Sexual function before and after non-surgical treatment
for stress urinary incontinence
Victoria L. Handa, MD, MHS1; Emily Whitcomb, MD2; Alison C. Weidner, MD3; Ingrid Nygaard
MD4; Linda Brubaker, MD5; Catherine S. Bradley, MD, MSCE6; Marie Fidela R. Paraiso, MD7;
Joseph Schaffer, MD8 ; Halina M. Zyczynski, MD9; Min Zhang, PhD10; and Holly E. Richter,
PhD, MD11; for the Pelvic Floor Disorders Network
1. Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine,
2. Department of Obstetrics and Gynecology, Kaiser Permanente San Diego Medical
Center, San Diego, CA
3. Department of Obstetrics and Gynecology, Duke University, Durham, NC
4. University of Utah School of Medicine, Salt Lake City, UT
5. Stritch School of Medicine. Loyola University Chicago, Maywood, IL
6. Departments of Obstetrics and Gynecology and Epidemiology, University of Iowa, Iowa
7. Obstetrics and Gynecology and Women’s Health Institute, Cleveland Clinic, Cleveland,
8. Department of Ob/Gyn, University of Texas Southwestern Medical Center, Dallas TX
9. Department of Obstetrics, Gynecology and Reproductive Sciences, University of
Pittsburgh, Pittsburgh, PA
10. Department of Biostatistics, University of Michigan, Ann Arbor, MI.
11. Department of Obstetrics and Gynecology, University of Alabama at Birmingham,
Corresponding Author: Victoria L. Handa, MD, MHS
Johns Hopkins University
Department of Gynecology and Obstetrics
4940 Eastern Avenue
Baltimore, MD 21224
410-550-2787 fax 410-550-2786
Source of funding: Supported by grants from the Eunice Kennedy Shriver National Institute
of Child Health and Human Development (K23HD045806, U10 HD41261, U10 HD 41250,
U10 HD54136, U10 HD41249, U10 HD41267, U10 HD41248, U10 HD41268, U10
HD41263, U10 HD54214, U10 HD54241, and U10 HD54215); National Institute of Diabetes
and Digestive and Kidney Diseases and NIH Office of Research on Women’s Health
Objectives: (1) to describe sexual function in women seeking treatment of stress urinary
incontinence (SUI); (2) to compare the impact on sexual function of three SUI treatments; and
(3) to investigate whether non-surgical treatment of SUI is associated with improved sexual
Methods: Women with SUI were randomized to continence pessary, behavioral therapy (pelvic
floor muscle training and continence strategies), or combination therapy. Sexual function was
assessed at baseline and 3-months using short forms of the Pelvic Organ Prolapse-Urinary
Incontinence Sexual Function Questionnaire (PISQ-12) and the Personal Experiences
Questionnaire (SPEQ). Successful treatment of SUI was assessed with a patient global
impression of improvement. ANOVA was used to compare scores between groups.
Results: At baseline, sexual function was worse among women with mixed incontinence
compared to those with pure SUI. After therapy, successful treatment of SUI was associated
with greater improvement in PISQ-12 score (2.26 ± 3.24 versus 0.48 ± 3.76, p=0.0007), greater
improvement in incontinence with sexual activity (0.45 ± 0.84 versus 0.01 ± 0.71, p=0.0002),
and greater reduction in restriction in sexual activity related to fear of incontinence (0.32 ± 0.76
versus -0.06 ± 0.78, p=0.0008). Among those successfully treated for SUI, improvement in
continence during sexual activity was greater in both the combined therapy group (p=0.019) and
the behavioral group (p=0.02) compared to the pessary group.
Conclusions: Successful non-surgical treatment of SUI is associated with improvements in
incontinence-specific measures of sexual function. Behavioral therapy may be preferred to
pessary for treatment of SUI among women whose incontinence interferes with sexual function.
Key words: Pessary; sexual health; stress urinary incontinence; pelvic muscle training
Approximately 25-50% of women with pelvic floor disorders report impaired sexual function
[1-3]. It is unknown whether the sexual dysfunction among these women is due to the physical
and emotional impact of the pelvic floor disorder or to other factors, such as increased age or
other co-morbid conditions [4-6]. However, recent research in clinical populations  suggests
that symptoms of pelvic floor disorders are independent risk factors for several common sexual
complaints, including reduced sexual arousal and increased dyspareunia.
