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Abstract Sleep disturbances are common and may impact fracture risk directly by influencing bone turnover or indirectly through shared risk factors or mediators. To investigate the association between self‐reported sleep disturbances across the menopausal transition (MT) and fractures, we prospectively studied 3101 women enrolled in the Study of Women's Health Across the Nation (SWAN). At each of 14 study visits spaced approximately 18 months apart, a standardized validated scale ascertained trouble falling asleep, waking up several times during the night, and waking up earlier than planned. Two time‐varying exposures were modeled: presence of any of the three disturbances at least three times per week and waking up several times during the night at least three times per week. Base models adjusted for fixed (race/ethnicity, study site) and time‐varying characteristics (age, body mass index, and MT stage). Fully adjusted models also included time‐varying bone beneficial and detrimental medications, smoking, alcohol, physical activity, diabetes, depression and sleep medications, and depressive symptoms. Women who experienced a fracture were more likely to report a greater frequency of having trouble falling asleep, waking up several times, and/or waking up earlier: 35% versus 30% at baseline, p = 0.02. In the base models, women who had any of the three sleep disturbances at least three times per week had a higher risk of any fracture, odds ratio (OR) = 1.23 (95% confidence intervals, 1.02, 1.48) and nontraumatic fracture, OR = 1.36 (1.03, 1.80). These associations were largely attenuated to nonsignificance in the fully adjusted model. Sensitivity analyses limiting our sample to 2315 SWAN women enrolled in the bone mineral density (BMD) centers yielded similar results. Additional adjustment for femoral neck BMD had no effect on our results. In conclusion, self‐reported sleep disturbances were associated with an increased risk of fractures, but these associations likely reflect shared risk factors or factors in the causal pathway. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

ABSTRACT Morphological parameters measured for the second metacarpal from hand radiographs are used clinically for assessing bone health during growth and aging. Understanding how these morphological parameters relate to metacarpal strength and strength at other anatomical sites is critical for providing informed decision‐making regarding treatment strategies and effectiveness. The goals of this study were to evaluate the extent to which 11 morphological parameters, nine of which were measured from hand radiographs, relate to experimentally measured whole‐bone strength assessed at multiple anatomical sites and to test whether these associations differed between men and women. Bone morphology and strength were assessed for the second and third metacarpals, radial diaphysis, femoral diaphysis, and proximal femur for 28 white male donors (18–89 years old) and 35 white female donors (36–89+ years old). The only morphological parameter to show a significant correlation with strength without a sex‐specific effect was cortical area. Dimensionless morphological parameters derived from hand radiographs correlated significantly with strength for females, but few did for males. Males and females showed a significant association between the circularity of the metacarpal cross‐section and the outer width measured in the mediolateral direction. This cross‐sectional shape variation contributed to systematic bias in estimating strength using cortical area and assuming a circular cross‐section. This was confirmed by the observation that use of elliptical formulas reduced the systematic bias associated with using circular approximations for morphology. Thus, cortical area was the best predictor of strength without a sex‐specific difference in the correlation but was not without limitations owing to out‐of‐plane shape variations. The dependence of cross‐sectional shape on the outer bone width measured from a hand radiograph may provide a way to further improve bone health assessments and informed decision making for optimizing strength‐building and fracture‐prevention treatment strategies. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Abstract Background Age at final menstrual period (FMP) and the accompanying hormone trajectories across the menopause transition do not occur in isolation, but likely share molecular pathways. Understanding the genetics underlying the endocrinology of the menopause transition may be enhanced by jointly analyzing multiple interrelated traits. Methods In a sample of 347 White and 164 Black women from the Study of Women's Health Across the Nation (SWAN), we investigated pleiotropic effects of 54 candidate genetic regions of interest (ROI) on 5 menopausal traits (age at FMP and premenopausal and postmenopausal levels of follicle stimulation hormone and estradiol) using multivariate kernel regression (Multi‐SKAT). A backward elimination procedure was used to identify which subset of traits were most strongly associated with a specific ROI. Results In White women, the 20 kb ROI around rs10734411 was significantly associated with the multivariate distribution of age at FMP, premenopausal estradiol, and postmenopausal estradiol (omnibus p‐value = .00004). This association did not replicate in the smaller sample of Black women. Conclusion This study using a region‐based, multiple‐trait approach suggests a shared genetic basis among multiple facets of reproductive aging.

