Predictors of hysterectomy: an Australian study

Women With a History of Primary Infertility and Increased Rates of Bilateral Oophorectomy

OBJECTIVE

To evaluate the association of primary infertility with subsequent bilateral oophorectomy and hysterectomy, using a population-based cohort of women with primary infertility and age-matched women in a referent group.

METHODS

The Rochester Epidemiology Project record-linkage system was used to assemble a population-based cohort of women with primary infertility diagnosed between 1980 and 1999 (index date). Women were age-matched (±1 year) 1:1 to women without a history of infertility or hysterectomy at the index date (referent group). Cox proportional hazards models were fit to compare long-term risks of bilateral oophorectomy and hysterectomy, respectively, between women with infertility and women in the referent group.

RESULTS

Among both groups of 1,001 women, the mean age at the index date was 29.2±4.4 years. Median duration of follow-up was 23.7 years for both groups. Women with primary infertility were 1.7 times (adjusted hazard ratio [aHR] 1.69, 95% CI 1.22-2.33) more likely to undergo bilateral oophorectomy compared with women in the referent group. In a sensitivity analysis that excluded women with a diagnosis of infertility related to endometriosis and their matched referent group participants, this association persisted (aHR 1.50, 95% CI 1.06-2.14). Women with primary infertility did not have a significant increased risk of hysterectomy (aHR 0.98, 95% CI 0.79-1.23). However, risk of hysterectomy was increased in those with primary infertility related to endometriosis (aHR 1.94, 95% CI 1.12-3.34). We observed that women with primary infertility were more likely to undergo hysterectomy with bilateral oophorectomy. Women in the referent group were more likely to undergo hysterectomy with ovarian conservation. Few women in either group had isolated bilateral oophorectomy.

CONCLUSION

Primary infertility, with and without a diagnosis of endometriosis, is associated with an increased risk of bilateral oophorectomy. In women with endometriosis-related infertility, there is an association with future hysterectomy. These findings represent important confounders in the evaluation of long-term health outcomes related to primary infertility.

Neither soyfoods nor isoflavones warrant classification as endocrine disruptors: a technical review of the observational and clinical data

Soybeans are a rich source of isoflavones, which are classified as phytoestrogens. Despite numerous proposed benefits, isoflavones are often classified as endocrine disruptors, based primarily on animal studies. However, there are ample human data regarding the health effects of isoflavones. We conducted a technical review, systematically searching Medline, EMBASE, and the Cochrane Library (from inception through January 2021). We included clinical studies, observational studies, and systematic reviews and meta-analyses (SRMA) that examined the relationship between soy and/or isoflavone intake and endocrine-related endpoints. 417 reports (229 observational studies, 157 clinical studies and 32 SRMAs) met our eligibility criteria. The available evidence indicates that isoflavone intake does not adversely affect thyroid function. Adverse effects are also not seen on breast or endometrial tissue or estrogen levels in women, or testosterone or estrogen levels, or sperm or semen parameters in men. Although menstrual cycle length may be slightly increased, ovulation is not prevented. Limited insight could be gained about possible impacts of in utero isoflavone exposure, but the existing data are reassuring. Adverse effects of isoflavone intake were not identified in children, but limited research has been conducted. After extensive review, the evidence does not support classifying isoflavones as endocrine disruptors.

Prevalence and incidence of endometriosis in Australian women: a data linkage cohort study

OBJECTIVE

To estimate the prevalence and incidence of endometriosis among Australian women.

DESIGN

Population-based cohort study linked to administrative health records.

SETTING

Secondary analysis of seven surveys collected between 2000 and 2018 from a population-based cohort study.

POPULATION

A total of 13 508 Australian women, born 1973-78, from a prospective cohort study of 14 247 women conducted between 1996 and 2018.

METHODS

During 2000 and 2018, self-reported longitudinal survey data were linked to three administrative health databases to separately identify women with clinically confirmed or suspected endometriosis across the multiple data sources.

MAIN OUTCOME MEASURES

Prevalence and incidence of clinically confirmed endometriosis in the cohort were first estimated using national hospital data. Data were then combined with other administrative health databases and the survey data to capture all clinically confirmed and suspected diagnoses of endometriosis.

RESULTS

The cumulative prevalence of clinically confirmed endometriosis was 6.0% (95% CI 5.8-6.2%) by age 40-44 years. The cumulative prevalence increased to 11.4% (95% CI 11.1-11.7%) when adding diagnoses of clinically suspected endometriosis. Age-specific incidence estimates peaked to 6 per 1000 person-years at age 30-34 years.

CONCLUSIONS

Among 13 508 Australian women followed for 20 years, one in nine women had clinically confirmed or suspected endometriosis by the age of 44, with most diagnosed during their early thirties. Endometriosis is a significant public health issue requiring increased surveillance, clinical awareness and management. Efforts to expand knowledge on the aetiology of the disease and optimal methods for disease management are crucial to women's health.

TWEETABLE ABSTRACT

In a national study of 13 508 Australian women, one in nine women were diagnosed with endometriosis by age 44.

Molecular targets of dietary phytochemicals for possible prevention and therapy of uterine fibroids: Focus on fibrosis

Uterine fibroids (myomas or leiomyomas) are common benign tumors of reproductive aged women. Fibroids are clinically apparent in 20-50% of women, and cause abnormal uterine bleeding, abdominal pain and discomfort, pregnancy complications and infertility. Unfortunately, limited numbers of medical treatment are available but no effective preventive strategies exist. Moreover, the benefits of medical treatments are tempered by lack of efficacy or serious adverse side effects. Fibrosis has recently been recognized as a key pathological event in leiomyoma development and growth. It is defined by the excessive deposition of extracellular matrix (ECM). ECM plays important role in making bulk structure of leiomyoma, and ECM-rich rigid structure is believed to be a cause of abnormal bleeding and pelvic pain/pressure. Dietary phytochemicals are known to regulate fibrotic process in different biological systems, and being considered as potential tool to manage human health. At present, very few dietary phytochemicals have been studied in uterine leiomyoma, and they are mostly known for their antiproliferative effects. Therefore, in this review, our aim was to introduce some dietary phytochemicals that could target fibrotic processes in leiomyoma. Thus, this review could serve as useful resource to develop antifibrotic drugs for possible prevention and treatment of uterine fibroids.

The epidemiological profile of hysterectomy in rural Chinese women: a population-based study

OBJECTIVES

Hysterectomy is one of the most common surgical procedures performed on women in developed countries; however, little is known about the epidemiology of hysterectomy in low-income to middle-income regions. This study seeks to evaluate the prevalence of hysterectomy and its risk factors in rural China.

METHODS

Questionnaires were collected from 3328 female adults aged 25â€"69 years in rural Anyang, China, in 2009â€"2011. Hysterectomy status was ascertained by the gynaecologist at the time of cytological test. Univariate and multivariate regression analyses were performed to assess the risk factors for hysterectomy.

