Cancer incidence, mortality, and pregnancy outcome among women treated for cervical intraepithelial neoplasia

Cervical cancer develops through precursor lesions, i.e. cervical intraepithelialneoplasms (CIN). These can be detected and treated before progression to invasive cancer. The major risk factor for developing cervical cancer or CIN is persistent or recurrent infection with high-risk human papilloma virus (hrHPV). Other associated risk factors include low socioeconomic status, smoking, sexually transmitted infections, and high number of sexual partners, and these risk factors can predispose to some other cancers, excess mortality, and reproductive health complications as well. The aim was to study long-term cancer incidence, mortality, and reproductive health outcomes among women treated for CIN. Based on the results, we could evaluate the efficacy and safety of CIN treatment practices and estimate the role of the risk factors of CIN patients for cancer incidence, mortality, and reproductive health. We collected a cohort of 7 599 women treated for CIN at Helsinki University Central Hospital from 1974 to 2001. Information about their cancer incidence, cause of death, birth of children and other reproductive endpoints, and socio-economic status were gathered through registerlinkages to the Finnish Cancer Registry, Finnish Population Registry, and Statistics Finland. Depending on the endpoints in question, the women treated were compared to the general population, to themselves, or to an age- and municipality-matched reference cohort. Cervical cancer incidence was increased after treatment of CIN for at least 20 years, regardless of the grade of histology at treatment. Compared to all of the colposcopically guided methods, cold knife conization (CKC) was the least effective method of treatment in terms of later CIN 3 or cervical cancer incidence. In addition to cervical cancer, incidence of other HPV-related anogenital cancers was increased among those treated, as was the incidence of lung cancer and other smoking-related cancers. Mortality from cervical cancer among the women treated was not statistically significantly elevated, and after adjustment for socio-economic status, the hazard ratio (HR) was 1.0. In fact, the excess mortality among those treated was mainly due to increased mortality from other cancers, especially from lung cancer. In terms of post-treatment fertility, the CIN treatments seem to be safe: The women had more deliveries, and their incidence of pregnancy was similar before and after treatment. Incidence of extra-uterine pregnancies and induced abortions was elevated among the treated both before and after treatment. Thus this elevation did not occur because they were treated rather to a great extent was due to the other known risk factors these women had in excess, i.e. sexually transmitted infections. The purpose of any cancer preventive activity is to reduce cancer incidence and mortality. In Finland, cervical cancer is a rare disease and death from it even rarer, mostly due to the effective screening program. Despite this, the women treated are at increased risk for cancer; not just for cervical cancer. They must be followed up carefully and for a long period of time; general health education, especially cessation of smoking, is crucial in the management process, as well as interventions towards proper use of birth control such as condoms.

Vascular dilatory function and cardiovascular risk factors in women with a history of pre-eclampsia

Women with a history of pre-eclampsia have an increased risk of cardiovascular disease in later life. The mechanisms which mediate this heightened risk are poorly understood; it was long believed that pre-eclampsia was a separate disease without any connection to other pathologies. The present study was undertaken to investigate the cardiovascular risk milieu, vascular dilatory function and cardiovascular risk factors, in women with pre-eclampsia, 5 6 years after index pregnancy. The aim was to understand better the cardiovascular risks associated with pre-eclampsia and add tools to the evaluation of cardiovascular risk in women. --- The study involved 30 women with previous severe pre-eclampsia and 21 controls. The 2-day study protocol included venous occlusion plethysmography and pulse wave analysis for assessment of vascular dilatory function and central pulse wave reflection, respectively, office and ambulatory blood pressure measurements, assessment of insulin sensitivity, using a minimal model technique, and tests regarding renal function, lipid metabolism, sympathetic activity and inflammation. Vasodilatory function was impaired in women with a history of pre-eclampsia; this was seen in both endothelium-dependent and endothelium-independent vasodilatation. Proteinuria during pre-eclampsia did not predict changes in vasodilatation, and renal function was similar in the two groups. Insulin sensitivity was related to vasodilatation and features of metabolic syndrome, but only in the patient group, despite similar insulin sensitivity in the control group. Arterial pressure was higher in the patient group than in the controls and correlated with endothelin-1 levels in the patient group, whilst the overall difference between the groups was diminished in 24 hour arterial pressure measurements. Additionally, women with previous pre-eclampsia were characterized by increased sympathetic activity. Impaired vasodilatory function at the vascular smooth muscle level seems to characterize clinically healthy women with a history of pre-eclampsia. These vascular changes and the features of metabolic syndrome may be related to the increased risk of cardiovascular disease. Furthermore, increased blood pressure in combination with enhanced sympathetic activity may be additive as regards this risk. These women should be informed about their potential cardiovascular risk profile and the possibilities to minimize it via their own actions. Medical cardiovascular risk assessment in women should include obstetric history.

