Few middle-aged women with severe mental symptoms use psychotropic drugs: The Women's Health in Lund Area (WHILA) Study

Aims: In a population of middle-aged women a survey was carried out to ascertain the prevalence of mental symptoms and psychotropic drug use, and further to investigate whether severe mental symptoms are associated with social situation, alcohol consumption, smoking, and physical health. Methods: All women (n=10,766) aged 50—59 years and living in the Lund area were invited to the WHILA study, a health survey including laboratory examinations and a self-administered questionnaire; 6,917 (64.2%) participated. This study is based on the questionnaire only. Results: During the past three months 25.4% (n=1,709) had been troubled by none or 1 mental symptom (labelled ``absent/slight''), 52.8% (n=3,555) by 2—6 mental symptoms (``moderate'') and 21.8% (n=1,471) by 7—10 mental symptoms (``severe''). Among women with severe mental symptoms 15.4% regularly used psychotropic drugs, mainly antidepressants. A multiple logistic regression analysis showed that women with severe mental symptoms had higher odds for living alone (OR 1.7; CI 1.3—2.2) or as single parents (OR 2.1; CI 1.2—3.6), being university-educated (OR 1.5; CI 1.1—2.0), being on long-term sick-leave (OR 8.8; CI 3.0—25.5), using hormone replacement therapy (OR 1.3; CI 1.1—1.6), and having severe physical symptoms (136.8; CI 89.2—209.7) compared with women with absent/slight mental symptoms. Conclusion: Mental symptoms were common among the participating women. The presence of severe mental symptoms was strongly associated with severe physical symptoms. Few women with severe mental symptoms used psychotropic drugs. Middle-aged women with severe mental symptoms need to be identified and provided with appropriate psychopharmacological, hormonal, and/or psychosocial treatment.

Self-rated Health in Middle-aged Women: Associations with Sense of Coherence and Socioeconomic and Health-related Factors

This study aimed to describe and analyse self-rated health in relation to sense of coherence and socioeconomic and health-related factors and to explore the associations between self-rated health and these factors in order to identify health resources and health limitations in a group of healthy middle-aged women. Healthy middle-aged women from a defined geographical area in Southern Sweden ( n =577) answered a postal survey with the sense of coherence scale and questions about socioeconomic and health-related conditions. The results showed that very good/rather good self-rated health was associated with high sense of coherence and good economic situation, and these factors can be seen as a health resource. Poor self-rated health was most strongly associated with perceived symptoms of tension, weak sense of coherence, treatment for depression, treatment for chronic disease, and difficult economic situation, and these factors can be seen as health limitations. In conclusion, only 29% of the women rated their health as very good and 41% of the women had symptoms of tension but they were not sick-listed. It is of major public health interest to improve the understanding of self-rated health and to develop health promotion for women and methods to prevent symptoms of tension and sick-listing.

Lack of adherence to hypertension treatment guidelines among GPs in southern Sweden-a case report-based survey

BACKGROUND

General practitioners (GPs) often fail to correctly adhere to guidelines for the treatment of hypertension. The reasons for this are unclear, but could be related to lack of knowledge in assessing individual patients' cardiovascular disease risk. Our aim was to investigate how GPs in southern Sweden adhere to clinical guidelines for the treatment of hypertension when major cardiovascular risk factors are taken into consideration.

METHOD

A questionnaire with five genuine cases of hypertension with different cardiovascular risk profiles was sent to a random sample of GPs in southern Sweden (n=109) in order to investigate the attitude towards blood pressure (BP) treatment when major cardiovascular risk factors were present.

RESULTS

In general, GPs who responded tended to focus on the absolute target BP rather than assessing the entire cardiovascular risk factor profile. Thus, cases with the highest risk of cardiovascular disease were not treated accordingly. However, there was also a tendency to overtreat the lowest risk individuals. Furthermore, the BP levels for initiating pharmacological treatment varied widely (systolic BP 140-210 mmHg). ACE inhibitors (70%) were the most common first choice of pharmacological treatment.

CONCLUSION

In this study, GPs in Southern Sweden were suggesting, for different cases, either under- or overtreatment in relation to current guidelines for treatment of hypertension. On reason may be that they failed to correctly assess individual cardiovascular risk factor profiles.

Primary aldosteronism among newly diagnosed and untreated hypertensive patients in a Swedish primary care area

OBJECTIVE

To evaluate the prevalence of primary aldosteronism (PA) in newly diagnosed and untreated hypertensive patients in primary care using the aldosterone/renin ratio (ARR), and to assess clinical and biochemical characteristics in patients with high and normal ARR.

DESIGN

Patient survey study.

SETTING AND SUBJECTS

A total of 200 consecutive patients with newly diagnosed and untreated hypertension from six primary health care centres in Sweden were included.

MAIN OUTCOME MEASURES

ARR was calculated from serum aldosterone and plasma renin concentrations. The cut-off level for ARR was 65. Patients with an increased ARR were considered for confirmatory testing with the fludrocortisone suppression test (FST), followed by adrenal computed tomographic radiology (CT) and adrenal venous sampling (AVS).

RESULTS

Of 200 patients, 36 patients had an ARR > 65. Of these 36 patients, 11 patients had an incomplete aldosterone inhibition during FST. Three patients were diagnosed with an aldosterone producing adenoma (APA) and eight with bilateral adrenal hyperplasia (BHA). Except for moderately lower level of P-K in patients with an ARR > 65 and in patients with PA, there were no biochemical or clinical differences found among hypertensive patients with PA compared with patients without PA.

CONCLUSION

Eleven of 200 evaluated patients (5.5%) were considered to have PA. The diagnosis of PA should therefore be considered in newly diagnosed hypertensive subjects and screening for the diagnosis is warranted.

Could androgens protect middle-aged women from cardiovascular events? A population-based study of Swedish women: The Women's Health in the Lund Area (WHILA) Study

OBJECTIVE

The aim of this analysis was to delineate perceived associations between androgens and cardiovascular events in perimenopausal women.

DESIGN

A cross-sectional, population-based study of 6440 perimenopausal women aged 50-59 years, living in Southern Sweden. In all, 461 (7.1%) women were premenopausal (PM), 3328 (51.7%) postmenopausal without hormone therapy (HT) (PM0) and 2651 (41.2%) postmenopausal with HT (PMT). For further comparisons, 104 women (1.6%) who reported cardiovascular disease (CVD) were studied in detail; 49 had had a myocardial infarction, 49 a stroke and six women both events. For each woman with CVD, two matched controls were selected (n=208).

RESULTS

In the matched controlled series, androstenedione levels were lower (p<0.005) in cases. Cases with hormone therapy had also lower testosterone levels than matched controls (p=0.05). In the total cohort, by using multiple logistic regression analyses, testosterone was positively associated with low density lipoprotein cholesterol (p<0.001) and high density lipoprotein cholesterol (HDL-C) (p<0.001) in all women, but negatively associated with levels of triglycerides in both the PM0 (p<0.001) and PMT (p<0.001) groups. Androstenedione levels were positively associated with HDL-C (p<0.05) and negatively with triglycerides (p<0.05) in the PM group.

CONCLUSION

Women with cardiovascular disease had lower serum androgen levels, particularly women using hormone replacement therapy, even when controlled for lipids and other potential risk factors.

Barriers to adherence to hypertension guidelines among GPs in southern Sweden: a survey

OBJECTIVE

To evaluate barriers to adherence to hypertension guidelines among publicly employed general practitioners (GPs).

DESIGN

Questionnaire-based survey distributed to GPs in 24 randomly selected primary care centres in the Region of Skåne in southern Sweden.

SUBJECTS

A total of 109 GPs received a self-administered questionnaire and 90 of them responded.

MAIN OUTCOME MEASURES

Use of risk assessment programmes. Reasons to postpone or abstain from pharmacological treatment for the management of hypertension.

RESULTS

Reported managing of high blood pressure (BP) varied. In all, 53% (95% CI 42-64%) of the GPs used risk assessment programmes and nine out of 10 acknowledged blood pressure target levels. Only one in 10 did not inform the patients about these levels. The range for immediate initiating pharmacological treatment was a systolic BP 140-220 (median 170) mmHg and diastolic BP 90-110 (median 100) mmHg. One-third (32%; 95% CI 22-42%) of the GPs postponed or abstained from pharmacological treatment of hypertension due to a patient's advanced age. No statistically significant associations were observed between GPs' gender, professional experience (i.e. in terms of specialist family medicine and by number of years in practice), and specific reasons to postpone or abstain from pharmacological treatment of hypertension.

CONCLUSION

These data suggest that GPs accept higher blood pressure levels than recommended in clinical guidelines. Old age of the patient seems to be an important barrier among GPs when considering pharmacological treatment for the management of hypertension.

