Specific and unspecific gynecological alarm symptoms prevalence estimates in different age groups: a populationbased

Transcription

1 A C TA Obstetricia et Gynecologica AOGS MAIN RESEARCH ARTICLE Specific and unspecific gynecological alarm symptoms prevalence estimates in different age groups: a populationbased study KIRUBAKARAN BALASUBRAMANIAM 1, PERNILLE RAVN 2, PIA V. LARSEN 1, JENS SØNDERGAARD 1 & DORTE E. JARBØL 1 1 Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, Odense, and 2 Department of Gynecology and Obstetrics, Odense University Hospital, Odense, Denmark Key words Symptoms, gynecological cancer, symptom patterns, self-reported, general population Correspondence Kirubakaran Balasubramaniam, Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, DK 5000 Odense, Denmark. kiruba@health.sdu.dk Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article. Please cite this article as: Balasubramaniam K, Ravn P, Larsen PV, Søndergaard J, Jarbøl DE. Specific and unspecific gynecological alarm symptoms prevalence estimates in different age groups: a population-based study. Acta Obstet Gynecol Scand 2015; 94: Received: 19 June 2014 Accepted: 6 November 2014 DOI: /aogs Abstract Objective. To determine prevalence estimates of gynecological alarm symptoms in different age groups and to describe common patterns of gynecological symptoms. Design. Web-based cross-sectional survey study. Setting. Nationwide in Denmark. Population. A random sample of women aged 20 years or above from the general population. Methods. An internet-based questionnaire study regarding the prevalence estimates of symptom experiences. A total of 18 symptoms of cervical, endometrial and ovarian cancer were selected through an extensive literature search, which included national and international guidelines. Main outcome measures. Prevalence estimates of self-reported experience of gynecological alarm symptoms within the preceding 4 weeks. Results. A total of women (54.5%) participated in the study. Some 80.3% had experienced at least one of the alarm symptoms within the preceding 4 weeks, and the median number of experienced symptoms was 2 (interquartile range 1 4). The most common symptoms were tiredness (53.0%) and abdominal bloating (36.7%); postmenopausal bleeding (2.3%) and involuntary weight loss (2.8%) were least frequent. Most of the symptoms were more prevalent among younger women, whereas only dyspnea and increased urgency of urination were more frequent among older women. Among younger women, multiple abdominal symptoms often occurred simultaneously and frequently in combination with pelvic pain, whereas older women were more likely to report single symptoms. Conclusions. Gynecological alarm symptoms are frequent in the general population, mostly among younger women. Older women reported fewer symptoms, and these often appeared as single symptoms. Abbreviations: IQR, interquartile range. Introduction Means of promoting better survival among cancer patients have included improvement of surgical procedures, radiation therapy and development of new chemotherapeutics, but also implementation of organizational changes such as centralized treatment facilities and clinical guidelines. A cornerstone in the clinical guidelines is that individuals experiencing alarm symptoms should Key Message Experiencing gynecological symptoms is common, especially among younger women, who often report multiple symptoms. Abdominal symptoms frequently occur together with pelvic pain among the younger women. In contrast, older women report fewer symptoms, often as single symptoms. ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

2 Gynecological alarm symptoms K. Balasubramaniam et al. immediately be referred to specialized surgical or oncological centers (1,2). For such an approach to be efficient and cost-effective, the symptoms must to a reasonable degree be indicative of cancer disease. Most of the existing knowledge about alarm symptoms is based on retrospective data from patients already diagnosed with cancer and may therefore be flawed by recall bias. Some alarm symptoms are easily recognizable and distinctive, such as postmenopausal bleeding, whereas others are more unspecific and vague, such as tiredness and weight loss. How often alarm symptoms occur in an unselected population is uncertain, which hampers the applicability of the guidelines to the general population. Recent studies have demonstrated that alarm symptoms associated with breast, colorectal, urinary tract and lung cancer are very frequent in the general population (3). Similar circumstances are likely to be the case with regard to symptoms attributed to gynecological cancers, but the occurrence of these symptoms in the general population has not been explored in large population-based studies. Most guidelines regarding