A Nationwide Study on Breast Cancer Risk in Postmenopausal Women Using Hormone Therapy in Finland

Since national differences exist in genes, environment, diet and life habits and also in the use of postmenopausal hormone therapy (HT), the associations between different hormone therapies and the risk for breast cancer were studied among Finnish postmenopausal women. All Finnish women over 50 years of age who used HT were identified from the national medical reimbursement register, established in 1994, and followed up for breast cancer incidence (n= 8,382 cases) until 2005 with the aid of the Finnish Cancer Registry. The risk for breast cancer in HT users was compared to that in the general female population of the same age. Among women using oral or transdermal estradiol alone (ET) (n = 110,984) during the study period 1994-2002 the standardized incidence ratio (SIR) for breast cancer in users for < 5 years was 0.93 (95% confidence interval (CI) 0.80–1.04), and in users for ≥ 5 years 1.44 (1.29–1.59). This therapy was associated with similar rises in ductal and lobular types of breast cancer. Both localized stage (1.45; 1.26–1.66) and cancers spread to regional nodes (1.35; 1.09–1.65) were associated with the use of systemic ET. Oral estriol or vaginal estrogens were not accompanied with a risk for breast cancer. The use of estrogen-progestagen therapy (EPT) in the study period 1994-2005 (n= 221,551) was accompanied with an increased incidence of breast cancer (1.31;1.20-1.42) among women using oral or transdermal EPT for 3-5 years, and the incidence increased along with the increasing duration of exposure (≥10 years, 2.07;1.84-2.30). Continuous EPT entailed a significantly higher (2.44; 2.17-2.72) breast cancer incidence compared to sequential EPT (1.78; 1.64-1.90) after 5 years of use. The use of norethisterone acetate (NETA) as a supplement to estradiol was accompanied with a higher incidence of breast cancer after 5 years of use (2.03; 1.88-2.18) than that of medroxyprogesterone acetate (MPA) (1.64; 1.49-1.79). The SIR for the lobular type of breast cancer was increased within 3 years of EPT exposure (1.35; 1.18-1.53), and the incidence of the lobular type of breast cancer (2.93; 2.33-3.64) was significantly higher than that of the ductal type (1.92; 1.67-2.18) after 10 years of exposure. To control for some confounding factors, two case control studies were performed. All Finnish women between the ages of 50-62 in 1995-2007 and diagnosed with a first invasive breast cancer (n= 9,956) were identified from the Finnish Cancer Registry, and 3 controls of similar age (n=29,868) without breast cancer were retrieved from the Finnish national population registry. Subjects were linked to the medical reimbursement register for defining the HT use. The use of ET was not associated with an increased risk for breast cancer (1.00; 0.92-1.08). Neither was progestagen-only therapy used less than 3 years. However, the use of tibolone was associated with an elevated risk for breast cancer (1.39; 1.07-1.81). The case-control study confirmed the results of EPT regarding sequential vs. continuous use of progestagen, including progestagen released continuously by an intrauterine device; the increased risk was seen already within 3 years of use (1.65;1.32-2.07). The dose of NETA was not a determinant as regards the breast cancer risk. Both systemic ET, and EPT are associated with an elevation in the risk for breast cancer. These risks resemble to a large extent those seen in several other countries. The use of an intrauterine system alone or as a complement to systemic estradiol is also associated with a breast cancer risk. These data emphasize the need for detailed information to women who are considering starting the use of HT.

