Lower Urinary Tract Symptoms in US Women: Contemporary Prevalence Estimates from the RISE FOR HEALTH Study

BACKGROUND

To estimate the prevalence of a wide range of lower urinary tract symptoms (LUTS) in US women, and to explore associations with bother and discussion with healthcare providers, friends, and family.

MATERIALS AND METHODS

We analyzed baseline data collected from 5/2022-12/2023 in the RISE FOR HEALTH study-a large, regionally-representative cohort study of adult female community members. LUTS and related bother were measured by the 10-item Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index and discussion was assessed by a study-specific item.

RESULTS

Of the 3000 eligible participants, 73% (95% confidence interval [CI] = 71-74%) reported any storage symptoms, 52% (95% CI = 50-53) any voiding or emptying symptoms, and 11% (95% CI = 10-13%) any pain with bladder filling, for an overall LUTS prevalence of 79% (95% CI = 78-81%). This prevalence estimate included 43% (95% CI = 41-45%) of participants with mild-to-moderate symptoms and 37% (95% CI = 35-38%) with moderate-to-severe symptoms. Over one-third of participants reported LUTS-related bother (38%, 95% CI = 36-39%) and discussion (38%, 95% CI = 36-40%), whereas only 7.1% (95% CI = 6.2-8.1%) reported treatment. Urgency and incontinence (including urgency and stress incontinence) were associated with the greatest likelihood of bother and/or discussion (adjusted prevalence ratios = 1.3-2.3), even at mild-to-moderate levels. They were also the most commonly treated LUTS.

CONCLUSIONS

LUTS, particularly storage LUTS such as urgency and incontinence, were common and bothersome in the RISE study population, yet often untreated. Given this large burden, both prevention and treatment-related interventions are warranted to reduce the high prevalence and bother of LUTS.

Immune Dysregulation, Inflammation in Characterizing Women with Vulvodynia, Depression, and Both

Background: Depression and vulvodynia are often comorbid. The onset of depression and vulvodynia may be immune and/or stress/environmentally induced. We explored whether vulvodynia, depression, or both occur in response to a Th1-mediated versus Th2-mediated immune response. Materials and Methods: We analyzed data from a case-control study of clinically confirmed vulvodynia and history of depression determined through structured clinical interviews. Immune dysregulation and inflammation were categorized based on the following self-reported conditions: rheumatoid arthritis, Sjogren's disease, scleroderma, systemic lupus erythematosus, inflammatory bowel disease, fibromyalgia, osteoarthritis, polycystic ovarian syndrome, diabetes mellitus, uterine fibroids, asthma, atopic dermatitis, and allergic rhinitis. Logistic regression analyses were adjusted for marital status, body mass index, age, and pack years. Results: Women with systemic immune dysregulation had higher odds of depression (adjusted odds ratio [aOR] = 1.61, confidence interval [95% CI]: 0.65-3.98), vulvodynia (aOR = 2.45, 95% CI: 1.00-5.96), and comorbid depression and vulvodynia (aOR = 4.93, 95% CI: 2.19-11.10) versus neither condition. Women reporting local immune dysregulation had similar odds of depression (aOR = 1.89, 95% CI: 0.99-3.59), vulvodynia (aOR = 2.12, 95% CI: 1.08-4.18), and comorbid depression and vulvodynia (aOR = 1.96, 95% CI: 0.98-3.90). Women with Th2 inflammation had similar odds of depression (aOR = 2.23, 95% CI: 1.05-4.77) and vulvodynia (aOR = 2.56, 95% CI: 1.20-5.49). Women with Th1 or Th2 inflammation had similar odds of comorbid depression and vulvodynia (aOR = 3.03, 95% CI: 1.48-6.19; aOR = 3.14, 95% CI: 1.49-6.60, respectively). Conclusions: Our results suggest that an imbalance of cytokines, indicated by the presence of one or more immune-related health conditions, is associated with an increased risk of vulvodynia and/or depression.

Depression and help-seeking behaviors among college students: Findings from the Healthy Minds Study 2018-2019

OBJECTIVE

To determine the likelihood of using formal and informal mental health services among college students according to prior history of depression diagnosis and presence of depression symptoms.

PARTICIPANTS

College students from 79 universities in the U.S. and Canada who participated in the Healthy Minds Study, 2018-2019.

METHODS

Odds ratios and 95% confidence intervals via logistic regression were estimated for the likelihood of using informal and formal mental health services stratified by depression diagnosis and severity of depression symptoms and further stratified by race/ethnicity.

RESULTS

We report increased odds of using formal mental health services with increasing depression severity symptoms and increased odds of using formal mental health services among students without a clinical depression diagnosis. The odds of service utilization varied by race/ethnicity.

CONCLUSIONS

The likelihood of seeking mental health services differs depending on the history of formal depression diagnosis, current symptoms, and race/ethnicity among college students.

The Association Between Immune-Related Conditions Across the Life-Course and Provoked Vulvodynia

Vulvodynia, impacts up to 8% of women by age 40, and is hypothesized to manifest through an altered immune-inflammatory response. To test this hypothesis, we identified all women born in Sweden between 1973 and 1996 diagnosed with localized provoked vulvodynia (N76.3) and/or vaginismus (N94.2 or F52.5) between 2001 and 2018. We matched each case to two women from the same birth year with no vulvar pain ICD codes. As a proxy for immune dysfunction, we used Swedish Registry data to capture 1) immunodeficiencies, 2) single organ and multiorgan autoimmune conditions, 3) allergy and atopies, and 4) malignancies involving immune cells across the life course. Women with vulvodynia, vaginismus or both were more likely to experience immune deficiencies (OR 1.8, 95% CI, 1.2-2.8), single organ (OR 1.4, 95% CI, 1.2-1.6) and/or multi-organ (OR 1.6, 95% CI, 1.3-1.9) immune disorders, and allergy/atopy conditions (OR 1.7, 95% CI, 1.6-1.8) compared to controls. We observed greater risk with increasing numbers of unique immune related conditions (1 code: OR = 1.6, 95% CI, 1.5-1.7; 2 codes: OR = 2.4, 95% CI, 2.1-2.9; 3 or more codes: OR = 2.9, 1.6-5.4). These findings suggest that women with vulvodynia may have a more compromised immune system either at birth or at points across the life course than women with no vulvar pain history. PERSPECTIVE: Women with vulvodynia are substantially more likely to experience a spectrum of immune related conditions across the life course. These findings lend support to the hypothesis that chronic inflammation initiates the hyperinnervation that causes the debilitating pain in women with vulvodynia.

Association between eating disorders and sleep duration among college students: Findings from the National Healthy Minds study

OBJECTIVES

Explore associations between eating disorders (EDs) and sleep duration and the impact of depression symptoms (DSs) in American college students.

PARTICIPANTS

College students from 2018 to 2019 Healthy Minds Study.

METHODS

Multivariate logistic regression evaluated associations between EDs (bulimia, anorexia, binge eating [BED]) and sleep duration. Stratified analyses assessed effect modification by DSs and gender.

RESULTS

Students reporting any eating disorder had no greater risk of not recommended sleep duration during weekdays compared to those with no eating disorder history (Adjusted OR = 0.99, 95% CI: 0.89-1.13). However, subjects reporting BED were at greater risk of deficient sleep during weekends compared to those with no EDs (Adjusted OR = 1.26, 95% CI: 1.01-1.58). This association was not impacted by DSs. However, all EDs were associated with not-recommended sleep duration among those who identified as other gender identity in comparison to those with no EDs.

CONCLUSION

Health educators should monitor academic performance in students with EDs for adequate sleep duration.

RISE FOR HEALTH: Rationale and protocol for a prospective cohort study of bladder health in women

INTRODUCTION

The spectrum of bladder health and the factors that promote bladder health and prevent lower urinary tract symptoms (LUTS) among women are not well understood. This manuscript describes the rationale, aims, study design, sampling strategy, and data collection for the RISE FOR HEALTH (RISE) study, a novel study of bladder health in women conducted by the Prevention of Lower Urinary Tract Symptom (PLUS) Research Consortium.