An important question is whether effective treatments for pelvic floor disorders result in
improved female sexual function. If we hypothesize that sexual function is worse among
women with symptoms of pelvic floor disorders, effective treatment of the underlying disorder
should result in improved sexual function. The objective of this secondary analysis of the ATLAS
trial  was to investigate the impact of three non-surgical treatments for stress urinary
incontinence (pessary, behavioral therapy, or combined treatment) on sexual function. Our
specific aims were to describe sexual activity and sexual function in women with stress
incontinence; to compare the impact of three non-surgical treatments for stress incontinence;
and to investigate whether successful treatment of incontinence is associated with a reduction in
This was a planned secondary analysis of the ATLAS trial . Briefly, women ages 18 and
older with symptoms of SUI who desired non-surgical therapy were randomized into one of
three groups: continence pessary, behavioral therapy (pelvic floor muscle training and
continence strategies), or combination therapy. Eligibility criteria included at least two SUI
episodes on a seven-day bladder diary and a greater number of stress leaks than other types of
leaks recorded on the diary. Women whose diary indicated only stress-type leaks were
classified as pure stress incontinence with others classified as mixed incontinence. Women
with stage III or greater pelvic organ prolapse or neurological disorders associated with UI were
excluded. Randomization was stratified by 7-day bladder diary results, including incontinence
type (stress only versus mixed) and severity (<14 versus >14 total incontinence episodes) .
Women receiving behavioral therapy or combined therapy attended four treatment
sessions over an eight week period. Trained interventionists instructed women on appropriate
pelvic muscle contraction, prescribed home exercise programs with increasing difficulty over
time, and taught women strategies to minimize leakage. Women in the pessary group were
fitted with a continence pessary for use as desired to decrease leakage. All participants
received a one-page handout containing tips on incontinence management. All sites obtained
IRB approval and all participants provided written informed consent.
A baseline seven-day bladder diary was used to assess incontinence frequency and
incontinence type (stress only versus mixed, defined as one or more urge leaks recorded). The
ATLAS primary outcome measure , collected 3 months after randomization, was the Patient
Global Impression of Improvement (PGI-I). For this analysis, successful treatment of urinary
incontinence was defined as a PGI-I response of “very much better” or “better”. Pelvic muscle
strength was described using the Brinks scale, in which a score is obtained based on the
pressure, displacement and duration palpated during a voluntary pelvic muscle contraction .
Research staff members who collected the outcome measures were masked to group
Sexual function was assessed before and after treatment, using two sexual function
questionnaires, one generic and one specific for women with pelvic floor disorders. The generic
instrument, the 9-item short form of the Personal Experiences Questionnaire (SPEQ) has been
validated among peri-menopausal women and reflects several domains of female sexual
function, including libido, arousal, and dyspareunia [11-13]. The SPEQ was completed by all
participants at baseline (before randomization) and again three months after randomization,
when the primary (incontinence) treatment outcome was also assessed. To more directly
assess the impact of urinary incontinence on sexual function, we used the short form of the
Pelvic Organ Prolapse-Urinary Incontinence Sexual Function Questionnaire (PISQ-12) .
Because the PISQ-12 has been validated only among women who are sexually active in a
heterosexual relationship, this instrument was administered only to women reporting sexual
activity with a partner during the past 3 months, while the SPEQ was administered to all
Three SPEQ domain scores were used to describe libido, arousal and dyspareunia.