Abstinence, occasional drinking and binge drinking in middle-aged women. The Women's Health in Lund Area (WHILA) Study

Although drinking patterns in women have received increased attention, few studies have focused on middle-aged women. Drinking patterns were investigated in a population sample of 513 Swedish women aged 50-59, and analysed in relation to social situation, and mental and physical health. The chi-square test was used to analyse differences in proportions. Variables showing significant differences were entered into a multivariate or multinomial logistic regression model. Abstainers and occasional drinkers had lower levels of education and more often regular medical control compared with weekly drinkers. Furthermore, abstainers more often had disability pension. Among women drinking alcohol, 56.6% affirmed binge drinking within the last year and 39.4% within the last month. Binge drinkers did not differ in terms of social situation, mental or physical health, compared with other drinkers. Drinking to relieve tension was affirmed by 7.2%. These women had more mental symptoms and less contact with friends compared with other drinkers; furthermore, they were more often binge drinkers. Binge drinking was common and health and social consequences of this drinking pattern in middle-aged women need to be further explored. Women drinking to relieve tension may need intervention for both drinking habits and mental health.

Stroke incidence and survival in the beginning of the 21st century in southern Sweden: comparisons with the late 20th century and projections into the future

BACKGROUND AND PURPOSE

We report trends of stroke incidence and survival up to year 2001/2002 in Lund-Orup, Sweden, and projections of future stroke incidence in Sweden.

METHODS

Lund Stroke Register, a prospective population-based study, included all first-ever stroke patients, between March 1, 2001 and February 28, 2002, in the Lund-Orup health care district. Institution-based studies for 1983 to 1985 and 1993 to 1995 were used for comparison. We calculated age-standardized incidence and Cox proportional hazards analysis of survival (stroke subtype, sex, age group, and study period in the analysis). Minimum follow-up was 46 months. Based on our register's stroke incidence and the official Swedish population projection, a projection for future stroke incidence on a national basis was calculated.

RESULTS

We included 456 patients with first-ever stroke in 2001/2002. The age-standardized incidence (to the European population) was 144 per 100 000 person-years (95%CI 130 to 158) in 2001/2002, 158 (95%CI 149 to 168) in 1993 to 1995, and 134 (95%CI 126 to 143) in 1983 to 1985. Cox proportional hazard analysis indicated decreased risk of death after stroke in 2001/2002 (hazard ratio 0.80; 95%CI 0.67 to 0.94) compared with 1993 to 1995. Up to year 2050, the annual number of new stroke patients in Sweden may increase by 59% based solely on demographic changes.

CONCLUSIONS

Despite possible underestimation of stroke incidence during the previous institution-based studies, the increased stroke incidence between 1983 to 1985 and 1993 to 1995 did not continue in 2001/2002. The long-term survival after stroke continues to improve. As the elderly population is growing in Sweden, stable incidence and increasing survival will result in a rapidly increasing prevalence of stroke patients in Sweden.

Medication report reduces number of medication errors when elderly patients are discharged from hospital

OBJECTIVE

To investigate whether a Medication Report can reduce the number of medication errors when elderly patients are discharged from hospital.

METHOD

We conducted a prospective intervention with retrospective controls on patients at three departments at Lund University Hospital, Sweden that where transferred to primary care. The intervention group, where patients received a Medication Report at discharge, was compared with a control group with patients of the same age, who were not given a Medication Report when discharged from the same ward one year earlier.

MAIN OUTCOME MEASURES

The main outcome measure was the number of medication errors when elderly patients were discharged from hospital.

RESULTS

Among 248 patients in the intervention group 79 (32%) had at least one medication error as compared with 118 (66%) among the 179 patients in the control group. In the intervention group 15% of the patients had errors that were considered to have moderate or high risk of clinical consequences compared with 32% in the control group. The differences were statistically significant (P<0.001).

CONCLUSION

Medication errors are common when elderly patients are discharged from hospital. The Medication Report is a simple tool that reduces the number of medication errors.

Insulin resistance and self-rated symptoms of depression in Swedish women with risk factors for diabetes: the Women's Health in the Lund Area study

Previous studies have suggested that depression increases the risk for diabetes and that this may be mediated through insulin resistance. The study aimed to analyze if self-rated symptoms of depression are related to insulin resistance among middle-aged and older Swedish women with features of the metabolic syndrome and being at risk for type 2 diabetes mellitus. We analyzed data from 1047 Swedish women aged 50 to 64 years without a history of diabetes and living in the southern part of Sweden. A variable self-rated symptoms of depression (SRSD) was defined by using the Gothenburg Quality of Life instrument. We estimated odds ratios (ORs) to determine whether or not SRSD was associated with the homeostasis model assessment of insulin resistance. The variable SRSD was not associated with insulin resistance. However, it was positively associated with waist-hip ratio (OR, 1.95; 95% confidence interval, 1.28-3.00) and negatively associated with physical exercise (OR, 1.29; 95% confidence interval, 0.99-1.68) after multivariate adjustment. In conclusion, lifestyle factors such as physical inactivity and abdominal obesity, but not insulin resistance, seem to be related to self-rated symptoms of depression in women with risk factors for diabetes mellitus. The relationship between insulin resistance and major depression needs to be further examined.

Health Hazards in Middle-Aged Women with Cardiovascular Disease: A Case-Control Study of Swedish Women. The Women's Health in the Lund Area (WHILA) Study

OBJECTIVE

To delineate the health profile in middle-aged women with cardiovascular disease (CVD).

METHODS

The Women's Health in the Lund Area (WHILA) project covered all women born 1935-1945 (n = 10,766) living in the Lund area; 6917 (64.2%) women completed a generic questionnaire and underwent physical and laboratory assessments. Of the 6917 women, 6416 were postmenopausal women, of whom 104 had CVD. For each woman with CVD, two controls were selected and matched for age, smoking habits, body mass index (BMI), waist/hip ratio (WHR), low-density lipoprotein cholesterol (LDL-C), high-density liproprotein cholesterol (HDL-C), diastolic blood pressure and hormonal status.

RESULTS

One hundred four women (1.6%) reported CVD. Forty-nine had a myocardial infarction (MI), 49 had a stroke, and 6 women had both events; 71.4% were postmenopausal, with never use of hormone therapy (HT) (PM0), and 28.6% were postmenopausal with ever use of HT (PMT). Compared with the control group, serum androstendione was lower (p = 0.004) in the case group, and menopausal estradiol (E(2)) values were less frequent (p = 0.037) in cases from the PM0 group. Among psychological and somatic symptoms, nervousness (p < 0.05), difficulty relaxing, crying easily, visual disturbance (p </= 0.01 for all), dizziness, difficulties in voiding urine, shortness of breath, breast tenderness, and constipation (p </= 0.001 for all) were more common among women with CVD. Women with CVD expressed less satisfaction with feeling healthy, body image, memory loss, irritability, and sexuality (p </= 0.05 for all). The case group had more problems with daily activities, more days spent in hospital during the previous 5 years, and more regular medical appointments with healthcare centers, more often had diabetes mellitus (DM) (p < 0.001 for all), and had experienced more falls in the previous year (p < 0.05). Urinary incontinence and decreased body weight were more common among cases (p </= 0.01 for both).

CONCLUSION

Several health hazards as well as somatic and psychological symptoms were more common in subjects with CVD, rendering them more susceptible to future disease.

Do sex hormones influence features of the metabolic syndrome in middle-aged women? A population-based study of Swedish women: the Women's Health in the Lund Area (WHILA) Study

OBJECTIVE

To outline perceived associations between various sex hormones and risk markers for cardiovascular disease in middle-aged women, with an emphasis on features of the metabolic syndrome (MS).

DESIGN

Cross-sectional analysis.

SETTING

Women's Health in the Lund Area Study.

PATIENT(S)

Population-based cohort.

INTERVENTION(S)

A generic questionnaire, physical examinations, and laboratory assessments were completed by 6,917 women aged 50-59 years living in the Lund area of southern Sweden. Women at or above defined cutoff limits for the MS were considered positively screened. After exclusion of women using hormone therapy (HT), 2,038 women with (MS+) and 2,054 women without features of the MS (MS-) were included. The ELISA techniques were used for the determination of serum androstendione (A), E2, T, sex hormone-binding globulin (SHBG), cortisol, insulin, and leptin levels. Serum lipids and lipoproteins were determined by conventional methods. Multiple linear regression analyses were performed, controlling for age, body mass index (BMI), and smoking habits.

MAIN OUTCOME MEASURE(S)

Features of the MS, sex steroids, cardiovascular risk markers.

RESULT(S)

In the MS+ group, a positive association was seen between A and systolic blood pressure. Estradiol was negatively associated with total cholesterol and diastolic blood pressure. The SHBG was negatively associated with triglycerides, blood glucose, and diastolic blood pressure and positively with high-density lipoprotein (HDL). In the MS- group, there were positive associations between A, blood glucose, and systolic blood pressure. Testosterone was positively associated with HDL. Estradiol was negatively associated with total cholesterol and positively with systolic blood pressure. The SHBG was positively associated with HDL and negatively with triglycerides and diastolic blood pressure. There were positive associations between cortisol, low-density lipoprotein (LDL) cholesterol, blood glucose, and systolic blood pressure and a negative association with triglycerides in both MS+ and MS- groups.