Abstract Background To assess whether Healing in Harmony (HiH), a form of music therapy, improved women's mental health following conflict-related trauma and sexual violence in the Democratic Republic of Congo. Methods This study used a step-wedged design and included 167 women, who completed up to two pre-tests, a post-test, and up to two follow-up interviews at 3 and 6 months after completing the program. The Hopkins Symptoms Checklist was used to measure anxiety and depression. The Harvard Trauma Questionnaire was used to measure post-traumatic stress disorder (PTSD). Generalized estimating equations with unstructured covariance were used to estimate mean change in mental health scores and relative risks (RRs) for screening positive. Results Prior to starting the HiH program, 73.9, 84.2, and 68.5% screened positive with median scores being 2.20, 2.70, and 2.06 for depression, anxiety, and PTSD, respectively. The RR for screening positive declined significantly (RR = 0.49 for depression, 0.61 for anxiety, and 0.54 for PTSD) and mean scores declined significantly by −0.54, −0.67, and −0.53 points, respectively, from the pre- to the post-test, declines that were sustained at the 3-month and 6-month follow-up interviews. Conclusion The HiH program was associated with significant improvement in women's mental health that was sustained up to 6 months post completion of the program despite instability in the region and evidence of continued experience of conflict-related trauma during the study. These data support the value of providing psychological care in the context of ongoing humanitarian crises.

Abstract Background Tanzania, like other low-income countries, has an increasing cancer burden that remains underestimated. Infection-associated malignancies, particularly HIV-infection, represent a great proportion of cancer burden in Tanzania and throughout Africa. Availability of HIV treatment and improved survival of HIV patients are suggested factors related to increasing prevalence of non-AIDS-defining cancers (NADCs). This study examined patterns of NADCs and proportions of HIV-positivity at the Ocean Road Cancer Institute (ORCI). Methods We reviewed logbooks of all ORCI patients diagnosed and/or treated for lung, liver, and head and neck cancers during 2002–2014. The number of total cancers diagnosed at ORCI during this period was used to calculate proportions of NADCs. We abstracted medical records to obtain demographic and clinical profiles and HIV status information for 1127 patients diagnosed or treated during 2010–2014. Trends in numbers and proportions of NADCs were analyzed using Joinpoint regression. Characteristics of NADC patients were analyzed using multinomial logistic regression. Results NADCs diagnosed at ORCI increased by 33.8% from 2002 to 2014 while the proportion of NADCs relative to all cancers significantly decreased from 6.8% in 2002 to 5.6% in 2014 (APC = -2.74%). Numbers and proportions of lung and liver cancers increased compared to all cancer diagnoses from 2002 to 2014. The number of head and neck cancers increased while decreasing proportionally compared to all cancer diagnoses from 2002 to 2014. Among patients with pathologically confirmed NADCs between 2010 and 2014, HIV prevalence showed a non-statistically significant decrease from 8.1 to 7.1% (APC = -3.77%). Conclusions Absolute numbers of lung, liver, and head and neck cancers increased at ORCI by 1/3 since 2002. Improving survivorship of HIV patients and varying immunodeficiency status may have contributed to the increasing number of NADCs. Total cancer diagnoses nearly doubled during this period, leading to a smaller relative proportion of NADCs diagnosed in 2014 compared to 2002. Late- stage diagnosis and short survival of NADCs included this study may explain possible underestimation and smaller increase in proportion of these particular NADCs compared to other NADCs studied in Tanzania. The slight decrease in proportion of HIV-positive NADC patients during 2010–2014 may suggest increasing patient longevity and more effective HIV management in Tanzania.

