Cervical Cancer

• Instituting new processes can reduce diagnostic errors in Pap smear interpretation.

  Lean methods are used to weigh the expenditure of resources against value received. For this study, researchers compared the diagnostic accuracy of Pap tests procured by five clinicians before (5,384 controls) and after (5,442 cases) implementing a process redesign using Lean methods. Following process redesign, there was a significant improvement in Pap smear quality, and the case group showed a 114 percent increase in newly detected cervical intraepithelial cancer following a previous benign Pap test. Raab, Andrew-Jaja, Grzybicki, et al, J Low Genit Tract Dis 12(2):103-10, 2008 (AHRQ grant HS13321).

• Despite new guidelines, most ob-gyns continue to over-screen low-risk women for cervical cancer.

  The American Cancer Society suggests that cervical cancer screening with Pap tests begin within 3 years after a woman becomes sexually active or by age 21, whichever comes first. The ACS no longer recommends annual screening in women over age 30 who have had three or more previous normal Pap tests. The American College of Obstetricians and Gynecologists has made similar recommendations. Yet, 185 randomly selected ob-gyns said that they would begin screening girls who were not yet sexually active at age 18. Also, 60 percent of respondents said that they would continue annual screening in a 35-year-old woman with three or more normal tests. Saint, Gildengorin, and Sawaya, Am J Obstet Gynecol 192:414-21, 2005 (AHRQ grant HS07373).

Return to Contents

Ovarian Cancer

• Less access to effective treatment may explain poorer survival of elderly black women with ovarian cancer.

  Researchers studied 5,131 elderly women diagnosed with ovarian cancer between 1992 and 1999 with up to 11 years of followup. Overall, 72 percent of white women and 70 percent of black women were diagnosed with stage III or IV (advanced) disease, however, fewer blacks received chemotherapy than whites (50 vs. 65 percent, respectively). Among those with stage IV disease, those who underwent ovarian surgery and received adjuvant chemotherapy were 50 percent less likely to die during the followup period compared with those who did not, regardless of race. Du, Sun, Milam, et al., Int J Gynecol Cancer 18:660-669, 2008 (AHRQ grant HS16743).

• Evidence does not support use of genomic tests to detect ovarian cancer.

  is no evidence relevant to the impact of genomic tests for ovarian cancer on health outcomes in asymptomatic women. The researchers used model simulations to predict the usefulness and efficacy of genomic tests for ovarian cancer. The model simulations suggest that annual screening, even with a highly sensitive test, will not reduce ovarian cancer mortality, and that frequent screening has a very low positive predictive value. Genomic Tests for Ovarian Cancer Detection and Management, Evidence Report/ Technology Assessment No. 145 (AHRQ Publication No. 07-E001)* (AHRQ Contract 290-02-0025). Available online at http://www.ahrq.gov/clinic/tp/genovctp.htm.

Return to Contents

Other Cancers

• Women's perception of risk affects screening for colon cancer but not cervical or breast cancer.

  Researchers interviewed 1,160 white, black, Hispanic, and Asian women (aged 50 to 80) about their perceived risk for breast, cervical, and colon cancer and compared their perceived risk with their screening behavior. The women's perceived lifetime risk of cancer varied by ethnicity, with Asian women generally perceiving the lowest risk and Hispanic women the highest risk for all three types of cancer. Nearly 90 percent of women reported having a mammogram, and about 70 percent of the women reported having a Pap test in the previous 2 years; 70 percent of the women were current with colon cancer screening. There was no relationship between screening and perception of risk for cervical or breast cancer; however, a moderate to very high perception for colon cancer risk was associated with nearly three times higher odds of having undergone colonoscopy within the last 10 years. Kim, Perez-Stable, Wong, et al., Arch Int Med 168(7):728-34, 2008 (AHRQ grant HS10856).

• Among older patients with early-stage lung cancer, women live longer than men, regardless of treatment choice.

  Researchers examined differences between women and men in the natural history of lung cancer, after controlling for unrelated causes of death and type of treatment among 18,967 Medicare patients with stages I and II non-small cell lung cancer who were diagnosed between 1991 and 1999. They found that the women lived longer than the men, regardless of the type of treatment they received, and that the women's longer survival was independent of differences in life expectancy between men and women due to unrelated causes of death. They found improved survival advantages even among untreated women, suggesting that lung cancer in women has a different natural history and potentially a different tumor biology. Wisnivesky and Halm, J Clin Oncol 25(13):1705-12, 2007 (AHRQ grant HS13312).