Soy supplementation and role of equol production capability in postmenopausal women using tibolone: effects on cardiovascular risk markers

Tibolone, a synthetic steroid, is effective in the treatment of postmenopausal symptoms. Its cardiovascular safety profile has been questioned, because tibolone reduces the levels of high-density lipoprotein (HDL) cholesterol. Soy-derived isoflavones may offer health benefits, particularly as regards lipids and also other cardiovascular disease (CVD) risk factors. The soy-isoflavone metabolite equol is thought to be the key as regards soy-related beneficial effects. We studied the effects of soy supplementation on various CVD risk factors in postmenopausal monkeys and postmenopausal women using tibolone. In addition, the impact of equol production capability was studied. A total of 18 monkeys received casein/lactalbumin (C/L) (placebo), tibolone, soy (a woman s equivalent dose of 138 mg of isoflavones), or soy with tibolone in a randomized order for 14 weeks periods, and there was a 4-week washout (C/L) in between treatments. Postmenopausal women using tibolone (N=110) were screened by means of a one-week soy challenge to find 20 women with equol production capability (4-fold elevation from baseline equol level) and 20 control women, and treated in a randomized cross-over trial with a soy powder (52 g of soy protein containing 112 mg of isoflavones) or placebo for 8 weeks. Before and after the treatments lipids and lipoproteins were assessed in both monkeys and women. In addition, blood pressure, arterial stiffness, endothelial function, sex steroids, sex hormone-binding globulin (SHBG), and vascular inflammation markers were assessed. A 14% increase in plasma low-density lipoprotein (LDL) + very low-density lipoprotein (VLDL) cholesterol was observed in tibolone-treated monkeys vs. placebo. Soy treatment resulted in a 18% decrease in LDL+VLDL cholesterol, and concomitant supplementation with tibolone did not negate the LDL+VLDL cholesterol-lowering effect of soy. A 30% increase in HDL cholesterol was observed in monkeys fed with soy, whereas HDL cholesterol levels were reduced (48%) after tibolone. Interestingly, Soy+Tibolone diet conserved HDL cholesterol levels. Tibolone alone increased the total cholesterol (TC):HDL cholesterol ratio, whereas it was reduced by Soy or Soy+Tibolone. In postmenopausal women using tibolone, reductions in the levels of total cholesterol and LDL cholesterol were seen after soy supplementation compared with placebo, but there was no effect on HDL cholesterol, blood pressure, arterial stiffness or endothelial function. Soy supplementation decreased the levels of estrone in equol producers, and those of testosterone in the entire study population. No changes were seen in the levels of androstenedione, dehydroepiandrosterone sulfate, or SHBG. The levels of vascular cell adhesion molecule-1 increased, and platelet-selectin decreased after soy treatment, whereas C-reactive protein and intercellular adhesion molecule-1 remained unchanged. At baseline and unrelated to soy treatment, equol producers had lower systolic, diastolic and mean arterial pressures, less arterial stiffness and better endothelial function than non-producers. To conclude, soy supplementation reversed the tibolone-induced fall in HDL cholesterol in postmenopausal monkeys, but this effect was not seen in women taking tibolone. Equol production capability was associated with beneficial cardiovascular changes and thus, this characteristic may offer cardiovascular benefits, at least in women using tibolone.

The Culture of Women's Housework : A Case Study of Bihar, India

This study examines gendered housework in India, particularly in Bihar. The perspective adopted in the study was in part derived from the data but also from sociological literature published both in Western countries and in India. The primary attention is therefore paid to modern and traditional aspects in housework. The aim is not to compare Indian practices to those of Western societies, but rather to use Western studies as a fruitful reference point. In that light, Indian housework practices appear to be traditional. Consequently, traditions are given a more significant role than is usually the case in studies on gendered housework, particularly in Western countries. The study approaches the topic mainly from the socio-cultural perspective; this provides the best means to understand the persistence of traditional habits in India. To get a wide enough picture of the division of labour, three methods were applied in the study: detailed time-use data, questionnaire and theme interviews. The data were collected in 1988 in two districts of Bihar, one rural and the other urban. The different data complement each other well but also bring to light contradictory findings: on a general level Biharian people express surprisingly modern views on gender equality but when talking in more detail (theme interviews) the interviewees told about how traditional housework practices still were in 1988. In the analysis of the data set four principal themes are discussed. Responsibility is the concept by which the study aims at understanding the logic of the argumentation on which the persistence of traditional housework practices is grounded. Contrary to the Western style, Biharian respondents appealed not to the principle of choice but to their responsibility to do what has to be done. The power of tradition, the early socialization of children to the traditional division of labour and the elusive nature of modernity are all discussed separately. In addition to the principle of responsibility, housework was also seen as an expression of affection. This was connected to housework in general but also to traditional practices. The purity principle was the third element that made Biharian interviewees favour housework in general, but as in the case of affection it too was interwoven with traditional practices. It seems to be so that if housework is in general preferred, this leads to preferring the traditional division of labour, too. The same came out when examining economic imperatives. However, the arguments concerning them proved to be rational. In analysing them it became clear that the significance of traditions is also much dependent on the economics: as far as the average income in India is very low, the prevalence of traditional practices in housework will continue. However, to make this work, cultural arguments are required: their role is to mediate more smoothly the iron rules of the economy. Key words: family, gendered housework, division of labour, responsibility, family togetherness, emotion, economy of housework, modernity, traditionality