Abstract This paper reviews differences in the experience of the menopause transition and midlife health outcomes between Black and White women who participated in the Study of Women’s Health Across the Nation (SWAN), a 25-year, longitudinal, multi-racial/ethnic cohort study. We identify health disparities, i.e., instances in which Black women’s outcomes are less favorable than those of White women, and consider whether structural racism may underlie these disparities. Although SWAN did not explicitly assess structural racism, Black women in SWAN grew up during the Jim Crow era in the United States, during which time racism was legally sanctioned. We consider how we might gain insight into structural racism by examining proxy exposures such as socioeconomic characteristics, reports of everyday discrimination, and a range of life stressors, which likely reflect the longstanding, pervasive and persistent inequities that have roots in systemic racism in the US. Thus, this paper reviews the presence, magnitude, and longitudinal patterns of racial disparities observed in SWAN in six areas of women’s health – menopause symptoms, sleep, mental health, health related quality of life, cardio-metabolic health, and physical function –and elucidates the contextual factors that are likely influencing these disparities. We review the strengths and weaknesses of SWAN’s design and approach to analysis of racial disparities and use this as a springboard to offer recommendations for future cohort studies.

Background: Exposure to metals and metal mixtures may influence ovarian aging. However, epidemiologic evidence of their potential impact is lacking. Objective: We prospectively examined the associations of 15 urinary metal concentrations and their mixtures with natural menopause in the Study of Women’s Health Across the Nation Multi-Pollutant Study. Methods: The study population consisted of 1082 premenopausal women from multiple racial/ethnic groups, aged 45–56 years at baseline (1999–2000), with the median follow-up of 4.1 years. Urinary concentrations of 15 metals, including arsenic, barium, cadmium, cobalt, cesium, copper, mercury, manganese, molybdenum, nickel, lead, antimony, tin, thallium, and zinc, were measured at baseline. Natural menopause was defined as the final bleeding episode prior to at least 12 months of amenorrhea, not due to surgery or hormone therapy. Cox proportional hazards models were used to examine associations between individual metal concentrations and timing of natural menopause. The associations between metal mixtures and natural menopause were evaluated using elastic net penalized Cox regression, and an environmental risk score (ERS) was computed to represent individual risks of natural menopause related to metal mixtures. Results: The median age at natural menopause was 53.2 years. Using the Cox proportional hazards models, the adjusted hazard ratio (HR) (and its 95% confidence interval (CI)) for natural menopause was 1.32 (1.03, 1.67) for arsenic and 1.36 (1.05, 1.76) for lead, comparing the highest with the lowest quartiles of metal concentrations. The predicted ages at natural menopause in the highest and lowest quartiles were 52.7 and 53.5 years for arsenic; and 52.9 and 53.8 years for lead. A significant association between ERS and menopause was also observed. Women in the highest vs. the lowest quartiles of ERS had an HR of 1.71 (1.36, 2.15), equivalent to a 1.6 year earlier median time to natural menopause. Conclusion: This study suggests that arsenic, lead, and metal mixtures are associated with earlier natural menopause, a risk factor for adverse health outcomes in later life.

Background: Epidemiologic studies on associations between metals and insulin resistance and β-cell dysfunction have been cross-sectional and focused on individual metals. Objective: We assessed the association of exposure to metal mixtures, based on assessment of 15 urinary metals, with both baseline levels and longitudinal changes in homeostatic model assessments for insulin resistance (HOMA-IR) and β-cell function (HOMA-β). Methods: We examined 1262 women, aged 45–56 years at baseline (1999–2000), who were followed through 2015–2016, from the Study of Women’s Health Across the Nation. Urinary concentrations of 15 metals (arsenic, barium, cadmium, cobalt, cesium, copper, mercury, manganese, molybdenum, nickel, lead, antimony, tin, thallium, and zinc) were determined at baseline. HOMA-IR and HOMA-β were repeatedly measured over 16 years of follow-up. A two-stage modeling was used to account for correlations in dependent and independent variables: In stage-1, linear mixed effects models were used to estimate the participant-specific baseline HOMA levels from random intercepts and participant-specific rates of changes from random slopes. In stage-2, adaptive elastic-net (AENET) models were fit to identify components of metal mixtures associated with participant-specific baseline levels and rates of changes in HOMA-IR and HOMA-β, respectively. An environmental risk score (ERS) was used to integrate metal mixture effects from AENET results. Results: In multivariable adjusted AENET models, urinary zinc was associated with higher HOMA-IR at baseline, whereas molybdenum was associated with lower HOMA-IR at baseline. The estimated changes in baseline HOMA-IR for one standard deviation increase in log-transformed urinary metal concentrations were 5.76% (3.05%, 8.55%) for zinc and −3.25% (−5.45%, −1.00%) for molybdenum, respectively. Urinary zinc was also associated with lower HOMA- β at baseline. Arsenic was associated with a slightly faster rate of decline in HOMA-β in the AENET model evaluating associations between metals and rate of changes. Significant associations of ERS with both HOMA-IR and HOMA-β at baseline were observed. ERS for the rate of changes was not calculated and examined in relation to rates of changes in HOMA-IR and HOMA-β because only a single metal was selected by AENET. Conclusion: Exposure to metal mixtures may be exerting effects on insulin resistance and β-cell dysfunction, which might be mechanisms by which metal exposures lead to elevated diabetes risks.