RESULTS

The overall prevalence of hysterectomy was 3.31% (110/3328). Women above the age of 40 years had a higher prevalence of prior hysterectomy, compared with those aged 25â€"39 years (5.01% vs 0.33%). Obesity was marginally related with a higher risk of hysterectomy (adjusted OR=1.59; 95% CI 0.99 to 2.56; body mass index (BMI) ≥28.0 vs 18.5 ≤ BMI <24.0). History of prior pregnancy loss conferred a greater risk for hysterectomy (adjusted OR=1.51; 95% CI 1.02 to 2.23). Of the 75 (68.18%, 75/110) cases who provided further information on hysterectomy, 84.00% (63/75) had undergone total abdominal hysterectomy and 70.67% (53/75) had received surgery for leiomyoma.

CONCLUSIONS

Rural Chinese women had a relatively low prevalence of hysterectomy, and the majority of reported hysterectomies were performed abdominally for leiomyoma. Hysterectomy prevalence differed significantly by age, BMI and history of pregnancy loss. This study expands the current understanding of the epidemiology of hysterectomy in lower resource areas.

Hysterectomy risk in premenopausal-aged military veterans: associations with sexual assault and gynecologic symptoms

BACKGROUND

Several gynecological conditions associated with hysterectomy, including abnormal bleeding and pelvic pain, have been observed at increased rates in women who have experienced sexual assault. Previous findings have suggested that one of the unique health care needs for female military veterans may be an increased prevalence of hysterectomy and that this increase may partially be due to their higher risk of sexual assault history and posttraumatic stress disorder (PTSD). Although associations between trauma, PTSD, and gynecological symptoms have been identified, little work has been done to date to directly examine the relationship between sexual assault, PTSD, and hysterectomy within the rapidly growing female veteran population.

OBJECTIVES

The objective of the study was to assess the prevalence of hysterectomy in premenopausal-aged female veterans, compare with general population prevalence, and examine associations between hysterectomy and sexual assault, PTSD, and gynecological symptoms in this veteran population.

STUDY DESIGN

We performed a computer-assisted telephone interview between July 2005 and August 2008 of 1004 female Veterans Affairs (VA)-enrolled veterans ≤ 52 years old from 2 Midwestern US Veterans Affairs medical centers and associated community-based outreach clinics. Within the veteran study population, associations between hysterectomy and sexual assault, PTSD, and gynecological symptoms were assessed with bivariate analyses using χ(2), Wilcoxon-Mann-Whitney, and Student t tests; multivariate logistic regression analyses were used to look for independent associations. Hysterectomy prevalence and ages were compared with large civilian populations represented in the Behavioral Risk Factor Surveillance System and American College of Surgeons National Surgical Quality Improvement Program databases from similar timeframes using χ(2) and Student t tests.

RESULTS

Prevalence of hysterectomy was significantly higher (16.8% vs 13.3%, P = .0002), and mean age at hysterectomy was significantly lower (35 vs 43 years old, P < .0001) in this VA-enrolled sample of female veterans compared with civilian population-based data sets. Sixty-two percent of subjects had experienced attempted or completed sexual assault in their lifetimes. A history of completed lifetime sexual assault with vaginal penetration (LSA-V) was a significant risk factor for hysterectomy (age-adjusted odds ratio, 1.85), with those experiencing their first LSA-V in childhood or in military at particular risk. A history of PTSD was also associated with hysterectomy (age-adjusted odds ratio, 1.83), even when controlling for LSA-V. These associations were no longer significant when controlling for the increased rates of gynecological pain, abnormal gynecological bleeding, and pelvic inflammatory disease seen in those veterans with a history of LSA-V.

CONCLUSION

Premenopausal-aged veterans may be at higher overall risk for hysterectomy, and for hysterectomy at younger ages, than their civilian counterparts. Veterans who have experienced completed sexual assault with vaginal penetration in childhood or in military and those with a history of PTSD may be at particularly high risk for hysterectomy, potentially related to their higher risk of gynecological symptoms. If confirmed in future studies, these findings have important implications for women's health care providers and policy makers within both the VA and civilian health care systems related to primary and secondary prevention, costs, and the potential for increased chronic disease and mortality.

Association between nm23 gene polymorphisms and the risk of endometriosis

The first tumor metastasis-suppressor gene, nm23, may have an important role in the pathogenesis of endometriosis (EM). The present study aimed to evaluate whether nm23 gene polymorphisms are correlated with the risk of the development of EM in North Chinese women, as a preliminary study. The case-control study was conducted with 379 EM patients and 384 unrelated healthy controls. Genotyping of two polymorphisms within the nm23 gene promoter region (rs16949649 T/C and rs2302254 C/T) were performed using polymerase chain reaction-restriction fragment length polymorphism. The data showed that the rs16949649 and rs2302254 polymorphisms within the nm23 gene were not associated with the risk of developing EM. There were no statistical differences in the distribution of nm23 genotypes between patients with EM and the control group (P=0.490 and P=0.440, respectively). For the rs16949649 T/C, compared with the C/T + T/T genotype, the C/C genotype did not increase the risk of EM [odds ratio (OR)=0.81; 95% confidence interval (CI), 0.57-1.17]. For the rs2302254 C/T, compared with the C/T + C/C genotype, the T/T genotype did not increase the risk of EM (OR=1.46; 95% CI, 0.81-2.64). In conclusion, the findings in the present pilot study suggest that nm23 polymorphisms do not contribute to EM susceptibility. However, more studies in larger populations are required to confirm these results.

Vegetarian diet and reduced uterine fibroids risk: A case-control study in Nanjing, China

AIM

The aim of this study was to investigate whether a vegetarian diet correlates with a potential reduced risk of uterine fibroids.

MATERIAL AND METHODS

We used data from a case-control study conducted in Southeast University Zhongda Hospital between February 2010 and December 2014. Cases included 600 Chinese Han women with uterine fibroids (case group) whose clinical diagnosis dated back no more than 1 year. Controls were 600 patients without uterine fibroids as well as healthy volunteers (control group). All of the information gathered through the questionnaire survey was analyzed for the risk factors of the uterine fibroids pathogenesis.

RESULTS

The multifactor analysis showed that women with uterine fibroids reported a less frequent consumption of broccoli (odds ratio [OR]: 0.552; 95% confidence interval [CI]: 0.316-0.964), cabbage (OR: 0.446; 95%CI: 0.211-0.943), Chinese cabbage (OR: 0.311; 95%CI: 0.102-0.946), tomato (OR: 0.453; 95%CI: 0.241-0.853), and apple (OR: 0.416; 95%CI: 0.213-0.814) (P < 0.05).

CONCLUSION

The original evidence from this epidemiological investigation shows that a high consumption of broccoli, cabbage, Chinese cabbage, tomato and apple seems to be a protective factor for uterine fibroids. We suggest that greater intake of fresh fruits and cruciferous vegetables may be able to reduce the incidence of uterine fibroids.

