Tomi Sakari Mikkola

Context: Both a history of pre-eclampsia and the use of menopausal hormone therapy (MHT) are determinants of breast cancer (BC) risk. Objective: To study the effects of prior pre-eclampsia and MHT use on BC risk. Design: Register-based cohort study with follow-up for BC (Finnish Cancer Register 1987-2023) and MHT use (National Reimbursement Register 1994-2019). Setting: Nationwide population-based study in Finland. Participants: Women with prior pre-eclampsia (n = 31 688) and age-matched control women without pre-eclampsia (n = 91 726) who had given birth in 1969-1993. Intervention: The BC risks were compared between prior pre-eclamptic and control women and between prior pre-eclamptic MHT users and nonusers. Results: Breast cancer occurred less frequently (P = .02) in prior pre-eclamptic women (6.6%, n = 2095) than in the controls (7.0%, n = 6410). The age-adjusted BC risk in prior pre-eclamptic women (adjusted hazard ratio (aHR) = 0.89, 95% CI 0.83-0.94) was reduced. No clinical characteristics from pre-eclamptic pregnancy (eg, severity) predicted the magnitude of the BC risk reduction. Menopausal hormone therapy use was accompanied with comparable BC risk rise in prior pre-eclamptic and control women (1.25, 1.12-1.40 vs 1.30, 1.18-1.42). The increased risk with any MHT use was seen in both cohorts already after 5 years. This was primarily associated with estrogen–progestogen use, whereas estrogen only was not associated with BC risk in prior pre-eclamptic women. Conclusion: Breast cancer risk is reduced in women with a history of pre-eclampsia. The MHT-associated increase in BC risk is similar among women with or without a history of pre-eclampsia. Thus, pre-eclampsia is no contraindication for the use of MHT.

Introduction and Hypothesis: Since 2018 we have offered polyacrylamide hydrogel (PAHG) injection as an alternative to tension-free vaginal tape (TVT) for primary stress urinary incontinence (SUI). Our study aim was to investigate patient choice, demographics, re-treatments, and complications for these procedures. Methods: Patient demographics were collected from the Hospital Registry for women with primary SUI treated with TVT or PAHG, including patient age, body mass index, smoking status, obstetric history, and prior pelvic surgeries. Re-treatments and complications were collected at 2-year follow-up after each primary procedure. Results: Among 391 primary procedures, 55% (n = 217) of women chose the TVT and 45% (n = 174) the PAHG treatment, with similar patient demographics. Within 2 years, the re-treatment rates were 0.9% (n = 2) for TVT and 27.0% (n = 47) for PAHG (p < 0.001). Among patients undergoing re-treatment after primary PAHG, 57.4% (n = 27) opted for re-injection and 42.6% (n = 20) chose a mid-urethral sling. Three patients received TVT after two PAHG injection treatments. Complications occurred in 14.3% and 9.2% after TVT and PAHG respectively (p = 0.124). Complications after TVT ranged from Clavien–Dindo grades I–IIIb, with 4.1% of patients requiring reoperations, whereas PAHG complications were grades I–II with no reoperations. Including re-treatments, complication rates were 14.3% (TVT) and 10.9% (PAHG; p = 0.322). Conclusions: Similar clinical profiles in both TVT and PAHG groups suggest no specific demographic factors predict decision making. After a 2-year follow-up, the overall complication rates were similar, with PAHG associated with a higher likelihood of requiring re-treatment, whereas TVT carried a greater risk of severe complications. The re-treatment rates were lower than previously reported, indicating that actual patients are fairly satisfied with their primary choice.

Context: Women with a history of preeclamptic pregnancy are predisposed to later occlusive vascular diseases. Objective: We compared the use of cyclic progestins or levonorgestrel-releasing intrauterine device (LNG-IUD) for treatment of menstrual cycle abnormalities between premenopausal women with and without a prior preeclamptic pregnancy. Methods: Register-based cohort study during 1994 to 2019 of oral progestin or LNG-IUD in Finnish women with (n = 31 688) and without (n = 91 726) prior preeclampsia in 1969 to 1993. Cyclic progestin or LNG-IUD use and its association with future use of menopausal hormone therapy (MHT). Results: Women with prior preeclampsia had used cyclic progestins more often (23.5% vs 9.1%; P < .001) and initiated the use at younger ages (41.8 years, SD 6.3 vs 45.9 years, 3.1; P < .001) than control women. Also, LNG-IUD was inserted more frequently (P < .001) in women with prior preeclampsia (9.3%) than in controls (4.7%). Cyclic progestin or LNG-IUD use was accompanied by significant 37% to 90% elevations in future MHT use. Conclusion: Increased use of cyclic progestins and LNG-IUD in premenopausal women with a history of preeclamptic pregnancy can be seen as indirect evidence of earlier onset of ovulatory dysfunction. This may contribute to the elevated risk of endometrial cancer in these women. Our findings may indicate an additional late sequela of preeclamptic pregnancy.

