher risk of developing depression, irrespective of HC use (adjusted hazard ratio [aHR] = 3.69, 95% CI = 3.60-3.78). Oral combined HC users with ADHD had a 5 times higher risk of depression compared with women without ADHD who were not using oral combined HC (aHR = 5.19, 95% CI = 4.94-5.47), and a 6 times higher risk in comparison with women without ADHD who were on oral combined HC (aHR = 6.10 (95% CI = 5.79-6.43). The corresponding risk of depression in women with ADHD who used a progestogen-only pill (aHR = 5.00, 95% CI = 4.56-5.49). The risk of developing depression when using non-oral HC was similarly moderately increased in both groups. CONCLUSION: Girls and young women with ADHD have an increased risk of developing depression when using oral HC compared with their unaffected peers. Information on risks with HCs as well as potential benefits with long-acting reversible contraceptives needs to be an integrated part of the shared decision making and contraception counseling for young women with ADHD.

Hormonal contraception and risk of breast cancer and breast cancer in situ among Swedish women 15-34 years of age: A nationwide register-based study.

Background: Evidence on a possible association between newer hormonal contraceptives (HC) and risk of breast cancer remains inconclusive, especially as concerns progestogen-only methods. Methods: In this nationwide prospective cohort study, all Swedish women aged 15-34 at study start on January 1st 2005, or who turned 15 years during the study period, were followed until December 31st 2017. Using information from seven National Registers, we assessed the risk ratio of developing breast cancer and breast cancer in situ in relation to different HC using Poisson regression. We adjusted the analyses for several known confounders of breast cancer. Findings: This cohort included 1.5 million women providing more than 14 million person-years. During the study period, 3842 women were diagnosed with breast cancer. Compared with never users of any HC, we found no increased risk of developing breast cancer among current users of any combined HC, IRR 1.03 (0.91-1.16), whereas current users of progestogen-only methods had an increased risk of developing breast cancer, IRR 1.32 (1.20-1.45). Across all types of HC, the risk of developing breast cancer appeared to be highest the first five years of use (combined HC IRR 1.39 (1.14-1.69); progestogen-only methods IRR 1.74 (1.44-2.10). The risk disappeared ten years after the women stopped using HC. The absolute risk of breast cancer per 100,000 women-years was 22.4 for never users, 10.9 for current users of combined HC, and 29.8 for current users of progestogen-only methods. Interpretation: Current use of progestogen-only methods is associated with a small increased risk of developing breast cancer, whereas we could only detect an increased risk among users of combined HC during the first five years of use. This may partly be explained by a selective prescription of progestogen-only methods to women with risk factors for breast cancer, like smoking or obesity. As the absolute risk of breast cancer was small, the many health benefits associated with HC must also be taken into account in contraceptive counselling. Funding: This study was funded by the Swedish Cancer Society and by the Uppsala County Council, the Faculty of Medicine at Uppsala University.

Associations between capillary glucose during pregnancy and childhood growth to the age of five: a cohort study.

The objective of this study was to evaluate the relationship between random capillary glucose levels in healthy pregnant women and infant size at birth and childhood growth to the age of five years. This population-based cohort study comprised 10,937 healthy mother-child dyads. Data on highest maternal random capillary glucose level during pregnancy and sequential anthropometric data on their children during the first five years of life were gathered from the Uppsala County Mother and Child Cohort. Statistical analyses were performed with linear regression and linear mixed effect regression models. We found that higher glucose level during pregnancy was associated with higher weight z-score (ß 0.10, 95% confidence interval (CI) 0.08-0.11), length z-score (ß 0.05, 95% CI 0.03-0.07) and BMI z-score (ß 0.09, 95% CI 0.07-0.12) at birth, adjusted for maternal BMI and country of birth, smoking during pregnancy and parity. The association did not remain at 1½, 3, 4 and 5 years of age. There was a positive relationship between higher glucose level during pregnancy and a decrease in weight z-score, height z-score and BMI z-score from birth to 5 years of age. In conclusion, higher random capillary glucose levels in pregnant healthy women were associated with greater infant size at birth, as well as decreased growth velocity in early childhood.

Translation, Cross-Cultural Adaptation, and Psychometric Evaluation of the Swedish Version of ENDOCARE: An Instrument to Measure Patient Centeredness of Endometriosis Care.