gynecological cancers do not take age into account when providing strategies for managing alarm symptoms, but both normal physiological changes and pathological conditions are dependent on age. Consequently, the occurrence of symptoms is likely to vary in different age groups. If this is not taken into consideration, it may lead to a different diagnostic precision in different age groups. In addition, symptoms are often considered single entities in the present guidelines, although from a clinical point of view it is well known that symptoms often occur as part of a complex picture in which several symptoms are present. In general, cancer diseases are believed to present with a number of simultaneous symptoms, but whether these symptoms also occur together in the general population has not been explored in detail (4 6). The aim of the present study was to obtain prevalence estimates of a number of gynecological alarm symptoms in a large population-based setting, and to explore how these prevalence estimates vary with age. Furthermore, the most common complexes or patterns of symptoms are described. Material and methods This web-based nationwide cross-sectional questionnaire study was part of the Danish Symptom Cohort (DaSC), a large questionnaire-based population study of the prevalence of symptom experiences in the general population. The data collection was conducted from June to December All Danish citizens are registered in the Danish Civil Registration System with a unique personal identification number enabling accurate linkage between national registers (7). A random sample of adults aged 20 or above was drawn from the Civil Registration System. In the sampling procedure, individuals who had indicated in the Civil Registration System that they did not want research-related inquiries were not included. Of the invited individuals, (51.1%) were women. Only data for the women are included. The participants in the study were informed that there would be no clinical follow-up, and that they should contact their own general practitioner in case of concern. The Regional Scientific Ethics Committee for Southern Denmark was notified prior to the survey and had no concerns regarding this project. The project has been approved by the Danish Data Protection Agency (j.nr ). The questionnaire was designed on the internet-based platform SurveyXact, and the invited individuals received a unique 12-digit login by postal letter (8). This login had to be entered on a secure webpage to access the questionnaire. Individuals who could not fill in the questionnaire on the electronic platform, were given the opportunity to complete the survey as a telephone interview conducted by trained interviewers. The questionnaire contained a number of symptom-related items, including occurrence of self-reported symptoms within a 4-week time period. Symptoms of cervical, endometrial and ovarian cancer were selected through an extensive literature search, which included national and international guidelines (2,9 12). Prior to inclusion in the questionnaire, the symptoms were reviewed by the project group. Only symptoms considered to be easily understood and assessed by the respondents were included. The gynecological alarm symptoms considered in the present paper are listed in Table 1. Regarding the more intimate symptoms, i.e. pelvic pain, pain during intercourse, bleeding after intercourse and postmenopausal bleeding, additional response categories to yes and no were available. Regarding pelvic pain, the respondent could answer not relevant for me, whereas pain during intercourse, bleeding after intercourse and postmenopausal bleeding could be answered with not relevant for me or do not wish to answer. The development of the questionnaire followed standardized and widely recognized procedures, including pilot testing (13). Prior to pilot testing, the questionnaire was discussed in an academic setting with researchers in the fields of healthcare, natural sciences and humanities. These discussions led to minor changes in the questionnaire. The first step of the pilot test was conducted by observing completion of the questionnaire, i.e. respondents filled in the questionnaire while remarking on problems and attitudes in relation to the questions. This step led to essential alterations in the captions, and subse- 192 ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

