Gita D. Mishra’s research while affiliated with The University of Queensland and other places
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Sex and gender differences in the epidemiology of mental disorders are well documented. Less well understood are the drivers of these differences. Reproductive health represents one of the gendered determinants of mental health that may affect women throughout their life course. In this paper, we review common reproductive events that may be associated with mental ill health, including menstruation (with premenstrual dysphoric disorder appearing for the first time in recent classifications of mental disorders), contraception, abortion, sexual dysfunction, hypersexuality, sexual violence, reproductive coercion, infertility and associated gynaecological conditions, and menopause. Such reproductive events may differentially affect women globally via a range of potential biological and psychosocial mechanisms. These include, for example, vulnerability to the physiological changes in hormone levels across the menstrual cycle; side effects of treatment of mental disorders; inflammation underpinning endometriosis and polycystic ovarian syndrome as well as mental disorders such as depression; intersections with gender disadvantage manifesting, for example, as structural barriers in accessing menstrual products and sanitation, contraception and abortion, underscoring the broader social determinants impacting women's mental health. Greater understanding of these mechanisms is guiding the development of effective interventions, which are also reviewed here. However, key evidence gaps remain, partly as a result of the historic gender bias in mental health research, and the neglect of reproductive health in clinical practice. Furthermore, while several women's health strategies have recently been proposed internationally, they do not usually include a focus on mental health across the life course, particularly for women with severe mental illness. Integrating co‐designed reproductive health interventions into primary and secondary mental health care settings, providing tailored care, increasing the evidence base on effective interventions, and empowering women to make informed choices about their reproductive health, could improve not only reproductive health but also women's mental health across the life course.
Hysterectomy, removal of the uterus, is a commonly performed surgery for gynaecological morbidities. Emerging evidence indicates that hysterectomy performed before age 45 (early hysterectomy), is associated with considerable risks to women’s health. While most evidence on hysterectomy is from high-income settings, national surveys from India report high prevalence of early hysterectomy in specific regions, as well as higher prevalence amongst women in rural areas and with less education. The median age at hysterectomy in India is close to ten years before the onset of natural menopause. India has recently introduced national guidelines to address early hysterectomy, but large evidence gaps on the causes and consequences remain – which in turn limits the potential effectiveness of interventions at the clinical, health system and community level. Methods SAHELI is a Team Science study that will examine: (i) individual, social and health system determinants of early hysterectomy; (ii) women’s treatment pathways to hysterectomy and for gynaecological morbidity in general; and (iii) the consequences of undergoing hysterectomy on women’s physical, mental, economic and social well-being across the life course. This mixed-methods study includes population surveys amongst women in ages 25–49 in three high-prevalence states; qualitative health systems research to trace treatment journeys with women, health care providers and other stakeholders; evidence syntheses; and knowledge translation activities to ensure findings inform co-produced strategies and interventions. The study is grounded in a feminist epidemiology approach, aiming to examine individual and structural causes of vulnerability and prioritising the views of women, particularly in knowledge translation. Conclusions SAHELI, implemented by an all-women, multi-disciplinary team, is the first study in India to examine the causes and consequences of hysterectomy in a life course approach. We aim to influence interventions, policy and future research on women’s health, particularly access to quality gynaecological care and comprehensive health services through the life course.
STUDY QUESTION
What are the patterns of health service use (HSU) before and after endometriosis diagnosis?
SUMMARY ANSWER
Women with endometriosis had higher rates of visits to general practitioners (GPs), specialists, and diagnostic imaging before and after diagnosis compared to those without the condition; however, after diagnosis, their visits to GPs and specialists other than obstetricians/gynaecologists decreased compared to before, while visits to obstetricians/gynaecologists and use of diagnostic imaging increased.
WHAT IS KNOWN ALREADY
Women with endometriosis have higher rates of healthcare use compared to those without the condition; however, no longitudinal study has examined patterns of HSU over a prolonged period before and after diagnosis.
STUDY DESIGN, SIZE, DURATION
The Australian Longitudinal Study on Women’s Health linked to a national administrative health record. A total of 30 473 women, born in 1973–1978 and 1989–1995, from two cohorts with data collected from 1996 to 2021, as online or postal questionnaires.
PARTICIPANTS/MATERIALS, SETTING, METHODS
Women with endometriosis were identified using the self-report surveys and their administrative health records. A control group of women without endometriosis was randomly selected and age-matched with women with endometriosis. The final sample included 9545 women from the 1973–1978 cohort (1909 cases, 7636 controls) and 7510 from the 1989–1995 cohort (1502 cases, 6008 controls). Women’s HSU was assessed using the Medicare Benefits Schedule database. A random intercept zero-inflated negative binomial model was used to compare outcomes between cases and controls, addressing skewed data, over-dispersion, and excess zeros.