METHODS AND RESULTS

RISE is a population-based, multicenter, prospective longitudinal cohort study of community-dwelling, English- and Spanish-speaking adult women based in the United States. Its goal is to inform the distribution of bladder health and the individual factors (biologic, behavioral, and psychosocial) and multilevel factors (interpersonal, institutional, community, and societal) that promote bladder health and/or prevent LUTS in women across the life course. Key study development activities included the: (1) development of a conceptual framework and philosophy to guide subsequent activities, (2) creation of a study design and sampling strategy, prioritizing diversity, equity, and inclusion, and (3) selection and development of data collection components. Community members and cross-cultural experts shaped and ensured the appropriateness of all study procedures and materials. RISE participants will be selected by simple random sampling of individuals identified by a marketing database who reside in the 50 counties surrounding nine PLUS clinical research centers. Participants will complete self-administered surveys at baseline (mailed paper or electronic) to capture bladder health and LUTS, knowledge about bladder health, and factors hypothesized to promote bladder health and prevent LUTS. A subset of participants will complete an in-person assessment to augment data with objective measures including urogenital microbiome specimens. Initial longitudinal follow-up is planned at 1 year.

DISCUSSION

Findings from RISE will begin to build the necessary evidence base to support much-needed, new bladder health promotion and LUTS prevention interventions in women.

Sexual Health Behaviors by Age 17 and Lower Urinary Tract Symptoms at Age 19: PLUS Research Consortium Analysis of ALSPAC Data

PURPOSE

We examined how antecedent sexual health factors affect lower urinary tract symptoms (LUTS) in adolescent women.

METHODS

We analyzed 1,941 adolescent women from the Avon Longitudinal Study of Parents and Children at age 19. At ages 15 and 17, participants reported use of oral contraceptives (OCs), history of sexual intercourse, number of sexual partners, and condom use. At age 19, The Bristol Female Lower Urinary Tract Symptoms questionnaire quantified the frequency over the past month: stress incontinence, any incontinence, urgency, sensation of incomplete emptying, bladder pain, and urinary tract infection. Multivariable regression models examined associations between sexual health behaviors reported at ages 15 and 17 and six LUTS reported at age 19, after controlling for covariates.

RESULTS

Commonly reported LUTS at age 19 were past-month stress incontinence (26.8%), bladder pain (26.3%), any urine leakage (22.1%), and urinary tract infection (15.4%). OC use by age 17 was associated with urgency (odds ratio [OR] = 1.62, 95% confidence interval [CI] 1.19-2.20), incomplete emptying (OR = 1.62, 95% CI = 1.17-2.26), bladder pain (OR = 1.45, 95% CI = 1.15-1.83), and urinary tract infections (OR = 1.68, 95% CI = 1.28-2.21) at age 19 after adjustment for covariates. However, associations were attenuated after adjustment for condom use and number of sexual partners. Sexual intercourse by age 17 was associated with 1.53-2.65 increased odds of LUTs categories except incontinence, with lower confidence interval boundaries > 1.0. Associations were stronger among women with ≥ 3 sexual partners (vs. 0) by age 17.

DISCUSSION

We found longitudinally assessed associations between OC use, sexual intercourse, and number of sexual partners during adolescence and LUTS at age 19.

Care Seeking for Chronic Vulvar Pain Among a Large, Population-Based Sample of Reproductive-Aged Women

Background: Chronic vulvar pain is a prevalent but often misdiagnosed and undertreated condition that adversely impacts quality of life. A large proportion of women report not seeking care for chronic vulvar pain, but little is known about the factors that underlie care-seeking decisions. Materials and Methods: We used a large, population-based survey of women aged 18-40 years to assess a history of chronic vulvar burning, pain on contact, or itching that had lasted ≥3 months. The survey also captured demographic characteristics and comorbidities. Women were asked if they had ever sought care for their chronic vulvar condition. Demographic characteristics and comorbidities were evaluated across pain categories and by care-seeking behaviors. Results: A higher proportion of women who described their pain as burning only and both burning and pain on contact had sought care for their pain (69.2% and 85.2%, respectively) compared with pain on contact only (41.8%). Women who described their pain as pain on contact only were also less likely to see multiple providers and to have ever received treatment for their pain. Care seekers were more likely to be married, have a college education, have a normal body mass index, and have multiple gynecologic comorbidities. Conclusions: Our study suggests that care-seeking behavior varies by pain type. Less than half of women who characterized their pain as pain on contact had sought medical care. Those who did seek care reported seeing fewer providers than those who experienced burning. Providers may wish to proactively ask patients about pain on contact.

Potential for Selection Bias in Studies of the Association of Hormonal Contraception and Chronic Vulvar Pain

Background: Hormonal contraceptive use is common among reproductive-aged women, but research evaluating its etiological relationship to vulvodynia remains mixed. We sought to evaluate this association and examine the potential for bias due to care-seeking behavior. Materials and Methods: We conducted a case-control study of women recruited from a large health care network database from 2008 to 2011. Of 26,455 eligible respondents, 1168 met the case definition for chronic vulvar pain (CVP). We matched each case to three controls by age and used conditional logistic regression to calculate odds ratios (ORs) for prior hormonal contraception (HC) use and CVP, stratifying cases by whether or not they sought care for their vulvar pain. We also simulated the influence of potential biases due to care seeking, using parameters based on this dataset. Results: HC users had higher odds of CVP (adjusted OR = 2.6, 95% confidence interval [CI]: 2.2-3.2). Effect estimates were stronger when cases were restricted to care seekers (adjusted OR = 2.9, 95% CI: 2.2-3.7). Effect estimates decreased slightly as time increased between HC initiation and pain onset. Our simulations suggested that effect estimates may be spuriously strengthened when cases are restricted to care-seeking women, but controls are recruited from the general population. Conclusions: Our results suggest an association between antecedent HC use and CVP that is potentially spuriously strengthened in case-control studies when cases are restricted to care seekers but controls are not.

Menstrual Cycle Characteristics and Vulvodynia

Objective: The menstrual cycle may influence vulvodynia through hormonal pathways or vulvar irritation due to menstruation or menstrual hygiene. We assessed menstrual cycle characteristics in those with and without clinically confirmed vulvodynia. Materials and Methods: Participants were recruited from the administrative database of a health care network serving ∼27% of Minneapolis-Saint Paul residents. For 220 clinically confirmed cases and 224 controls, menstrual cycle characteristics were retrospectively assessed at three time points: before age 18, the year before onset of vulvar pain, and 3 months before study participation. Logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between menstrual characteristics at all three time points and vulvodynia. Models adjusted for prespecified confounders were evaluated against crude effect estimates. Results: Women with heavier menstrual flows had higher odds of vulvodynia compared with women with lighter menstrual flows during their adolescent years (OR 1.62, 95% CI 0.91-2.86), the year before onset of vulvar pain (OR = 2.11, 95% CI 1.10-4.02), and during the 3 months before study participation (OR = 1.67, 95% CI 0.91-3.06). Women with more severe cramps also had higher odds of vulvodynia compared with women with no or mild cramps during their adolescent years (OR = 2.45, 95% CI 1.45-4.15), the year before onset of vulvar pain (OR = 3.30, 95% CI 1.67-6.51), and during the 3 months before study participation (OR = 4.96, 95% CI 1.99-12.36). Women with specific premenstrual symptoms also reported higher odds of vulvodynia. Among those with vulvodynia, half reported a change in vulvar pain across the menstrual cycle, with 60% of these reporting greater pain just before and during menstruation. Furthermore, we observe a trend of decreased tampon use and increased use of sanitary pads as women with vulvodynia moved closer to their date of diagnosis. Conclusions: Menstrual cycle characteristics were associated with vulvodynia, and associations were consistent across different phases of the reproductive life cycle.

Characterizing Differences in Thymic Function in Women With and Without Vulvodynia: A Community-Based Study

OBJECTIVE

The aim of the study was to evaluate the association between vulvodynia and thymic function.

MATERIALS AND METHODS

In this case-control study of 200 clinically confirmed cases of vulvodynia and 205 general population controls residing in the Minneapolis/Saint Paul metropolitan area, we used DNA extracted from whole blood to measure levels of signal joint T-cell receptor excision circles (sjTRECs), a measure of thymic output. We used logistic regression to evaluate the association between vulvodynia and thymic function.