3 K. Balasubramaniam et al. Gynecological alarm symptoms Table 1. Gynecological alarm symptoms. Specific alarm symptoms Pelvic pain Postmenopausal bleeding Bleeding during intercourse Pain during intercourse Unspecific alarm symptoms Abdominal pain Nausea Abdominal bloating Change in stool texture Change in bowel movement frequency Constipation Increased waist circumference Increased frequency of urination Increased urgency of urination Tiredness Involuntary weight loss Dyspnea Back pain Loss of appetite quently the second round of pilot testing was conducting. The second pilot test was carried out in the same way as the first one and yielded a few further alterations. The final version of the questionnaire was field-tested on 500 individuals randomly sampled from the Civil Registration System prior to the survey. Further details of the design of the study and the process of data collection are described in a separate article (14). Statistical analysis Prevalence estimates of each alarm symptom are reported as percentages (%) with 95% confidence intervals, based on the binominal distribution. Answers classified as not relevant for me were excluded from the analyses, whereas do not wish to answer answers were treated as missing. Two sensitivity analyses were conducted to explore the effects on the results if all individuals who stated do not wish to answer had either experienced the given symptom or not. The prevalence of symptoms is presented separately for the following age groups: years, years and 60+ years. We tested whether the prevalence estimates differed between age groups using chi-squared tests. The number of gynecological alarm symptoms reported by each individual was calculated for each age group. To explore common patterns of symptom experiences in the population, a cluster analysis using simple matching as dissimilarity measure and Ward s linkage was performed (15). Data analyses were conducted using STATA statistical software 13.1 (StataCorp, College Station, TX, USA). Results A total of women returned the questionnaire, yielding a response rate of 54.5%. Reasons for non-participation are shown in Figure 1. The median age of the participants was 51 years [interquartile range (IQR) 39 63] and 53 years (IQR 37 71) for non-participants. Regarding the more intimate questions the proportion of respondents not wishing to answer ranged from 1.25% for postmenopausal bleeding to 2.49% for pain during intercourse. The results show that experiencing a gynecological alarm symptom is common. Only 19.7% of the respondents reported that they had not experienced any of the symptoms in the preceding 4 weeks. Experiencing symptoms was more frequent in the younger age groups, with 92.1% of the individuals aged years reporting at least one symptom experience, compared to individuals aged years (82.4%) and 60+ years (68.5%), respectively. Similarly, the number of symptoms experienced was highest in individuals aged years, compared with individuals aged years and 60+ years (Table 2). The median number of reported symptoms was 4 (IQR 2 6) among the youngest women, compared with 2 (IQR 1 4) and 1 (IQR 0 3) among women aged years and women aged 60 or more, respectively. There was a large variation in the prevalence estimates of the different symptoms in the overall study population. The least common symptom reported was postmenopausal bleeding with a prevalence of 2.3%, and the most common symptom was tiredness, which was reported by 53.0% of the population (Table 3). The sensitivity analyses showed nearly the same prevalence estimates as in Table 3, under the assumption that individuals stating do not wish to answer did not experience the given symptom. Assuming that all individuals stating do not wish to answer had indeed experienced the given symptom, resulted in prevalence estimates slightly higher than in Table 3: 16.5% (pelvic pain), 4.2% (postmenopausal bleeding), 5.7% (bleeding during intercourse) and 13.0% (pain during intercourse). The three age groups presented with markedly different prevalence estimates for each symptom (all p < 0.001) (Table 3). For most of the symptoms the estimates were highest in the youngest age group. Only dyspnea and increased urgency of urination were more frequent among women in the oldest age group. The cluster analysis revealed a number of frequent symptom complexes in the youngest age group. In particular, the analysis indicated a cluster of women with multiple abdominal symptoms, and a cluster of women with multiple abdominal symptoms in combination with pelvic pain (Table 4). In the older age groups there were also ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