Not in all Walks of Life? : Social Differences in Suicide Mortality

In Finland, the suicide mortality trend has been decreasing during the last decade and a half, yet suicide was the fourth most common cause of death among both Finnish men and women aged 15 64 years in 2006. However, suicide does not occur equally among population sub-groups. Two notable social factors that position people at different risk of suicide are socioeconomic and employment status: those with low education, employed in manual occupations, having low income and those who are unemployed have been found to have an elevated suicide risk. The purpose of this study was to provide a systematic analysis of these social differences in suicide mortality in Finland. Besides studying socioeconomic trends and differences in suicide according to age and sex, different indicators for socioeconomic status were used simultaneously, taking account of their pathways and mutual associations while also paying attention to confounding and mediatory effects of living arrangements and employment status. Register data obtained from Statistics Finland were used in this study. In some analyses suicides were divided into two groups according to contributory causes of death: the first group consisted of suicide deaths that had alcohol intoxication as one of the contributory causes, and the other group is comprised of all other suicide deaths. Methods included Poisson and Cox regression models. Despite the decrease in suicide mortality trend, social differences still exist. Low occupation-based social class proved to be an important determinant of suicide risk among both men and women, but the strong independent effect of education on alcohol-associated suicide indicates that the roots of these differences are probably established in early adulthood when educational qualifications are obtained and health-behavioural patterns set. High relative suicide mortality among the unemployed during times of economic boom suggests that selective processes may be responsible for some of the employment status differences in suicide. However, long-term unemployment seems to have causal effects on suicide, which, especially among men, partly stem from low income. In conclusion, the results in this study suggest that education, occupation-based social class and employment status have causal effects on suicide risk, but to some extent selection into low education and unemployment are also involved in the explanations for excess suicide mortality among the socially deprived. It is also conceivable that alcohol use is to some extent behind social differences in suicide. In addition to those with low education, manual workers and the unemployed, young people, whose health-related behaviour is still to be adopted, would most probably benefit from suicide prevention programmes.

Depression in / by / for women : agency, feminism and self-help in groups

Depression in / by / for Women: Agency, Feminism and Self-Help in Groups on ensimmäinen väitöstasoinen tutkimus feministisestä terapiasta Suomessa sijoittuen psykologian, sosiaalitieteellisen mielenterveystutkimuksen sekä feministisen tutkimuksen alueille. Perinteisen näkemyksen mukaan feministisen tutkimuksen tulee olla ”naisista, naisten tekemää ja naisille kohdistettua”. Naiset ja masennus -projektitutkimus keskittyy naisten kokemaan masennukseen sisältäen mahdollisen miesten sekä patriarkaalisen hyvinvointivaltion osuuden masennukseen. Masennusta kokevat naiset ovat tutkimuksessa sekä tutkimuksen kohteena että aktiivisia osanottajia, mikä tuo heidän äänensä kuuluville. Tutkimus perustuu vuosien 1994-2000 välisenä aikana kerättyyn 11 ryhmän osallistujia koskevaan kvalitatiivisiin ja kvantitatiivisiin aineistoon. Irmeli Laitinen on ollut suunnittelemassa, keräämässä ja analysoimassa sitä yhdessä projektin muiden jäsenten kanssa. Tutkimuksessa mitattiin kuinka ryhmiin osallistuvien seka masennuksen tunteet että toiminnat muuttuivat yhden vuoden aikana. Tutkimuksen tavoitteena oli sekä masennuksesta kärsivien naisten osallistuminen feministiseen toimintatutkimukseen että ammatillisesti ohjatun oma-apuryhmämenetelmän kehittäminen suomalaiseen mielenterveyspalveluun. Projektin tutkimustulosten mukaan siihen osallistuneet naiset voimaantuivat ymmärtämään itseään sekä saivat luottamusta sosiaaliisiin taitoihinsa. Pidemmällä aikavälillä naisten tunteet muuttuivat myönteisiksi, heidän suhteensa itseensä positiivisemmaksi ja he aktivoituivat fyysisesti. Lisäksi tutkimustulokset viittaavat siihen, että masennus voi johtua näkymättömästä, sukupuolisesti virittyneestä jännitteestä naisystävällisessä hyvinvointivaltiossa paljastaen ”hyvinvointimasennusoireilun”. Suomalaisen sosiologi Erik Allardtin hyvinvointitypologian - having, loving, being – mukaisesti nämä ryhmään osallistuvat naiset eivät koe puutteita niinkään materiaalisessa hyvinvoinnissa (having) vaan pikeminkin suhteiden, sosiaalisen ja emotionaalisen hyvinvoinnin ulottuvuuksilla (loving ja being). Se, että masentuneet naiset pystyvät tuomaan esille pitkään vaiennettuja kokemuksiaan, voi merkitä paljon heidän paranemisessaan ja voimaantumisessaan. Ammatillisesti ohjatut oma-apuryhmät ja naisystävälliset hoitokäytännöt mahdollistivat tämänkaltaisen paranemisprosessin alkamisen tutkimukseen osallistuneissa ryhmissä.