RESULTS

In 405 participants (aged 18-40 years), we observed an association between decreasing thymic function and increasing age. Women with vulvodynia had a steeper decline in sjTREC values across age categories compared with women without vulvodynia. In addition, at younger ages, women with vulvodynia had higher sjTREC values compared with women without vulvodynia. In older women, those with vulvodynia had lower sjTREC than those without vulvodynia. When accounting for recency of vulvar pain onset, women with a shorter time since pain onset had higher thymic function compared with women with a longer time since vulvar pain onset.

CONCLUSIONS

These findings suggest that at younger ages, women with vulvodynia have higher thymic output and a more precipitous decline of thymic function than those without vulvodynia. It also seems that a strong immune inflammatory response is present proximate to the onset of vulvar pain and may wane subsequently over time.

School Toileting Environment, Bullying, and Lower Urinary Tract Symptoms in a Population of Adolescent and Young Adult Girls: Preventing Lower Urinary Tract Symptoms Consortium Analysis of Avon Longitudinal Study of Parents and Children

OBJECTIVES

To examine whether the school toilet environment at age 13, including bullying at toilets, is associated with female lower urinary tract symptoms (LUTS) at ages 13 and 19, as little is known about the association among school toilet environment, voiding behaviors, and LUTS in adolescent girls.

METHODS

The sample comprised 3962 female participants from the Avon Longitudinal Study of Parents and Children. At age 13, participants reported on 7 school toilet environment characteristics and a range of LUTS items. At age 19, participants completed the Bristol Female Lower Urinary Tract Symptoms questionnaire.

RESULTS

All toilet environmental factors were associated with at least 1 LUTS outcome at age 13. Holding behavior was associated with all school toilet environmental factors, with odds ratios ranging from 1.36 (95% confidence interval [CI]: 1.05, 1.76) for dirty toilets to 2.38 (95% CI: 1.60, 3.52) for feeling bullied at toilets. Bullying was associated with all daytime LUTS symptoms and nocturia; odds ratios ranged from 1.60 (95% CI: 1.04, 2.07) for nocturia to 2.90 (95% CI: 1.77, 4.75) for urgency. Associations between age 13 school toilets and age 19 LUTS were in the same direction as age 13 LUTS.

CONCLUSION

This is the first examination of associations between school toilets and LUTS. Toileting environments were cross-sectionally associated with LUTS in adolescent girls. While further work is needed to determine whether these associations are causal, school toilet environments are modifiable and thus a promising target for LUTS prevention.

Early Life Health in Women with Provoked Vestibulodynia and/or Vaginismus

Background: The lifetime prevalence of prolonged vulvar pain ranges from 3% to 28% among premenopausal women. Provoked vestibulodynia (PVD), often accompanied with various degrees of vaginismus, is the predominant cause. We explored the association between birth-related events and the risk of developing PVD/vaginismus during adulthood. Materials and Methods: We identified all women born in Sweden between 1973 and 2001 and categorized those with and without a diagnosis of PVD/vaginismus between 2001 and 2016 (during ages 15-43 years). Nationwide registry data were used to estimate the association between health during infancy (preterm birth, low birth weight, small for gestational age [SGA], Appearance, Pulse, Grimace, Activity and Respiration [APGAR] scores <7, and pain exposure during infancy) and the onset of PVD/vaginismus later in life using an event probability model. Results: Of the 1,359,315 women born in Sweden during 1973-2001, 9,247 were diagnosed with PVD (n = 6,648), vaginismus (n = 3,567), or both (n = 969). Preterm delivery <37 weeks (adjusted odds ratios [aOR]: 1.15, 95% confidence interval [CI]: 1.05-1.26), low birth weight <2,500 g (aOR: 1.24, 95% CI: 1.12-1.36), extremely low birth weight <1,500 g (aOR 1.41, 95% CI: 1.10-1.82), and SGA (aOR 1.20, 95% CI: 1.08-1.34) were factors associated with developing PVD/vaginismus. APGAR scores <7 or pain exposure during birth or infancy was not associated with PVD/vaginismus. Advanced maternal age, higher educational attainment, and being born in Sweden were associated with having a female offspring diagnosed with PVD/vaginismus. Conclusions: In a population of Swedish women 15-43 years of age, adverse health at birth was associated with developing PVD/vaginismus later on in life.

Association between a history of depression and anti-müllerian hormone among late-reproductive aged women: the Harvard study of moods and cycles

Background

There is conflicting evidence regarding the association between a history of depression and risk of early menopause. In a cohort of premenopausal women, we investigated the association between depression history and ovarian reserve, as measured by anti-müllerian hormone (AMH).

Methods

The Harvard Study of Moods and Cycles (HSMC) was a prospective cohort study of women living in the Boston, MA metropolitan-area (1995–1999). Women aged 36–45 years at cohort entry (1995) were sampled from seven Boston metropolitan-area communities using census directories. We measured serum AMH in early-follicular phase venous blood specimens from 141 women with a Structured Clinical Interview for DSM-IV (SCID)-confirmed history of depression and 228 without such a history. We calculated prevalence ratios (PR) for the association between characteristics of depression history and low AMH (≤1.4 ng/mL), adjusting for several potential confounders.

Results

The prevalence of low AMH was similar among depressed (57.5%) and non-depressed (57.9%) women (Adjusted [Adj] PR = 0.90, 95% CI: 0.75, 1.08). Among depressed women, results were not appreciably different among those who had ever used antidepressants and those with comorbid anxiety. Modest inverse associations between depression and low AMH were seen among women aged 36–40 years (Adj PR = 0.75, 95% CI: 0.52, 1.09) and nulliparous women (Adj PR = 0.77, 95% CI: 0.59, 1.00). No dose-response association with greater duration or length of depressive symptoms was observed.

Conclusions

Overall, the prevalence of low AMH was similar for depressed and non-depressed women 36–45 years of age. Surprisingly, among younger and nulliparous women, those with a history of depression had a slightly reduced prevalence of low AMH relative to those without such a history. These results do not indicate reduced ovarian reserve among women with a history of depression.

Characteristics of the vaginal microbiome in women with and without clinically confirmed vulvodynia

BACKGROUND

Vulvodynia (idiopathic vulvar pain) affects up to 8% of women by age 40 years, has a poorly understood etiology, and has variable treatment efficacy. Several risk factors are associated with vulvodynia from a history of yeast infections to depression and allergies. Recent work suggests an altered immune inflammatory mechanism plays a role in vulvodynia pathophysiology. Because the vaginal microbiome plays an important role in local immune-inflammatory responses, we evaluated the vaginal microbiome among women with vulvodynia compared with controls as 1 component of the immune system.

OBJECTIVE

The objective of the study was to characterize the vaginal microbiome in women with clinically confirmed vulvodynia and age-matched controls and assess its overall association with vulvodynia and how it may serve to modify other factors that are associated with vulvodynia as well.

STUDY DESIGN

We conducted a case-control study of 234 Minneapolis/Saint Paul-area women with clinically confirmed vulvodynia and 234 age-matched controls clinically confirmed with no history of vulvar pain. All participants provided vulvovaginal swab samples for culture-based and non-culture (sequencing)-based microbiological assessments, background and medical history questionnaires on demographic characteristics, sexual and reproductive history, and history of psychosocial factors. Vaginal microbiome diversity was assessed using the Shannon alpha diversity Index. Data were analyzed using logistic regression.

RESULTS

Culture and molecular-based analyses of the vaginal microbiome showed few differences between cases and controls. However, among women with alpha diversity below the median (low), there was a strong association between increasing numbers of yeast infections and vulvodynia onset, relative to comparable time periods among controls (age-adjusted odds ratio, 8.1, 95% confidence interval, 2.9-22.7 in those with 5 or more yeast infections). Also among women with low-diversity microbiomes, we observed a strong association between moderate to severe childhood abuse, antecedent anxiety, depression, and high levels of rumination and vulvodynia with odds ratios from 1.83 to 2.81. These associations were not observed in women with high-diversity microbiomes.