Background: Limited information exists regarding longitudinal trends in midlife women’s exposure to perfluoroalkyl and polyfluoroalkyl substances (PFAS). Further, little is known about how patterns of exposure differ by race/ethnicity and reproductive characteristics including parity and menopause. Objective: We aimed to examine temporal variations in serum PFAS concentrations among midlife women from the Study of Women′s Health Across the Nation. Methods: Serum concentrations of 11 PFAS homologues were measured in 75 White, Black and Chinese women with blood samples collected in 1999–2000, 2002–2003, 2005–2006, and 2009–2011. Rates of changes in PFAS concentrations were calculated assuming a first-order elimination model. Associations between PFAS concentrations and race/ethnicity, menstruation and parity were evaluated with linear mixed models, adjusting for age, body mass index and study site. Results: Serum concentrations of linear-chain perfluorooctanoic acid (n-PFOA), linear- and branched-chain perfluorooctane sulfonic acid (n-PFOS and sm-PFOS) decreased significantly (-6.0%, 95% CI: −8.3%, −3.6% per year for n-PFOA; −14.8%, 95% CI: −17.3%, −12.3% per year for n-PFOS; −16.9%, 95% CI: −19.1%, −14.6% per year for sm-PFOS); whereas perfluorononanoic acid (PFNA) increased (16.0%, 95% CI: 10.6%, 21.6% per year). Detection rates of perfluorodecanoic acid (PFDeA) and perfluoroundecanoic acid (PFUA) doubled. Temporal trends varied significantly by race/ethnicity. Chinese women tended to have consistently higher PFNA concentrations at each follow-up visit, compared with White and Black women. Serum PFHxS concentrations significantly decreased in White and Black women, but not in Chinese. Menstruating women consistently had lower concentrations. Parity was associated with lower concentrations at baseline but the differences between nulliparous and parous women became smaller over time. Conclusions: Our results suggest longitudinal declines in serum concentrations of legacy PFAS and increases in serum concentrations of emerging compounds from 1999 to 2011 in midlife women. Temporal trends in PFAS concentrations are not uniform across race/ethnicity and parity groups. Keywords: Perfluoroalkyl and polyfluoroalkyl substances (PFAS), Biomonitoring, Midlife women, Racial/ethnic disparities, Menstruation, Parity

