4/17/2018. Gynecologic Care for Female Veterans. Objectives. No conflicts of interest to disclose

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1 Gynecologic Care for Female Veterans Raj Narayan, MD Associate Professor of OB/Gyn Medical College of Wisconsin Staff Physician, Gynecology Milwaukee VA Medical Center No conflicts of interest to disclose Objectives Understand the changing demographics in the female veteran population Identify unique challenges faced by female veterans including military sexual trauma Review recent research on care for female veterans 1

2 Breaking news In recent months Dr. Shulkin began to use a new, more inclusive motto for the department, changing the phrase To care for him who shall have borne the battle and for his widow, and his orphan so that it included female veterans, a former department official said. Mr. Ullyot, carrying out orders from the White House, reversed the decision, and Dr. Shulkin relented. Fandos N, Philipps D. In Battle Over Future of Veterans Care, Moderation Wins, for Now. New York Times. 3/6/2018. VA: Changing Demographic 1988 Women represented 4.4% Veteran population (1) Women Veterans Health Program created 2017 Women represented 8.7% of living Veterans 1) "Women Veterans Health Care" Accessed online 4/4/ ) National Center for Veterans Analysis and Statistics (2/2018). Profile of Veterans: 2016 Data from the American Community Survey. Accessed online 4/4/2018. Fewer women age yo than non-veterans (typically ages women may be in active duty) Mean female veteran age 50 compared to male veteran 65 National Center for Veterans Analysis and Statistics (2/2018). Profile of Veterans: 2016 Data from the American Community Survey. Accessed online 4/4/

3 More likely nonwhite, non-hispanic compared to non-veterans National Center for Veterans Analysis and Statistics (2/2018). Profile of Veterans: 2016 Data from the American Community Survey. Accessed online 4/4/2018. More likely to have some college, Bachelor s or Advanced degree compared to non-veterans National Center for Veterans Analysis and Statistics (2/2018). Profile of Veterans: 2016 Data from the American Community Survey. Accessed online 4/4/2018. Female veterans more likely to hold management/professional positions compared to nonveterans National Center for Veterans Analysis and Statistics (2/2018). Profile of Veterans: 2016 Data from the American Community Survey. Accessed online 4/4/

4 Fewer live at or below the poverty level compared to non-veterans Higher median personal income $30,493 for female Veterans compared to $18,030 for non-veterans Median household income higher for Veterans compared to non- Veterans across all age groups. National Center for Veterans Analysis and Statistics (2/2018). Profile of Veterans: 2016 Data from the American Community Survey. Accessed online 4/4/2018. Female veterans less likely to be uninsured compared to non-veterans Female veterans more likely than non-veterans to have combination of public and private insurance Employment second career after military service Use of VA health care National Center for Veterans Analysis and Statistics (2/2018). Profile of Veterans: 2016 Data from the American Community Survey. Accessed online 4/4/2018. Where do Female Veterans live? National Center for Veterans Analysis and Statistics (2/2018). Profile of Veterans: 2016 Data from the American Community Survey. Accessed online 4/4/