CONCLUSION

Although there were no overall differences in microbiome profiles between cases and controls, vaginal microbiome diversity influenced associations between environmental and psychosocial risk factors and vulvodynia. However, it is unclear whether vaginal diversity modifies the association between the risk factors and vulvodynia or is altered as a consequence of the associations.

Psychosocial Factors Influence Sexual Satisfaction among Women with Vulvodynia

Vulvodynia affects about 8% of women, many of whom report a negative impact on their ability to have sexually satisfying relationships. In this study, we examined predictors of sexual satisfaction in 207 women with clinically confirmed vulvodynia. We adapted a model examining resilience in chronic pain patients originally developed by Sturgeon and Zautra to include resilience factors (communication with partner about sexual health and coping strategies) and vulnerable factors (abuse history, pain intensity, rumination). These variables were regressed onto sexual satisfaction. In the full model, only emotion-based rumination was predictive of sexual satisfaction. Thus, focusing on emotion-based rumination in clinical intervention may improve sexual satisfaction.

Is the juice worth the squeeze? Transdisciplinary team science in bladder health

AIMS

Prior research on lower urinary tract symptoms (LUTS) has focused on the treatment and management of these conditions with scant attention to prevention. The Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium was formed to address the complexities of preventing LUTS and promoting bladder health.

METHODS

Herein, we describe challenges faced and strategies used to develop the PLUS Research Consortium into an engaged and productive transdisciplinary scientific team. We apply four previously defined team science phases (development, conceptualization, implementation, and translation) to frame our progress.

RESULTS

Strategies to progress through the development phase included the generation of a shared mission, and valuing of other disciplinary perspectives. The conceptualization phase included generating a shared language and developing a team transdisciplinary orientation. During the implementation phase, the group developed roles and procedures and focused on conflict management. The translation phase includes continued refinement of the mission and goals, implementation of research protocols, and robust dissemination of the scientific work products related to bladder health.

CONCLUSION

A diverse group has matured into a productive transdisciplinary team science consortium. Achieving this outcome required dedicated effort for each member to engage in activities that often required more time than single discipline research activities. Provision of the necessary time and tools has fostered a transdisciplinary team science culture and rich research agenda that reflects the complexity of the health issue to be addressed. Our experience may be useful for others embarking on team science projects.

Applying concepts of life course theory and life course epidemiology to the study of bladder health and lower urinary tract symptoms among girls and women

AIMS

Although lower urinary tract symptoms (LUTS) may occur at different periods during the life course of women, a little research on LUTS has adopted a life course perspective. The purpose of this conceptual paper is to demonstrate how life course theory and life course epidemiology can be applied to study bladder health and LUTS trajectories. We highlight conceptual work from the Prevention of Lower Urinary Tract Symptoms Research Consortium to enhance the understanding of life course concepts.

METHODS

Consortium members worked in transdisciplinary teams to generate examples of how life course concepts may be applied to research on bladder health and LUTS in eight prioritized areas: (a) biopsychosocial ecology of stress and brain health; (b) toileting environment, access, habits, and techniques; (c) pregnancy and childbirth; (d) physical health and medical conditions; (e) musculoskeletal health; (f) lifestyle behaviors; (g) infections and microbiome; and (h) hormonal status across the life span.

RESULTS

Life course concepts guided consortium members' conceptualization of how potential risk and protective factors may influence women's health. For example, intrapartum interventions across multiple pregnancies may influence trajectories of bladder health and LUTS, illustrating the principle of life span development. Consortium members also identified and summarized methodologic and practical considerations in designing life course research.

CONCLUSIONS

This paper may assist researchers from a variety of disciplines to design and implement research identifying key risk and protective factors for LUTS and bladder health across the life course of women. Results from life course research may inform health promotion programs, policies, and practices.

The association of vulvar pain and urological urgency and frequency: findings from a community-based case-control study

INTRODUCTION AND HYPOTHESIS

Vulvodynia is chronic debilitating burning vulvar pain or pain on contact. Although women who suffer from vulvodynia are more likely than others to experience co-morbid interstitial cystitis (IC) and urinary tract infections (UTIs), few studies have explored whether women with vulvodynia experience adverse urinary symptoms (lower urinary tract symptoms [LUTS]) in the absence of urological pain.

METHODS

Two hundred and eleven participants with and 226 participants without clinically confirmed vulvodynia completed the Pelvic Pain and Urgency/Frequency (PUF) questionnaire and were scored using all questions, and then a subset of questions relating only to their current frequency and bother of urination during day and night, and the frequency, severity and bother of urgency after voiding. Total, symptom, and bother scores were compared in women with and without vulvodynia, and regression models estimated adjusted odds ratios and 95% confidence intervals for the various LUTS symptoms.

RESULTS

As expected, 40% of women with vulvodynia met the criteria for IC (PUF > 12) compared with 2% without vulvodynia. After excluding questions related to bladder or vulvovaginal pain, women with vulvodynia, compared with those without, were skewed toward higher PUF scores, including being 2.4 times more likely to report usually or always bothered by night-time voiding (95% CI 1.22-4.74), and 18 times more likely to report moderate/severe urgency after urination (95% CI 5.48-64.12).

CONCLUSIONS

Women with vulvodynia are substantially more likely to report voiding dysfunction and symptoms of urgency than women with no history of vulvar pain. These findings are independent of comorbid interstitial cystitis or history of UTIs.

Early-life Chronic Stressors, Rumination, and the Onset of Vulvodynia

INTRODUCTION

Vulvodynia is a debilitating, chronic vulvar pain condition. Community-based case-control studies have consistently shown associations between early-life chronic stressors and vulvodynia onset.

AIM

We examined rumination as a specific stress response involved in the psychobiological mechanism of vulvodynia.

METHODS

A psychosocial survey with questions specific to early-life traumatic events and rumination were administered to 185 matched case-control pairs of women with and without vulvodynia. Conditional logistic regression was used to examine associations between rumination constructs (ie, total rumination, emotion-focused, instrumental, and searching for meaning) and vulvodynia onset. Conditional logistic regression was also used to determine whether these associations depended on early-life stressors (ie, severity of childhood abuse and of self-reported antecedent traumatic events). Age at interview, antecedent pain disorders, any childhood abuse, and antecedent psychiatric morbidity were included as covariates.

MAIN OUTCOME MEASURES

We estimated the odds of rumination in relation to the onset of vulvodynia within a community-based and clinically confirmed sample of women with and without vulvodynia.

RESULTS

Vulvodynia was associated with the highest tertile of emotion-focused (odds ratio [OR] = 2.1; 95% CI = 1.2, 3.2) and instrumental (OR = 2.1; 95% CI = 1.1, 4.0) rumination. These associations were attenuated after additional adjustment for antecedent psychiatric morbidity. Among women who reported rumination about early-life stressors before vulvar pain in cases or matched reference age in control subjects, those with vulvodynia were >2 times more likely to report the highest tertile of total rumination (OR = 2.3; 95% CI = 1.1, 5.0) compared with those without vulvodynia.

CLINICAL IMPLICATIONS

Healthcare providers may be able to identify subsets of women who could benefit from preventive measures before the development of vulvodynia.

STRENGTH & LIMITATIONS

This is the first study to use a community-based and clinically confirmed sample of women with and without vulvodynia to examine the associations between rumination about early-life trauma and the onset of vulvodynia. However, as with all retrospective studies, the reporting of information (eg, traumatic events) was subject to recall bias and misclassification.

CONCLUSION

Our findings indicate that a prolonged cognitive stress response (ie, rumination) may be 1 important mechanism by which early-life chronic stressors contribute to the onset vulvodynia. Prospective studies are recommended to examine whether and how cognitive, affective, and physiological components of prolonged stress responses interact to influence the development of vulvodynia. Understanding both the psychobiological and behavioral mechanisms may help in addressing and treating individuals to potentially reverse the development of vulvodynia. Khandker M, Brady SS, Rydell SA, et al. Early-life Chronic Stressors, Rumination, and the Onset of Vulvodynia. J Sex Med 2019;16:880-890.

Exploring Hygienic Behaviors and Vulvodynia

OBJECTIVES

Vulvodynia is common and characterized by vulvar discomfort and pain. However, few studies have assessed hygienic practices in relation to onset. We investigated whether hygienic behaviors were associated with the onset of vulvodynia.