Abstract Background Human trafficking is a pervasive global crime with important public health implications that entail fundamental human rights violations in the form of severe exploitation, violence and coercion. Sex-specific associations between types of violence or coercion and mental illness in survivors of trafficking have not been established. Methods We conducted a cross-sectional study with 1015 female and male survivors of trafficking (adults, adolescents and children) who received post-trafficking assistance services in Cambodia, Thailand or Vietnam and had been exploited in various labor sectors. We assessed anxiety and depression with the Hopkins Symptoms Checklist (HSCL-25) and post-traumatic stress disorder (PTSD) symptoms with the Harvard Trauma Questionnaire (HTQ), and used validated questions from the World Health Organization International Study on Women’s Health and Domestic Violence to measure physical and sexual violence. Sex-specific modified Poisson regression models were estimated to obtain prevalence ratios (PRs) and their 95% confidence intervals (CI) for the association between violence (sexual, physical or both), coercion, and mental health conditions (anxiety, depression and PTSD). Results Adjusted models indicated that for females, experiencing both physical and sexual violence, compared to not being exposed to violence, was a strong predictor of symptoms of anxiety (PR = 2.08; 95% CI: 1.64–2.64), PTSD (PR = 1.55; 95% CI: 1.37–1.74), and depression (PR = 1.57; 95% CI: 1.33–1.85). Among males, experiencing physical violence with additional threats made with weapons, compared to not being exposed to violence, was associated with PTSD (PR = 1.59; 95% CI: 1.05–2.42) after adjustment. Coercion during the trafficking experience was strongly associated with anxiety, depression, and PTSD in both females and males. For females in particular, exposure to both personal and family threats was associated with a 96% elevated prevalence of PTSD (PR = 1.96; 95% CI: 1.32–2.91) and more than doubling of the prevalence of anxiety (PR = 2.11; 95% CI: 1.57–2.83). Conclusions The experiences of violence and coercion in female and male trafficking survivors differed and were associated with an elevated prevalence of anxiety, depression, and PTSD in both females and males. Mental health services must be an integral part of service provision, recovery and re-integration for trafficked females and males.

Abstract Background In women, midlife is a period of social and physiological change. Ostensibly stressful, cross-sectional studies suggest women experience decreasing stress perceptions and increasing positive outlook during this life stage. The aim of this paper was to describe the longitudinal changes in perceived stress as women transitioned through the midlife. Methods Premenopausal women (n = 3044) ages 42–52 years at baseline, were recruited from seven sites in the Study of Women’s Health Across the Nation, and followed approximately annually over 13 visits with assessment of perceived stress and change in menopausal status. Longitudinal regression models were used to assess the effects of age, menopausal status and baseline sociodemographic variables on the trajectory of perceived stress over time. Results At baseline, mean age was 46.4 ± 2.7 years; participants were white (47%), black (29%), Hispanic (7%), Japanese (9%), or Chinese (8%). Hispanic women, women with lesser educational attainment, and women reporting financial hardship were each more likely to report high perceived stress levels at baseline (all p

Abstract Background Previous reports have noted that dehydroepiandrosterone-sulfate (DHEAS) increases prior to the final menstrual period (FMP) and remains stable beyond the FMP. How DHEAS concentrations correspond with other sex hormones across the menopausal transition (MT) including androstenedione (A4), testosterone (T), estrone (E1), and estradiol (E2) is not known. Our objective was to examine how DHEAS, A4, T, E1, and E2 changed across the MT by White vs. African-American (AA) race/ethnicity. Methods We conducted a longitudinal observational analysis of a subgroup of women from the Study of Women’s Health Across the Nation observed over 4 visits prior to and 4 visits after the FMP (n = 110 women over 9 years for 990 observations). The main outcome measures were DHEAS, A4, T, E1, and E2. Results Compared to the decline in E2 concentrations, androgen concentrations declined minimally over the MT. T (β 9.180, p < 0.0001) and E1 (β 11.365, p < 0.0001) were higher in Whites than in AAs, while elevations in DHEAS (β 28.80, p = 0.061) and A4 (β 0.2556, p = 0.052) were borderline. Log-transformed E2 was similar between Whites and AAs (β 0.0764, p = 0.272). Body mass index (BMI) was not significantly associated with concentrations of androgens or E1 over time. Conclusion This report suggests that the declines in E2 during the 4 years before and after the FMP are accompanied by minimal changes in DHEAS, A4, T, and E1. There are modest differences between Whites and AAs and minimal differences by BMI.

Abstract This commentary discusses the limited availability of information on contraceptive preferences and unmet need for contraception among midlife women in both high and low income countries. Given that risk of pregnancy continues until women reach menopause and given the increased risk of pregnancy complications, elective abortion, and maternal mortality in women aged 45 to 54 years old, increased focus on gathering basic data on midlife women’s preferences and unmet need is warranted.