CONCLUSION(S)

Androstendione, E2, and T levels were associated with cardiovascular risk factors in middle-aged women. Effects by sex steroids on cardiovascular risk markers seem to be different in women with or without features of the MS.

Lund Stroke Register: hospitalization pattern and yield of different screening methods for first-ever stroke

OBJECTIVES

To explore case ascertainment, hospitalization, characteristics of both hospitalized and non-hospitalized patients in a population-based group of stroke patients.

MATERIALS AND METHODS

One-year screening in Lund-Orup district for first-ever strokes using multiple prospective and retrospective methods.

RESULTS

A total of 456 patients with first-ever stroke (n = 412 prospective screening methods, n = 17 primary care, n = 12 hospital registers, n = 10 death register, n = 2 autopsy registers, n = 3 other). Hospitalization proportion within 14 days was 84%. Patients sent home from emergency unit (n = 36) were often males (75%), had low 28-day case-fatality (0%), and less severe strokes (median National Institute of Health Stroke Scale score 2 vs 4 for all). Patients managed solely within primary care (n = 18) were elderly (median age 89 vs 77 years for all), resided in nursing homes (86% vs 8% for all) and had high 28-day-case-fatality (61%).

CONCLUSIONS

Hospitalization was lower than expected. Two main categories of patients were not hospitalized: elderly patients at nursing homes with high case-fatality and patients with mild stroke.

High blood pressure despite treatment: results from a cross-sectional primary healthcare-based study in southern Sweden

OBJECTIVE

To study degree of blood pressure (BP) control in primary healthcare (PHC) treated hypertensive patients in relation to sex, age, drug treatment, and concomitant diseases.

DESIGN

Random sample of patients with hypertension.

SETTING

Ten PHC centres in the Region of Skåne, Sweden.

SUBJECTS

All the 30- to 95-year-old patients with hypertension who during the period 12 September to 24 September 2004 attended their PHC (146 men and 229 women).

MAIN OUTCOME MEASURES

Achievement of BP control (< 140/90 mmHg) according to European guidelines.

RESULTS

Some 90% had been treated > 12 months, 40% had mono-therapy, 15% > or = 3 drugs. Use of diuretics was more common in women while use of ACE inhibitors and calcium channel blockers was common in men. Inadequate BP control was related to age; only 22% had BP < 140/90 mmHg, 38% had a BP > or = 160/100 mmHg. BP decline was inversely related to BP measured 12 months or more prior to the present follow-up (r = - 0.64, p < 0.001, for systolic and r = - 0.67, p < 0.001, for diastolic BP). The systolic or diastolic BP had in every fifth patient during treatment increased by > or = 10 mmHg. No association was found between average BP decline and prescribed number of drugs.

CONCLUSION

A minority of the patients had BP below the level (< 140/90 mmHg) recommended by European guidelines. This study illustrates the need for continued follow-up of defined groups of patients in order to improve quality of care.

High frequency of primary hyperaldosteronism among hypertensive patients from a primary care area in Sweden

OBJECTIVE

To search for primary hyperaldosteronism (PHA) among previously known hypertensive patients in primary care, using the aldosterone/renin ratio (ARR), and to evaluate clinical and biochemical characteristics in patients with high or normal ratio.

DESIGN

Patient survey study.

SETTING AND SUBJECTS

The study population was recruited by written invitation among hypertensive patients in two primary care areas in Sweden. A total of 200 patients met the criteria and were included in the study.

MAIN OUTCOME MEASURES

The ARR was calculated from serum aldosterone and plasma renin concentrations. The cut-off level for ARR was set to 100, as confirmed in 28 healthy subjects. Patients with increased ARR were considered for a confirmatory test, using the fludrocortisone suppression test.

RESULTS

Of 200 patients, 50 patients had ARR > 100; 26 patients were further evaluated by fludrocortisone suppression test. Seventeen of these patients had an incomplete aldosterone inhibition.

CONCLUSION

In total 17 of 200 evaluated patients (8.5%) had an incomplete suppression with fludrocortisone. This confirms previous reports on a high frequency of PHA. No significant biochemical or clinical differences were found among hypertensive patients with PHA compared with the whole sample.

Does the hormonal situation modify lipid effects by lifestyle factors in middle-aged women? Results from a population-based study of Swedish women: the women's health in the Lund area study

The aim of the study was to outline whether the influence by lifestyle factors on serum lipids was modified by the hormonal situation in middle-aged women. Six thousand nine hundred eight women, aged 50 to 59 years, participated in a health assessment program, including a serum lipid profile evaluation. The women were grouped according to their hormonal status into premenopausal (PM) (n = 492), postmenopausal without hormone therapy (HT) (PM0) (n = 3600), and postmenopausal with HT (PMT) (n = 2816). From the PMT group, we analyzed oral (n = 901) and transdermal HT (n = 351) regimens, containing norethisterone acetate and 17beta-estradiol. Serum lipids and lipoproteins were determined by conventional methods. Lifestyle factors included smoking and physical activity at leisure time and at work. Multivariate linear regression analysis controlling for age, education, and dietary habits showed that current smoking was positively associated with triglycerides in the PM, PM0, PMT, and oral HT groups. In the PM0, PMT, and oral HT groups, current smoking was positively associated with total cholesterol and low-density lipoprotein and negatively associated with high-density lipoprotein (HDL). Low physical activity at leisure time was positively associated with triglycerides in the PM and PMT groups and negatively associated with HDL in the PM0 and PMT groups. High physical activity at work was positively associated with triglycerides in the PMT group and with total cholesterol in the PM0 group, but negatively associated with HDL in the PMT and transdermal groups. Body mass index was positively associated with triglycerides and negatively with HDL in all the groups regardless of the hormonal situation. The serum lipid profile as influenced by lifestyle factors was modified by the hormonal situation. Compared with the postmenopausal women without HT use, the use of HT contributes to fewer "negative" effects by lifestyle factors on serum lipids.

Cadmium-induced effects on bone in a population-based study of women

High cadmium exposure is known to cause bone damage, but the association between low-level cadmium exposure and osteoporosis remains to be clarified. Using a population-based women's health survey in southern Sweden [Women's Health in the Lund Area (WHILA) ] with no known historical cadmium contamination, we investigated cadmium-related effects on bone in 820 women (53-64 years of age) . We measured cadmium in blood and urine and lead in blood, an array of markers of bone metabolism, and forearm bone mineral density (BMD) . Associations were evaluated in multiple linear regression analysis including information on the possible confounders or effect modifiers: weight, menopausal status, use of hormone replacement therapy, age at menarche, alcohol consumption, smoking history, and physical activity. Median urinary cadmium was 0.52 microg/L adjusted to density (0.67 microg/g creatinine) . After multivariate adjustment, BMD, parathyroid hormone, and urinary deoxypyridinoline (U-DPD) were adversely associated with concentrations of urinary cadmium (p < 0.05) in all subjects. These associations persisted in the group of never-smokers, which had the lowest cadmium exposure (mainly dietary) . For U-DPD, there was a significant interaction between cadmium and menopause (p = 0.022) . Our results suggest negative effects of low-level cadmium exposure on bone, possibly exerted via increased bone resorption, which seemed to be intensified after menopause. Based on the prevalence of osteoporosis and the low level of exposure, the observed effects, although slight, should be considered as early signals of potentially more adverse health effects. Key words: biochemical bone markers, bone mineral density, cadmium, lead, osteoporosis, women.

Effects of educational outreach visits on prescribing of benzodiazepines and antipsychotic drugs to elderly patients in primary health care in southern Sweden

BACKGROUND

Different methods have previously been tested to affect GPs' prescribing habits. Attention has been drawn to benzodiazepines and antipsychotic drugs that are associated with several adverse effects in the elderly.

OBJECTIVE

To evaluate if educational outreach visits to GP practices can affect the prescribing of benzodiazepines and antipsychotic drugs to the elderly and to evaluate the opinions of the participating GPs on such education.

METHODS

In the county of Skåne, Sweden, 41 GP practices were invited to participate in educational outreach visits. Fifteen GP practices accepted the invitation. Practices were randomised to active (8 practices, 23 physicians) and control group (7 practices, 31 physicians). After the educational outreach visits prescribing of benzodiazepines and antipsychotic drugs to patients 65 years or older were measured for 1 year. The control group participated in the education after the study period. The opinions of GPs on educational outreach visits were evaluated.

RESULTS

One year after the educational outreach visits there were significant decreases in the active group compared to control group in the prescribing of medium- and long-acting benzodiazepines and total benzodiazepines but not so for antipsychotic drugs.

CONCLUSIONS

Educational outreach visits can be effective in modifying GPs' prescribing habits. We have shown this to be so for prescribing of benzodiazepines to elderly patients in primary health care. Educational outreach visits are also very well appreciated by participating GPs.