Sexual desire (libido) was assessed by one item (“…how many times during the last month
have you have had sexual thoughts or fantasies”), rated on an ordinal scale, with answers
ranging from “never” (0 points) to “several times a day” (5 points). Sexual arousal
(”responsivity”) was defined by the average of three items: “How enjoyable are sexual activities
for you”, “Do you currently experience orgasm (climax) during sex activity” and “How often
during sex do you feel aroused or excited?”, each rated on an ordinal scale, with “1”
corresponding to “not at all” and “6” corresponding to “a great deal”. Dyspareunia was
assessed among women who reported having a sexual partner. This domain score was based
on a single item (“Do you currently experience pain during intercourse?”), rated from 0 (“not at
all”) to 5 (”a great deal”), with an option for women who do not have intercourse to mark “not
applicable”. Other SPEQ domain scores (feelings for partner, partner difficulty, and sexual
frequency) were not included in this analysis. An overall SPEQ score was generated for each
participant, with higher scores corresponding to better sexual function
The PISQ-12 has a maximum score of 48, with higher scores reflecting better sexual
function. In addition to reporting the overall score, we considered two individual PISQ-12 items
that directly address the impact of incontinence on sexual function: “Are you incontinent of urine
(leak urine) with sexual activity?” and “Does fear of incontinence (either urine or stool) restrict
your sexual activity?” Both items were rated on a 5-point Likert scale, including “never,”
“seldom,” “sometimes,” “usually” and “always.” These items were available only for women who
reported sexual activity with a partner during the preceding three months.
We used data from the baseline questionnaires to describe sexual function among women
presenting with stress urinary incontinence. We used data from 3 month and baseline
questionnaires to compare sexual function before and after treatment. Women who completed
the 3 month questionnaire were included in this analysis. Finally, we compared post-treatment
sexual function between women with and without successful treatment of SUI (based on the
PGI-I, as above).
We compared characteristics of the study population by randomization group using
Mantel-Haenszel test or ANOVA. ANOVA, controlling for age, was used to compare Likert
scales describing sexual function at baseline by incontinence type and incontinence frequency.
Similarly, ANOVA was used to compare changes in sexual function at follow-up by treatment
success. Finally, to investigate the impact of changes in pelvic muscle function on sexual
function, we considered the relationship between the change in Brink score and the change in
sexual function scores. This was accomplished with an analysis of the association between
change in Brinks score and change in sexual function score using ANOVA. For all analyses,
P<0.05 was considered statistically significant.
A total of 445 women enrolled in the study (Table 1), with 149 assigned to pessary
treatment, 146 assigned to behavioral therapy, and 151 assigned to combined therapy. The
mean age was 49.8 years and 42.2% were postmenopausal. These and other baseline
characteristics did not differ by treatment group (Table 1). Of the 445 women who enrolled in
this study, 281 (63.1%) reported a current sexual partner at baseline, 83 (8.6%) reported no
current sexual partner, and 81 (18.2%) did not answer the question. At baseline, 281 (63.1%)
reported sexual activity in the three months prior to enrollment, 121 (27.2%) reported no sexual
activity, and 43 (9.7%) did not answer the question about recent sexual activity. There were no
group differences in the proportion of women with a current partner (p=0.115) or who reported
recent sexual activity (p=0.091).
At enrollment, the SPEQ was completed by 364 women and the PISQ-12 was completed by
the 281 women who reported sexual activities with a partner in the 3 months prior. Sexual
function measures differed significantly by incontinence type (Table 2). Compared to women
with pure stress incontinence, women with mixed incontinence had significantly lower PISQ-12
scores, reported more frequent incontinence of urine with sexual activity, and were more likely
to report that fear of incontinence restricts sexual activity. Dyspareunia scores were also
significantly worse among women with mixed incontinence.
We noted a statistically significant association between incontinence type and incontinence
frequency (p<0.0001, Chi-square test). Specifically, more subjects (60%) with mixed
incontinence reported >14 incontinence episodes/week than subjects with pure stress
incontinence (28%). However, when incorporating incontinence frequency into the model
described in Table 2, incontinence frequency was not significantly associated with the PISQ-12
score, while incontinence type remained significant (p=0.002).
At baseline, sexual function did not differ among the three treatment groups. Twelve weeks
after randomization, the change in measured aspects of sexual function also did not differ
among treatment groups. Specifically, there was no difference among treatment groups in the
change in PISQ-12 score, SPEQ score, or any component of these scores.