• Up to 12 percent of tissues examined by pathologists for cancer result in diagnostic errors, many involving women.

  Researchers examined pathology errors over a 1-year period in patients at four hospitals who underwent laboratory tests to determine the presence or absence of cancer or precancerous lesions. Cancer diagnosis errors were dependent on the hospital and ranged from 2 to 20 percent of gynecologic cases and from 5 to 12 percent of nongynecologic cases. Errors due to pathologic misinterpretation ranged from 5 to 51 percent. The remaining errors were due to clinical sampling problems. Overall, 45 percent of gynecologic pathology errors were associated with harm. The researchers estimate that each year, nearly 128,000 U.S. patients will suffer harm as a result of cancer diagnosis errors. Raab, Grzybicki, Janosky, et al., Cancer 104(10):2205-13, 2005 (AHRQ grant HS13321).

Return to Contents

Reproductive Health

AHRQ's research on reproductive health focuses on pregnancy and childbirth, fertility problems, use of contraceptives, chronic pelvic pain, sexually transmitted diseases, and other conditions that can affect fertility and childbearing.

Pregnancy and Childbirth

The last half of the 20th century saw a decline in maternal deaths among U.S. women—from about 74 deaths in 1950 to about 7 deaths in 1993 for every 100,000 live births. Mortality related to pregnancy and childbirth is low for U.S. women compared with other causes of death, primarily because of health care advances that have occurred over the past 50 years. However, black women and older women continue to be at higher risk of death from complications of pregnancy.

• Bariatric surgery results in improved fertility in formerly obese women.

  There has been a six-fold increase in bariatric (weight loss) surgery over the past 7 years, and nearly half of all bariatric surgery patients are women of reproductive age. This review of the evidence indicates that fertility improves after bariatric surgical procedures, nutritional deficiencies for mother and child are minimal, and maternal and neonatal outcomes are acceptable with laparoscopic band and gastric bypass, as long as adequate nutrition and supplemental vitamins are maintained. There was no evidence that delivery complications are higher in post-surgery pregnancies. Bariatric Surgery in Women of Reproductive Age: Special Concerns for Pregnancy, Evidence Report/Technology Assessment No. 169 (AHRQ Publication No. 08-E013)* (AHRQ contract 290-02-0003). Available online at http://www.ahrq.gov/clinic/tp/barireptp.htm.

• Researchers find little high-quality evidence to support the choice of assisted reproductive technology.

  Researchers reviewed the available evidence on the outcomes of interventions used in ovulation induction, superovulation, and in vitro fertilization (IVF) for the treatment of infertility. They found that the majority of studies (80 percent) were conducted outside the United States, and there was little high-quality evidence on which to base a choice among the various interventions for infertility. They were able to substantiate improved pregnancy or live birth rates for several of the therapies. Effectiveness of Assisted Reproductive Technology, Evidence Report/Technology Assessment No. 167 (AHRQ Publication No. 08-E012)* (AHRQ contract 290-02-0025). Available online at http://www.ahrq.gov/clinic/tp/infertiltp.htm.

• Study examines factors related to infertility in women who have had pelvic inflammatory disease.

  Women who have been exposed to Chlamydia trachomatis, as evidenced by the presence of C. trachomatis elementary bodies (EBs), have lower rates of pregnancy and higher rates of recurrence of pelvic inflammatory disease (PID) after an initial episode of mild to moderate PID, according to this study. The researchers examined Chlamydia antibodies and adverse sequelae after PID among 443 women with mild to moderate PID; they followed the women for a mean of 84 months. Ness, Soper, Richter, et al., Sex Transm Dis 35(2):129-35, 2008 (AHRQ grant HS08383).

• Several factors affect women's perceived risk of prenatal diagnostic screening procedures.

  Invasive prenatal diagnostic tests—such as chorionic villus sampling and amniocentesis—are used to detect Down syndrome and other fetal chromosomal abnormalities, and they entail some risk, principally to the fetus. According to this study, women's perceived risk of adverse procedure-related outcomes varies based on factors that have little to do with risk. For example, among women younger than age 35, the perceived risk of carrying a fetus with Down syndrome was higher in women who had not attended college or had poor health status. Hispanic women, women with incomes less than $35,000, and those who had difficulty conceiving perceived a higher procedure-related risk of miscarriage. Caughey, Washington, and Kuppermann, Am J Obstet Gynecol 198:333.e1-333. e8, 2008 (AHRQ grant HS07373).