We summarize convincing evidence that future cardiovascular disease (CVD) risk increases one-fold to four-fold for women with a history of pregnancy complicated by hypertensive disorders, gestational diabetes, fetal growth restriction, placental abruption and preterm birth. A concomitant occurrence of two or more complications in the same pregnancy further potentiates the risk. These women should be informed of their future CVD risks during the postpartum check-up taking place after delivery, and also, if needed, treated, for example, for persisting high blood pressure. In these women with high blood pressure, check-up should take place within 7-10 days, and if severe hypertension, within 72 h. Women without diagnostic signs and symptoms should be examined for the first time 1-2 years postpartum and then at intervals of 2-3 years for a complete CVD risk profile including clinical and laboratory assessments. Women should be informed for future CVD risks and their effective prevention with healthy lifestyle factors. Combined oral contraceptives should be avoided or used with caution. If laboratory or other clinical findings indicate, then vigorous treatments consisting of non-medical and medical (antihypertensives, statins, antidiabetic and anti-obesity therapies) interventions should be initiated early with liberal indications and with ambitious therapeutic goals. Low-dose aspirin and menopausal hormone therapy should be used in selected cases. Active control and treatment policies of these women with pregnancy-related risks will likely result in decreases of CVD occurrence in later life.

Introduction and hypothesis: To assess quality of life (QoL) and sexual function outcomes at 3 years after tension-free vaginal tape (TVT) and polyacrylamide hydrogel injection (PAHG) for stress urinary incontinence (SUI). Methods: In this randomized trial comparing TVT (n = 104) and PAHG (n = 108), we assessed changes in QoL and sexuality using the Urogenital Distress Inventory (UDI-6), Incontinence Impact Questionnaire, Short Form (IIQ-7), Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and RAND-36 Item Health Survey (RAND-36) at baseline and at 3 years. This is a secondary analysis of a randomized, noninferiority trial comparing patient satisfaction after TVT and PAHG. Results: In both groups, incontinence-related QoL improved from the baseline (p < 0.00), except for difficulty emptying the bladder and pain/discomfort. Total scores of UDI-6 and IIIQ-7 were lower for TVT compared to PAHG (p < 0.00) indicating better QoL at 3 years. Urinary incontinence with sexual activity or fear of incontinence restricting sexual activity improved in both groups (p < 0.00), with higher scores for physical section subscale in PISQ-12 (p = 0.02) for TVT. Physical and social functioning (RAND-36) improved from the baseline in both groups (p < 0.01) with a better outcome in the TVT group for physical functioning (p = 0.00). Conclusions: Both TVT and PAHG improve QoL and sexual function in primary SUI with better incontinence and health-related QoL scores in the TVT group compared to the PAHG group at 3 years.

ObjectiveWe compared the trends of hormone therapy (HT) use among women with and without a history of pre-eclampsia.MethodsThis national cohort study consisted of women with a pre-eclamptic pregnancy (n = 31,688) or a normotensive pregnancy (n = 91,726) (controls) during 1969-1993. The data on their use of HT during 1994-2019 were traced from the National Medicine Reimbursement Register.ResultsBoth women with a history of pre-eclampsia and controls initiated HT at a mean age of 49.9 years. Cumulative HT & TRADE; use during the total follow-up did not differ between the groups (31.1% vs. 30.6%, p = 0.066). However, HT use in previously pre-eclamptic women was less common in 1994-2006 (20.2% vs. 22.4%, p < 0.001) and more common in 2007-2019 (22.1% vs. 21.1%, p < 0.001) than in controls. This trend was also seen in the annual changes of HT starters. Women with a history of pre-eclampsia used HT for a shorter time (6.3 vs. 7.1 years, p < 0.001).ConclusionsIn contrast to controls, HT use in previously pre-eclamptic women increased during the last half of the follow-up. This may reflect the changes in the international recommendations, the increased awareness of pre-eclampsia-related cardiovascular risk later in life and the aim to diminish this risk with HT.