Mental symptoms, psychotropic drug use and alcohol consumption in immigrated middle-aged women. The Women's Health in Lund Area (WHILA) Study

This study aims to analyse mental symptoms, psychotropic drug use and alcohol consumption, in immigrant women born in Finland, the other Nordic countries, Eastern Europe, Western Europe and countries outside Europe, compared with Swedish-born women, and furthermore, to study if age at immigration may have an influence. All women (n=10,766) aged 50-59 years and living in the Lund area of southern Sweden received a postal invitation to a health survey named the Women's Health in Lund Area; 64.2% (n=6917) participated. The participants answered a questionnaire including prevalence of mental symptoms during the past 3 months, regular use of psychotropic drugs, alcohol consumption during an average week, country of birth and age at immigration. Severe mental symptoms were more common among most immigrant groups compared with native Swedes, but the association to country of birth was not significant after adjustment for possible confounders. Regular use of hypnotics was more common among Nordic immigrants only (odds ration, OR = 4.4). East European and non-European immigrants less often were alcohol consumers (OR = 1.6 and OR = 3.8). Heavy drinking was more common among non-Nordic immigrants who immigrated at a younger age than at an older age. Furthermore, it was found that although East European and non-European immigrants had a higher educational level, they were less often gainfully employed compared with native Swedes. In middle-aged women, country of birth as well as age at immigration are important factors to consider in relation to alcohol consumption, but these factors may be of less importance considering mental health.

The hysterectomized woman

OBJECTIVE

To delineate the health profile of hysterectomized women and to assess whether women who have undergone hysterectomy have a different health profile even before surgery.

MATERIAL AND METHODS

The WHILA project covers all women (n = 10,766) aged 50-60, living in the Lund area and are based on questionnaires and personal interviews tied to laboratory examinations.

RESULTS

6917 women (64.2%) had complete questionnaires and laboratory tests, 800 were hysterectomized (11.6%). Logistic regression analysis revealed that hysterectomized women had more "dizziness" 1.40 (1.19-1.66), "nervous problems" 1.29 (1.07-1.56), "backache" 1.37 (1.16-1.62), "joint problems" 1.29 (1.09-1.52), "eye problem" 1.20 (1.02-1.42) and "headache" 1.17 (1.00-1.37). For both somatic (5.22 versus 4.49 mean value, p < 0.001) and psychological (4.19 versus 3.86 mean value, p = 0.002) symptoms, the number was higher in hysterectomized women. Logistic regression analysis revealed that among hysterectomized women university education was less common odds ratios 0.73 (95% confidence interval 0.58-0.91) as well as working full time 0.76 (0.62-0.93). A higher body weight at the age 25, 1.01 (1.001-1.02) as well as a weight gain of more than 5 kg during the last 5 years 1.27 (1.07-1.50), elevation of serum triglycerides 1.29 (1.16-1.44), high-density (HDL) 1.44 (1.14-1.80) and low-density lipoprotein (LDL) cholesterol 1.11 (1.02-1.21) as well as the bone density 1.08 (1.00-1.17). Hysterectomized women had a lower age at giving first birth (p < 0.001), shorter interval between menstrual periods (p < or = 0.001) and less frequent amenorrhic episodes (p < 0.05). The hysterectomized women used IUD to a lesser extent (p < 0.05) but used hormone therapy (HT) (p < 0.001) and utilized health care services (p < 0.001) more often.

CONCLUSIONS

Long after surgery, several somatic and psychological symptoms were still more common in hysterectomized women. A low frequency of amenorrhic episodes and lower age at giving first birth, concomitant with a higher body weight already at age 25 may imply that women who end up hysterectomized have a specific health profile long before as well as long after surgery.

Tubular and glomerular kidney effects in Swedish women with low environmental cadmium exposure

Cadmium is a well-known nephrotoxic agent in food and tobacco, but the exposure level that is critical for kidney effects in the general population is not defined. Within a population-based women's health survey in southern Sweden (Women's Health in the Lund Area, WHILA), we investigated cadmium exposure in relation to tubular and glomerular function, from 1999 through early 2000 in 820 women (71% participation rate) 53-64 years of age. Multiple linear regression showed cadmium in blood (median, 0.38 microg/L) and urine (0.52 microg/L; density adjusted = 0.67 microg/g creatinine) to be significantly associated with effects on renal tubules (as indicated by increased levels of human complex-forming protein and N-acetyl-beta-D-glucosaminidase in urine), after adjusting for age, body mass index, blood lead, diabetes, hypertension, and regular use of nephrotoxic drugs. The associations remained significant even at the low exposure in women who had never smoked. We also found associations with markers of glomerular effects: glomerular filtration rate and creatinine clearance. Significant effects were seen already at a mean urinary cadmium level of 0.6 microg/L (0.8 microg/g creatinine). Cadmium potentiated diabetes-induced effects on kidney. In conclusion, tubular renal effects occurred at lower cadmium levels than previously demonstrated, and more important, glomerular effects were also observed. Although the effects were small, they may represent early signs of adverse effects, affecting large segments of the population. Subjects with diabetes seem to be at increased risk.

Lower urinary tract symptoms in middle-aged women - prevalence and attitude towards mild urinary incontinence. A community-based population study

OBJECTIVE

To investigate the prevalence and perceived bother of lower urinary tract symptoms (LUTS) in middle-aged women with and without self-reported urinary incontinence.

PATIENTS AND METHODS

In the Women's Health In the Lund Area study (WHILA 1995--2000), 32% of the participating 6,917 women, 50--59 years, reported urinary incontinence defined as involuntary urinary leakage causing a social and/or hygienic problem. Out of these, 1,500 women with (INCONT) and 1,500 without incontinence (CONT) received the Bristol Female lower urinary tract symptoms (LUTS) questionnaire in January 2001.

RESULTS

A total of 2,682 (89%) women were included. Most common LUTS in the INCONT and CONT groups, respectively, were any urinary leakage (93.8% vs. 53.3%, P<0.001), urgency (86.2% vs. 62.5%, P<0.001), stress incontinence (85.1% vs. 41%, P<0.001), and frequency (86.9% vs. 35.6%, P<0.001). The two groups differed significantly in the degree of reported bother by infrequently occurring stress and urge incontinence. Urinary leakage more than once a week was reported as bothersome by 97.5%. The prevalence of self-reported urinary incontinence increased from 32% to estimated 66% if the demand for social and/or hygienic bother was omitted from the definition. Conclusion. The prevalence of self-reported urinary incontinence increased from 32% to estimated 66%, if the demand for social and/or hygienic bother was omitted from the definition. LUTS other than incontinence are common in middle-aged women, with a significantly higher prevalence in women with self-reported incontinence than in continent women. The attitude towards stress- and urge incontinence varied widely when the symptoms occurred infrequently. Urinary leakage more than once a week was considered bothersome by 97.5%.

Women living alone have an increased risk to develop diabetes, which is explained mainly by lifestyle factors

OBJECTIVE

The purpose of this study was to assess the role of household conditions for the progression to diabetes in women with impaired glucose tolerance (IGT).

RESEARCH DESIGN AND METHODS

A total of 461 women, aged 50-64 years, with IGT defined by an oral glucose tolerance test, had baseline advice on physical exercise, diet, smoking, and alcohol habits. Physical examination, blood tests, and questionnaires were completed at baseline and after 2.5 years. Household status was categorized into living alone or with a partner, other adults, or children.

RESULTS

Women living alone had a 2.68-fold increased risk (95% CI 1.02-7.05) of developing diabetes after adjustments for biological risk factors. Further stepwise adjustments for education, occupation, subjective mental health, exercise, diet, and alcohol showed remaining significant odds ratios (ORs), decreasing from 3.26 (1.19-8.96) to 3.03 (1.02-8.99). However, when smoking status was added, the OR became nonsignificant, 2.07 (0.62-6.88). More women who lived alone smoked and did not reduce their daily cigarette consumption compared with women in other household conditions. At follow-up, women living alone had reduced their alcohol consumption and were more often abstainers and fewer had healthy dietary habits or had improved their diet. Physical exercise did not differ among the groups. Separate analyses of any other household status did not show any excess risk for development of diabetes.

CONCLUSIONS

Women living alone had a higher risk to progress from IGT to diabetes, mostly explained by smoking, alcohol, and dietary habits. Household conditions should be accounted for when assessing future risk for diabetes.

Prevalence of urinary incontinence in relation to self-reported depression, intake of serotonergic antidepressants, and hormone therapy in middle-aged women: a report from the Women's Health in the Lund Area study

OBJECTIVE

To study a perceived relationship of urinary incontinence with self-reported depression among middle-aged women, and to outline whether hormone therapy, selective serotonin reuptake inhibitors, or serotonin norepinephrine reuptake inhibitors influence the prevalence of urinary incontinence.

DESIGN

A population-based cross-sectional study of 6,642 women from the Lund area, Sweden, aged 50 to 64 years, who answered questions on urinary incontinence. We obtained information on urinary incontinence, self-reported depression, and medication by questionnaire and personal interviews between December 1995 and February 2000.