• Pregnant women with a prior c-section often receive insufficient information about delivery options.

  According to this study, many women with a prior cesarean delivery who choose to have a subsequent vaginal birth (VBAC) or another cesarean receive little or no information about the risk of both procedures, including forceps or vacuum delivery, future incontinence problems, and risk of fetal death or injury. Researchers surveyed 92 women who had a prior cesarean after either a VBAC or repeat cesarean at a large teaching hospital. Overall 44 percent of the women had scheduled cesarean deliveries, 29 percent had VBAC, and 27 percent had a cesarean following an attempted VBAC. Renner, Eden, Osterweil, et al., Am J Obstet Gynecol 196(5):e14-e16, 2007 (AHRQ grant HS11338).

• Nearly one-third of pregnant women deliver via c-section.

  The proportion of American women having their babies delivered by cesarean section jumped to nearly one in three in 2006 (1,345 million deliveries), a 65 percent increase over the 817,000 c-sections performed in 1993. The increase occurred as vaginal deliveries among women who gave birth in hospitals declined slightly, from about 3 million in 1993 to 2.9 million in 2006. Hospitals charged $23.4 billion for patient stays involving vaginal delivery in 2006 and $19.1 billion for births involving c-section. HCUP Facts and Figures; online at http://www.hcup-us.ahrq.gov/ (Intramural).

• Race, education, income, and social status all interact to affect the health of pregnant women.

  Researchers studied 1,802 ethnically diverse women receiving prenatal care at one of six San Francisco area delivery sites; the women were generally healthy and had low depression scores. Differences by race/ethnicity were pronounced, with whites and Asians doing better on all measures. More black and Hispanic women were in the lower social and economic strata than white and Asian women, and they reported worse physical functioning. Subjective social standing was more highly correlated with education and income in whites and Asians than in Hispanic and black women. Stewart, Dean, Gregorich, et al., J Health Psychol 12(2):285-300, 2007 (AHRQ grant HS10856).

• One-third of homeless women are at risk for unintended pregnancy.

  This survey of 974 homeless women in Los Angeles County in 1997 showed that one-third of the women rarely or never used contraception. Women who had a partner, were monogamous, and did not engage in the sex trade were 2.4 times as likely as other women to not use or rarely use contraception. Having a regular source of care and having been encouraged to use contraception increased the likelihood of contraception use. Gelberg, Lu, Leake, et al., Matern Child Health 12:52-60, 2008 (AHRQ grant HS08323).

• Several factors contribute to high rates of maternal birth trauma in one State.

  Compared with national rates, the State of Iowa has lower rates of cesarean delivery and higher rates of maternal trauma, according to this study. Researchers analyzed Iowa data for the years 2002-2004 and national data from 2003 and found significant risk factors for one type of maternal trauma—third/fourth degree lacerations—including episiotomy, artificial rupture of the amniotic membranes, obstructed labor, and late pregnancies, as well as disproportionately large babies. They note that the higher rates of maternal birth trauma at predominantly rural hospitals may be due in part to lack of infrastructure to perform cesareans for difficult deliveries. Roberts, Ely, and Ward, Am J Med Qual 22(5):334-43, 2007 (AHRQ grant HS15009).

• Postpartum discharge against medical advice usually signals serious financial or mental health issues.

  Researchers used hospital discharge data for women who gave birth in California, Florida, and New York during the period 1998-2000 to examine factors associated with discharge against medical advice, which averaged 0.10 percent. Women who were more likely to leave the hospital against medical advice were black; had low income, no insurance or public health insurance, and greater medical problems (e.g., drug abuse, mental illness); lived in medium or large metropolitan areas; and were discharged from hospitals in California or New York (compared with Florida). Fiscella, Meldrum, and Franks, Matern Child Health J 11:431-36, 2007 (AHRQ grant HS10910).

• Pregnancies that progress beyond the estimated due date are risky for both mother and baby.

  This study found that women who delivered babies beyond 37 weeks' gestational age had higher rates of operative vaginal delivery (use of forceps or vacuum extraction), perineal laceration, primary cesarean delivery, postpartum hemorrhage, and infection of the amniotic fluid and/or placental membranes. Other risks of prolonged pregnancy (38-42 weeks) included nonreassuring fetal heart rate and cephalopelvic disproportion (i.e., the baby's head is too large for the woman's pelvis). The researchers studied more than 119,000 fully insured, low-risk women who delivered babies beyond 37 weeks gestational age from 1995 to 1999. Caughey, Stotland, Washington, and Escobar, Am J Obstet Gynecol 196:155.e1-155. e6, 2007 (HS07373).