Common variants in the CYP2C19 gene are associated with susceptibility to endometriosis

OBJECTIVE

To follow-up previous studies highlighting a possible role for cytochrome P450, family 2, subfamily C, 19 (CYP2C19) in susceptibility to endometriosis by searching for additional variants in the CYP2C19 gene that may be associated with the disease.

DESIGN

Case-control study.

SETTING

Academic research.

SUBJECT(S)

The cases comprised 2,271 women with surgically confirmed endometriosis; the controls comprised 939 women with self-report of no endometriosis and 1,770 unscreened population samples.

INTERVENTION(S)

Sequencing of the CYP2C19 region and follow-up of 80 single nucleotide polymorphisms (SNPs) in two case-control samples.

MAIN OUTCOME MEASURE(S)

Allele frequency differences between cases and controls.

RESULT(S)

Sequencing of the CYP2C19 gene region resulted in the detection of a large number of known and novel SNPs. Genotyping of 80 polymorphic SNPs in 901 endometriosis cases and 939 controls resulted in study-wide significant association signals for SNPs in moderate or complete linkage disequilibrium with rs4244285, a functional SNP in exon 5 that abrogates CYP2C19 function through the creation of an alternative splice site. Evidence of association was also detected for another functional SNP in the CYP2C19 promoter, rs12248560, which was highlighted in our previous study.

CONCLUSION(S)

Functional variants in CYP2C19 may contribute to endometriosis susceptibility in both familial and sporadic cases.

Use of dietary phytochemicals to target inflammation, fibrosis, proliferation, and angiogenesis in uterine tissues: promising options for prevention and treatment of uterine fibroids?

Uterine leiomyomas (fibroids, myomas) are the most common benign tumors of female reproductive tract. They are highly prevalent, with 70-80% of women burdened by the end of their reproductive years. Fibroids are a leading cause of pelvic pain, abnormal vaginal bleeding, pressure on the bladder, miscarriage, and infertility. They are the leading indication for hysterectomy, and costs exceed 6 billion dollars annually in the United States. Unfortunately, no long-term medical treatments are available. Dysregulation of inflammatory processes are thought to be involved in the initiation of leiomyoma and extracellular matrix deposition, cell proliferation, and angiogenesis are the key cellular events implicated in leiomyoma growth. In modern pharmaceutical industries, dietary phytochemicals are used as source of new potential drugs for many kinds of tumors. Dietary phytochemicals may exert therapeutic effects by interfering with key cellular events of the tumorigenesis process. At present, a negligible number of phytochemicals have been tested as therapeutic agents against fibroids. In this context, our aim was to introduce some of the potential dietary phytochemicals that have shown anti-inflammatory, antiproliferative, antifibrotic, and antiangiogenic activities in different biological systems. This review could be useful to stimulate the evaluation of these phytochemicals as possible therapies for uterine fibroids.

Common fibroid-associated genes are differentially expressed in phenotypically dissimilar cell populations isolated from within human fibroids and myometrium

Uterine fibroids are a prevalent gynaecological condition in reproductive-aged women and are the commonest reason for hysterectomy. The cellular composition of clonal fibroids are heterogeneous, with phenotypically dissimilar cells that include smooth muscle cells (SMC), vascular SMC (VSMC) and fibroblasts. The aim of our study was to investigate genes that are commonly differentially expressed between fibroid and myometrial whole tissues in phenotypically different sub-populations of cells isolated from fibroid and myometrium. Genes to be investigated by fluorescence-activated cell sorting, quantitative real-time PCR and immunocytochemistry include transforming growth factor β (TGFB) and retinoic acid (RA) signalling families and steroid hormone receptors. We hypothesised that each cell population isolated from fibroid and myometrium would differ in the expression of fibroid-associated genes. We demonstrated that phenotypically different cellular constituents of uterine fibroids differentially express cellular RA-binding protein 2 (CRABP2), progesterone receptor B (PRB) and TGFB receptor 2 mRNA in fibroid-derived cells of VSMC and SMC phenotype. CRABP2 mRNA was also differentially expressed in fibroblasts and VSMC sub-populations from within clonal fibroid tumours. We conclude that differential regulation of RA, TGFB and PR pathway transcription occurs in fibroid-associated SMC and -fibroblasts and that investigation of paracrine interactions between different cell types within the fibroid microenvironment provides an important new paradigm for understanding the pathophysiology of this common disease.

Prevalence and knowledge of heavy menstrual bleeding among African American women

OBJECTIVE

To assess self-reported prevalence, knowledge, and health literacy regarding heavy menstrual bleeding (HMB) among African American women.

METHODS

A quantitative cross-sectional survey study was conducted. An original survey was developed and distributed to a convenience sample of African American women aged 18-60 years at a community fair in a large city in the Midwestern region of the USA.

RESULTS

Of the 274 surveys distributed, 247 were returned, 193 of which met the inclusion criteria. Overall, 163 (84.5%) participants demonstrated adequate health literacy; however, 168 (87.0%) answered fewer than 8 of 15 knowledge questions correctly. Although 75 (38.9%) women reported seeing a clinician for HMB, 89 (46.1%) believed that there was nothing that they could do to prevent it from occurring.

CONCLUSION

The present study found that the proportion of HMB among participants was higher than the nationwide prevalence. However, a gap existed in knowledge of HMB among the women surveyed. The study findings indicate an opportunity for community-based education to raise awareness of HMB, its associated clinical presentations, and available treatment modalities.

Aberrant expression and regulation of NR2F2 and CTNNB1 in uterine fibroids

Uterine fibroids are the most common benign tumour afflicting women of reproductive age. Despite the large healthcare burden caused by fibroids, there is only limited understanding of the molecular mechanisms that drive fibroid pathophysiology. Although a large number of genes are differentially expressed in fibroids compared with myometrium, it is likely that most of these differences are a consequence of the fibroid presence and are not causal. The aim of this study was to investigate the expression and regulation of NR2F2 and CTNNB1 based on their potential causal role in uterine fibroid pathophysiology. We used real-time quantitative RT-PCR, western blotting and immunohistochemistry to describe the expression of NR2F2 and CTNNB1 in matched human uterine fibroid and myometrial tissues. Primary myometrial and fibroid smooth muscle cell cultures were treated with progesterone and/or retinoic acid (RA) and sonic hedgehog (SHH) conditioned media to investigate regulatory pathways for these proteins. We showed that NR2F2 and CTNNB1 are aberrantly expressed in fibroid tissue compared with matched myometrium, with strong blood vessel-specific localisation. Although the SHH pathway was shown to be active in myometrial and fibroid primary cultures, it did not regulateNR2F2orCTNNB1mRNA expression. However, progesterone and RA combined regulatedNR2F2mRNA, but notCTNNB1, in myometrial but not fibroid primary cultures. In conclusion, we demonstrate aberrant expression and regulation of NR2F2 and CTNNB1 in uterine fibroids compared with normal myometrium, consistent with the hypothesis that these factors may play a causal role uterine fibroid development.