Abstract Background Patterns of symptom clustering in midlife women may suggest common underlying mechanisms or may identify women at risk of adverse health outcomes or, conversely, likely to experience healthy aging. This paper assesses symptom clustering in the Study of Women’s Health Across the Nation (SWAN) longitudinally by stage of reproductive aging and estimates the probability of women experiencing specific symptom clusters. We also evaluate factors that influence the likelihood of specific symptom clusters and assess whether symptom clustering is associated with women’s self-reported health status. Methods This analysis includes 3289 participants in the multiethnic SWAN cohort who provided information on 58 symptoms reflecting a broad range of physical, psychological and menopausal symptoms at baseline and 7 follow-up visits over 16 years. We conducted latent transition analyses to assess symptom clustering and to model symptomatology across the menopausal transition (pre, early peri-, late peri- and post-menopausal). Joint multinomial logistic regression models were used to identify demographic characteristics associated with premenopausal latent class membership. A partial proportional odds regression model was used to assess the association between latent class membership and self-reported health status. Results We identified six latent classes that ranged from highly symptomatic (LC1) across most measured symptoms, to moderately symptomatic across most measured symptoms (LC2), to moderately symptomatic for a subset of symptoms (vasomotor symptoms, pain, fatigue, sleep disturbances and physical health symptoms) (LC3 and LC5) with one class (LC3) including interference in life activities because of physical health symptoms, to numerous milder symptoms, dominated by fatigue and psychological symptoms (LC4), to relatively asymptomatic (LC6). In pre-menopause, 10% of women were classified in LC1, 16% in LC2, 14% in LC3 and LC4, 26% in LC5, and 20% in LC6. Intensity of vasomotor and urogenital symptoms as well as sexual desire) differed minimally by latent class. Classification into the two most symptomatic classes was strongly associated with financial strain, White race/ethnicity, obesity and smoking status. Over time, women were most likely to remain within the same latent class as they transitioned through menopause stages (range 39–76%), although some women worsened or improved. The probability of moving between classes did not differ substantially by menopausal stage. Women in the highly symptomatic classes more frequently rated their health as fair to poor compared to women in the least symptomatic class. Conclusion Clear patterns of symptom clustering were present early in midlife, tended to be stable over time, and were strongly associated with self-perceived health. Notably, vasomotor symptoms tended to cluster with sleep disturbances and fatigue, were present in each of the moderate to highly symptomatic classes, but were not a defining characteristic of the symptom clusters. Clustering of midlife women by symptoms may suggest common underlying mechanisms amenable to interventions. Given that one-quarter of midlife women were highly or moderately symptomatic across all domains in the pre-menopause, addressing symptom burden in early midlife is likely critical to ameliorating risk in the most vulnerable populations.

Background Measures of subclinical atherosclerosis are predictors of future cardiovascular outcomes as well as of physical and cognitive functioning. The menopausal transition is associated with accelerated progression of atherosclerosis in women. The prospective association between a healthy lifestyle during the midlife and subclinical atherosclerosis is unclear. Methods and Results Self‐reported data on smoking, diet, and physical activity from 1143 women in the Study of Women's Health Across the Nation were used to construct a 10‐year average Healthy Lifestyle Score (HLS) during the midlife. Markers of subclinical atherosclerosis were measured 14 years after baseline and included common carotid artery intima‐media thickness (CCA‐IMT), adventitial diameter (CCA‐AD), and carotid plaque. The associations of average HLS with CCA‐IMT and CCA‐AD were estimated using linear models; the association of average HLS with carotid plaque was estimated using cumulative logit models. Average HLS was associated with smaller CCA‐IMT and CCA‐AD in the fully adjusted models (P=0.0031 and