• Midwife practices vary widely in compensation and employment structure.

  Researchers surveyed 102 certified nurse-midwives in Connecticut in 2005 and found variations in practice freedom and style, income, benefits, job descriptions, and requirements for full-time work. Full-time midwives in Connecticut worked an average of 77 hours per week and had a mean salary of nearly $80,000 per year; 87 percent had on-call responsibilities. Among the midwives surveyed, 75 percent provided gynecologic care, antepartum care, and interpartum care; 16 percent did not offer gynecologic care; and 6 percent offered gynecologic care without antepartum or interpartum care. Some midwives performed endometrial biopsies, repaired third-degree perineal lacerations, and/or acted as a surgical assistant at cesarean births. Holland and Holland, J Midwifery Women's Health 52(2):106-15, 2007 (AHRQ grant T32 HS00044).

• Fewer girls under age 18 are having babies.

  The rate of teens and younger girls giving birth in U.S. hospitals dropped by one-fourth between 1997 and 2004, from 55 to 41 admissions per 100,000 girls under age 18, according to a recent AHRQ report. Despite this drop, the United States continues to lead all industrialized nations in teen pregnancy and childbirth. There were 4 million childbirth-related hospitalizations in 2004; 148,000 of these were for girls younger than age 18, resulting in nearly $465 million in hospital costs. Medicaid was billed for nearly three of every four teen childbirths, with total costs of about $348 million. Go to Childbirth-Related Hospitalizations Among Adolescent Girls, 2004, HCUP Statistical Brief No. 31; online at http://www.hcup-us.ahrq.gov/reports/statbriefs.jsp (Intramural).

• Prenatal screening is needed to identify pregnant women with asymptomatic chlamydial infection.

  Nine percent of pregnant women who have Chlamydia have no symptoms associated with the infection, according to this study of nearly 2,000 pregnant women with Chlamydia. In 44 percent of the women, the infection resolved spontaneously, but most women with asymptomatic infection who were not treated had persistent infection. This finding reinforces the current recommendation for screening pregnant women for Chlamydia at the first prenatal visit and, for at-risk women, screening a second time in the third trimester. Sheffield, Andrews, Klebanoff, et al., Obstet Gynecol 105:557-62, 2005 (AHRQ contract 290-92-0055).

• Evidence is insufficient to determine safety of inducing labor in women with a prior cesarean.

  According to this systematic review, there is little high-quality evidence to guide clinical and health policy decisions about the safety of inducing labor in women who have had a prior cesarean delivery. Evidence is particularly lacking on the appropriate dose of oxytocin and other agents used to induce labor and the reasons for inducing labor instead of waiting for spontaneous labor. Better quality studies that include appropriate comparison groups are also needed. McDonagh, Osterweil, and Guise, BJOG 112:1007-15, 2005 (AHRQ grant HS11338).

• Screening asymptomatic, low-risk pregnant women for hepatitis C is not cost effective.

  An estimated 1 to 4 percent of pregnant women are infected with hepatitis C virus (HCV), yet screening all pregnant women for HCV would not be cost effective, according to this study. Compared with no screening, the additional cost of screening, treatment, and cesarean delivery was $117, with a cost-effectiveness ratio of $1.17 million per quality-adjusted life year (QALY). This estimate is way above the $50,000 per QALY typically considered to be cost effective. Plunkett and Grobman,Am J Obstet Gynecol 192:1153-61, 2005 (AHRQ grant T32 HS00078).

• Task Force recommends HIV screening for all pregnant women.

  The U.S. Preventive Services Task Force recommends that all pregnant women—not just at-risk women—be screened for HIV infection. This recommendation is based on evidence that currently available tests accurately identify pregnant women who are HIV infected. This will permit the use of recommended treatments to dramatically reduce the chances that an infected mother will transmit HIV to her infant. In addition, elective cesarean section and avoidance of breastfeeding have been shown to further reduce mother-to-infant transmission of HIV infection. Chou, Smits, Huffman, et al., Ann Intern Med 143(1):38-54, 2005; also in the same journal, see pages 32-37, and pages 55-73 (AHRQ contract 290-97-0011).