Genome-wide linkage and association analyses implicate FASN in predisposition to Uterine Leiomyomata

Uterine leiomyomata (UL), the most prevalent pelvic tumors in women of reproductive age, pose a major public health problem given their high frequency, associated morbidities, and most common indication for hysterectomies. A genetic component to UL predisposition is supported by analyses of ethnic predisposition, twin studies, and familial aggregation. A genome-wide SNP linkage panel was genotyped and analyzed in 261 white UL-affected sister-pair families from the Finding Genes for Fibroids study. Two significant linkage regions were detected in 10p11 (LOD = 4.15) and 3p21 (LOD = 3.73), and five additional linkage regions were identified with LOD scores > 2.00 in 2q37, 5p13, 11p15, 12q14, and 17q25. Genome-wide association studies were performed in two independent cohorts of white women, and a meta-analysis was conducted. One SNP (rs4247357) was identified with a p value (p = 3.05 × 10(-8)) that reached genome-wide significance (odds ratio = 1.299). The candidate SNP is under a linkage peak and in a block of linkage disequilibrium in 17q25.3, which spans fatty acid synthase (FASN), coiled-coil-domain-containing 57 (CCDC57), and solute-carrier family 16, member 3 (SLC16A3). By tissue microarray immunohistochemistry, we found elevated (3-fold) FAS levels in UL-affected tissue compared to matched myometrial tissue. FAS transcripts and/or protein levels are upregulated in various neoplasms and implicated in tumor cell survival. FASN represents the initial UL risk allele identified in white women by a genome-wide, unbiased approach and opens a path to management and potential therapeutic intervention.

Type and timing of menopause and later life mortality among women in the Iowa Established Populations for theEpidemiological Study of the Elderly (EPESE) cohort

BACKGROUND

The relationship between menopausal characteristics and later life mortality is unclear. We tested the hypotheses that women with surgical menopause would have increased all-cause and cardiovascular mortality compared with women with natural menopause, and that women with earlier ages at natural or surgical menopause would have greater all-cause and cardiovascular mortality than women with later ages at menopause.

METHODS

Women who participated in the Iowa cohort of the Established Populations for the Epidemiologic Study of the Elderly (n=1684) reported menopausal characteristics and potential confounding variables at baseline and were followed up for up to 24 years. Participants were aged 65 years or older at baseline and lived in rural areas. We used survival analysis to examine the relationships between menopausal characteristics and all-cause and cardiovascular mortality.

RESULTS

A total of 1477 women (87.7% of respondents) died during the study interval. Women with an age at natural menopause ≥55 years had increased all-cause and cardiovascular disease mortality compared with women who had natural menopause at younger ages. Type of menopause and age at surgical menopause were not related to mortality. These patterns persisted after adjustment for potential confounding variables.

CONCLUSIONS

Among an older group of women from a rural area of the United States, later age at natural menopause was related to increased all-cause and cardiovascular mortality. Monitoring the cardiovascular health of this group of older women may contribute to improved survival times.

Factors associated with age of onset and type of menopause in a cohort of UK women

OBJECTIVE

We sought to describe the pattern of age at menopause and factors associated with type of menopause.

STUDY DESIGN

This was a prospective cohort study of 5113 postmenopausal health survey respondents in the Royal College of General Practitioners' Oral Contraception Study. Logistic regression was used to evaluate associations between sociodemographics, lifestyle, and medical history and menopause type.

RESULTS

Median age at natural menopause (n = 3650) was 49.0 years (interquartile range, 45.0-51.0), and at surgical menopause (n = 1463) was 42.4 years (38.0-46.4). Early natural menopause was associated with smoking, ever-use of oral contraception, sterilization, and history of endometriosis (all increased odds ratios) and ever-use of hormone replacement therapy (decreased). Surgical menopause was associated with manual social class, sterilization, and having a history of endometriosis, menorrhagia, or painful menstruation (all increased), and ever-use of hormone replacement therapy (decreased).

CONCLUSION

Age at natural menopause was younger in this cohort than in other studies. More associations were found for surgical menopause than early natural menopause.

High-density fine-mapping of a chromosome 10q26 linkage peak suggests association between endometriosis and variants close to CYP2C19

OBJECTIVE

To refine a previously reported linkage peak for endometriosis on chromosome 10q26, and conduct follow-up analyses and a fine-mapping association study across the region to identify new candidate genes for endometriosis.

DESIGN

Case-control study.

SETTING

Academic research.

PATIENT(S)

Cases=3,223 women with surgically confirmed endometriosis; controls=1,190 women without endometriosis and 7,060 population samples.

INTERVENTION(S)

Analysis of 11,984 single nucleotide polymorphisms on chromosome 10.

MAIN OUTCOME MEASURE(S)

Allele frequency differences between cases and controls.

RESULT(S)

Linkage analyses on families grouped by endometriosis symptoms (primarily subfertility) provided increased evidence for linkage (logarithm of odds score=3.62) near a previously reported linkage peak. Three independent association signals were found at 96.59 Mb (rs11592737), 105.63 Mb (rs1253130), and 124.25 Mb (rs2250804). Analyses including only samples from linkage families supported the association at all three regions. However, only rs11592737 in the cytochrome P450 subfamily C (CYP2C19) gene was replicated in an independent sample of 2,079 cases and 7,060 population controls.

CONCLUSION(S)

The role of the CYP2C19 gene in conferring risk for endometriosis warrants further investigation.

Negative attitudes and affect do not predict elective hysterectomy: a prospective analysis from the Study of Women's Health Across the Nation

OBJECTIVE

Cross-sectional studies suggest an association between hysterectomy and negative affect. Using prospective data, we examined the associations of negative affect, attitudes toward aging and menopause, premenstrual symptoms, and vasomotor symptoms with elective hysterectomy in midlife.

METHODS

Data were from the Study of Women's Health Across the Nation, a multisite, community-based prospective cohort study of the menopausal transition (n = 2,818). Annually reported hysterectomy at visits 2 to 9 was verified with medical records when available (71%). Anxiety, perceived stress, depressive symptoms, attitudes toward aging and menopause, vasomotor symptoms, and premenstrual symptoms were assessed at baseline using standardized questions. Cox proportional hazards models were used to relate these variables to subsequent elective hysterectomy. Covariates included demographic variables, menstrual bleeding problems, body mass index, hormone levels, and self-rated health, also assessed at baseline.

RESULTS

Elective hysterectomy was reported by 6% (n = 168) of participants over an 8-year period. Women with hysterectomy were not higher in negative affect or negative attitudes toward aging and menopause compared with women without hysterectomy. Vasomotor symptoms (hazard ratio [HR], 1.44; 95% CI, 1.03-2.01; P = 0.03) and positive attitudes toward aging and menopause (HR, 1.74; 95% CI, 1.04-2.93) at baseline predicted hysterectomy over the 8-year period, controlling for menstrual bleeding problems, site, race/ethnicity, follicle-stimulating hormone, age, education, body mass index, and self-rated health. Menstrual bleeding problems at baseline were the strongest predictor of hysterectomy (HR, 4.30; 95% CI, 2.05-9.05).