MATERIALS AND METHODS

We assessed a self-reported history of personal hygienic behaviors, including wearing tight-fitting clothing, vulva care and genital washing, pubic hair removal, douching, and powdering, a year before first reported onset of vulvar pain among 213 clinically confirmed cases and a similar time period among 221 general population controls.

RESULTS

Compared with women who reported never wearing tight-fitting jeans or pants, women wearing tight-fitting jeans or pants 4 or more times per week had twice the odds of vulvodynia (95% CI = 1.14-3.95). Relative to controls, women with vulvodynia were substantially less likely to report use of soaps and gels to cleanse the vulva (95% CI = 0.17-0.63). Among women who chose to remove pubic hair, those who removed pubic hair from the mons pubis compared with bikini-area only hair removal, were 74% more likely to have vulvodynia (95% CI = 1.05-2.89). Finally, compared with women who reported bikini-area only hair removal less than monthly, those who removed hair from the mons pubis weekly or more were nearly 2 times more likely to be vulvodynia cases (95% CI = 0.83-3.49).

CONCLUSIONS

Wearing tight-fitting jeans or pants and removing hair from the mons pubis area were associated with increased odds of vulvodynia. Research on how hygienic practices could influence vulvar pain in larger and more temporally addressed populations is warranted.

A longitudinal study of neurotrophic, oxidative, and inflammatory markers in first-onset depression in midlife women

Prospective studies have shown during the years preceding and following menopause, also known as "menopause transition", that midlife women are at higher risk for developing first-onset major depressive disorder (MDD). The biological factors associated with risk and resilience in this population are, however, largely unknown. Considering the growing body of evidence suggesting that inflammation, oxidative stress, and brain-derived neurotrophic factor (BDNF) are associated with the pathophysiology of MDD, we investigated serum levels of protein carbonyl, lipid peroxidation (thiobarbituric acid reactive substances-TBARS), thiol group content, BDNF, 3-nitrotyrosine, and heat shock protein 70 (HSP70) in a longitudinal cohort of first-onset MDD. One hundred and forty-eight women from the Harvard Study of Moods and Cycles, a prospective study of midlife women monitored throughout the transition to menopause, were studied. Within- and between-groups analyses of these peripheral markers were conducted in 37 women who developed and 111 women that did not develop MDD during the 3-year follow-up period. In women who developed MDD, HSP70 and 3-nitrotyrosine were elevated at baseline, whereas TBARS were elevated 6 months prior to development of MDD, as compared to those who did not develop MDD. Within-group analyses showed that HSP70, 3-nitrotyrosine, and BDNF decreased over time, whereas protein carbonyl was elevated only at 12 months prior to development of MDD. In women who did not develop MDD, HSP70 and thiol decreased over time. The development of MDD in midlife women may be associated with a systemic cascade of pro-oxidative and pro-inflammatory events including increased HSP70, 3-nitrotyrosine, protein carbonyl, and lipid peroxidation and decreased BDNF.

Web-Delivered Multimedia Training Materials for the Self-Collection of Dried Blood Spots: A Formative Project

Background

The use of dried blood spots (DBS) in biomedical research has been increasing as an objective measure for variables that are typically plagued by self-report, such as smoking status and medication adherence. The development of training materials for the self-collection of DBS that can be delivered through the Web would allow for broader use of this methodology.

Objective

The objective of this study was to evaluate the acceptability and feasibility of the self-collection of DBS using newly developed multimedia training materials that were delivered through the Web. We also aimed to assess the usability of the collected DBS samples.

Methods

We recruited participants through Facebook advertising for two distinct studies. The first study evaluated the acceptability of our newly developed DBS training materials, while the second assessed the implementation of this protocol into a larger Web-based study.

Results

In the first study, participants (N=115) were aged, on average, 26.1 (SD 6.4) years. Training materials were acceptable (113/115, 98.2%, of participants were willing to collect DBS again) and produced usable samples (110/115, 95.7%, collected DBS were usable). In the second study, response rate was 25.0% (41/164), with responders being significantly younger than nonresponders (20.3 [SD 0.2] vs 22.0 [SD 0.4]; P<.001), and 92% (31/41) of collected DBS samples were usable by the laboratory.

Conclusions

Overall, while the protocol is acceptable, feasible, and produced usable samples, additional work is needed to improve response rates.

Patterns of postpartum contraceptive use among Somali immigrant women living in Minnesota

Background

The postpartum period is a crucial time to provide family planning counseling and can decrease incidence of adverse reproductive outcomes. The purpose of this study was to characterize patterns of postpartum contraception and to investigate long acting reversible contraceptive (LARC) use among Somali women living in a metropolitan area of Minnesota in an effort to provide better family planning and reproductive health counseling in this growing immigrant population.

Methods

A retrospective chart review was conducted of Somali women who delivered between January 1, 2011 and December 31, 2014. Information was collected regarding family planning counseling provided and contraceptive methods chosen at the postpartum clinic visit.

Results

Of the 747 Somali women who delivered during this time period, 56.4% had no postpartum follow up visit. At the postpartum visit, 88.3% of women received family planning counseling and 80.8% chose a contraceptive method with the remainder declining. The intrauterine device (IUD) was the most popular contraceptive method, chosen by 39.7% of women. Other than parity, no statistically significant differences were observed between women who chose LARC versus other contraceptive methods. Of the women that chose a LARC, 39.4% had it placed at the time of their postpartum visit; immediate placement was statistically significantly more likely with more recent delivery, lower BMI and obstetrician as the provider type.

Conclusions

The IUD was the most popular method of postpartum contraception. There was a trend toward increase in LARC use with increasing parity. Same-day LARC placement was uncommon, but should be encouraged in this population given high loss to follow up rate.

The Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium: A Transdisciplinary Approach Toward Promoting Bladder Health and Preventing Lower Urinary Tract Symptoms in Women Across the Life Course

Lower urinary tract symptoms (LUTS) are highly prevalent in women, and are expected to impose a growing burden to individuals and society as the population ages. The predominance of research related to LUTS has focused on underlying pathology, disease mechanisms, or the efficacy of treatments for women with LUTS. Although this research has been vital for helping to reduce or ameliorate LUTS conditions, it has done little to prevent the onset of LUTS. Health promotion and prevention require an expansion of scientific inquiry beyond the traditional paradigm of studying disease mechanisms and treatment to the creation of an evidence base to support recommendations for bladder health promotion and, in turn, prevention of LUTS. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) introduced the concept of prevention as an important priority for women's urologic research as a prelude to supporting the formation of the Prevention of Lower Urinary Tract Symptoms (PLUS) research consortium. In this article, we introduce the PLUS research consortium to the scientific community; share the innovative paradigms by which the consortium operates; and describe its unique research mission: to identify factors that promote bladder health across the life course and prevent the onset of LUTS in girls and women.

Recurrent Yeast Infections and Vulvodynia: Can We Believe Associations Based on Self-Reported Data?

OBJECTIVE

We determined whether self-reported new or recurrent yeast infections were a risk factor for and/or consequence of vulvodynia and then determined the extent to which various levels of misclassification of self-reported yeast infections influenced these results.

MATERIALS AND METHODS

In this case-control study we retrospectively assessed self-reported new and recurrent yeast infections prior and subsequent to first vulvar pain onset among 216 clinically confirmed cases and during a similar time period for 224 general population controls.

RESULTS

A history of >10 yeast infections before vulvodynia onset was strongly but imprecisely associated with currently diagnosed vulvodynia after adjustment for age, age at first intercourse, and history of urinary tract infections [adjusted odds ratio = 5.5, 95% confidence interval (CI) 1.7-17.8]. Likewise, a history of vulvodynia was associated with a twofold risk of subsequent new or recurrent onset of yeast infections after adjustment for age, age at first intercourse, and history of yeast infections before vulvodynia onset (comparable time period among controls, 95% CI 1.5-2.9). Bias analyses showed that our observed associations were an underestimation of the true association when nondifferential misclassification of self-reported yeast infections and certain differential misclassification scenarios were present. However, if women with vulvodynia more frequently misreported having them when they truly did not, our observed associations were an overestimate of the truth.