• Half of pregnant women who support abortion availability would only consider a first-trimester procedure.

  Researchers interviewed more than 1,000 socioeconomically diverse pregnant women receiving prenatal care in the San Francisco Bay area; nearly half were aged 35 or older. Most of the women (92 percent) were in favor of abortion availability, but half (50 percent) said they would only consider having the procedure in the first trimester of pregnancy. Among women willing to consider abortion, 84 percent would do so after rape or incest or if their life was endangered by continuing the pregnancy. Three-quarters of the women (76 percent) would consider an abortion if their fetus had Down syndrome. Learman, Drey, Gates, et al., Am J Obstet Gynecol 192:1939-47, 2005 (AHRQ grants HS10214, HS10856).

• Difficulty sleeping and other problems common during pregnancy may mask symptoms of perinatal depression.

  According to this evidence report, depression is as common in women while they are pregnant as it is after childbirth. However, health care providers and patients may not recognize depression during pregnancy because signs of depression like tiredness, inability to sleep, emotional changes, and weight gain may also occur with pregnancy. Factors contributing to depression during or after pregnancy include personal or family history of depression or substance abuse, anxiety about the unborn child, problems with a previous pregnancy or birth, and marital or financial problems. The report also discusses screening for depression, the effectiveness of psychotherapy and antidepressants, and the value of providing psychosocial support to pregnant and postpartum women with depression. Perinatal Depression: Prevalence, Screening, Accuracy, and Screening Outcomes. Evidence Report No. 119 (AHRQ Publication Nos. 05-E006-1, summary; 05-E006-2, report) (AHRQ contract 290-02-0016).* Available online at http://www.ahrq.gov/clinic/tp/perideptp.htm.

• Potential benefits of episiotomy do not offset the fact that many women would have less injury without it.

  Episiotomy is a common procedure used in an estimated one-third of vaginal deliveries to hasten birth or prevent tearing of the skin during delivery. According to this evidence report, routine use of episiotomy for uncomplicated vaginal births does not provide immediate or longer term benefits for the mother. The evidence shows that women who experience spontaneous tears without episiotomy have less pain than women with episiotomies. Furthermore, complications related to the healing of the perineum are the same with and without episiotomy. Use of Episiotomy in Obstetrical Care: A Systematic Review. Evidence Report No. 112 (AHRQ Publication Nos. 05-E009-1, summary and 05-E009-2, report). Available online at http://www.ahrq.gov/clinic/tp/epistp.htm. What You Need to Know About Episiotomy (AHRQ Publication No. 06-0005, consumer card) (AHRQ contract 290-02-0016).*

Birth Outcomes

• Race and ethnicity appear not to have an effect on c-section delivery outcomes.

  The researchers tested two risk-adjustment models for primary c-section rates to determine whether adding race and ethnicity to an otherwise identical model would improve the predictive impact of the model. They found that the two models did not differ substantially in predictive discrimination or in model calibration. They conclude that race and ethnicity can safely be left out of cesarean rate risk-adjustment models. Bailit and Love, Am J Obstet Gynecol 69:e1-e5, 2008 (AHRQ grant HS14352).

• Few data are available on the incidence and outcomes of cesarean delivery on maternal request.

  The researchers reviewed published reports from 1990 through 2005 and found only 82 articles marginally related to cesarean delivery on maternal request (CDMR). They report that the incidence of CDMR appears to be increasing, but accurately assessing either its true incidence or trends over time is difficult because of the dearth of research focused on the topic. They cite the need to create a minimum data set, reach a consensus on terminology to be used, improve study design and statistical analyses, deal better with confounders, and consider the value and/or utility of different outcomes. Cesarean Delivery on Maternal Request, Evidence Report/Technology Assessment No. 133 (AHRQ Publication No. 06-E009)* (AHRQ contract 290-02-0016). Available online at http://www.ahrq.gov/clinic/tp/cesarreqtp.htm.

• Maternal weight gain is associated with some outcomes for mothers and babies.

  According to this review of the scientific evidence, there is a strong association between a pregnant woman's weight gain and the following outcomes: preterm birth, total birthweight, low birthweight, large-and small-for-gestational-age infants, and very large infants. The researchers found a moderate association between maternal weight gain and two additional outcomes: cesarean delivery and postpartum weight retention for up to 3 years following childbirth. Outcomes of Maternal Weight Gain, Evidence Report/Technology Assessment No. 168 (AHRQ Publication No. 08-E009)* (AHRQ Contract 290-02-0016). Available online at http://www.ahrq.gov/clinic/tp/admattp.htm.