4 Gynecological alarm symptoms K. Balasubramaniam et al. Sampling frame: randomly selected Danish women aged 20 years or more Eligible for the study: (95.1 %) Excluded: (4.9 %) Dead: 157 Addresses unknown: 394 Suffering from severe illness (including dementia): Language problems: 464 Moved abroad: 284 Non-respondents: (45.5 %) Respondents: (54.5 %) Completed the web-based questionnaire: (97.1 %) Completed the questionnaire by telephone interview: 770 (2.9 %) Not wishing to participate (indicated by telephone/ or postal contact): Indicated other reasons for non-participation: 162 Questionnaire not completed (no achieved contact in the reminder procedure): Figure 1. Study cohort. clusters of women with multiple abdominal symptoms, but the clusters were smaller, and the abdominal symptoms were less likely to occur in combination with pelvic pain. Only 3.6% of the women aged 60 years or more experienced at least one abdominal symptom in combination with pelvic pain, compared with 12.1 and 27.4% in women aged years and years, respectively. Women in the oldest age group generally tended to report solitary symptoms or a symptom in combination with tiredness and/or back pain. The occurrence of tiredness and back pain was high in all three age groups, and both symptoms often occurred in combination with all the other symptoms and symptom complexes. Discussion This study adds to existing knowledge that having experienced a gynecological alarm symptom within the preceding 4 weeks is very common in the general population. Most of the symptoms as well as the number of symptoms experienced by each individual (as a proxy for the symptom burden) were reported more frequently among younger women. The cluster analysis indicated a number of clusters among young women experiencing multiple abdominal symptoms, whereas women in the oldest age group more often reported solitary symptoms or a symptom in combination with tiredness or back Table 2. Number of symptoms experienced per individual in different age groups years (n = 6712) years (n = ) 60 years or above (n = 8637) Total (n = ) Number of symptoms n % n % n % n % ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

5 K. Balasubramaniam et al. Gynecological alarm symptoms Table 3. Prevalence of symptom experiences in each age group years (n = 6712) years (n = ) 60 years or above (n = 8637) Total (n = ) Symptom n % (95% CI) n % (95% CI) n % (95% CI) n % (95% CI) Specific alarm symptoms Pelvic pain a ( ) ( ) ( ) ( ) Postmenopausal bleeding b ( ) ( ) ( ) ( ) Bleeding during intercourse c ( ) ( ) ( ) ( ) Pain during intercourse c ( ) ( ) ( ) ( ) Unspecific alarm symptoms Abdominal pain ( ) ( ) ( ) ( ) Nausea ( ) ( ) ( ) ( ) Abdominal bloating ( ) ( ) ( ) ( ) Change in stool texture ( ) ( ) ( ) ( ) Change in bowel movement ( ) ( ) ( ) ( ) frequency Constipation ( ) ( ) ( ) ( ) Increased waist circumference ( ) ( ) ( ) ( ) Increased frequency of urination ( ) ( ) ( ) ( ) Increased urgency of urination ( ) ( ) ( ) ( ) Tiredness ( ) ( ) ( ) ( ) Involuntary weight loss ( ) ( ) ( ) ( ) Dyspnea ( ) ( ) ( ) ( ) Back pain ( ) ( ) ( ) ( ) Loss of appetite ( ) ( ) ( ) ( ) a Including only women willing to answer questions regarding the symptom. b Including only women indicating that they were postmenopausal and willing to answer questions regarding the symptom. c Including only women indicating that they were sexually active and willing to answer questions regarding the symptom. pain. Furthermore, women in the youngest age group often experienced abdominal symptoms in combination with pelvic pain. A major strength of the present study is the large number of participants, which increases the precision of prevalence estimates of rare symptoms. To our knowledge such a large-scale study has not been conducted previously. The study population was intended to be as representative of the general population as possible with regard to age composition, socioeconomic status, ethnicity and health status, thus minimizing the risk of selection bias. However, the respondents were slightly younger than the non-respondents, suggesting that other differences between respondents and non-respondents might also be present. A general weakness of questionnaire-based studies is that the respondents may understand or interpret the items differently than intended. To minimize this source of bias, we conducted pilot studies and field testing and made adjustments in items and formulations prior to the Table 4. Prevalence of multiple abdominal symptoms per individual in each age group years (n = 6712) years (n = ) 60 years or above (n = 8637) Symptoms n % n % n % 0 abdominal symptoms a abdominal symptom a abdominal symptoms a abdominal symptoms a abdominal symptoms a + pelvic pain a Abdominal pain, nausea, abdominal bloating, increased waist circumference, change in stool texture, change in bowel movement frequency, constipation. ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