BackgroundAdverse pregnancy outcomes, such as preterm birth (PTB), have been associated with elevated risk of maternal cardiovascular disease, but their effect on late midlife blood pressure (BP) and subclinical vascular measures remains understudied. Methods and ResultsWe conducted a cross‐sectional analysis with 1220 multiethnic parous women enrolled in SWAN (Study of Women's Health Across the Nation) to evaluate the impact of self‐reported history of adverse pregnancy outcomes (PTB, small‐for‐gestational‐age, stillbirth), on maternal BP, mean arterial pressure, and subclinical vascular measures (carotid intima‐media thickness, plaque, and pulse wave velocity) in late midlife. We also examined whether these associations were modified by race/ethnicity. Associations were tested in linear and logistic regression models adjusting for sociodemographics, reproductive factors, cardiovascular risk factors, and medications. Women were on average aged 60 years and 255 women reported a history of an adverse pregnancy outcome. In fully adjusted models, history of PTB was associated with higher BP (systolic: β=6.40; SE, 1.62 [P

Background Antihypertensive medication use may vary by race and ethnicity. Longitudinal antihypertensive medication use patterns are not well described in women. Methods and Results Participants from the Study of Women's Health Across the Nation (SWAN), a prospective cohort of women (n=3302, aged 42–52), who reported a diagnosis of hypertension or antihypertensive medication use at any annual visit were included. Antihypertensive medications were grouped by class and examined by race/ethnicity adjusting for potential confounders in logistic regression models. A total of 1707 (51.7%) women, mean age 50.6 years, reported hypertension or used antihypertensive medications at baseline or during follow‐up (mean 9.1 years). Compared with whites, blacks were almost 3 times as likely to receive a calcium channel blocker (odds ratio, 2.92; 95% CI, 2.24–3.82) and twice as likely to receive a thiazide diuretic (odds ratio, 2.38; 95% CI, 1.93–2.94). Blacks also had a higher probability of reporting use of ≥2 antihypertensive medications (odds ratio, 1.95; 95% CI, 1.55–2.45) compared with whites. Use of angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers and thiazide diuretics increased over time for all racial/ethnic groups. Contrary to our hypothesis, rates of β‐blocker usage did not decrease over time. Conclusions Among this large cohort of multiethnic midlife women, use of antihypertensive medications increased over time, with angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers becoming the most commonly used antihypertensive medication, even for blacks. Thiazide diuretic utilization increased over time for all race/ethnic groups as did use of calcium channel blockers among blacks; both patterns are in line with guideline recommendations for the management of hypertension.

Objective: To assess the prevalence of urogenital infection symptoms and their association with occupational stress among women working in export production factories in China. Methods: Six hundred and thirty-eight women workers in three factories in Tianjin, China were surveyed. Information was collected on women's demographic characteristics, levels of occupational stress, and urogenital infection symptoms. Data were analyzed using multiple logistic regression. Results: Among the 638 women who provided information on urogenital symptoms, 30.9% reported at least one symptom: 27.9% reported abnormal discharge, 2.4% reported genital sores, and 6.3% reported pain with urination. Feeling exhausted was associated with an increased risk for reporting genital sores [OR=1.35 (1.05, 1.73)] and pain with urination [OR=1.21 (1.06, 1.39)], while reporting low job security was significantly associated with reporting at least one symptom of urogenital infection [OR=1.51 (1.03, 2.20)]. Conclusions: Many women working in China's export factories report symptoms of urogenital infection. Occupational stress may be linked to an increased risk for urogenital infection. Focused efforts are needed to improve accessibility to reproductive health services for women working in China's export production factories.

Motivated by the study of the longitudinal development and progression of knee osteoarthritis (OA) over a 15-year period, this study developed non-parametric mixed-effect models for ordinal outcomes. A stochastic mixed-effect model was used to evaluate the similarity of trajectories associated with increasing disease severity of OA in both knees. Then, a non-parametric mixed-effects model, based on cubic B-splnes, was developed to characterize the unknown nonlinear trend of logits as a function of time1-order. A Markov Transition Model was developed to characterize the transitions among multi-states of knee OA. This newly developed approach allows more flexible functional dependence of the ordinal outcome, levels of increasing knee OA severity, on the covariates.