5 Where to Female Veterans access care? Increasing rate of utilization of VA benefits amongst female Veterans (1) Annual growth of female Veteran population ( ) 0.8% From , female Veterans increased by 7.7%; female VA users increased by 45.4% Annual growth of women using VA benefits 4.3% in the same time period Median age female VA users 46 yo; non-users 48 yo Most Veteran women access some or all of their care outside of the VA (2) 78% respondents in one study of VA users reported receiving GYN or reproductive care outside the VA in last 5 yrs (3) 1) National Center for Veterans Analysis and Statistics (11/2017). VA Utilization Profile FY Accessed online 4/4/ ) Lehavot K, Hoerster KD, et al. Health Indicators for Military, Veteran and Civilian Women. (2012). American Journal of Preventative Medicine. Vol 42 No 5. ( ). 3) Ryan GL, Mengeling MA, et al. Hysterectomy risk in premenopausal-aged military veterans: associations with sexual assault and gynecologic symptoms. (March, 2016). American Journal of Obstetrics and Gynecology. Vol 214, Issue 3. (352.e1-352.e13). Services at the MKE VA Women s Health primary care providers General gynecology care including procedures and GYN surgery Services not available: Obstetric care Sub-specialty GYN care Unique Healthcare Needs (MST) Higher rates of sexual assault (outside of military service) 62% respondents in one study reported sexual assault exposure during their lifetime (1) PTSD 10.4% in all women; 35-60% in female veterans; higher in women w/ MST Increased prevalence of hysterectomy Increased cardiac disease and risk factors (obesity, tobacco use, decreased exercise) Depressive and/or anxiety disorder Overactive Bladder - 22% (3) Ryan GL, Mengeling MA, et al. Hysterectomy risk in premenopausal-aged military veterans: associations with sexual assault and gynecologic symptoms. (March, 2016). American Journal of Obstetrics and Gynecology. Vol 214, Issue 3. (352.e1-352.e13). Lehavot K, Hoerster KD, et al. Health Indicators for Military, Veteran and Civilian Women. (2012). American Journal of Preventative Medicine. Vol 42 No 5. ( ). Bradley CS, Nygaard IE. Longitudinal Associations Between Mental Health Conditions and Overactive Bladder in Women Veterans. (10/2017). American Journal of Obstetrics and Gynecology. Issue 217 (430.e1-8) 5

6 Unique Healthcare Needs Ryan et al - Phone survey 989 VA-enrolled women <52 yo 60% sample reported at least one of following: GYN pain, GYN bleeding or PID 55% of above >/= 2 gyn symptoms Higher rates in women reporting sexual assault (69% versus 51% not assaulted p<0.0001) 65% reported hysterectomy at non-va facility Ryan GL, Mengeling MA, et al. Hysterectomy risk in premenopausal-aged military veterans: associations with sexual assault and gynecologic symptoms. (March, 2016). American Journal of Obstetrics and Gynecology. Vol 214, Issue 3. (352.e1-352.e13). Unique Healthcare Needs Lower self-reported scores in physical and mental health compared to general population, active duty and National Guard/Reserve (NG/R) More likely to report fair or poor health Higher frequency of medical and mental health conditions compared to non-veterans Despite protective factors: health insurance, higher income and education level Lehavot K, Hoerster KD, et al. Health Indicators for Military, Veteran and Civilian Women. (2012). American Journal of Preventative Medicine. Vol 42 No 5. ( ). Defined by the Department of Veterans Affairs as repeated, threatening sexual harassment that occurred while the Veteran was in the military Sexual activity against one s will Threat of negative consequences for refusing OR implied better treatment/promotion in exchange for sex Sex when unable to consent (e.g. intoxicated) Physical force Unwanted sexual touching/grabbing Threatening, offensive remarks about body or sexual activities and/or unwanted sexual advances (Accessed 4/11/2018) 6

7 (1) VA resources for MST: (2) Designated MST coordinator at every VA health care facility Provider training on MST MST-related mental health outpatient services Inpatient programs for acute-care needs (e.g. psychiatric emergencies) 1) (Accessed 4/11/2018) 2) Quick Facts About VA s Health Care Services for (MST). May, Accessed online on 4/11/2018. Prevalence Rates vary depending on method of assessment, definition of MST, etc In-person response % Mail/telephone resonse 17-30% Rate varies based on definition used in each study (e.g. assault versus any harassment) 22% of women per VA national MST survey (most studies ranges 20-43%) Significantly higher than civilian prevalence rates of sexual assault (16.7%) Suris A, Lind L. : A Review of Prevalence and Associated Health Consequences in Veterans. (2008). Trauma, Violence & Abuse. Vol 9, No 4 (250-69). Zinzow HM, Grubaugh AL, et al. Trauma Among Female Veterans: A Critical Review. (2007). Trauma Violence and Abuse. Vol 8, No 4 ( ). Risk factors: Entered military at a younger age Risk doubled for women entering at </= 19 yo Enlisted rank Combat exposure Less than college education History of prior childhood physical/sexual violence or rape Escape from home environment primary reason for entering military In-service sexual harassment associated with increased risk for sexual assault Suris A, Lind L. : A Review of Prevalence and Associated Health Consequences in Veterans. (2008). Trauma, Violence & Abuse. Vol 9, No 4 (250-69). Zinzow HM, Grubaugh AL, et al. Trauma Among Female Veterans: A Critical Review. (2007). Trauma Violence and Abuse. Vol 8, No 4 ( ). 7