OBJECTIVES: The need for quality improvement within endometriosis healthcare is widely acknowledged. The ENDOCARE questionnaire (ECQ) measures patient centeredness of endometriosis care. The aims of this study were (1) to translate and culturally adapt ECQ into Swedish, (2) to evaluate validity (construct validity), and (3) to measure reliability (internal consistency and test-retest reliability). DESIGN: This is a cross-sectional randomized study. Participants, Setting, and Methods: ECQ was first translated according to a well-established guideline and was thereafter sent to 500 randomly selected women with endometriosis, who had visited participating clinics during the past 3 years. The first 150 women who returned their questionnaires were immediately sent the same questionnaire again. The ECQ consists of 3 parts. The first part contains demographic and clinical questions, while part II has 38 items that are answered according to 2 aspects: percentage of negative experience of care and mean personal importance. A patient-centeredness score (PCS) is calculated based on these 2 aspects. The items are also divided into 10 dimensions of care. Part III is a grading of overall experience and an open-ended question on any missing aspect in the questionnaire. RESULTS: A total of 187 native Swedish-speaking women participated. Data completeness was high (>90%). The overall PCS median was 3.5. The highest median PCS was found in the dimension regarding endometriosis clinic staff and the lowest in emotional support and alleviation of fear and anxiety and the involvement of significant others. Factor analysis could roughly confirm 2 of the 10 dimensions. The Cronbach's α coefficient for PCS ranged from 0.35 to 0.73. The test-rest analysis showed acceptable reliability. LIMITATIONS: The most important limitation was the relatively low participation rate and the risk of recall bias. It is likely that women gave their answers based on their most recent experiences. CONCLUSIONS: Overall, our results indicate that the Swedish version of the ECQ is a usable instrument to measure patient centeredness in endometriosis care, but due to the unstable factor analysis, conclusions based on the dimensions should be made with caution.

Psychometric evaluation of the Swedish version of the 30-item endometriosis health profile (EHP-30).

BACKGROUND: The 30-Item Endometriosis Health Profile (EHP-30) is a specific instrument measuring quality of life among women with endometriosis. Although the Swedish version of EHP-30 is widely used in research and clinical settings, it has not yet been evaluated psychometrically. Ensuring validity and reliability is of most importance when using translated instruments. Therefore, the aim of the study was to evaluate the psychometric properties of the Swedish version of the EHP-30. METHODS: This study was conducted at a Swedish referral university hospital specializing in endometriosis. Data collection was performed in January 2013. The EHP-30 was sent to 369 randomly selected women with a laparoscopy-verified endometriosis diagnosis. The psychometric evaluation included evaluation of data completeness, score distributions, floor and ceiling effects, internal consistency, factor analysis and test-retest reliability. RESULTS: Out of the 211 women with endometriosis who answered the questionnaire, 128 were native Swedish speakers who had experienced symptoms of endometriosis during the past 4 weeks, and were included in the psychometric evaluation. Data completeness was 99.5%. The highest median score was found in the Control and Powerlessness subscale, and lowest in Pain. Distributions towards ill health were found in all subscales except for the pain subscale, but there were no noteworthy floor or ceiling effects. Internal consistency was good (Cronbach's α 0.83-0.96). Factor analysis could roughly confirm three of the five subscales. The test-rest analysis showed good reliability. Scores were systematically lower during the second measurement. CONCLUSIONS: We conclude that the Swedish version of EHP-30 is a valid and reliable instrument to measure health-related quality of life in women with endometriosis. It is understandable, acceptable and usable and can be recommended for use in clinical daily routines and for research purposes.

Trivial risks and the new radiation protection system.

The International Commission on Radiological Protection proposes that doses below a certain level should be excluded from the system of protection, without regard to the number of people exposed. As the Commission assumes that there is a risk of harm even from very low doses, the proposal also disregards these very low risks. The arguments for this proposal are examined here. It is argued that the fact that risks are small compared to natural sources cannot be used as justification for accepting them. The principle 'if the risk of harm to the health of the most exposed individual is trivial, then the total risk is trivial--irrespective of how many people are exposed' is analysed. It is found to equivocate on the meaning of the word trivial and to ignore the total risk. It is also argued that the new proposal is not justified by a change from a utilitarian ethic to an ethic based on individual rights. Finally, it is suggested that small doses should only be disregarded if the expected value of harm is small, and the exclusion level should thus depend on the number of people exposed.