Twelve weeks after randomization, 203 women met our definition for successful treatment of
SUI and 142 were not considered successfully treated (the 3-month assessment was not
completed for the remaining 100 women). Compared to those who did not experience
successful treatment of SUI, those with successful treatment experienced greater improvement
in PISQ score (2.26 ± 3.24 versus 0.48 ± 3.76, p=0.0007) (Table 3). Also, successful treatment
of SUI was associated with a greater improvement from baseline in incontinence with sexual
activity (0.45 ± 0.84 versus 0.01 ± 0.71, p=0.0002) and a greater reduction in restriction of
sexual activity related to fear of incontinence (0.32 ± 0.76 versus -0.06 ± 0.78, p=0.008).
Improvement in SUI was not associated with changes in sexual responsivity (p=0.15),
dyspareunia (p=0.64), libido (p=0.43) or SPEQ score (p=0.14). A post-hoc power calculation
suggested that the power of this study to detect a true difference in SPEQ score of 2-3 points
(the range of difference observed) given the observed sample size and a significance level of
0.05 was 32%-55%.
Given that improvement in sexual function was more closely associated with improved
continence than was treatment group, we considered whether treatment group had any
influence on changes in sexual function. Among those successfully treated for SUI, the mean
improvement in score for incontinence during sexual activity was 0.45 greater in the combined
therapy group compared to the pessary group (p=0.019, controlling for menopause). Similarly
the mean improvement in score for incontinence during sexual activity was 0.42 greater in the
behavioral therapy group compared to the pessary group (p= 0.02, controlling for menopause).
Among those not successfully treated for SUI, there was no significant difference among groups
with respect to any measure of sexual function.
To investigate the impact of pelvic muscle training on incontinence-specific measures of
sexual function, we considered the relationship between the change in Brink score and the
change in sexual function scores. At baseline, the mean Brink score was 8.6±2.1. After
treatment, the mean score was 9.3±2.0. Successful treatment of SUI was associated with a
significantly higher mean Brink score (9.5±2.0 versus 9.0±2.0, p=0.028). The change in Brink
score, representing the change in pelvic muscle strength, was not associated with change in
PISQ-12 total score (p=0.19). This finding was not affected by adjustment for age, treatment
success and treatment group (p=0.64). Similarly, the change in Brink score was not associated
with change in SPEQ score (p=0.79), even after adjusting for age, treatment success, and
treatment group (p=0.98).
In this planned secondary analysis of data from a randomized trial, comparing pessary to
behavioral therapy versus combined therapy, successful non-surgical treatment of SUI was
associated with statistically significant improvements in several incontinence-specific measures
of sexual function, including less incontinence during sex and less perception that incontinence
interferes with sex. Nevertheless, these improvements did not translate into any measurable
effect on libido, dyspareunia, or arousal. Thus, while incontinence-specific measures of sexual
function improved with restoration of continence, we did not observe improvements in more
general aspects of sexual function.
Prior studies document an improvement in PISQ-12 score after surgical treatment of SUI.
Frick and colleagues , observed a mean increase in PISQ-12 score of 2.9 ± 5.0 one year
after mid-urethral sling for treatment of SUI. In another surgical trial, Brubaker and colleagues
saw PISQ-12 scores increase by a mean of 5.8 points after successful surgery but only 3.8
points for unsuccessful surgery . The magnitude of improvement seen in our trial, 2.26 ±
3.24 points, was somewhat more modest than the gains documented after surgical intervention,
possibly reflecting a less robust treatment effect from non-surgical therapy. Indeed, nonsurgical
treatments may have a more modest impact on PISQ score. For example, in a study of women
with overactive bladder,  medical treatment increased the total PISQ score by 4.7 points,
corresponding to a increase in PISQ-12 score of less than 2 points.