CONCLUSIONS

In this prospective examination, negative affect and attitudes were not associated with subsequent hysterectomy. Menstrual bleeding problems were the major determinant of elective hysterectomy.

Anthropometric and gynaecological history according to the socioeconomic status of postmenopausal women: poverty and the menopause

Background

Less advantaged social classes usually have unhealthier lifestyles and have more difficult access to health resources. In this work we study the possible association between poverty and the prevalence of obesity and oophorectomy in a population of postmenopausal women.

Design

Cross-sectional observational study.

Objective

To study in a population of postmenopausal women in poverty the possible differences in the prevalence of obesity and oophorectomy, and to compare some other gynaecological data: age at menarche, age at menopause, fertile years, number of pregnancies, breastfeeding and the use of hormonal replacement therapy (HRT).

Method

All patients were interviewed personally. A questionnaire was used to find out about their lifestyles and the medication they were taking. Their medical records were reviewed to confirm the existence of some diseases. A complete physical examination was performed with every patient. Weight and height were measured with the patient dressed in light clothes. Blood was obtained in a fasting state in order to carry out some analyses. Poverty was defined according to the Spanish National Institute of Statistics criteria.

Results

We enrolled 1225 postmenopausal women; 449 (36.6%) were under the threshold of poverty, defined by the Spanish National Institute of Statistics. Postmenopausal women in poverty had higher body mass index (29.2 ± 4.8 versus 27.0 ± 4.7 kg/m2 P < 0.001), and a higher prevalence of obesity than postmenopausal women not in poverty (44.2% versus 24.3%, P = 0.001). The prevalence of oophorectomy was also higher in women in poverty (32.7% versus 27.2%, P < 0.04). Women in poverty had had a greater number of pregnancies (3 versus 2, P = 0.001). They also showed a higher rate of breastfeeding than women in medium and high social classes (65% versus 59%, P = 0.037). There were no statistically significant differences between the groups in either the age of menopause or fertile years, nor in the use of HRT.

Conclusions

Postmenopausal women in poverty have higher levels of obesity, and also a greater prevalence of oophorectomy than women of medium and high social classes. They also presented a higher rate of breastfeeding and a greater number of pregnancies than those women not in poverty.

Hysterectomy and weight gain

OBJECTIVE

To investigate whether overweight women are more likely to have a hysterectomy and whether hysterectomy leads to increased weight gain.

METHODS

Survey data of middle-aged women participating in the Australian Longitudinal Study on Women's health in 1996 (ages 45-50 y; n = 13,125), 1998 (n = 10,612), 2001 (n = 10,293), and 2004 (n = 9309) included self-reported height, weight, and hysterectomy. First, we conducted a cohort analysis, comparing body mass index (BMI) of women categorized according to hysterectomy status. Second, we used a nested case-control analysis to compare weight gain between women who underwent hysterectomy and women who did not have a hysterectomy, matched for prehysterectomy weight, height, menopause status, and educational level.

RESULTS

At survey 1, the mean BMI of women who subsequently had a hysterectomy was greater than that of women without a hysterectomy by survey 2 (difference, 1.1 kg/m; 95% CI, 0.5-1.6). Results were similar for surveys 2 to 3 (BMI difference, 0.8 kg/m; 95% CI, 0.3-1.3) and surveys 3 to 4 (BMI difference, 0.8 kg/m; 95% CI, 0.1-1.4). Having a hysterectomy between surveys 1 and 2 was not associated with percentage of weight gain over the 3 or 6 years after survey 2 (odds ratio, 0.98 [95% CI, 0.96-1.01] and 0.99 [95% CI, 0.97-1.01], respectively). Having a hysterectomy between surveys 2 and 3 was weakly associated with percentage of weight gain over 3 years (odds ratio, 1.03 [95% CI, 1.00-1.05]).

CONCLUSIONS

Among women older than 45 to 50 years, hysterectomy did not lead to greater weight gain but was more likely to be performed in heavier women.

Early life circumstances and their impact on menarche and menopause

Ages at menarche and menopause have been shown to be associated with adverse health outcomes in later life. For example, earlier menarche and later menopause have been independently linked to higher risk of breast cancer. Earlier menarche may also be associated with an increased risk of endometrial cancer, menstrual problems and adult obesity. Given the associations of ages at menarche and menopause with future health outcomes, it is important to establish what factors across life, and generations, may influence these. This article examines the associations of early life factors, namely birthweight, bodyweight and growth during childhood, childhood socioeconomic circumstances and psychosocial factors with ages at menarche and menopause. It examines possible explanations of the associations found, including life history theory, and discusses areas for future research.

Breast cancer risk and hysterectomy status: the Multiethnic Cohort study

OBJECTIVE

The main objective was to examine the association between simple hysterectomy (without bilateral oophorectomy) and breast cancer risk. Because hysterectomy prevalence varies by ethnicity, the secondary objective was to examine whether inclusion of women with hysterectomies affects the estimates of breast cancer risk by ethnicity.

METHODS

The Multiethnic Cohort study was assembled between 1993 and 1996 and included 68,065 women from Hawaii and Los Angeles, aged 45-75 years, without any missing information or bilateral oophorectomy. Hysterectomy status was self-reported. After 7.7 years median follow-up, 1,862 cases of invasive breast cancer were identified. Proportional hazards models were used to estimate relative risks (RR) while controlling for known risk factors.

RESULTS

Prevalence of simple hysterectomy varied from 12% to 29% among the ethnic groups (White, African American, Native Hawaiian, Japanese American, and Latina). Overall, hysterectomy was not associated with breast cancer risk (RR = 0.98). Although the RRs were nonsignificantly elevated by 15% in White women and nonsignificantly reduced by 15% in Latinas of non-US origin, the variation by ethnicity was not significant (p(interaction) = 0.48). The breast cancer risk associated with ethnicity was very similar when estimated with and without women with hysterectomies.

CONCLUSIONS

This study suggests that simple hysterectomy status does not alter breast cancer risk. Therefore, inclusion of women with simple hysterectomies does not substantially change estimated risk of breast cancer by ethnicity.

Black-White differences in hysterectomy prevalence: the CARDIA study

OBJECTIVES

We evaluated the cross-sectional association between race and hysterectomy prevalence in a population-based cohort of US women and investigated participant characteristics associated with racial differences.

METHODS

The cohort consisted of 1863 Black and White women in the Coronary Artery Risk Development in Young Adults (CARDIA) study from 2000 to 2002 (years 15 and 16 after baseline). We used logistic regression to examine unadjusted and multivariable adjusted odds ratios.