• Among disadvantaged minority women, Hispanics have better birth outcomes than blacks.

  Researchers analyzed the pregnancy outcomes of 10,755 Medicaid-insured women who gave birth at one North Carolina medical center between 1994 and 2004. They found that black women were younger than the other women and were more likely to have another medical condition while pregnant, to remain in the hospital for more than 4 days, to have a preterm birth or small-for-gestational-age infant, to have preeclampsia, and to have a stillbirth. Birth outcomes for Hispanic women were similar to or better than those for white women. For example, Hispanic women were 34 percent less likely than other women to have a preterm birth. Brown, Chireau, Jallah, and Howard, Am J Obstet Gynecol 197:e1-e9, 2007 (AHRQ grant HS13353).

• Study details association between maternal asthma and smoking and bronchiolitis in infants.

  Researchers studied hospitalizations for bronchiolitis among infants of 100,000 women enrolled in the Tennessee Medicaid program during 1995-2003. They found that infants of mothers who smoked and had asthma were twice as likely to end up in the emergency department (ED) with bronchiolitis as infants whose mothers had neither problem. Infants whose mothers had only one of the problems had a lower but still significantly elevated risk for ED visits and hospitalizations compared with infants whose mothers had neither problem. Although maternal asthma was the most important of these two risk factors, infants were 50 percent more likely to be hospitalized for bronchiolitis if their mothers had asthma and also smoked. Carroll, Gebretsadik, and Griffin, Pediatrics 119(6):1104-12, 2007 (AHRQ grant HS10384).

• Pregnant minority women with asthma are at increased risk for poor outcomes.

  Among pregnant women with asthma, this study found that minority women have significantly higher rates of preterm labor, gestational diabetes, and infection of the amniotic cavity than white women. Black women were the youngest (age 24) and had the highest incidence of preterm labor (5.5 percent) and pregnancy-induced hypertension (5 percent). Asian women had the highest occurrence of gestational diabetes (7.2 percent) and were more than three times as likely as white women to have infection of the amniotic cavity (5.7 vs. 1.8 percent, respectively). Black and Hispanic women also had more infections of the amniotic cavity (3.1 and 2.7 percent, respectively) than white women. Findings are based on examination of 11 adverse outcomes across four ethnic groups of 13,900 pregnant women with asthma who gave birth in 1998 and 1999. MacMullen, Tymkow, and Shen, Am J Matern Child Nurs 31(4):263-8, 2006 (AHRQ grant HS13506).

• Majority of low-income black women are unhappy with their body size 6 months after giving birth.

  Body image dissatisfaction is associated with negative self-esteem and depression, and all three can be intensified during the postpartum period. Black mothers are twice as likely to suffer from postpartum depression as white mothers, according to this study. The researchers examined body perceptions among black women at four inner city clinics at 2 and 6 months postpartum. At 6 months postpartum, 79 percent of the women felt they did not meet what they considered to be a healthy size for women their age; 20 percent of the women thought they were too small and wanted to gain weight. Boyington, Johnson, and Carter-Edwards, J Obstet Gynecol Neonatal Nurs 36(2):144-51, 2007 (AHRQ grant HS13353).

• Evidence is weak, but it appears to show a positive effect of breastfeeding on infant outcomes.

  A history of breastfeeding appears to be associated with a reduced risk of many diseases in infants and mothers from developed countries, according to this review of the evidence. However, nearly all of the data available for use in the review were gathered from observational studies and are not sufficient to infer causality. The authors of the review call for additional, well-designed studies to gather more reliable data on any disparities in health outcomes as a result of breastfeeding. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries, Evidence Report/Technology Assessment No. 153 (AHRQ Publication No. 07-E007)* (AHRQ contract 290-02-0022). Available online at http://www.ahrq.gov/clinic/tp/brfouttp.htm.

• Screening new mothers for postpartum depression is particularly important in women of color.

  According to this survey of 655 women who were 2 to 6 weeks postpartum, nearly one-half of Hispanic (47 percent) and black (45 percent) mothers reported depressive symptoms, compared with less than one-third (31 percent) of white mothers. Factors associated with postpartum depression—the burden of physical symptoms, lack of social support, and lack of self-confidence in infant care—were the same for all women regardless of race. Howell, Mora, Horowitz, and Leventhal, Obstet Gynecol 105(6):1442-50, 2005 (AHRQ grant HS09698).