Among women with bothersome SUI, there has been little research on the impact that
nonsurgical treatments have on sexual function. Although one study found that sexually active
women were more likely than their inactive counterparts to continue pessary use, the study did
not directly examine the impact of pessary use on sexual function . Some studies of pelvic
floor strengthening have suggested improved sexual outcomes in women with stress
incontinence [19, 20], although other studies  have not confirmed these findings. We found
no association between changes in pelvic muscle strength, as measured by the Brink score,
and either the SPEQ or PISQ-12 scores. This would suggest that pelvic muscle strengthening,
in the absence of improved continence, does not have a measurable effect on female sexual
Furthermore, our results suggest that improvements in sexual function related to pelvic
muscle training are mediated by improvements in continence. Across the three treatment
groups, improvements in sexual function were limited to women who experienced successful
treatment of SUI symptoms. Thus, women who received behavioral therapy (with pelvic muscle
training) did not experience improvement in sexual function unless they reported that their
incontinence was “better” or “very much better” after treatment. However, women successfully
treated for stress incontinence were more likely to experience improvement in continence during
sexual activity after treatment with either behavioral therapy or combined therapy than with
pessary. The reason for this treatment effect is not immediately apparent. Study participants
were not provided with specific instructions regarding whether they should remove the pessary
for sexual activity. We speculate that removal of the pessary for sexual activity, even among
those successfully treated, might have prevented these women from experiencing
improvements in continence during sex. An alternative conclusion is that behavioral therapy,
either alone or in combination, is responsible for the improvement in continence with sexual
activity. The literature on how pelvic floor muscle strengthening might improve this aspect of
sexual function is not clear. Some researchers have found that pelvic muscle exercise
improves broader aspects of sexual function, including desire, arousal and orgasm . We
could not confirm these findings, as our participants did not experience improvements in libido,
arousal or more general aspects of sexual function. However, our power to detect a difference
in SPEQ score was limited.
Our results suggest that women with mixed incontinence have worse dyspareunia scores,
worse PISQ-12 scores, worse scores for incontinence of urine with sexual activity, and worse
fear of incontinence restricting sexual activity than women with pure stress incontinence. Our
findings are consistent with prior research suggesting that women with mixed incontinence have
worse sexual function that those with stress incontinence alone . However, consistent with
the literature, more general aspects of sexual function, such as libido and arousal, were not
strongly correlated with symptoms of urinary incontinence. Certainly the reasons for impairment
in sexual function are complex, multi-factorial and incompletely understood. Continence status
is only one of many factors contributing to sexual function.
A strength of this study is the use of validated questionnaires that comprehensively assess
the multiple domains of sexual function in a large, well characterized sample of women
presenting for conservative treatment of stress urinary incontinence. The PISQ measured
condition-specific sexual function, with two of its items (incontinence with sexual activity and
restrictions on sex from fear of incontinence) providing the most plausible direct causal links
between incontinence and sexual function. In contrast, the SPEQ evaluated generic sexual
function. This measure has the advantage over some other measures of sexual function in that
it can be completed by women who do not have intercourse. As noted, one-third of participants
in this trial were not sexually active with a partner at enrollment. Thus, the SPEQ provides a
validated means of assessing sexual function among the subset of women who do not have a
current partner or for whom intercourse is not part of the intimate relationship. Although we
found incontinence-specific measures of sexual function improved with restoration of
continence, we did not observe improvements in more general aspects of sexual function.
These findings suggest that the PISQ measures were more responsive to changes in sexual
function related to pelvic floor disorders than the more generic measure in this cohort of women.
One study limitation is that our population of women joining a clinical trial of conservative
treatment of stress incontinence may limit the generalizability of the findings. In addition, there
are limitations attendant to lack of a sexual partner in nearly 40% of the study population.
Although women with more advanced pelvic organ prolapse and severe atrophic vaginitis were
excluded from the present study, other unmeasured factors associated with sexual dysfunction
could have influenced our results. Finally, women may under-disclose sexual problems, or
those complaints may be overwhelmed by women’s concerns regarding stress incontinence and
its treatment in this cohort of women.
In summary, our results demonstrate that measures of sexual function did not vary among
treatment groups three months after randomization in this trial of non-surgical treatment of SUI.
Regardless of treatment group, improvements in sexual function were limited to women who
experienced successful treatment of SUI. These results should be reassuring to women
seeking conservative treatment of stress incontinence. Moreover, we found that successful
treatment led to greater improvements in incontinence-specific measures of sexual function
among women treated with behavioral therapy than those treated with pessary. Therefore our
results suggest that clinicians should consider behavioral therapy (including pelvic floor muscle
exercises and continence strategies) for non-surgical treatment of SUI for women with
incontinence during sexual activity and for those who restrict sexual activity due to fear of
Table 1: Characteristics of the study population at baseline, by treatment group. Data
presented as N (%) unless otherwise noted.