RESULTS

Black women demonstrated greater odds of hysterectomy compared with White women (odds ratio [OR] = 3.52; 95% confidence interval [CI] = 2.52, 4.90). Adjustment for age, educational attainment, perceived barriers to accessing medical care, body mass index, polycystic ovarian syndrome, tubal ligation, depressive symptoms, age at menarche, and geographic location minimally altered the association (OR = 3.70; 95% CI = 2.44, 5.61). In a subset of the study population, those with directly imaged fibroids, the association was minimally attenuated (OR = 3.47; 95% CI = 2.23, 5.40).

CONCLUSIONS

In both unadjusted and multivariable adjusted models, Black women, compared with White women, had increased odds of hysterectomy that persisted despite adjustment for participant characteristics. The increased odds are possibly related to decisions to undergo hysterectomy.

Timing of menarche, childbearing and hysterectomy risk

OBJECTIVES

To examine the associations of age at menarche, timing of first birth and parity with hysterectomy rates; to investigate whether these associations were independent of each other and other potential confounders and varied by reason for hysterectomy.

METHODS

Women from the Medical Research Council National Survey of Health and Development, a cohort followed prospectively since birth in March 1946 across England, Scotland and Wales, were studied. Survival analyses were used to assess the relationships between reproductive characteristics and hysterectomy.

RESULTS

Age at menarche was inversely associated with hysterectomy rates (adjusted Hazard Ratio for hysterectomy associated with a 1 year increase in menarche=0.85 (95% CI: 0.77-0.95)). Parity was also associated with hysterectomy; women with > or =3 children experienced higher rates of hysterectomy than women with 1-2 children, who themselves experienced higher rates than nulliparous women. The associations of parity and age at menarche with hysterectomy were independent of each other and potential confounders. The association between age at menarche and hysterectomy was stronger for hysterectomies performed for fibroids than for other reasons.

CONCLUSIONS

Our findings suggest that age at menarche is most likely acting to influence hysterectomy risk through its association with lifetime oestrogen exposure whereas parity is most likely acting through an effect on decision-making processes. This highlights the importance of considering both biological and social pathways to hysterectomy and confirms that medical need is not the only factor which needs to be considered when making treatment decisions for gynaecological problems.

The search for genes contributing to endometriosis risk

BACKGROUND

Genetic variation contributes to the risk of developing endometriosis. This review summarizes gene mapping studies in endometriosis and the prospects of finding gene pathways contributing to disease using the latest genome-wide strategies.

METHODS

To identify candidate-gene association studies of endometriosis, a systematic literature search was conducted in PubMed of publications up to 1 April 2008, using the search terms 'endometriosis' plus 'allele' or 'polymorphism' or 'gene'. Papers included were those with information on both case and control selection, showed allelic and/or genotypic results for named germ-line polymorphisms and were published in the English language.

RESULTS

Genetic variants in 76 genes have been examined for association, but none shows convincing evidence of replication in multiple studies. There is evidence for genetic linkage to chromosomes 7 and 10, but the genes (or variants) in these regions contributing to disease risk have yet to be identified. Genome-wide association is a powerful method that has been successful in locating genetic variants contributing to a range of common diseases. Several groups are planning these studies in endometriosis. For this to be successful, the endometriosis research community must work together to genotype sufficient cases, using clearly defined disease classifications, and conduct the necessary replication studies in several thousands of cases and controls.

CONCLUSIONS

Genes with convincing evidence for association with endometriosis are likely to be identified in large genome-wide studies. This will provide a starting point for functional and biological studies to develop better diagnosis and treatment for this debilitating disease.

Socioeconomic position and hysterectomy: a cross-cohort comparison of women in Australia and Great Britain

OBJECTIVES

To examine the associations between indicators of socioeconomic position (SEP) and hysterectomy in two Australian and two British cohorts.

STUDY POPULATION

Women participating in the Australian Longitudinal Study on Women's Health (ALSWH), born 1921-1926 and 1946-1951, and two cohorts of British women, the British Women's Heart and Health Study and the MRC National Survey of Health and Development, born at similar times (1920 to 1939 and 1946, respectively) and surveyed at similar ages to the ALSWH cohorts.

METHODS

Relative indices of inequality were derived for own and head of household occupational class, educational level attained and age at leaving school. Logistic regression was used to test the associations between these indicators of SEP and self-reported hysterectomy and/or oophorectomy.

RESULTS

Inverse associations between indicators of SEP and hysterectomy were found in both the Australian and British cohorts of women born in 1946 or later. There was also evidence of an inverse association between education and hysterectomy in the older Australian cohort. However, the associations in this older cohort were weaker than those found in the mid-aged Australian cohort. In the older British cohort, born in the 1920s and 1930s, little evidence of association between SEP in adulthood and hysterectomy was found.

CONCLUSIONS

These results suggest that inverse associations between indicators of SEP and hysterectomy are stronger in younger than in older cohorts in both Australia and Great Britain. They provide further evidence of the dynamic nature of the association between indicators of SEP and hysterectomy.

Common variation in the fibroblast growth factor receptor 2 gene is not associated with endometriosis risk

BACKGROUND

Endometriosis is a polygenic disease with a complex and multifactorial aetiology that affects 8-10% of women of reproductive age. Epidemiological data support a link between endometriosis and cancers of the reproductive tract. Fibroblast growth factor receptor 2 (FGFR2) has recently been implicated in both endometrial and breast cancer. Our previous studies on endometriosis identified significant linkage to a novel susceptibility locus on chromosome 10q26 and the FGFR2 gene maps within this linkage region. We therefore hypothesized that variation in FGFR2 may contribute to the risk of endometriosis.

METHODS

We genotyped 13 single nucleotide polymorphisms (SNPs) densely covering a 27 kb region within intron 2 of FGFR2 including two SNPs (rs2981582 and rs1219648) significantly associated with breast cancer and a total 40 tagSNPs across 150 kb of the FGFR2 gene. SNPs were genotyped in 958 endometriosis cases and 959 unrelated controls.

RESULTS

We found no evidence for association between endometriosis and FGFR2 intron 2 SNPs or SNP haplotypes and no evidence for association between endometriosis and variation across the FGFR2 gene.

CONCLUSIONS

Common variation in the breast-cancer implicated intron 2 and other highly plausible causative candidate regions of FGFR2 do not appear to be a major contributor to endometriosis susceptibility in our large Australian sample.