6 Gynecological alarm symptoms K. Balasubramaniam et al. final questionnaire. To measure the prevalence of certain symptom experiences, the final questionnaire was based on predefined symptoms, thus reducing the risk of information and recall bias. The questionnaire included commentary boxes in which respondents were able to report symptoms or symptom experiences other than the prespecified ones. Only very few respondents used the commentary boxes, suggesting that the comprehensiveness and comprehensibility of the questionnaire were high. Some of the symptoms mentioned in the questionnaire were intimate and thus the opportunity to answer do not wish to answer was given. Very few of the respondents chose not to answer the questions, and the sensitivity analyses did not change the results markedly, considering that the symptoms are rare and it is very unlikely that all respondents not wishing to answer had experienced the symptoms. This underlines the robustness of our findings. Our results add to those of other studies, namely that many of the symptoms attributed to cancer diseases are quite frequent in the general population. However, differences in study population and recall interval impede direct comparisons. Few studies have explored prevalence estimates of symptoms in an unselected population. One study found that the 12-month cumulative incidence of postcoital bleeding was 6% (16), compared with the 3% who had experienced postcoital bleeding within the preceding four weeks in the present study. A study by Sandler et al. (17) found prevalence estimates of abdominal pain and bloating in the preceding month of 24.4% and 19.2%, respectively. However, in their study the participants were asked not to report any symptoms thought to be related to menstruation. We did not make such restrictions on symptom report, which may explain the higher prevalence estimates for abdominal pain and bloating found in our study (24.6 and 36.7%, respectively). In a recent study, Low et al. (18) investigated the prevalence of gynecological alarm symptoms in a population-based study and found that 44% of the study population had experienced at least one alarm symptom, compared with 80.3% in our study population. However, there are some differences between the two studies which may explain the higher prevalence in our study. Low et al. (18) reported the occurrence of 13 symptoms within the past 3 months, which differs from items in the present study, where 18 symptoms were experienced within the past 4 weeks. Further, in the study by Low et al. the symptoms were reported during a face-to-face survey, whereas our study is based on questionnaires completed on the internet or through telephone interviews. We found that the prevalence of most of the symptom experiences decreased with increasing age. This tendency has been described in previous studies (19,20). One explanation for the results in the present study may be that some of the symptom experiences could be associated with the normal menstrual cycle, for example pelvic pain, abdominal pain, bloating and increased waist circumference, and hence these symptoms will be more frequent in the younger population (21,22). An additional explanation could be that there might be some inattention to or acceptance of certain symptoms in the older segments of the population. With increasing age, women are likely to have experienced pelvic pain many times before and thus perceive these symptoms less alarming over time. This may in turn lead to an underreporting of symptom experiences in the oldest age group. Further, it is possible that younger women are more aware of symptoms when they interfere with the demands of everyday life such as studies, career and children, in contrast to older women without the same demands, thus resulting in the differences in reported symptom experiences. The intention of fast diagnosis and treatment is commendable, but if an approach based on alarm symptoms is to be efficient and cost-effective, the symptoms must to a reasonable degree be indicative of cancer disease. However, many of these symptoms are very common, and studies from a general practice setting have demonstrated that the predictive values for cancer disease of alarm symptoms generally are low (23). Hence investigating every woman experiencing any of these symptoms for gynecological malignancy would be inappropriate utilization of health care resources. Our study contributes with knowledge on the presence of gynecological alarm symptoms in a general population, and future studies on our study population will provide further insight into the predictive values of the different symptoms included in the guidelines. Data on experienced symptoms will prospectively be linked to information on emerging diseases obtained from national registers. By doing so it is possible to evaluate the predictive values of the symptoms with minimal risk of recall bias. Furthermore, the large study population may provide the possibility of identifying subgroups in the population in which symptoms may be useful to predict serious diseases, including cancer. This, in turn, could help healthcare providers and policy makers implement earlier and more effective healthcare utilization. Conclusion We found that having a gynecological alarm symptom is very common in the general population. A large variation in the frequencies of different alarm symptoms was seen. Younger women were more likely to report most of the symptoms. Similarly, the number of symptoms (as a proxy for the symptom burden) was higher in the 196 ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)