CONCLUSIONS

There appears to be a positive relationship between yeast infections preceding and following the diagnosis of vulvodynia, but this relationship varies from strong to nonexistent depending on the relative accuracy of the recalled diagnosis of yeast infections among cases and controls. To better understand the bidirectional associations between yeast infections and vulvodynia, future validation studies are needed to determine the extent to which misclassification of self-reported yeast infections differs between women with and without vulvodynia.

Obstetric Outcomes of Mothers Previously Exposed to Sexual Violence

Background

There is a scarcity of data on the association of sexual violence and women's subsequent obstetric outcomes. Our aim was to investigate whether women exposed to sexual violence as teenagers (12–19 years of age) or adults present with different obstetric outcomes than women with no record of such violence.

Methods

We linked detailed prospectively collected information on women attending a Rape Trauma Service (RTS) to the Icelandic Medical Birth Registry (IBR). Women who attended the RTS in 1993–2010 and delivered (on average 5.8 years later) at least one singleton infant in Iceland through 2012 formed our exposed cohort (n = 1068). For each exposed woman's delivery, nine deliveries by women with no RTS attendance were randomly selected from the IBR (n = 9126) matched on age, parity, and year and season of delivery. Information on smoking and Body mass index (BMI) was available for a sub-sample (n = 792 exposed and n = 1416 non-exposed women). Poisson regression models were used to estimate Relative Risks (RR) with 95% confidence intervals (CI).

Results

Compared with non-exposed women, exposed women presented with increased risks of maternal distress during labor and delivery (RR 1.68, 95% CI 1.01–2.79), prolonged first stage of labor (RR 1.40, 95% CI 1.03–1.88), antepartum bleeding (RR 1.95, 95% CI 1.22–3.07) and emergency instrumental delivery (RR 1.16, 95% CI 1.00–1.34). Slightly higher risks were seen for women assaulted as teenagers. Overall, we did not observe differences between the groups regarding the risk of elective cesarean section (RR 0.86, 95% CI 0.61–1.21), except for a reduced risk among those assaulted as teenagers (RR 0.56, 95% CI 0.34–0.93). Adjusting for maternal smoking and BMI in a sub-sample did not substantially affect point estimates.

Conclusion

Our prospective data suggest that women with a history of sexual assault, particularly as teenagers, are at increased risks of some adverse obstetric outcomes.

Childhood abuse victimization, stress-related eating, and weight status in young women

PURPOSE

Abuse in childhood predicts stress-related overeating and excess weight gain in young women. We investigated whether two stress-related overeating behaviors--binge eating and coping-motivated eating--explain childhood abuse associations with weight status in young women.

METHODS

Analyses included 4377 women participating in the Growing Up Today Study, a longitudinal cohort of youth enrolled at age 9 to 14 years. We used marginal structural models to estimate the effects of abuse before age 11 years on weight status at age 22 to 29 years with and without adjustment for binge eating and coping-motivated eating.

RESULTS

Women with severe physical, sexual, and emotional abuse had early adult body mass indexes (BMIs) that were 0.74 kg/m(2) (95% confidence interval [CI]: 0.15-1.33), 0.69 (95% CI: -0.46 to 1.83), and 0.85 (95% CI: 0.24-1.45) kg/m(2) higher, respectively, than those without abuse. Adjustment for coping-motivated eating attenuated the excess BMI associated with severe physical abuse, but no other important attenuations were found.

CONCLUSIONS

Physical, sexual, and emotional abuse before age 11 years were associated with higher early adult weight status, although the sexual abuse estimate was not statistically significant. Evidence for a role of stress-related eating in abuse--BMI associations was limited and inconsistent across abuse types.

Differences in pain subtypes between Hispanic and non-Hispanic white women with chronic vulvar pain

OBJECTIVES

Compared with non-Hispanic Whites, Hispanic women have significantly higher prevalence of chronic vulvar pain (CVP), which is known to have heterogeneous subtypes. However, it is not known whether subtypes differ by ethnicity, and improved understanding of subtypes may allow for targeted clinical assessment and therapies. We examined subtypes to determine whether they differed by ethnicity.

METHODS

Data were from 1,551 women who reported chronic vulvar pain consistent with vulvodynia in a population-based, cross-sectional study of women from the Minneapolis/St. Paul metropolitan area, during the years 2010-2013, who returned a validated screener survey about vulvar pain.

RESULTS

Among women with CVP, Hispanics reported more primary vulvodynia (adjusted [adj.] risk ratio=1.47; p<0.01), defined as pain with first intercourse or tampon use, and tended to be more likely to describe a burning pain (adj. risk ratio=1.45; p=0.06). Hispanic women with CVP were 17% more likely than non-Hispanic Whites with CVP to have their pain alleviated with some type of behavior/remedy (p=0.01); for example, among the subgroup of women with CVP who used yeast cream, Hispanics more often reported benefit to their pain (adj. risk ratio=1.51; p<0.01).

DISCUSSION

We examined women with CVP and found that in comparison to their non-Hispanic White counterparts, Hispanic women are more likely to report a burning sensation and more likely to have primary vulvodynia, a subtype that is associated with great burden on the lives of affected women.

Is chronic stress during childhood associated with adult-onset vulvodynia?

BACKGROUND

Vulvodynia is an unexplained chronic vulvar pain condition. Case-control studies provide opportunities to examine potential mechanisms by which vulvodynia may develop. Findings inform etiological models that can be tested in subsequent prospective studies.

METHODS

A survey of interpersonal relationships and the Structured Clinical Interview for DSM-IV Axis I Disorders was administered to 215 case-control pairs of women with and without vulvodynia. Conditional logistic regression was used to examine associations between affect-based chronic stressors (i.e., living in fear of abuse, perceived abuse, and antecedent mood disorders) with vulvodynia. These associations were then examined among women with and without a history of childhood abuse.

RESULTS

Among women with a history of severe childhood abuse, those with vulvodynia had three times the odds of living in fear of any abuse compared to women without vulvodynia (95% confidence interval: 1.0, 11.0), after adjustment for childhood poverty. Among women with no history of childhood abuse, those with vulvodynia had over six times the odds of antecedent mood disorder compared to women without vulvodynia (95% confidence interval: 1.9,19.6).

CONCLUSION

Our findings suggest that affect-based chronic stressors may be important to the psychobiological mechanisms of vulvodynia. Prospective studies are recommended to test biopsychosocial models of the etiology of vulvodynia.

Prevalence of symptoms consistent with a diagnosis of vulvodynia: population-based estimates from 2 geographic regions

OBJECTIVE

We used validated sensitive and specific questions associated with clinically confirmed diagnoses of unexplained vulvar pain (vulvodynia) to compare the cumulative incidence of vulvar pain and prevalence of care-seeking behavior in Boston metropolitan area (BMA) and in Minneapolis/Saint Paul metropolitan area (MSP) from 2001 through 2005 using census-based data, and 2010 through 2012, using outpatient community-clinic data, respectively.

STUDY DESIGN

We received self-administered questionnaires from 5440 women in BMA and 13,681 in MSP, 18-40 years of age, describing their history of vulvar burning or pain on contact that persisted >3 months that limited/prevented intercourse.

RESULTS

By age 40 years, 7-8% in BMA and MSP reported vulvar pain consistent with vulvodynia. Women of Hispanic origin compared to whites were 1.4 times more likely to develop vulvar pain symptoms (95% confidence interval, 1.1-1.8). Many women in MSP (48%) and BMA (30%) never sought treatment, and >50% who sought care with known health care access received no diagnosis.

CONCLUSION

Using identical screening methods, we report high prevalence of vulvar pain in 2 geographic regions, and that access to health care does not increase the likelihood of seeking care for chronic vulvar pain.

Perceived stereotyping and seeking care for chronic vulvar pain

OBJECTIVES

We examined stereotyping of chronic pain sufferers among women aged 18-40 years and determined whether perceived stereotyping affects seeking care for women with chronic vulvar pain.

DESIGN

Cross-sectional study using a community-based survey of vulvodynia asking if "Doctors think that people with chronic pain exaggerate their pain," and if "People believe that vulvar pain is used as an excuse to avoid having sex".