RESULTS

Thirty-one percent of the women reported urinary incontinence of various severities and 52% reported episodes of depression. Urinary incontinence and self-reported depression were significantly associated [odds ratio (OR) 1.37; 95% CI, 1.23-1.52; P < 0.001]. Among women with self-reported depression, the use of serotonergic antidepressants was statistically associated with urinary incontinence (OR 1.78; 95% CI, 1.33-2.38; P < 0.001). Among women not reporting depression, hormone therapy was significantly associated with urinary incontinence (OR 1.45; 95% CI, 1.22-1.70; P < 0.001). After adjustment for other potential risk factors, serotonergic antidepressants and hormone therapy use were no longer associated with urinary incontinence in women with self-reported depression. However, among women not reporting depression, hormone therapy was still significantly more common in women with urinary incontinence.

CONCLUSIONS

Urinary incontinence and self-reported depression seemed to be associated in middle-aged women. Use of serotonergic antidepressants or hormone therapy does not seem to be associated with a lower prevalence of urinary incontinence.

Cardiovascular risk factors in middle-aged women and the association with use of hormone therapy: results from a population-based study of Swedish women. The Women's Health in the Lund Area (WHILA) Study

OBJECTIVE

Cardiovascular diseases in women are multifactorial. Women carry different risk factors compared to men and these specific risk factors need to be delineated, particularly in relation to the hormonal situation, and effects of diet and lifestyle.

METHODS

Out of the total cohort of 10,766 women born 1935-1945 living in the Lund area of southern Sweden, 6917 women completed a generic questionnaire and underwent a physical and laboratory assessment. According to hormonal status, 492 women were premenopausal (PM), 3600 were postmenopausal without hormone therapy (HT) (PM0) and 2816 were postmenopausal with ever-use of HT (PMT). Major cardiovascular risk factors as well as level of education, diet, and degree of physical activity were assessed in relation to hormonal status.

RESULTS

Compared to the PM0 group, the women in the PMT group had a higher level of education, more often worked full time, more often had sedentary work and lived a more regular life. They also had a lower rate of cigarette consumption, lower waist-to-hip ratio and lower body mass index than women in the PM0 group. The PMT group had lower levels of serum total cholesterol, low density lipoprotein cholesterol, high density lipoprotein cholesterol and triglycerides than the PM0 group and also had lower systolic and diastolic blood pressures, a lower prevalence of type II diabetes mellitus, of deep venous thrombosis and of coronary artery disease. Low-risk factors for cardiovascular disease and high level of education were still associated with HT, after adjustment by multiple logistic regression. Major risk factors for coronary heart disease were similar between the PM and the PMT groups.

CONCLUSION

Use of HT is accompanied by a lower risk profile for cardiovascular disease and also by several factors indicating a healthier lifestyle.

Does hormone therapy increase allergic reactions and upper gastrointestinal problems? Results from a population-based study of Swedish woman. The women's health in the Lund area (WHILA) study

OBJECTIVES

To delineate the use of various drugs particularly pertaining to allergy and upper gastrointestinal problems in relation to hormone status in middle aged women.

METHODS

An analysis from a population-based study on women born between 1935 and 1945 and lived in the Lund area southern Sweden. Of 10,766 women, 6,917 provided complete data sets; in turn 5,673 were assessed for the use of medication in this study. Among the cohort, 9% of women were premenopausal (PM), 54% were postmenopausal without hormone replacement therapy (PM0) and 37% were current hormone replacement therapy users (PMT).

RESULTS

There were 7 (1.3%) women in PM, 11 (0.4%) in PM0 and 21 (1.0%) in PMT group who used loratadine regularly. There was a significant difference between the PM and PM0 groups and also between the PM0 and PMT groups in the use of loratadine (P < 0.05 ). Among 21 loratadine users in PMT group 4 (19%) used transdermal patches and 17 (81%) used oral HRT. The result for omeprazole use was as follows: 4 (0.8%) of PM group, 39 (1.3%) of PM0 group and 42 (2.0%) of PMT group. The use of omeprazole was significantly higher in the PMT group than in the PM (P = 0.05 ) and PM0 group (P < 0.05 ). There was no relation between the use of omeprazole and smoking or alcohol consumption.

CONCLUSIONS

Use of hormone replacement therapy seems to be related to a higher frequency of omeprazole and loratadine use, which implies that hormone replacement therapy, may be associated with more upper gastrointestinal symptoms as well as allergy.

Well-being and occupational roles among middle-aged women

One purpose of the present study is to explore the stability of the pattern of health/work and sickness absence among middle-aged women over a period of three years. This study tested two hypotheses: (a) that enduringly healthy working women would perceive more valued occupational roles and higher well-being than long-term sick-listed women; (b) that high levels of well-being at baseline would predict enduring health and occupational role value at a 3-year follow-up. Middle-aged women (n = 208) answered a postal survey with the Role checklist, a well-being scale and questions about work and sickness situation. The results showed that there was a considerable variability in the pattern of health/work and sickness absence. The variability was greatest among the women who were long-term sick-listed at baseline, and the internal drop out was great among them. The results showed that the enduringly healthy women experienced a more valued worker role and higher well-being than the long-term sick-listed women. Furthermore, high levels of well-being concerning health and work predicted enduring health in the studied sample, and high well-being concerning work was predictive of a valued worker role. Interventions that enable women to develop valuable worker and leisure roles, as well as harmony between different roles, may be important constituents of health promotion/rehabilitation programmes.

Combined hormone therapy in postmenopausal women with features of metabolic syndrome. Results from a population-based study of Swedish women: Women’s Health in the Lund Area study

OBJECTIVE

To delineate the influence of hormone therapy (HT) on features of metabolic syndrome with special reference to the composition and mode of administration of three specific HT regimens, all containing estradiol (E2) + norethisterone.

DESIGN

The Women's Health in the Lund Area project screened all women (n = 10,766), born between 1935 and 1945. Complete data were obtained from 6,917 women. Those at or above defined cutoff limits were considered positively screened (n = 3,593) for metabolic syndrome. All of them were invited to undergo an oral glucose tolerance test; 2,923 women accepted. After excluding 200 women with impaired fasting glucose, 2,723 women were included in the present analysis. Serum lipids were determined by conventional standard methods at the department of clinical chemistry of Lund University Hospital.

RESULTS

According to World Health Organization criteria, 2,123 women had normal glucose tolerance and 600 women had impaired glucose tolerance (IGT). IGT was less common (P = 0.001) among users of a transdermal patch [CYC-TRANS; E2 50 microg + norethisterone acetate (NETA) 250microg] compared with the two-combined oral regimen [CON-O (continuous oral E2 2 mg + NETA 1 mg) + CYC-O (sequential oral E2 2 mg + NETA 1 mg)]. Furthermore, IGT was more common among CON-O users when compared with either the CYC-O + CYC-TRANS group (P = 0.002) or the CYC-TRANS only group (P = 0.001). There were no significant differences between CYC-O versus CYC-TRANS or CON-O. Serum levels of total cholesterol were higher in the CYC-TRANS group than in the combined CON-O + CYC-O group (P < 0.05); they also were higher (P = 0.05) when comparing the CYC-O + CYC-TRANS versus CON-O as well as higher in CYC-TRANS versus CON-O (P < 0.05). Serum high-density lipoprotein cholesterol levels were higher in the CYC-O (P = 0.001), CYC-TRANS (P < 0.05), and the CYC-O + CYC-TRANS (P = 0.001) groups when compared with the CON-O users. There were no differences in the mean age, blood pressure (systolic and diastolic), body mass index, waste-hip ratio, or the rate of cigarette and alcohol consumption between the different hormone regimens.

CONCLUSION

The risk of having a pathological glucose load was lower in transdermal versus oral users of HT. Transdermal HT could be regarded as first-line treatment in women at risk of developing diabetes.

Overactive bladder: prevalence, risk factors and relation to stress incontinence in middle-aged women

OBJECTIVE

To investigate the prevalence of and factors associated with overactive bladder in middle-aged women.

DESIGN

Cross sectional population-based study.

SETTING

Southern Sweden and the Women's Health in the Lund Area study (WHILA 1995-2000) where 6917 (64% of the invited) women, 50-59 years old in 1995, participated.

POPULATION

From the WHILA study, 1500 women reporting troublesome urinary incontinence (INCONT-1) and 1500 without incontinence (CONT-1) were selected by computerised randomisation and received the Bristol Female Lower Urinary Tract Symptoms (BFLUTS) questionnaire in January 2001.

METHODS

Overactive bladder was defined in two versions using the ICS definition of 2002 as either urgency alone (OAB-1) or urgency combined with frequency more than eight times per day and/or nocturia twice or more per night (OAB-2). Risk factors were analysed by multiple logistic regression analyses.

MAIN OUTCOME MEASURES

Prevalence figures and odds ratios with corresponding 95% confidence intervals.

RESULTS

The prevalence of OAB-1 was 46.9% in the INCONT-1 and 16.7% in the CONT-1 group, and that of OAB-2 was 21.6% and 8.1%, respectively. Most urgency occurred in combination with stress incontinence (i.e. as mixed incontinence). The overlap between stress and urge symptoms increased with the frequency of stress incontinence episodes (P < 0.001). Metabolic risk factors were body mass index (BMI) >/= 30 for OAB-1, OAB-2 and stress incontinence, positive metabolic screening for OAB-1, family history of diabetes for OAB-2 and elevation of BMI >/= 25% since the age of 25 for stress incontinence. Stress incontinence was associated with the current use of hormonal replacement therapy.