7 K. Balasubramaniam et al. Gynecological alarm symptoms younger population. Multiple abdominal symptoms often occur simultaneously and often in combination with pelvic pain. These symptom complexes were more common among younger women than older women, who were more likely to experience solitary symptoms. Funding The study is financially supported by the Novo Nordisk Foundation and the Danish Cancer Society, the Region of Southern Denmark, the University of Southern Denmark and Eva and Henry Fraenkel Memorial Fund. Acknowledgments The Danish Symptom Cohort is conducted as a collaboration between University of Southern Denmark and Aarhus University, and the project is imbedded in the research portfolio at the Research Center for Cancer Diagnosis in Primary Care (CaP). The questionnaire, on which the study is based, was developed in collaboration with Sanne Rasmussen, Sandra Elnegaard, Rikke Pilsgaard Svendsen, Anette Fischer Pedersen, Rikke Sand Andersen and Peter Vedsted. References 1. The Danish National Board of Health. National cancer plan II. Copenhagen: National Board of Health, National Institute for Health and Clinical Excellence. Referral guidelines for suspected cancer. London: NICE, Svendsen RP, Stovring H, Hansen BL, Kragstrup J, Sondergaard J, Jarbol DE. Prevalence of cancer alarm symptoms: a population-based cross-sectional study. Scand J Prim Health Care. 2010;28: Goff B. Symptoms associated with ovarian cancer. Clin Obstet Gynecol. 2012;55: Hamilton W, Peters TJ, Round A, Sharp D. What are the clinical features of lung cancer before the diagnosis is made? A population based case-control study. Thorax. 2005;60: Hamilton W, Round A, Sharp D, Peters TJ. Clinical features of colorectal cancer before diagnosis: a population-based case-control study. Br J Cancer. 2005;93: Thygesen LC, Daasnes C, Thaulow I, Bronnum-Hansen H. Introduction to Danish (nationwide) registers on health and social issues: structure, access, legislation, and archiving. Scand J Prim Health. 2011;39(7 Suppl): SurveyXact [Computer program]. Rambøll Management Consulting, The Danish National Board of Health. Pakkeforløb for kræft i æggestokkene [Cancer package for ovarian cancer]. Copenhagen: National Board of Health, The Danish National Board of Health. Pakkeforløb for kræft i livmoderen [Cancer package for endometrial cancer]. Copenhagen: National Board of Health, The Danish National Board of Health. Pakkeforløb for livmoderhalskræft [Cancer package for cervical cancer]. Copenhagen: National Board of Health, National Institute for Health and Clinical Excellence. The recognition and initial management of ovarian cancer. London: NICE, de Vet HCW, Terwee CB, Mokkink LB, Knol DL. Measurement in medicine a practical guide. Cambridge: Cambridge University Press, Rasmussen S, Sondergaard J, Larsen PV, Balasubramaniam K, Elnegaard S, Svendsen RP, et al. The Danish Symptom Cohort: Questionnaire and Feasibility in the Nationwide Study on symptom experience and healthcare-seeking among individuals. Int J Family Med. 2014;2014: Kaufman L, Rousseeuw PJ. Finding groups in data: an introduction to cluster analysis. Hoboken: John Wiley & Sons, Shapley M, Jordan K, Croft PR. An epidemiological survey of symptoms of menstrual loss in the community. Br J Gen Pract. 2004;54: Sandler RS, Stewart WF, Liberman JN, Ricci JA, Zorich NL. Abdominal pain, bloating, and diarrhea in the United States: prevalence and impact. Dig Dis Sci. 2000;45: Low EL, Simon AE, Waller J, Wardle J, Menon U. Experience of symptoms indicative of gynecological cancers in UK women. Br J Cancer. 2013;109: Svendsen RP, Paulsen MS, Larsen PV, Hansen BL, Stovring H, Jarbøl DE, et al. Associations between reporting of cancer alarm symptoms and socioeconomic and demographic determinants: a population-based, cross-sectional study. BMC Public Health. 2012;12: McAteer A, Elliott AM, Hannaford PC. Ascertaining the size of the symptom iceberg in a UK-wide community-based survey. Br J Gen Pract. 2011;61:e Moore J, Barlow D, Jewell D, Kennedy S. Do gastrointestinal symptoms vary with the menstrual cycle? BJOG. 1998;105: Bernstein MT, Graff LA, Avery L, Palatnick C, Parnerowski K, Targownik LE. Gastrointestinal symptoms before and during menses in healthy women. BMC Womens Health. 2014;14: Astin M, Griffin T, Neal RD, Rose P, Hamilton W. The diagnostic value of symptoms for colorectal cancer in primary care: a systematic review. Br J Gen Pract. 2011;61: e ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015)