Variants in EMX2 and PTEN do not contribute to risk of endometriosis

Endometriosis has a genetic component, and significant linkage has been found to a region on chromosome 10q. Two candidate genes, EMX2 and PTEN, implicated in both endometriosis and endometrial cancer, lie on chromosome 10q. We hypothesized that variation in EMX2 and/or PTEN could contribute to the risk of endometriosis and may account for some of the linkage signal on 10q. We genotyped single nucleotide polymorphisms (SNPs) in a case-control design to evaluate association between endometriosis and common variations in these two genes. The genotyping and statistical analysis were based on samples collected from Australian volunteers. The cases were 768 unrelated women with surgically confirmed endometriosis selected from affected sister pair (ASP) families participating in the Australian Genes behind Endometriosis Study. The controls were 768 female participants in twin studies who, based on screening questions, did not have a diagnosis of endometriosis. Genotypes of 22 SNPs in the EMX2 gene and 15 SNPs in the PTEN gene were the main outcome measures. Statistical analysis provided measures of linkage disequilibrium and association. Permutation testing showed no globally significant association between any SNPs or haplotypes and endometriosis for either gene. It is unlikely that the EMX2 or PTEN gene variants investigated contribute to risk for initiation and/or development of endometriosis.

Why do they do it? A pilot study towards understanding participant motivation and experience in a large genetic epidemiological study of endometriosis

OBJECTIVE

This exploratory, pilot study aimed to investigate motivations and reflections of participants who had provided epidemiological information, blood samples and access to clinical records and data in a large genetic epidemiological study of endometriosis, a common multifactorial disorder affecting women. We also aimed to explore understanding of complex genetic or multifactorial conditions in general.

METHODS

In-depth interviews were conducted with 16 endometriosis study participants with diverse characteristics.

RESULTS

Interviewees generally described their participation in the genetic study using altruistic frameworks of reference. Themes that emerged included unquestioning willingness and consent to participate, little concern about privacy issues, desire for more information from the researchers about the condition rather than scientific progress, the benefits of research participation to family communication, and differing ideas about genetic influences on endometriosis. Specific features of endometriosis also influenced reflections on research participation experience.

CONCLUSIONS

As increasing numbers of individuals and families in the community become involved in genetic epidemiological studies of common diseases, more extensive research will be needed to better understand their expectations with a view to improving researchers' communications with study participants.

KRAS variation and risk of endometriosis

Endometriosis is a common gynaecological disease with symptoms of pelvic pain and infertility which affects 7-10% of women in their reproductive years. Activation of an oncogenic allele of Kirsten rat sarcoma viral oncogene homologue (KRAS) in the reproductive tract of mice resulted in the development of endometriosis. We hypothesized that variation in KRAS may influence risk of endometriosis in humans. Thirty tagSNPs spanning a region of 60.7 kb across the KRAS locus were genotyped using iPLEX chemistry on a MALDI-TOF MassARRAY platform in 959 endometriosis cases and 959 unrelated controls, and data were analysed for association with endometriosis. Genotypes were obtained for most individuals with a mean completion rate of 99.1%. We identified six haplotype blocks across the KRAS locus in our sample. There were no significant differences between cases and controls in the frequencies of individual single-nucleotide polymorphisms (SNPs) or haplotypes. We also developed a rapid method to screen for 11 common KRAS and BRAF mutations on the Sequenom MassARRAY system. The assay detected all mutations previously identified by direct sequencing in a panel of positive controls. No germline variants for KRAS or BRAF were detected. Our results demonstrate that any risk of endometriosis in women because of common variation in KRAS must be very small.

Persistent high rates of hysterectomy in Western Australia: a population-based study of 83 000 procedures over 23 years

OBJECTIVE

To investigate incidence trends and demographic, social and health factors associated with the rate of hysterectomy and morbidity outcomes in Western Australia and compare these with international studies.

DESIGN

Population-based retrospective cohort study.

SETTING

All hospitals in Western Australia where hysterectomies were performed from 1981 to 2003.

POPULATION

All women aged 20 years or older who underwent a hysterectomy.

METHODS

Statistical analysis of record-linked administrative health data.

MAIN OUTCOME MEASURES

Rates, rate ratios and odds ratios for incidence measures and length of stay in hospital and odds ratios for morbidity measures.

RESULTS

The age-standardised rate of hysterectomy adjusted for the underlying prevalence of hysterectomy decreased 23% from 6.6 per 1000 woman-years (95% CI 6.4-6.9) in 1981 to 4.8 per 1000 woman-years (95% CI 4.6-4.9) in 2003. Lifetime risk of hysterectomy was estimated as 35%. In 2003, 40% of hysterectomies were abdominal. The rate of hysterectomy to treat menstrual disorders fell from 4 per 1000 woman-years in 1981 to 1 per 1000 woman-years in 1993 and has since stabilised. Low socio-economic status, having only public health insurance, nonindigenous status and living in rural or remote areas were associated with increased risk of having a hysterectomy for menstrual disorders. Indigenous women had higher rates of hysterectomy to treat gynaecological cancers compared with nonindigenous women, particularly in rural areas. The odds of a serious complication were 20% lower for vaginal hysterectomies compared with abdominal procedures.

CONCLUSION

Western Australia has one of the highest hysterectomy rates in the world, although proportionally, significantly fewer abdominal hysterectomies are performed than in most countries.

Ethnic differences in past hysterectomy for benign conditions

BACKGROUND

Hysterectomy for a benign condition is common, particularly in the underserved. The objective was to determine if ethnic differences could be explained by known risk factors.

METHODS

A phone survey was conducted at random on 15,160 women, ages 40-55, from seven US cities. Subjects were 49.9% Caucasian, 28.1% African American, 12.3% Hispanic, and 9.8% Asian American.

RESULTS

Ethnicity was associated with past hysterectomy (odds ratio [OR]: Caucasian = 1.0, African American = 1.66; confidence interval [CI] = 1.46-1.88, Hispanic = 1.64, CI = 1.29-2.07; Asian American = 0.44, CI = 0.34-0.56), after adjustment for age, education, fibroids, body mass index, marital status, smoking, geographic site, and country of education.

CONCLUSION

Because the highest rates occurred in the disadvantaged African American and Hispanic subgroups, and could not be explained by known risk factors, disparity in the form of overuse in these disadvantaged groups may exist.

Differences between the pre-menopausal and post-menopausal uterine fibroid vasculature

OBJECTIVES

To quantitatively examine differences in microvascular density between fibroid and myometrial tissue from fibroid uteri removed at hysterectomy, both before and after the menopause, and with hormone replacement therapy.

METHODS

Factor VIII immunostaining of formalin fixed tissues was used to identify blood vessels, and the vessels counted by an investigator blinded to tissue type or menopausal status.

RESULTS

The mean myometrial: fibroid MVD ratio was 2.38 higher in the post-menopausal group (95% CI: 0.12, 4.65, p=0.0474) than in the pre-menopausal group, with the hormone therapy (HT)-using post-menopausal group lying in between. An increase in microvascular density in the myometrium after the menopause was responsible for most of the change in ratios seen between the pre and post-menopausal pairs. There was a trend to increasing myometrial MVD with increasing number of years post-menopause.

CONCLUSIONS

Myometrial microvascular density increases markedly after the menopause, while fibroid microvascular density does not alter. Thus, the difference between myometrial and fibroid vasculature becomes greater after the menopause. The implications of this for the treatment of fibroids in post-menopausal women is discussed.