CONCLUSIONS

Overactive bladder and stress incontinence are intimately associated with each other. Both OAB and stress incontinence are associated with abnormal metabolic factors, mainly increased BMI.

Serum lipids and lipoproteins in relation to endogenous and exogenous female sex steroids and age

BACKGROUND

Different studies have presented conflicting results concerning the effect of menopause on lipid levels.

AIMS

To describe the serum lipid profile and the prevalence of hyperlipidemia in women aged 50-60 and the perceived relation to endogenous and exogenous hormones and age.

METHODS

Out of a total population of 10,766 women aged 50-59 years, 6908 (64%) participated in a health assessment program, including a lipid profile evaluation. The women were grouped according to hormonal status into pre-menopausal (PM), post-menopausal without hormone replacement therapy (PM0) (HRT) and post-menopausal with hormone replacement therapy (PMT). Age groups used were 50-54, 55-59 and >60 years.

RESULTS

Serum cholesterol and triglycerides increased significantly by age in PM0 (P < 0.0001) and triglycerides also in PMT (P < 0.0001). Serum high-density lipoprotein cholesterol (HDL) levels decreased significantly by age in PMT (P = 0.002) and low-density lipoprotein cholesterol (LDL) increased in PM0 (P < 0.0001) and PMT (P = 0.007). The co-prevalence of levels of cholesterol >7 and triglycerides >2 mmol/l decreased by age in PM, but increased by age in PM0 and PMT. The prevalence of high-risk lipid levels and the prevalence of coexisting additional two metabolic risk factors were higher in the PM0 compared to the PMT group. The prevalence of serum triglycerides >1.5 and serum cholesterol >5 mmol/l were increasing by age in each of the hormonal groups.

CONCLUSIONS

These data suggest that loss of endogenous sex steroids contribute substantially to an increased atherogenic lipid profile. Hormone replacement therapy may partly reverse these differences.

A prospective study of different types of hormone replacement therapy use and the risk of subsequent breast cancer: the women's health in the Lund area (WHILA) study (Sweden)

OBJECTIVES

Reports suggest that combined estrogen plus progestin hormone replacement therapy (HRT) confers a higher breast cancer risk than estrogen alone. We aimed to establish whether breast cancer risk depends on the type of HRT formula.

METHODS

The cohort consisted of 6586 women, aged 50-64 years, from the Lund area, Sweden, with no reported breast cancer upon inclusion. We obtained information such as HRT use through a questionnaire between December 1995 and February 2000. New breast cancers were identified through the South Swedish tumor registry.

RESULTS

Between inclusion and December 2001, 101 women developed breast cancer. Only ever use of the continuous combined estrogen plus progestin (CCEP) formula differed between cases and controls (45.2% versus 23.5%; p = 0.000001). Compared with never users, exclusive CCEP users had the highest age-adjusted hazard ratio HR 3.3 (95% CI: 1.9-5.6; p < 0.001), followed by users of CCEP in addition to other HRT formulas HR 2.8 (95% CI: 1.4-5.5; p = 0.003). No significant increase was seen in women who exclusively used other HRT formulas.

CONCLUSION

Women who used CCEP had over three times the risk of developing breast cancer compared with never users and twice the risk compared with users of other types of HRT.

Alcohol consumption among middle-aged women: a population-based study of Swedish women. The Women's Health in Lund Area (WHILA) study

From a total population of 10,766 Swedish 50- to 59-year-old women, 6,917 (64.2%) participated in the Women's Health in Lund Area (WHILA) study, and among them 6,623 (95.7%) answered the questions on alcohol consumption. One out of 4 women (26.0%) consumed no alcohol in an ordinary week (non-drinkers), 57.4% consumed not more than 83 g alcohol, 12.5% consumed 84-167 g and 4.2% consumed 168 g or more. The weekly drinkers had a median consumption of 40.0 g alcohol (range 2.5-1,036.0) and the main sort of alcohol was wine. Comparing the four drinking groups, most differences occurred between the non-drinking and the weekly drinking women. The non-drinkers had lower socio-demographic status, poorer health and more symptoms, especially physical symptoms. In a multivariate logistic regression analysis, most associations between non-drinking and lower socio-demographic status remained.

Menopause-related symptoms: What are the background factors? A prospective population-based cohort study of Swedish women (The Women's Health in Lund Area study)

OBJECTIVE

The purpose of this study was to analyze the influence of sociodemographic characteristics and environmental factors on self-reported menopause-related symptoms among middle-aged Swedish women.

STUDY DESIGN

Women who were born in the years 1935 to 1945 and who were living in the Lund area of southern Sweden were investigated. Each woman completed a generic questionnaire and underwent a personal interview that pertained to sociodemographic characteristics, lifestyle, and current health-related problems. With these background factors, the frequency and intensity of hot flushes and vaginal dryness were determined; risk factor analysis was evaluated with the use of the multiple regression models.

RESULTS

There were 6917 participants, with a response rate of 64%. A lower risk for hot flushes was related to older age, high education, and vigorous physical exercise. The major risk factors for vasomotor complaints were current weight gain, part-time employment, oophorectomy, unhealthy lifestyle, and concomitant health problems. Light smoking, late age of menopause, higher education, and excessive weight reduced the risk of vaginal dryness. However, older age, marriage, and chronic diseases negatively affected vaginal complaints. The background factors had less impact on symptoms in women who used hormone replacement therapy.

CONCLUSION

Sociodemographic characteristics, lifestyle, and concomitant health problems appear to be important modifiable determinants for menopause-related symptoms.

Urethral pressure changes in response to squeeze: a population-based study in healthy and incontinent 53- to 63-year-old women

OBJECTIVE

The purpose of this study was to investigate the urethral pressure pattern during short squeezes in incontinent and healthy women before and after pelvic floor exercise and to correlate the findings with vaginal measurements.

STUDY DESIGN

Sixty women with urinary incontinence and 28 healthy control subjects all aged 53 to 63 years were subject to urethral pressure measurements and vaginal palpation, pressure and surface electromyography measurements. Measurements were repeated after 4 months of pelvic floor exercise in the incontinent group.

RESULTS

The appearance of the urethral pressure curve during a squeeze on a semiquantitative scale from 0 to 4, in the healthy group, was 2.2+/-0.3 and, in the incontinent group, was 1.5+/-0.2 (P<.0 5), rising to 2.2+/-0.2 after pelvic floor exercise (P<.01). The semiquantitative grading correlated with vaginal measurements.

CONCLUSION

The increase of the urethral pressure in response to short squeeze is reduced significantly in incontinent women compared with healthy women of the same age and parity. A normalization was seen after pelvic floor exercise in the incontinent group.

Does blood pressure differ between users and non-users of hormone replacement therapy? The Women's Health In the Lund Area (WHILA) Study

OBJECTIVE

To examine whether blood pressure over 24 h differed between postmenopausal women receiving and not receiving hormone replacement therapy.

METHODS

One group of hormone replacement postmenopausal women (n = 32) and one group of non-hormone replacement (n = 32) postmenopausal women underwent non-invasive 24-h ambulatory blood pressure monitoring. They were randomly selected among the 2000 firstly screened women in an ongoing project in Lund, Sweden. The study was designed to detect a difference of 5 mmHg in diastolic blood pressure over 24 h with a power of 80% and 5% significance (two-tailed test).

RESULTS

The hormone replacement women had a mean (SD) office blood pressure of 128/76 (12/8) mmHg and the non-hormone replacement 126/78 (16/8) mmHg. Mean ambulatory blood pressure over 24 h, day and night, in the hormone replacement group was 121/72 (11/7), 126/76 (12/8), 111/64 (11/7) mmHg. The corresponding values in the non-hormone replacement group were 118/72 (12/7), 124/77 (12/7), and 107/64 (13/7) (p > 0.40 for diastolic blood pressure and p > 0.20 for systolic blood pressure). Mean heart rate over 24 h was 71 (7) and 73 (8) beats/min in the hormone and non-hormone replacement groups, respectively.

CONCLUSION

There was no difference in blood pressure or heart rate between the hormone replacement and non-hormone replacement postmenopausal women, either over 24 h or during the day or night. Hormone replacement in postmenopausal women seems not to have an influence on blood pressure, but of course we are aware that this is a cross-sectional study, which has its limitations.

The influence of calcium and magnesium in drinking water and diet on cardiovascular risk factors in individuals living in hard and soft water areas with differences in cardiovascular mortality

BACKGROUND

The role of water hardness as a risk factor for cardiovascular disease has been widely investigated and evaluated as regards regional differences in cardiovascular disease. This study was performed to evaluate the relation between calcium and magnesium in drinking water and diet and risk factors for cardiovascular disease in individuals living in hard and soft water areas with considerable differences in cardiovascular mortality.

METHODS

A random sample of 207 individuals living in two municipalities characterised by differences in cardiovascular mortality and water hardness was invited for an examination including a questionnaire about health, social and living conditions and diet. Intake of magnesium and calcium was calculated from the diet questionnaire with special consideration to the use of local water. Household water samples were delivered by each individual and were analysed for magnesium and calcium.