8 Associated Mental Health consequences Increased number and severity of psychological symptoms (e.g. depression, alcohol abuse, eating disorders) 60% MST victims reported current depression in a national survey Increased rates of PTSD 9x greater than women w/ no sexual assault hx; 5x greater than those w/ civilian sexual trauma MST 4x more likely to cause PTSD than other military trauma Suris A, Lind L. : A Review of Prevalence and Associated Health Consequences in Veterans. (2008). Trauma, Violence & Abuse. Vol 9, No 4 (250-69). Himmelfarb N, Yaeger D, Mintz J. Posttraumatic Stress Disorder in Female Veterans with Military and Civilian Sexual Trauma. (2006). Journal of Traumatic Stress, Vol 19, No 6 ( ). Associated physical symptoms/diseases MST survivors report significantly more physical symptoms Pelvic pain, menstrual problems, back pain, headaches, GI symptoms, chronic fatigue Obesity, smoking, sedentary lifestyle Suris A, Lind L. : A Review of Prevalence and Associated Health Consequences in Veterans. (2008). Trauma, Violence & Abuse. Vol 9, No 4 (250-69). MST and Chronic Pain Cichowski S, et al. Retrospective study using VHA Corporate Data Warehouse, compared prevalence of chronic pain disorders in Veterans with and without MST Cohort 516,950 women who established care w/ VA PCP since 1997: 123,417 w/ MST; 393,533 no MST VA EHR validated questionnaire for MST ICD-9 codes for: chronic pelvic pain, endometriosis, interstitial cystitis, IBS, headaches, generalized abdominal pain, fibromyalgia, chronic pack pain, dyspareunia and vulvodynia Excluded: MST response unknown/not asked; history of appendicitis, abdominal/pelvic cancer, adnexal torsion, diverticulitis Cichowski ST, Rogers RG, et al. in Female Veterans is Associated with Chronic Pain Conditions. (2017). Military Medicine. Vol 182. (e1895-e1899). 8

9 MST and Chronic Pain Cichowski, et al. Women with MST more concurrent diagnoses of all pain conditions studied (p<0.001, OR 1.26 CI ) Association remained for IBS, CPP, back pain, chronic joint pain, fibromyalgia, dyspareunia, chronic abdominal pain and headache when adjusting for baseline differences in age, BMI, smoking, ethnicity. Association did not remain for vulvodynia when controlling for above differences Cichowski ST, Rogers RG, et al. in Female Veterans is Associated with Chronic Pain Conditions. (2017). Military Medicine. Vol 182. (e1895-e1899). MST and Chronic Pain Haskell et al. 213 women VA Connecticut Healthcare System outpatient women s health clinic from 10/2004-3/2005 Anonymous questionnaire given to all women during the eligible period. Persistent pain associated with having two or more chronic conditions and depression symptom severity score not significantly associated with reported sexual trauma Greater pain severity significantly associated with reported sexual trauma (p<0.05) Haskell SG, Papas RK, et al. The Association of Sexual Trauma with Perisstent Pain in a Sample of Women Veterans Receiving Primary Care. (2008). Pain Medicine. Vol 9, No 6. ( ). Veteran Women and Hysterectomy Ryan et al. Telephone interviews 7/2005-8/2008 of 989 VAenrolled veterans <52 yo from 2 Midwest centers and outreach clinics; compared to data from large civilian database during similar timeframe Increased hysterectomy in Veterans vs. Civilians 16.8% Veteran group versus 13.3% civilian (p=0.002) Younger age at time of hysterectomy 35 yo Vet vs 43 yo civilian (p<0.0001) Indication for hysterectomy consistent with commonly cited indications noted in the literature and consistent w/ indications from civilian data Higher rates d/t pelvic pain in Veteran group (71% compared to 5% in civilian data set) Ryan GL, Mengeling MA, et al. Hysterectomy risk in premenopausal-aged military veterans: associations with sexual assault and gynecologic symptoms. (March, 2016). American Journal of Obstetrics and Gynecology. Vol 214, Issue 3. (352.e1-352.e13). 9