Hysterectomy

More than 500,000 hysterectomies are performed in the United States each year at an annual cost of more than $5 billion. More than one-third of women in the United States have had a hysterectomy by age 60.

• Type of hysterectomy does not affect sexual functioning and quality of life 2 years later.

  Women who undergo supracervical hysterectomy (cervix is left in place) or total abdominal hysterectomy (cervix is removed) achieve similar sexual functioning and quality of life 2 years after the procedure, according to this study of 135 premenopausal women who underwent hysterectomy in one of four U.S. clinical centers. At 6 months postsurgery, sexual problems had improved dramatically in both groups, and at 2 years the women reported few problems in this area. Both groups also had substantial improvement in most other quality of life measures. Kuppermann, Summit, Varner, et al., Obstet Gynecol 105(6):1309-18, 2005 (AHRQ grant HS09478).

• Three clinical characteristics increase the likelihood of hysterectomy for women with certain noncancerous conditions.

  In this study of 734 women at several California clinics and offices, three clinical characteristics—abnormal uterine bleeding, chronic pelvic pain, and symptomatic uterine fibroids—predicted the likelihood of subsequent hysterectomy. Nearly half of the women had suffered from symptoms for more than 5 years, and some of the women had already had surgery to remove fibroids, undergone removal of uterine lining, or had hormone treatment. A total of 99 of the women (13.5 percent) underwent hysterectomies during the 4-year study period. Women with multiple pelvic symptoms or symptomatic fibroids were nearly twice as likely to have a hysterectomy as other women. Learman, Kuppermann, Gates, et al., J Am Coll Surg 204:633-41, 2007 (AHRQ grants HS07373, HS09478, HS11657).

• Many young women who underwent hysterectomy during their childbearing years had lingering depression.

  Researchers interviewed 1,140 women before they underwent hysterectomies in 1992 and 1993 and followed up with them for 2 years after surgery. Although 86 percent of the women said they were fine with their childbearing days being over, 14 percent were either ambiguous or said they would have liked to have children. The women who wanted children tended to put off their surgeries for 4.5 years, despite severe pelvic pain. Women who wanted children were twice as likely as those who did not to have sought mental health counseling prior to surgery and to still be depressed 2 years after surgery. Leppert, Legro, and Kjerulff, J Psychosom Res 63(3):269-74, 2007 (AHRQ grant HS06865).

• Removal of the ovaries in premenopausal women does not negatively affect quality of life.

  This study found that women who underwent bilateral salpingo-oophorectomy had an initial decline in quality of life in the first 6 months after surgery, but they had no apparent differences in quality of life 2 years later, compared with women who had hysterectomies but kept their ovaries. At 6 months after surgery, there were no differences between the two groups in sexual functioning, hot flushes, urinary incontinence, or pelvic pain. And at the 2-year followup, scores were similar for both groups on all measures of health-related quality of life and sexual functioning, irrespective of estrogen use. Teplin, Vittinghoff, Lin, et al., Obstet Gynecol 109(2):347-54, 2007 (AHRQ grant HS09478).

Other

• Noncancerous pelvic problems are linked to poor quality of life for premenopausal women.

  Researchers examined the treatment and outcomes of 1,493 women who sought care for noncancerous pelvic problems and had not undergone a hysterectomy. Such problems typically include heavy bleeding and pelvic pain and pressure. The women were asked about their symptoms, attitudes, quality of life, sexual functioning, and treatment satisfaction. The majority of women reported no or only partial symptom resolution from treatment, and nearly half said their pelvic problems interfered with their ability to have and enjoy sex. The women's physical and mental health scores were substantially lower than population norms for women aged 40 to 49 years, and overall, less than half of the women were satisfied with their treatment. Kuppermann, Learman, Schembri, et al., Obstet Gynecol 110(3):633-42, 2007 (AHRQ grants HS09478, HS11657, HS07373).

• Researchers find that evidence is lacking on the effectiveness of most interventions for symptomatic fibroids.

  This review was intended to update a previous AHRQ report published in 2001 on the management of symptomatic fibroids. The first evidence review found that the overall quality of the literature on the management of fibroids was poor, and that there was almost no evidence to support the effectiveness of commonly recommended treatments. The authors of this review found essentially the same thing. They found the lack of well-conducted trials in U.S. populations that directly compared treatment options to be particularly notable. Management of Uterine Fibroids: An Update of the Evidence, Evidence Report/Technology Assessment No. 154 (AHRQ Publication No. 07-E011)* (AHRQ contract 290-02-0016). Available online at http://www.ahrq.gov/clinic/tp/uteruptp.htm.