SETTING AND PARTICIPANTS

Twelve thousand eight hundred thirty-four women aged 18-40 years in metropolitan Minneapolis/St. Paul, Minnesota.

OUTCOME MEASURES

Women were considered to have a history of chronic vulvar pain if they reported vulvar burning lasting more than 3 months or vulvar pain on contact.

RESULTS

Four thousand nine hundred eighty-seven (38.9%) women reported a chronic pain condition; 1,651 had chronic vulvar pain. Women experiencing chronic pain were more likely than those without to perceive stereotyping from both doctors and others; a dose-response with the number of pain conditions existed. Women with chronic vulvar pain were more likely to believe that people think vulvar pain is an excuse to avoid intercourse. Half of the women with chronic vulvar pain did not seek medical care for it; of these, 40.4% perceived stereotyping from doctors. However, it was women who actually sought care (45.1%) who were more likely to feel stigmatized by doctors (adjusted relative risk = 1.11, 95% confidence interval: 1.01-1.23).

CONCLUSIONS

Perceived negative stereotyping among chronic pain sufferers is common, particularly negative perceptions about physicians. In fact, chronic vulvar pain sufferers who felt stigmatized were more likely to have sought care than those who did not feel stigmatized.

Assessing the utility of methods for menopausal transition classification in a population-based cohort: the CARDIA Study

OBJECTIVES

Perimenopause significantly impacts women's health, but is under-researched due to challenges in assessing perimenopause status. Using CARDIA data, we compared the validity of six approaches for classifying perimenopause status in order to better understand the performance of classification techniques which can be applied to general cohort data. Specifically, we examined the validity of a self-reported question concerning changes in menstrual cycle length and two full prediction models using all available data concerning menstrual cycles as potential indicators of perimenopause. The validity of these three novel methods of perimenopause classification were compared to three previously established classification methods.

METHODS

For each method, women were classified as pre- or peri-menopausal at Year 15 of follow-up (ages 32-46). Year 15 perimenopause status was then used to predict Year 20 post-menopausal status (yes/no) to estimate measures of validity and area under the curve.

RESULTS

The validity of the methods varied greatly, with four having an area under the curve greater than 0.8.

CONCLUSIONS

When designing studies, researchers should collect the data required to construct a prediction model for classifying perimenopause status that includes age, smoking status, vasomotor symptoms, and cycle irregularities as predictors. The inclusion of additional data regarding menstrual cycles can be used to construct a full prediction model which may offer improved validity. Valid classification methods that use readily available data are needed to improve the scientific accuracy of research regarding perimenopause, promote research on this topic, and inform clinical practices.

Disparate rates of new-onset depression during the menopausal transition in 2 community-based populations: real, or really wrong?

This study took place in eastern Massachusetts and included respondents from the Harvard Study of Moods and Cycles Cohort 1, enrolled between 1995 and 1997, and the Harvard Study of Moods and Cycles Cohort 2, enrolled between 2005 and 2009. In prospectively assessing rates of new-onset depression in 2 populations of late-reproductive-aged women with no Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) lifetime history of depression, we were surprised to find far lower rates of depression in the population with greater racial diversity and lower socioeconomic status, contrary to what had been reported in the scientific literature. To better understand why these disparate results occurred, we assessed confounding and outcome misclassification as potential explanations for the discrepancy. After determining that these were unlikely explanations for the findings, we explored 2 potential sources of selection bias: one induced by self-referral of healthy participants into the study and the other induced by the design of the study itself. We concluded that both types of selection bias were likely to have occurred in this study and could account for the observed difference in rates.

Are prenatal, obstetric, and infant complications associated with postpartum psychosis among women with pre-conception psychiatric hospitalisations?

OBJECTIVE

To examine the associations of maternal and infant complications with postpartum hospitalisation for psychosis in women with a pre-conception history of psychiatric hospitalisation.

DESIGN

Population-based study.

SETTING

Swedish medical birth register.

POPULATION

Primiparous women who gave birth between 1 January 1987 and 31 December 2001, and who had a pre-conception history of psychiatric hospitalisation but who were not hospitalised during pregnancy (n = 1842).

METHODS

International Classification of Diseases (ICD) codes were used to identify prenatal, obstetric, postpartum maternal complications, and newborn health conditions. We used multivariable logistic regression to describe the associations between maternal and infant health conditions and the odds for postpartum hospitalisation for psychosis.

MAIN OUTCOME MEASURE

Psychiatric hospitalisation within 90 days of delivery.

RESULTS

Compared with women who did not have a postpartum psychiatric hospitalisation, hospitalised women were at 2.3 times higher odds (95% CI 1.0-4.9) of having non-psychiatric puerperium complications (e.g. infection, lactation problems or venous complications). No other maternal complications were associated with postpartum psychiatric hospitalisation. Although their infants were at no higher odds for health complications, the offspring of women who had a postpartum psychiatric hospitalisation were at 4.1 times higher odds (95% CI 1.3-12.6) of death within the first 365 days of life than those of women who were not hospitalised.

CONCLUSIONS

We found no prenatal indicators of postpartum risk for psychiatric hospitalisation among high-risk women, but they had higher odds of postpartum pregnancy-related medical problems and, rarely, offspring death.

A population-based study of pregnancy and delivery characteristics among women with vulvodynia

Introduction

To examine pregnancy and delivery characteristics of women with and without vulvodynia.

Methods

The authors analyzed 227 vulvodynia cases that were less than 45 years old at pain onset; controls were age matched 1:1 to cases and had no history of vulvar pain. Pregnancy and delivery events were assessed after age at first vulvar pain onset (the reference age) in cases and a matched age in controls.

Results

The authors observed no significant difference between cases and controls in achieving pregnancy after reference age. Also, no difference in pregnancy outcome was observed between cases and controls (P = 0.87). There was an indication that cases were more likely to receive a Cesarean section delivery (P = 0.07). In addition, 37.1% of cases who had vaginal delivery versus 11.3% of controls (P < 0.01) reported pain at 2 months postpartum. Comparing only women with vulvodynia, women who had intermittent pain versus constant pain were more than twice as likely to have a pregnancy (adjusted odds ratio 2.26, 95% CI 1.10–4.60).

Conclusions

Women with vulvodynia may be as likely as other women to carry their pregnancy to birth; however, they may experience higher rates of Cesarean section delivery and could reflect a selection towards those women with vulvodynia who have inconsistent pain.

Comfort in discussing vulvar pain in social relationships among women with vulvodynia

OBJECTIVE

To assess women's likelihood of feeling comfortable in discussing vulvar pain.

STUDY DESIGN

Using a survey of women with self-reported clinician-diagnosed vulvodynia, we assessed the likelihood of comfort in discussing vulvar pain within four types of relationships: husband/partner, mother/sister, best friend, and other women friends. Separate multivariable models were fit for relationship type to determine whether vulvar pain characteristics (length, severity,family history) were associated with likelihood of feeling comfortable in discussing.

RESULTS

A total of 67% of women with a partner were comfortable discussing their vulvar pain with that person, whereas 39% were comfortable with family and 26% were comfortable with women friends. Independent of age, the more years women had vulvodynia the less likely they would be comfortable discussing it. Compared to lower levels of vulvar pain, increasing levels (mild, moderate and severe) were associated with greater comfort in discussing their pain with friends; women were 10% more likely to be comfortable with each increase in pain level, and 12% more likely to be comfortable with other women friends.

CONCLUSION

Our data suggest that vulvar pain characteristics may determine how comfortable a woman is to discuss her vulvar pain, but it varies by relationship type.