10 Hysterectomy and Hx Sexual Assault Ryan, et al. Compared hysterectomy prevalence by sexual assault status Vet group w/ LSA-V twice as likely to undergo hysterectomy vs no SA >/= 4 lifetime LSA-V and LSA- NV significantly more likely to have hyst compared with 3 or fewer assaults Association no longer significant when controlling for GYN pain, bleeding, PID, PTSD Ryan GL, Mengeling MA, et al. Hysterectomy risk in premenopausal-aged military veterans: associations with sexual assault and gynecologic symptoms. (March, 2016). American Journal of Obstetrics and Gynecology. Vol 214, Issue 3. (352.e1-352.e13). Childlessness and Hx Sexual Assault Ryan et al Telephone interviews 7/2005-8/2008 of 1004 VA-enrolled veterans <52 yo from 2 Midwest centers and outreach clinics 62% reported lifetime sexual assault exposure (LSA); 51% completed sexual assault Mean 7 sexual assaults Women with LSA: Increased rates of pregnancy termination (31% LSA versus 19% no-lsa) Higher termination rates reported during military service Increased rates infertility (23% LSA versus 12% no-lsa) Findings remained when controlling for depression, postpartum dysphoria, PTSD or STI 23% reported delaying/foregoing pregnancy as a result of the rape Ryan GL, Mengeling MA, et al. Voluntary and Involuntary Childlessness in Female Veterans: Associations with Sexual Assault. (8/2014). Fertility and Sterility. Vol 102, Issue 2. ( ). OAB Association with Mental Health Conditions Bradley et al 1-year prospective cohort study - telephone interviews women veterans previously deployed to Iraq/Afghanistan within 2 years of enrollment and separated from military service Excluded urologic or neurologic conditions that may cause urinary symptoms; current or pregnancy within past 3 months Phone interview at enrollment (1702) and 1 year later (1107) Bradley CS, Nygaard IE. Longitudinal Associations Between Mental Health Conditions and Overactive Bladder in Women Veterans. (10/2017). American Journal of Obstetrics and Gynecology. Issue 217 (430.e1-8) 10

11 OAB Association with Mental Health Conditions New OAB increased in patients with baseline PTSD (18.7%) versus no PTSD (9.4%), p<0.01; anxiety (OR 2.4) and sexual assault (OR 1.7) Anxiety and sexual assault predicted OAB at 1 year Remission at 1 year significantly less often in patients with baseline depression (19.2% versus 41.3% no depression) and anxiety (28.7% vs 42.2% no anxiety) PTSD and prior sexual assault not associated w/ OAB remission OAB at baseline had increased risk of PTSD at 1 year but not anxiety/depression Bradley CS, Nygaard IE. Longitudinal Associations Between Mental Health Conditions and Overactive Bladder in Women Veterans. (10/2017). American Journal of Obstetrics and Gynecology. Issue 217 (430.e1-8) Take-Aways Women Veterans may be your patients! Important to consider unique healthcare needs of female veterans when providing care /Lifetime sexual assault MST treatment resources available at local VA Associated with mental/physical co-morbidities Mental health disorders GYN disorders - OAB, pelvic pain, hysterectomy Medical co-morbidities - obesity, CV risk factors Questions? 11