• Evidence review focuses on key questions relating to symptoms of menopause and their management.

  This report presents the results of a systematic review of the evidence about symptoms associated with menopause, the benefits and side effects of therapies, and future research needs. The review found that vasomotor symptoms (e.g., hot flashes) and vaginal dryness are symptoms most consistently associated with the menopause transition. In addition, other symptoms—such as sleep disturbance, urinary problems, sexual dysfunction, mood swings, and quality of life—are inconsistently reported. Trials of therapy were conclusive only for estrogen, although further studies may show that other therapies are effective. Additional, larger scale studies are needed. Management of Menopause-Related Symptoms, Evidence Report/Technology Assessment No. 120 (AHRQ Publication No. 05-E016, summary; 05-E016-2, full report)* (AHRQ contract 290-02-0024). Available online at http://www.ahrq.gov/clinic/tp/menopstp.htm.

• Both behavioral and drug therapies can help women with urinary incontinence.

  Researchers analyzed existing evidence on nonsurgical treatment for urinary incontinence (UI) in women and found that pelvic floor muscle training (Kegel exercises) and bladder training resolved women's UI compared with usual care. Certain medications also resolved UI compared with placebo, while the effects of electrostimulation, medical devices, injectable bulking agents, and vaginal estrogen therapy were inconsistent. UI affects nearly one in five women age 44 or younger and as many as one in three elderly women. Shamliyan, Kane, Wyman, and Wilt, Ann Intern Med 148(6):459-73, 2008 (AHRQ contract 290-02-0009).

• Uterine artery embolization found to be a low-risk procedure.

  Researchers examined the outcomes of more than 3,000 women who underwent uterine artery embolization for fibroids. The women were treated at 72 sites across the United States. Overall, less than 1 percent of women suffered from major inpatient complications; 4.8 percent suffered from major events (mostly inadequate pain relief) within the first 30 days following hospital discharge. There were no deaths related to the procedure, but 31 women required additional surgical intervention with 30 days of the procedure. Worthington-Kirsch, Spies, Myers, et al., Obstet Gynecol 106(1):52-9, 2005; see also pp. 44-51 by the same authors in the same journal (AHRQ grant HS09760).

• Task Force recommends screening at-risk women for certain sexually transmitted infections.

  The U.S. Preventive Services Task Force recommends that women at increased risk of infection be screened for Chlamydia, gonorrhea, HIV, and syphilis. The Task Force also recommends that pregnant women be screened for hepatitis B, HIV, and syphilis. Those pregnant women at high risk for STIs should be additionally screened for Chlamydia and gonorrhea, and sexually active women younger than age 25 should be considered at increased risk for Chlamydia and gonorrhea. The Task Force identifies women as being at high risk for STIs if they have multiple current partners, have unprotected sex, or have sex in exchange for money or drugs. Meyers, Wolff, Gregory, et al., Am Fam Physician 77(6):819-24, 2008 (AHRQ Publication No. 08-R056)* (Intramural).

• Two simple steps can improve rates of screening for Chlamydia in young women.

  Use of exam room screening reminders and clinic-level intervention strategies (physician opinion leaders and physician feedback) can improve Chlamydia testing rates in young women making preventive care visits, according to this study. Researchers randomized 23 primary care clinics in one managed care plan to either standard care or intervention care. They found that a combination of clinic-level change and patient activation may improve testing, particularly among asymptomatic women. Scholes, Grothaus, McClure, et al., Prev Med 43:343-50, 2006 (AHRQ grant HS10514).

• Certain factors predict chronic pelvic pain after PID.

  One-third of women with pelvic inflammatory disease (PID) subsequently suffer from chronic pelvic pain. A study of 780 urban women with PID found that women who smoked, those who had previous episodes of PID, women who were married, and those who had low mental health scores were more likely than other women to experience chronic pelvic pain. The researchers also note that recurrent PID can cause adhesions to form and may represent persistent, chronic infection or inflammation, all of which can result in chronic pelvic pain. Haggerty, Peipert, Weitzen, et al., Sex Trans Dis 32(5):293-99, 2005 (AHRQ grant HS08358).

Return to Contents
Proceed to Next Section