Co-morbid pain conditions and feelings of invalidation and isolation among women with vulvodynia

Many women with vulvodynia also suffer from other chronic co-morbid pain conditions. Alone, these pain conditions are associated with feeling invalidated by others and feeling socially isolated. It is unclear, however, how the presence of additional pain co-morbidities are associated with the psychosocial wellbeing of women with vulvodynia. We used data from a survey administered by the National Vulvodynia Association. Women reported clinician-diagnosed vulvodynia, presence of co-morbid pain, and how often they felt that they felt no one believed their pain existed (invalidated) and isolated. Analyses determined prevalence of feeling invalidated or isolated, and the difference in prevalence when co-morbidities existed. Forty-five percent of these 1847 women with vulvodynia reported having at least one of the following five chronic pain conditions, chronic fatigue syndrome, endometriosis, fibromyalgia, interstitial cystitis, or irritable bowel syndrome. Adjusted baseline prevalence among all women of feeling invalidated was 9% and of feeling isolated was 14%. Having a co-morbid condition with vulvodynia, as well as having an increasing number of co-morbid conditions with vulvodynia, was significantly associated with the presence of feeling both invalidated and isolated. Chronic fatigue syndrome was the co-morbidity most strongly associated with feelings invalidation and isolation. One or more co-morbid pain conditions in addition to vulvodynia were significantly associated with psychosocial wellbeing. However, the temporality of the association could not be elucidated and therefore we cannot conclude that these pain conditions cause poor psychosocial wellbeing. Despite this, future studies should explore the utility of promoting validation of women's pain conditions and reducing social isolation for women with chronic pain.

The influence of depression and anxiety on risk of adult onset vulvodynia

BACKGROUND

Studies have shown that women with vulvodynia are more psychologically distressed than women without vulvodynia. These studies, however, have not effectively established temporal associations between diagnosed psychiatric disorders and vulvodynia.

METHODS

The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) was administered to 240 case-control pairs of women with and without vulvodynia. Interviews established age at first onset of diagnosed mood and anxiety disorder. Age information was used to determine whether the first episode of mood and/or anxiety was antecedent or subsequent to the first onset of vulvodynia symptoms. Conditional logistic regressions tested whether antecedent depression or anxiety was more likely among women with or without vulvodynia. Cox proportional hazards modeling was then used to estimate risk of subsequent new or recurrent onset of mood or anxiety disorder.

RESULTS

After adjusting for education, race, age at menarche, age at first tampon use, and age at first sexual intercourse, odds of vulvodynia were four-times more likely among women with antecedent mood or anxiety compared to women without (95% confidence interval [CI] 2.1-7.5). Vulvodynia was associated with new or recurrent onset of mood or anxiety disorder after adjustment (hazard ratio [HR] 1.7, 95% CI 1.1-2.6) and did not significantly change after including history of mood or anxiety disorder before the onset of vulvodynia or reference age of controls in the models.

CONCLUSIONS

This is the first community-based epidemiologic study demonstrating that DSM-IV-diagnosed antecedent depression and anxiety disorders influence the risk of vulvodynia and that vulvodynia increases the risk of both new and recurrent onset of psychopathology.

The association between depression and diabetes in the perinatal period

Both depression and diabetes are common in the perinatal period and result in serious consequences for mother and fetus. Although the association between depression and diabetes is well established, few studies have examined the association between these disorders during the perinatal period, when the etiology of depression and diabetes may differ from other periods over the life course. This article reviews the four most relevant epidemiologic papers that examined the association between depression and diabetes in the perinatal period and makes recommendations for future studies about how best to examine the association between these disorders during the perinatal period.

Allergic reactions and risk of vulvodynia

PURPOSE

A recent histological study of vestibular tissue from women with localized vulvodynia found universal presence of mast cells compared to no presence in vestibular tissue among controls. Since histamine is generated by mast cells, and mast cells contribute to the production of cytokines during chronic inflammation, we assessed the association between conditions that elicit a clinically relevant histamine response and vulvodynia.

METHODS

We studied 239 women with and 239 women without vulvodynia to assess the influence of self-reported allergic reactions antecedent to first development of vulvar pain symptoms among cases, and a matched reference age among controls.

RESULTS

Women with self-reported hives prior to first report of vulvar pain or reference age among controls were 2.5 times more likely to develop vulvodynia (95% confidence interval [CI], 1.7-4.4). Those reporting a history of allergic reactions to insect bites were 2.1 times more likely (95%CI, 1.1-4.0), and those reporting a history of seasonal allergies were 2.0 times (95%CI, 1.3-3.2) more likely to develop vulvodynia. Findings were similar in a restricted subset of clinically confirmed cases and matched controls.

CONCLUSIONS

An altered immuno-inflammatory response to environmentally induced allergic reactions may predispose women to the development of vulvodynia or may be markers of an already heightened immuno-inflammatory response.

Psychosocial predictors of the onset of anxiety disorders in women: results from a prospective 3-year longitudinal study

In a prospective, longitudinal, population-based study of 643 women participating in the Harvard Study of Moods and Cycles we examined whether psychosocial variables predicted a new or recurrent onset of an anxiety disorder. Presence of anxiety disorders was assessed every 6 months over 3 years via structured clinical interviews. Among individuals who had a new episode of anxiety, we confirmed previous findings that history of anxiety, increased anxiety sensitivity (the fear of anxiety related sensations), and increased neuroticism were significant predictors. We also found trend level support for assertiveness as a predictor of anxiety onset. However, of these variables, only history of anxiety and anxiety sensitivity provided unique prediction. We did not find evidence for negative life events as a predictor of onset of anxiety either alone or in interaction with other variables in a diathesis-stress model. These findings from a prospective longitudinal study are discussed in relation to the potential role of such predictors in primary or relapse prevention efforts.

Self-reported vulvar pain characteristics and their association with clinically confirmed vestibulodynia

OBJECTIVE

We evaluated a series of questions pertaining to vulvar pain symptoms to determine their association with a localized vulvodynia (vestibulodynia) diagnosis in women from the general population.

METHODS

A sample of 12,435 women completed a self-administered screening questionnaire for the presence of specific types and characteristics of vulvar pain lasting 3 months or longer. Sensitivity, specificity, and predictive values were calculated for each cross-classification of vulvar pain type and characteristic, using as the gold standard 121 subjects with a clinically confirmed vestibulodynia diagnosis.

RESULTS

Relative to women with clinically confirmed vestibulodynia, 83% reported >10 episodes of pain on contact at the time of tampon insertion, intercourse, or pelvic examination, and 83% also reported pain on contact that limited or prevented sexual intercourse. These strong associations with a vestibulodynia diagnosis were not observed with respect to women who reported vulvar pain symptoms of burning or knifelike pain, or vulvar pain characteristics of continuous versus intermittent pain, or provoked versus spontaneous pain.

CONCLUSIONS

Our findings suggest that a small number of symptoms may be suitable for identifying a large proportion of women suffering from vestibulodynia which may be ideal for the development of an effective screening test in the future. However, we also recognize that a large proportion of women experiencing vulvar pain symptoms will not meet the diagnostic criteria for vestibulodynia. Thus, implementing such a screening procedure as part of a routine examination or testing would require a subsequent pelvic examination to confirm a vestibulodynia diagnosis and to rule out other known explanations for vulvar pain.

Self-reported vulvar pain characteristics and their association with clinically confirmed vestibulodynia

OBJECTIVE

We evaluated a series of questions pertaining to vulvar pain symptoms to determine their association with a localized vulvodynia (vestibulodynia) diagnosis in women from the general population.

METHODS

A sample of 12,435 women completed a self-administered screening questionnaire for the presence of specific types and characteristics of vulvar pain lasting 3 months or longer. Sensitivity, specificity, and predictive values were calculated for each cross-classification of vulvar pain type and characteristic, using as the gold standard 121 subjects with a clinically confirmed vestibulodynia diagnosis.

RESULTS

Relative to women with clinically confirmed vestibulodynia, 83% reported >10 episodes of pain on contact at the time of tampon insertion, intercourse, or pelvic examination, and 83% also reported pain on contact that limited or prevented sexual intercourse. These strong associations with a vestibulodynia diagnosis were not observed with respect to women who reported vulvar pain symptoms of burning or knifelike pain, or vulvar pain characteristics of continuous versus intermittent pain, or provoked versus spontaneous pain.

CONCLUSIONS

Our findings suggest that a small number of symptoms may be suitable for identifying a large proportion of women suffering from vestibulodynia which may be ideal for the development of an effective screening test in the future. However, we also recognize that a large proportion of women experiencing vulvar pain symptoms will not meet the diagnostic criteria for vestibulodynia. Thus, implementing such a screening procedure as part of a routine examination or testing would require a subsequent pelvic examination to confirm a vestibulodynia diagnosis and to rule out other known explanations for vulvar pain.