Endometriosis: New Genetic Approaches and Therapy

Endometriosis is a relatively common condition in women of reproductive age and is associated with considerable morbidity. Despite an extensive literature describing its multiple clinical manifestations, their management, and many aspects of the biology of endometriotic lesions, the pathophysiological mechanisms involved remain poorly understood. A genetic component in endometriosis is now recognized, and several groups have taken up the challenge of using genetic techniques to identify the aberrant molecular and cellular mechanisms in endometriosis with the intention of providing much-needed insights that might, in turn, lead to new therapies. The techniques that have been applied include expression profiling, tumor genetic studies, functional candidate gene studies, and linkage studies that can adopt a hypothesis-free approach. This review describes the current status of these studies and explores the prospects for new therapies.

Uterine leiomyoma and menstrual cycle characteristics in a population-based cohort study

BACKGROUND

We examined the association of uterine leiomyoma with menstrual cycle characteristics in a population of non-care-seeking women.

METHODS

This cross-sectional study uses data from the Seveso Women's Health Study (SWHS), a population-based cohort in Italy. Participants included 341 premenopausal women, 30-60 years old, who had an intact uterus and were not pregnant, lactating, or using oral contraception or intra-uterine devices. We examined the presence of any ultrasound-detected uterine leiomyoma in relation to self-reported menstrual cycle length, flow length and heaviness of flow. The association of leiomyoma number, volume, tissue layer location and axial position with menstrual cycle characteristics was also examined.

RESULTS

Uterine leiomyomata were detected in 73 women (21.4%). After adjustment for covariates, the presence of a leiomyoma was not significantly related to menstrual cycle length, flow length or heaviness of flow [odds ratio (OR) for scanty flow =1.9, 95% confidence interval (CI) 0.8-4.3; OR for heavy flow =1.3, 95% CI 0.7-2.5; relative to moderate flow]. Number, volume, tissue layer location (subserosal or intramural) and axial position (anterior or posterior) of the leiomyoma were also not related to menstrual cycle characteristics.

CONCLUSION

In this Italian population of women not seeking gynaecological care, menstrual characteristics are not related to leiomyoma.

Use of health services associated with increased menstrual loss in the United States

OBJECTIVE

The study was conducted to estimate the effect of abnormal uterine bleeding on health care use.

STUDY DESIGN

Data were taken from the National Health Interview Survey 1999, a nationwide representative sample of the civilian noninstitutionalized population of the United States. The participants who were eligible for the study were 3133 women aged between 18 and 64 years who reported having a natural menstrual period in the last 12 months and in the last 3 months, never having taken medication containing estrogen (except past use of oral contraceptives), and never been told they had reproductive cancer. From these, 328 women were excluded-5 women because they were more than 64 years old and 323 because of the imprecision of their answers related to their menstrual flow. Analysis was performed with the data from 2805 women: 373 having self-described heavy flow and 2432 having normal flow.

RESULTS

Age, family size, insurance coverage, perception of health, and flow of menstrual periods are associated with the majority of questions used to measure health care use (P < or =.05). The odds ratios related to the flow of menstrual periods were all equal to or higher than 1.45 (P < or =.05), which indicates that women who have a heavier flow are at least 1.45 times as likely to use health care as are women who have a lighter or normal flow.

CONCLUSION

Women having heavy flow of menstrual bleeding are more likely to use health care than women having a normal flow.

Hysterectomy and socioeconomic position in Rome, Italy

STUDY OBJECTIVE

There exists conflicting evidence regarding the higher risk of hysterectomy among women of a lower educational and economic level. This study aims to assess whether in Italy socioeconomic level is related to hysterectomy undertaken for different medical reasons.

DESIGN

An area based index was used to assign socieconomic status (SES; four levels defined) to 3141 women (aged 35 years or older) who underwent a hysterectomy in 1997 and were residing in Rome. Data were taken from hospital discharge records. Direct age standardised hospitalisation rates by SES level were calculated for overall hysterectomies and for those performed for either malignant or non-malignant causes. Statistical differences were detected using the ratios of standardised rates and the test for linear trend.

MAIN RESULTS

The hysterectomy rate was 36.7 per 10 000 women aged 35 years or more. Hysterectomy for uterine leiomyoma accounted for 41% of all operations and was more frequent among women aged 35-49 years than for those aged 50 years or more (crude rates: 28.6 and 7.7 per 10 000, respectively). The risk of hysterectomy was 35% higher for the lowest SES group, compared with the highest group. No association was found between SES and hysterectomy rates for malignant causes, although less affluent women in age group 35-49 years had 87% higher risk of hysterectomy compared with most affluent women. The inverse association between SES and hysterectomy rates attributable to non-malignant causes was statistically significant for women aged 35-49 years but not for those aged 50 years or more.

CONCLUSIONS

The inverse relation between hysterectomy and SES is largely attributable to benign disorders of the uterus, namely leiomyoma and prolapse. More affluent women may have a greater uptake of less invasive techniques for removing uterine leiomyoma compared with less affluent women, who are more likely to undergo unnecessary hysterectomies irrespective of their reproductive age.

Expression profile of 11 proteins and their prognostic significance in patients with chronic lymphocytic leukemia (CLL)

It has been suggested that the expansion of the leukemic cells in chronic lymphocytic leukemia (CLL) is due to dysregulation of pathways of programmed cell death (apoptosis) rather than cell proliferation, although differences may exist in early vs late and treated vs untreated patients. In the present study, we analyzed the expression of 11 proteins in CLL cells that are implicated in the control of apoptosis, proliferation, and differentiation, and correlated this expression profile with survival. Using a quantitative solid-phase radioimmunoassay (RIA), we measured the cellular protein levels of Bcl-2, cyclin D1, PCNA, ATM, Fas, Bax, retinoic acid receptor alpha (RARalpha), retinoic acid receptor beta (RXRbeta), Flt1, VEGF, and cellular beta2-microglobulin in 230 samples of CLL. Univariate analysis using the Cox proportional hazard model showed a correlation with survival of only the following proteins: Bcl-2 (P < 0.001), cyclin D1 (P = 0.027), Fas (P = 0.055), PCNA (P < 0.001), and ATM (P = 0.028). In a multivariate analysis using classification and regression tree analysis (CART), five groups of patients (nodes) could be generated with significant differences of survival expectation (P < 0.0001) based on levels of expression of the above proteins. Based on CART analysis, Bcl-2 levels emerge as the most important protein in predicting survival between all 11 proteins studied. Patients with marked elevation in Bcl-2 levels had the worst outcome while patients with intermediate levels, but with high levels of PCNA and cyclin D1 or abnormal ATM expression had intermediate survival. These data indicate that intracellular levels of proteins such as Bcl-2, ATM, cyclin D1, and PCNA can be used as markers to predict clinical behavior and survival in patients with CLL. The pathways in which these proteins are involved may also represent possible targets for future therapeutic trials in CLL.