RESULTS

In the total sample, there were positive correlations between the calcium content in household water and systolic blood pressure (SBP) and negative correlations with s-cholesterol and s-LDL-cholesterol. No correlation was seen with magnesium content in household water to any of the risk factors. Calcium content in diet showed no correlation to cardiovascular risk factors. Magnesium in diet was positively correlated to diastolic blood pressure (DBP). In regression analyses controlled for age and sex 18.5% of the variation in SBP was explained by the variation in BMI, HbA1c and calcium content in water. Some 27.9% of the variation in s-cholesterol could be explained by the variation in s-triglycerides (TG), and calcium content in water.

CONCLUSIONS

This study of individuals living in soft and hard water areas showed significant correlations between the content of calcium in water and major cardiovascular risk factors. This was not found for magnesium in water or calcium or magnesium in diet. Regression analyses indicated that calcium content in water could be a factor in the complexity of relationships and importance of cardiovascular risk factors. From these results it is not possible to conclude any definite causal relation and further research is needed.

Are current rapid detection tests for Group A Streptococci sensitive enough? Evaluation of 2 commercial kits

A new, 1-step, enzyme-linked immunoassay kit for detection of Group A Streptococci (GAS) in throat samples (QuickVue In-Line One-Step Strep A Test; Quidel Corporation, San Diego, CA) was evaluated for use in a study comprising 536 patients in 8 primary healthcare centres. Compared to conventional culture at the clinical microbiology laboratory, the sensitivity achieved was 73.9% and the specificity 86.8%; these figures were not affected to any major extent by broth enrichment of samples before culturing or following PCR testing of the cysteine proteinase gene for independent diagnosis of GAS. It was also found that most samples containing low numbers of GAS were missed by the rapid test. We therefore evaluated the kit in use in our area (TestPack Plus Strep A Test; Abbott Laboratories, Chicago, IL) in a separate study of 615 patients. Somewhat increased sensitivity (82.8%) and specificity (96.1%) were obtained. As current antigen tests depend on subjective judgement of test outcome, improvements in test design or provision of more detailed instructions may be desirable in order to achieve optimal results.

Biological factors are more important than socio-demographic and psychosocial conditions in relation to hypertension in middle-aged women. The Women's Health in the Lund Area (WHILA) study

The objective of this cross-sectional study was to analyse the influence of biological, socio-demographic, and psychosocial factors and current perimenopausal status on hypertension in a geographically defined population of 10,766 women aged 50-59 years, of whom 6901 attended the study. Altogether 1887 (27.3%) women had hypertension: 996 with drug treatment and 891 diagnosed at the study. In a logistic multiple regression analysis (controlled for age), drug treatment of hyperlipidaemia, family history of hypertension, waist-to-hip ratio, body mass index (BMI) increase > or = 25% during the past 25 years, S-triglycerides, S-cholesterol, education up to comprehensive school, and to upper secondary school, consumption of 84-167 g of alcohol/week, and of > or = 168 g of alcohol/week, were positively associated with hypertension, while high-density lipoprotein cholesterol and current smoking were negatively associated. A significant interaction was found between current smoking and BMI increase, with a lower risk for hypertension among smokers who had increased their BMI > or = 25%. No interaction was found between smoking and alcohol. In conclusion, hypertension was predominantly associated with biological factors, and with heredity for hypertension. Of the socio-demographic factors, only low level of education was associated with hypertension in a comprehensive analysis. Perimenopausal status showed no relation to occurrence of hypertension in the multiple regression analysis. The risk for hypertension increased with moderate and high consumption of alcohol, whereas smoking showed a decreased risk. Among women with weight gain, present smoking remained protective. Although both smoking and hypertension are established risk factors for cardiovascular disease, they seem not to be directly linked, indicating a complexity of mechanisms.

Socio-demographic and psychosocial factors are associated with features of the metabolic syndrome. The Women's Health in the Lund Area (WHILA) study

AIM

The aim was to analyse any associations between socio-demographic and psychosocial factors and different features of the metabolic syndrome in a geographically well-defined population of middle-aged women.

METHODS

A population of 10 766 Caucasian women aged 50-59 years was investigated regarding biological and socio-demographic conditions, physical activity, dietary habits, aspects of quality of life, and subjective physical and mental symptoms. The screening instrument was used to discriminate subjects as positive or negative on one or more of a total of eight variables considered to be linked to the metabolic syndrome. The cut-off values for positive screening were non-fasting capillary blood glucose >/= 8.0 mmol/l and serum triglycerides >/= 2.3 mmo/l, BMI >/= 30 kg/m2, WHR >/= 0.90, blood pressure >/= 160 and/or 95 mmHg, a family history of diabetes, and pharmacological treatment for hypertension or hyperlipidaemia.

RESULTS

Altogether 6805 women (63.2%) participated: 3535 with positive and 3270 with negative screening. Multiple logistic regression analyses showed that comprehensive (OR 1.62, 95% CI 1.41-1.87) and upper secondary (1.40, 1.24-1.57) school, low physical quality of life (1.41, 1.23-1.61) and high sum of subjective physical symptoms (1.06, 1.04-1.08) were positively associated with one or more features of the metabolic syndrome, while high leisure-time exercise and healthy diet (0.84, 0.71-0.99), and low (</= 83 g/week) (0.71, 0.63-0.81) and moderate (84-167 g/week) (0.78, 0.65-0.93) alcohol consumption were negatively associated.

CONCLUSIONS

To identify middle-aged women with cardiovascular risk factors and high risk for diabetes, it is important to consider not only biological, but also socio-demographic and psychosocial conditions.

Urodynamic characterisation of women with naive urinary incontinence: a population-based study in subjectively incontinent and healthy 53-63 years old women

OBJECTIVES

To compare the urodynamic characteristics in a group of middle-aged women with untreated urinary incontinence with the findings in a control group of healthy women.

METHODS

Sixty women with mild-to-moderate urinary incontinence and 28 symptom-free women, 53-63 years old, were randomly chosen out of a large health questionnaire study. All were investigated with a detailed history, gynaecological examination, urinalysis, frequency-volume chart, and urodynamics including cystometry and pressure-flow analysis.

RESULTS

The maximum urinary flow was significantly higher in the incontinent group of women, 22+/-1ml/s, than in the healthy controls, 16+/-2ml/s (p<0.01). The acceleration of flow, with a theoretical maximum of 0 degrees, was also significantly faster in the incontinent, 20 degrees, than in the healthy women, 32 degrees (p=0.01). In the five women with urge incontinence only, maximum urinary flow was 26+/-2.4ml/s and the flow acceleration 7 degrees. In incontinent women, both a lower opening pressure and detrusor pressure at maximum flow were seen compared with the healthy women, though the difference did not reach statistical significance. The incontinent and the healthy women did not differ regarding bladder volumes or pressures during filling.

CONCLUSION

The findings of this study indicate the presence of an increased efficiency of the urethral opening mechanism in incontinent women compared to normal, irrespective of the type(s) of symptoms present.

A screening procedure detecting high-yield candidates for OGTT. The Women's Health in the Lund Area (WHILA) study: a population based study of middle-aged Swedish women

The objective was to evaluate a screening procedure for detecting high-yield candidates for an OGTT, in a population of middle-aged Swedish women. A two-step screening procedure was performed in 6917 subjects. Women with a positive screening outcome, i.e. increased non-fasting capillary blood glucose, serum triglycerides, BMI, WHR, blood pressure or a family history of diabetes, pharmacological treatment of hypertension or hyperlipidaemia at the primary screening underwent a 75-g OGTT. A control group of women with negative screening outcome (n = 221) also underwent an OGTT. In 2923 women with positive screening outcome, 517 (17.7%) had NFG/IGT (normal fasting venous blood glucose <5.6 mmol/l and 2h-glucose 6.7-9.9 mmol/l), 109 (3.7%) IFG/IGT (fasting 5.6-6.0 and 2h 6.7-9.9 mmol/l) and 223 (7.6%) diabetes (fasting > or = 6.1 or 2h > or = 10.0 mmol/l). These figures were three, five and four times higher, respectively, than in the control group with negative screening outcome (p < 0.001 for all); no differences were found for IFG/NGT (fasting 5.6-6.0 and normal 2h < 6.7 mmol/l) (4.6% vs. 7.2%). For predicting impaired glucose metabolism (IFG/NGT, NFG/IGT, IFG/IGT, diabetes), the screening instrument showed an estimated sensitivity of 70%, specificity of 55%, positive predictive value of 34% and negative predictive value of 85%, based on findings in the control sample. The odds ratio for NFG/IGT increased with the numbers of risk factors from 2.8 to 7.7, for IFG/ IGT from 5.7 to 55.0 and for diabetes from 2.5 to 18.1. High B-glucose, WHR and BMI were the three most important factors associated with an increased risk for NFG/IGT, IFG/IGT and diabetes. In subjects with IFG/NGT, none of the screening variables was associated with an increased risk. In summary, the results show a population screening method focused on features of the metabolic syndrome that discloses high-yield candidates for OGTT. A high prevalence of unknown impaired glucose metabolism was found in middle-aged women with a positive screening profile.