Mean age (SD) 49.5 (11.8) 49.6 (13.0) 50.2 (11.0) 0.86
Caucasian race 122 (81.3%) 132 (90.4%) 125 (84.5%) 0.26
66 (44.0%) 62 (42.5%) 60 (40.3%)
16 (10.7%) 13 (8.9%) 14 (9.4%)
Current Estrogen Use 16 (10.7%) 24 (16.4%) 27 (18.1%) 0.17
Body Mass Index (SD) 29.84 (7.54) 29.01 (6.89) 29.50 (6.05) 0.54
80 (53.3%) 81 (55.5%) 80 (53.7%)
83 (55.3%) 79 (54.1%) 81 (54.4%)
1 ANOVA, controlling for stratification based on baseline incontinence episodes and
2 Incontinence type and frequency based on 7-day bladder diary: stress (no urge leaks
recorded) or mixed (one or more urge leaks recorded).
Table 2: Sexual function at baseline in participants with stress and mixed incontinence1 Data
are expressed as mean (SD).
Characteristic Stress UI
SPEQ total score 9.84 (3.23) 9.30 (3.24) 0.3650
Sexual arousal3 4.12 (1.51) 3.90 (1.55) 0.4050
Libido*4 3.02 (1.29) 2.76 (1.21) 0.1260
Dyspareunia5 1.70 (1.17) 1.99 (1.23) 0.0170
PISQ-12 score6 36.28 (5.25) 33.73 (5.96) 0.0007
Incontinence with sexual activity 7
Sexual activity restricted by fear of
incontinence (either urine or stool) 7
1 Incontinence type based on 7-day bladder diary: stress (no urge leaks recorded) or mixed (1
or more urge leaks recorded).
2 ANOVA, adjusted for age
3 Arousal score is the average of “How enjoyable are sexual activities
currently for you?”; “How often during sex activities do you feel aroused or excited (heart
beating fast/heavier breathing/vaginal wetness/flushing)?”; “Do you currently experience
orgasm (climax) during sex activity?” Each is rated on an ordinal scale, with answers
ranging from “never” (0 points) to “several times a day” (5 points).
4 Libido, defined by frequency of sexual thoughts or fantasies (eg. daydreams) during the last
month. This SPEQ response is defined by a tLikert scale Never = 1; Several times a day = 6
5 “Do you currently experience pain during intercourse?” This SPEQ response is limited to those
subjects reporting a current sexual partner and was defined by a Likert scale Not at all =1; A
great deal = 5
6 PISQ-12 score is measured among those who have engaged in sexual activities with a
partner over the past 3 months
7 These PISQ responses are defined on Likert scale, 0=always, 4=never
Table 3: Changes in sexual function after treatment, in women successfully treated for stress
incontinence versus those whose treatment was not successful. Data are expressed as mean
Change in SPEQ total score -5.75 (12.71) -3.62 (11.00) 0.1358
Change in sexual arousal2 -0.15 (0.98) 0.03 (0.99) 0.1505
Change in libido2 0.12 (0.96) 0.03 (0.87) 0.4267
Change in dyspareunia2 -0.24 (0.94) -0.18 (0.89) 0.6375
Change in PISQ-12 score2 0.48 (3.76) 2.26 (3.24) 0.0007
Change in incontinence with sexual
0.01 (0.71) 0.45 (0.84) 0.0002
Change in sexual activity restricted by
fear of incontinence (either urine or
-0.06 (0.78) 0.32 (0.76) 0.0008
2 Outcomes as defined in Table 2
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Pelvic Floor Disorders Network:
Mathew D. Barber, MD, MHS, Principal Investigator
Marie Fidela R. Paraiso, MD, Co-Investigator
Mark D. Walters, MD, Co-Investigator
J. Eric Jelovsek, MD, Co-Investigator
Linda McElrath, RN, Research Nurse Coordinator