Women and Marital Breakdown in South India : Reconstructing Homes, Bonds and Persons

Women and Marital Breakdown in South India: Reconstructing Homes, Bonds and Persons is an ethnographic analysis of the situation of divorced and separated women and their families in the South Indian city of Bangalore. The study is based on 16 months of anthropological fieldwork, i.e., participant observation and life history interviews among 50 divorced and separated women from different socio-religious backgrounds in their homes, in the women s organisations and in the Family Court. The study follows the divorced and separated women from their natal homes to their affinal homes through homelessness and legal battles to their reconstructed natal, affinal or single homes in order to find out what it means to be a person within hierarchical gender and kinship relations in South India. Marital breakdown impacts on kin relations and discloses the existing gender relations and power structure through its consequences. It makes the transformability of relational personhood as well as the transformability of relational society and culture visible. Although the study reveals the painful history of women s ill-treatment in marriage, family and kinship systems, it also demonstrates the women s rejection of the domination; and shows their ability to re-negotiate and promote changes not only to their own positions but to the whole hierarchical system as well. The study explores the divorced and separated women s manifold dilemmas, complicated legal battles, and endless arrangements when they have to struggle with the very practical problems of supporting themselves financially, finding and making a new home for themselves, and re-arranging relationships with their kin and friends. As marital breakdown fundamentally transforms the women s relational field, it forces them to recreate substitutive relations in a flexible way and, simultaneously, to re-construct themselves and their lives without a ready or positive cultural or behavioural template. This process reveals the agency of the divorced and separated women as well as shedding light on issues of gender and the cultural construction of the person in South India. This topical study explores the previously neglected subject of marital breakdown in India and shows the new meaning of kinship in South India.

Leadership through the Gender Lens: Women and Men in Organisations

Leadership and management remain highly gendered. Recent decades have seen a major international growth of studies on gender relations in leadership, organisations and management, in both empirical research and theoretical analysis. The differential relations of women and men to leadership and management are a key question for both theory and practice. Recent research and discussion on the gendering of leadership have been influenced by and have addressed: feminism; recognition of women and women’s situations, experiences and voices in leadership; organisational culture; communication; divisions of labour, hierarchy, power and authority; imagery and symbolism; information technology; sexuality, harassment, bullying and violence in organisations; home-work relations; men and masculinities in leadership; globalisation, transnationalism, intersectionality and post¬¬colonialism – amongst other issues. Having said that, the vast majority of mainstream work on leadership retains little or no gender analysis. In most business schools and other universities the position of gender-explicit work on leadership is still not well established. Leadership through the Gender Lens brings together critical analyses and debates on gender, leadership and management with contributions from 13 countries and five continents. How leadership and management are gendered can mean more gender equal or more gender unequal conditions for women and men. This includes how education and training can contribute to gendered leadership and management. The volume is organised in three main sections, on: careers and leadership; management, hierarchy and leadership: and interventions in leadership.