Effects of a lipid lowering fibrate and hormone replacement therapy on serum lipids and lipoproteins in overweight postmenopausal women with elevated triglycerides

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in women after menopause. In essence major risk factors for CVD are similar in women as for men inclusive of serum lipid perturbations. The effects of estrogens and hormone replacement therapy on lipid metabolism is widely discussed and warrant further evaluation especially when combined with other lipid lowering drugs.

STUDY DESIGN

Postmenopausal women were studied by an open randomised study during 9 months. Subjects were recruited from outpatient clinics in a rural area of Sweden. Major inclusive criteria comprised body mass index (BMI) >28, serum triglycerides >1.5 mmol/l. Participants were at least 12 months postmenopause with a concomitant serum Follicle Stimulating Hormone (FSH) above 28 IU/l. After inclusion in the study patients were instructed to adhere to a low-fat and caloric diet for 3 months and after this period randomised into two groups of intervention; a lipidlowering fibrate (LLF) group and one hormone replacement therapy group (HRT). The LLF group was given gemfibrozil 600 mg orally twice daily and HRT group received 2 mg oestradiol in combination with 1 mg norethisterone acetate as a continuous combined therapy once daily. After 3 months, the LLF group added the HRT regimen and patients in the HRT group added gemfibrozil. Hence, all participants received the regimens combined for the last 6 months of the study.

RESULTS

Serum s-cholesterol was markedly decreased in both groups during the first 3 months of single treatment (P<0.0001). This decrease reflected a reduction especially of calculated low density lipoprotein (LDL) s-cholesterol (P<0.001). High density lipoprotein (HDL) s-cholesterol was reduced in the HRT group (P<0.005) but increased (P<0.004) in the LLF group. Triglycerides were also decreased by both treatments but more marked in the LLF group (P<0.0001) than in the HRT group (P<0.02). After 9 months the reduction remained in both groups but no additive effects were encountered in any of the groups.

CONCLUSION

The effects by gemfibrozil on s-cholesterol and triglycerides levels seem to be superior to continuous combined HRT in overweight women with elevated triglycerides. The combination of the two drugs did not seem to offer any additional benefit concerning the routine serum lipid or lipoprotein profile.

Health profile of middle-aged women: The Women's Health in the Lund Area (WHILA) study

BACKGROUND

Middle-aged women experience various health-related problems. The aim of this study was to evaluate the impacts of menopause status and hormone intervention on women's health.

METHODS

In an ongoing, population-based study, 4943 women, born 1935 to 1945 and living in the Lund area of Southern Sweden, were included in this analysis. They completed a generic questionnaire pertaining to socio-demographic background and current health-related symptoms. Among the cohort, 9% of women were pre-menopausal (PM), 52% were post-menopausal without hormone replacement therapy (PMO) and 39% were current hormone replacement therapy users (PMT).

RESULTS

Hot flushes and vaginal dryness were strongly related to menopausal status. The prevalence of somatic symptoms worsened progressively from the groups of PM to PMO to PMT. The most abundant complaints were headache and muscle-skeletal-joint problems. A total of 85% of women experienced psychological problems. Contrary to our expectation, a poorer profile of psychological health was found in the PMT group when compared with the PMO group.

CONCLUSIONS

The high prevalence of symptoms in middle-aged women could be attributed to age, hormonal influence as well as personality.

Effects of pelvic floor exercises in middle aged women with a history of naïve urinary incontinence: a population based study

OBJECTIVE

To follow the effect of a 4-month pelvic floor exercise (PFE) program in women with naïve urinary incontinence with vaginal electromyography (EMG), pressure and palpation and also to compare the initial findings with symptom-free women of the same age.

METHODS

The pelvic floor function expressed with vaginal EMG, pressure and palpation was measured before, during and after 4 months of PFEs in 60 previously untreated incontinent women, 50 of whom completed the study. The patients' perception of the situation and the amount of leakage were estimated before and after PFE. The incontinent group was compared at baseline and after PFE with 28 healthy controls. All women in this study (age 53-63) were randomly recruited from a major population based study.

RESULTS

At baseline, the incontinent women had significant reductions of both vaginal EMG activity and pelvic floor muscle condition as estimated by palpation compared to the healthy group. During training a successive, significant increase was seen in both EMG, pressure and palpation and the values eventually exceeded those of the healthy women. The measures reflecting improvement of pelvic floor function thus showed a consistent and progressive pattern. The degree of improvement was higher in those with initial high values in the muscle function tests than in the women with lower initial EMG values, pressures and findings on palpation. No differences were seen between patients with a history of stress incontinence and patients with an urge component, i.e. urge or mixed incontinence. Sixty-four percent of the women were satisfied and wanted no further treatment. The median leakage at pad-test decreased from 5 (range 0-328) to 1 (range 0-126) g/24h. The correlation between the vaginal and the pad-test measurements was weak.

CONCLUSION

Women with urinary incontinence have a significant reduction of pelvic floor function as estimated with vaginal EMG and palpation as compared to symptom-free controls. A successive normalization of vaginal EMG, pressure and findings at palpation was seen during the 4-month training period. Incontinence of both stress type and with an urge component can be alleviated in most of the women with PFE. These methods might be useful for routine evaluation of the pelvic neuromuscular disorder present in incontinent women.

[High sense of coherence can have health enhancing effects]

Sense of coherence (SOC), e.g. meaningfulness of life, is according to the sociologist A. Antonovsky a health-promoting construct, which has been used in a number of descriptive studies in various populations. The aim of this population-based cross-sectional study was to investigate if middle-aged women with a self-reported low level of SOC also differed in biological variables, e.g. related to glucose and lipid metabolism, from women with a high level of SOC. These variables could potentially represent links in the pathophysiological chain of events causing somatic disease. We found significant differences according to dyslipidaemia (low HDL cholesterol and increased triglyceride levels) between groups of women with differing SOC scores, most negative findings were found in the group with lowest SOC. Women with medium-high or high SOC also reported less symptoms and need of regular medical controls. The results support a potential association between cognitive processes (SOC) and biological mechanisms causing adverse health effects.

The influence of hormonal status and features of the metabolic syndrome on bone density: a population-based study of Swedish women aged 50 to 59 years. The women's health in the Lund area study

This study investigated whether there is an association between bone density and features of the metabolic syndrome in relation to hormonal status. All women aged 50 to 59 years living in a defined geographic area in Sweden were offered a health assessment program including blood glucose, lipid profile, blood pressure, and bone densitometry. Women were divided into 3 groups according to their hormonal status: premenopausal (PM), postmenopausal with hormone replacement therapy (PMT), and postmenopausal without hormone replacement therapy (PM0). Of the 6,886 women investigated, 7% were PM, 41% PMT, and 52% PM0. The overall prevalence of osteopenia and osteoporosis, according to the World Health Organization (WHO) definition, was 42.6% and 6.6%, respectively. T-score in the PM group was higher than in the PMT (P <.05) and PM0 groups (P <.001) and higher in the PMT group compared with the PM0 group (P <.001). Also, in the total cohort, the bone density was positively associated with body weight, body mass index (BMI), waist-to-hip ratio (WHR), systolic blood pressure (SBP), diastolic blood pressure (DBP), serum triglycerides, and blood glucose (P <.001 for all) and negatively associated with serum levels of cholesterol (P <.05) and high-density lipoprotein (HDL) (P <.001). This was most evident among the PMO women, suggesting that the influence of metabolic factors on bone density increases when the levels of hormones decrease. This indicates that hormone replacement therapy maintains treated women in a premenopausal status concerning the metabolic factors.

Dyslipidaemia and impaired well-being in middle-aged women reporting low Sense of Coherence. The Women's Health in the Lund Area (WHLA) Study

OBJECTIVE

A low Sense of Coherence (SOC) is a concept related to a feeling of ill health. Not much is known about possible relationships between SOC and biological factors.

SETTING

Population-based study of middle-aged women.

SUBJECTS AND METHODS

Four-hundred-and-fifty women participated as a subgroup of a larger study of cardiovascular risk factor screening. A self-administered questionnaire with 29 questions related to SOC was completed in addition to questions on social background factors and medical history.

RESULTS

The mean score of SOC was 150.9 (SD 23.4). HDL cholesterol was lower (p < 0.05) and triglyceride levels higher (p < 0.05) in women with low SOC (1.5 and 2.1 mmol/L) compared to women with medium (1.8 and 1.4 mmol/L) or high SOC (1.7 and 1.5 mmol/L). In multiple regression analysis, a low HDL cholesterol level was still significantly associated with low SOC (p < 0.05) after adjustment for possible confounders. Women reporting low SOC were further characterised by a higher proportion of subjects with regular clinical visits for health care (49% vs 35% and 29%).

CONCLUSIONS

Middle-aged women reporting low SOC showed lower HDL cholesterol and higher triglyceride levels, and reported more clinical visits and medical symptoms than women with higher SOC.