Donel Murphy, RN, MSN, Research Nurse
Cheryl Williams, Research Assistant
Anthony G. Visco, MD, Principal Investigator
Jennifer Wu, MD, Co-Investigator
Alison Weidner, MD, Co-Investigator
Cindy Amundsen, MD, Co-Investigator
Mary J. Loomis, RN, BSN, Research Coordinator
Linda Brubaker, MD, MS, Principal Investigator
Kimberly Kenton, MD, MS, Investigator
MaryPat FitzGerald, MD, MS, Investigator
Elizabeth Mueller, MD, MSME, Investigator
Mary Tulke, RN, Research Nurse Coordinator
Kathy Jesse, RN, Research Nurse Coordinator
Kathy Marchese, RN, Research Nurse Coordinator
University of Alabama at Birmingham
Holly E. Richter, PhD, MD, Principal Investigator
Kathryn L. Burgio, PhD, Co-Principal Investigator
R. Edward Varner, MD, Co-Investigator
Robert L. Holley, MD, Co-Investigator
Patricia S. Goode, MD, Co-Investigator
L. Keith Lloyd, MD, Co-Investigator
Alayne D. Markland, DO, Co-Investigator
Tracey Wilson, MD, Co-Investigator
Velria Willis, RN, BSN, Research Coordinator
Nancy Saxon, BSN, Research Nurse Clinician
LaChele Ward, LPN, Research Specialist
Lisa S. Pair, CRNP
University of California, San Diego and Kaiser Permanente, San Diego
Charles W. Nager, MD Principal Investigator
Shawn A. Menefee, MD, Co- Investigator
Emily Lukacz, MD, Co-Investigator
Margie Kahn, MD, Co-Investigator
Karl M. Luber, MD, Co-Investigator
Leah Merrin, Research Coordinator
Giselle Zazueta-Damian, Research Coordinator
Patsy Riley, R.N.
Lynn Hall, R.N.
Judy M. Condino, RN
University of Michigan
Cathie Spino, DSc, Principal Investigator
John T. Wei, MD, MS, Co-Principal Investigator
Morton B. Brown, PhD, Co-Investigator
Donna DiFranco, BS, Clinical Monitor
John O.L. DeLancey, MD, Co-Investigator
Dee Fenner, MD, Co-Investigator
Nancy K. Janz, PhD, Co-Investigator
Wen Ye, PhD, Statistician
Zhen Chen, MS, Statistician
Yang Wang Casher, MS, Database Programmer
University of Texas, Southwestern
Joseph Schaffer MD, Principal Investigator
David Rahn, MD, Co-Investigator
Clifford Wai, MD, Co-Investigator
Marlene Corton, MD, Co-Investigator
Gary Lemack, MD, Co-Investigator
Philippe Zimmern, MD Co-Investigator
Kelly Moore - Research Coordinator
Shanna Atnip, NP
Margaret Hull, NP
Pam Martinez, NP
Deborah Lawson, NP
University of Utah
Ingrid Nygaard, MD, Principal Investigator
Peggy Norton, MD, Co-Investigator
Yvonne Hsu, MD, Co-Investigator
Jan Baker, Interventionist
Linda Freeman, RN, Research Coordinator
Steering Committee Chair
Katherine E. Hartmann, MD, PhD
NIH Project Scientist
Susan Meikle, MD, MSPH
Other Participating Sites:
Magee Women’s Hospital, Pittsburgh, PA
Halina Zyczynski, MD, Principal Investigator
Wendy Leng, MD, Co-Investigator
Pamela Moalli, Ph.D, MD, Co-Investigator
Chaira Ghetti, MD, Co-Investigator
Jerry Lowder, MD, Co- Investigator
Judy Gruss and Karen Mislanovich, Nurse Coordinators
Interventionist: Karen Debes
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Johns Hopkins Medical Institutes
Geoffrey Cundiff, M.D., Principal Investigator
Victoria Handa, M.D., Co-Investigator
Jamie Wright, M.D., Co-Investigator
Mary Elizabeth Sauter, N.P., Research Coordinator
Laura Scheufele, PT, Interventionist
University of Iowa
Catherine S. Bradley, MD, MS