An integrative methodology is developed to characterize the complex patterns of change in highly variable dynamic biological processes. The method permits estimatation of the population mean profile, multiple change points and length of time-windows defined by any two change points of interest using a semi-/non-parametric stochastic mixed effect model and a Bayesian Modeling Average (BMA) approach to account for model uncertainty. It also allows estimation of the mean rate of change of sub-processes by fitting piecewise linear mixed effect models. The methodology is applied to characterize the stages of female ovarian aging and the menopausal transition defined by hormone measures of estradiol (E2) and follicle stimulating hormone (FSH) from two large-scale epidemiological studies with community-based longitudinal designs and ethnic diversity.

Objetivo. Estudiar la asociación entre condiciones de trabajo materno y bajo peso al nacer en la Ciudad de México. Material y métodos. Se encuestaron 2 623 trabajadoras que atendieron sus partos en tres grandes hospitales de la Ciudad de México en 1992. Se obtuvo información sobre los principales factores biológicos y sociales que se asocian al bajo peso al nacer; asimismo, se determinó el estrés ocupacional utilizando el instrumento desarrollado por Karasek. Se utilizaron modelos de regresión logística para evaluar la relación de las condiciones de trabajo con el bajo peso al nacer, controlando por variables confusoras. Resultados. El bajo peso al nacer fue más alto en trabajadoras con jornadas mayores a 50 horas semanales (RM= 1.6; IC= 1.17, 2.28) y con conflictos laborales (RM= 1.5; IC= 1.0, 2.25). La falta de apoyo social tangible fue identificado como un factor de riesgo de bajo peso al nacer (RM= 1.7; IC= 1.20, 2.33). Las medidas preventivas laborales como el cambio de tareas, disminución de la jornada y las salidas por enfermedad no mostraron un efecto benéfico en el peso al nacer, a excepción de la licencia de maternidad; las madres que no la tuvieron mostraron una probabilidad 2.2 veces mayor para bajo peso al nacer (IC= 1.66, 2.93). Conclusiones. Estos hallazgos resaltan la importancia de identificar los factores de riesgo ocupacional en el embarazo..Objective. To study the association between maternal working conditions and low birth-weight in Mexico City. Material and methods. Interviews of 2 623 workers who gave birth in Mexico City hospitals during 1992 were analyzed. Information on the main biologic and social factors associated to low birth-weight was registered. Occupational stress was determined with the instrument designed by Karasek. Logistic regression models to evaluate the relationship between working conditions and low birth-weight were used, controlling by confounding variables. Results. Low birth-weight was more frequent in workers with working periods of more than 50 h/week (OR= 1.6; 95% CI= 1.17, 2.28) and with problems at work (OR= 1.5; 95% CI= 1.0, 2.25). Lack of tangible social support was identified as a risk factor for low birth-weight (OR= 1.7; 95% CI= 1.20, 2.33). Preventive working measures such as changes in tasks, shortening of working hours and leaves of absence due to illness did not show a beneficial effects on birth-weight, except for the maternity leave of absence. Mothers with no right to this had a 2.2 higher probability of giving birth to low weight children (95% CI= 1.66, 2.93). Conclusions. These results emphasize the importance of identifying the occupational risk factors during pregnancy.

Background: High incidence of cervical cancer among Hispanics and low utilization of cervical screening among farmworkers led us to examine Pap test use and knowledge among Hispanic farmworkers in Michigan. Methods: Patients and potential patients of Northwest Michigan Health Services, Inc were surveyed in 2 communities (A and B) about their screening knowledge, attitudes, and practice. Results: In all, 324 farmworkers participated, including 184 seasonal and 125 migrant farmworkers. Among the entire study population, 87.7% women reported receiving a Pap test recently, with no difference between migrant and seasonal farmworkers (88.0% and 87.4%, respectively, P = .088). More women from community B reported a recent Pap (93%) compared with those from community A (83%, P = .01). Only 35% of the participants had knowledge of any cervical cancer risk factors. Discussion: Migrant farmworkers may not experience more difficulty in accessing Pap tests than seasonal farmworkers in Michigan. Knowledge about cervical cancer risk factors is low and needs to be addressed in future educational interventions.