MAIN RESULTS AND THE ROLE OF CHANCE
In both cohorts, women with endometriosis had a higher level of HSU, both before and after diagnosis, compared with those without the condition. For the 1973–1978 cohort, women with endometriosis had a higher rate of visits to GPs before and after diagnosis (adjusted incidence rate ratio: 1.19, 95% CI 1.14, 1.23 and 1.24, 95% CI 1.19, 1.30, respectively), specialists other than obstetricians/gynaecologists (1.50, 95% CI 1.40, 1.61, and 1.36, 95% CI 1.27, 1.46), and for diagnostic imaging (1.15, 95% CI 1.10, 1.21, and 1.20, 95% CI 1.15, 1.26). The average number of these visits remained consistent in the early years, peaked around 3 years before diagnosis, and then partly declined post-diagnosis, to later stabilize at a higher level than those without the condition. Following the diagnosis, women with endometriosis had a higher number of visits to obstetricians/gynaecologists (1.11, 95% CI 1.05, 1.17) than their matched controls, with a marked increase in the first 6 years post-diagnosis, but gradually returned to same levels as the control group. After diagnosis, women with endometriosis had a lower rate of visits to GPs (0.95, 95% CI 0.93, 0.98) and specialists other than obstetricians/gynaecologists (0.88, 95% CI 0.82, 0.93) compared to before their diagnosis, while they had a higher rate of visits to obstetricians/gynaecologists (1.09, 95% CI 1.01, 1.18) and diagnostic imaging (1.07, 95% CI 1.01, 1.14). Similar patterns of HSU were observed in the 1989–1995 cohort, regardless of whether surgically confirmed or clinically suspected cases of endometriosis were used, though the evidence for changes in specific HSU before and after diagnosis was weaker.
LIMITATIONS, REASONS FOR CAUTION
Approximately half of the women with endometriosis were clinically suspected cases without laparoscopic confirmation, which may result in an overestimation of prevalence and introduce the risk of misdiagnosis, potentially influencing clinical management and research findings.
WIDER IMPLICATIONS OF THE FINDINGS
The continued high level of HSU among women with endometriosis, even over a decade after diagnosis, suggests that they have substantially greater healthcare needs than other women. The distinct patterns of the use of healthcare in the years before and after endometriosis diagnosis can support efforts to improve diagnosis, management, and treatment outcomes for patients and to reduce healthcare costs.
STUDY FUNDING/COMPETING INTEREST(S)
The Australian Longitudinal Study on Women’s Health is funded by the Australian Government Department of Health and Aged Care. G.D.M. and G.M. are Australian National Health and Medical Research Council Leadership Fellows (GNT2009577 and GNT1177194). D.G.G. was funded by MRFF EndoAIMM (RFEHP100126). Funding sources had no role in the study design, data analysis, interpretation, or manuscript writing. The authors have no conflict of interest to declare.
TRIAL REGISTRATION NUMBER
N/A.
Background
Pregnancy complications, such as gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP), affect a significant proportion of women in Australia, with long-term implications for cardiovascular disease (CVD) risk. Despite existing preventive measures, participation in ongoing health monitoring remains low. This study aims to explore women’s preferences and experiences regarding preventive healthcare after GDM and HDP, and to identify their unanswered questions about the association between these conditions and future CVD risk.
Methods
A participatory, qualitative approach was adopted, involving a Lived Experience Expert Group (LEE Group) to plan, conduct, and interpret focus groups with women who had experienced either GDM or HDP. Participants were recruited through health consumer and community organisations and took part in two focus groups conducted via Zoom. The focus groups involved a stimulus presentation about CVD and GDM or HDP, facilitated group discussion about participants’ health and healthcare since their pregnancy, and Nominal Group Technique to prioritise participants’ questions about their CVD risk. Focus groups were audio recorded and transcripts from each group were analysed thematically. Synthesised Member Checking was used to verify the trustworthiness of findings.
Results
Twelve women participated in the focus groups, with distinct themes emerging from the GDM and HDP focus groups. Participants were previously unaware of the association between their pregnancy complication and increased risk of future CVD and wished to know more. Three themes were generated from the GDM focus groups: ‘a distressing diagnosis’; ‘degrees of diabetes’; and ‘balancing motherhood and self-care’. Two themes were generated from the HDP focus groups: ‘women’s concerns were dismissed’ and ‘wanting follow up at the right time and with the right person’. The ‘top ten’ questions from each group focussed on improving maternity care, preventing CVD, and (for the HDP group) concerns beyond CVD.
Conclusions
Women’s capacity to engage in preventive health after GDM and HDP is influenced by their maternity care experiences and the accessibility of primary care pathways. Future interventions should focus on improving woman-centred maternity care, ensuring seamless transitions to primary care, and addressing the social determinants of health for new mothers.
BACKGROUND
Cardiovascular disease (CVD) is the leading cause of mortality in women. We aimed to assess whether adding female-specific risk factors to traditional factors could improve CVD risk prediction.
METHODS
We used a cohort of women from the UK Biobank Study aged 45 to 69 years, free of CVD at baseline (2006–2010) followed until the end of 2019. We developed Cox proportional hazards models using the risk factors included in 3 contemporary CVD risk calculators: Pooled Cohort Equation - Atherosclerotic Cardiovascular Disease, Qrisk2, and PREDICT. We added each of the following female-specific risk factors, individually and all together, to determine if these improved measures of discrimination and calibration for predicting CVD: early menarche (<11 years), endometriosis, excessive, frequent or irregular menstruation, miscarriage, number of miscarriages, number of stillbirths, infertility, preeclampsia or eclampsia, gestational diabetes (without subsequent type 2 diabetes), premature menopause (<40 years), early menopause (<45 years), and natural or surgical early menopause (menopause <45 years or timing of menopause reported as unknown and oophorectomy reported at age <45).
RESULTS
In the model of 135 142 women (mean age, 57.5 years; SD, 6.8) using risk factors from Pooled Cohort Equation - Atherosclerotic Cardiovascular Disease, CVD incidence was 5.3 per 1000 person-years. The c-indices for the Pooled Cohort Equation - Atherosclerotic Cardiovascular Disease, Qrisk2, and PREDICT models were 0.710, 0.713, and 0.718, respectively. Adding each of the female-specific risk factors did not improve the c-index, the net reclassification index, the integrated discrimination index, the slope of the regression line for predicted versus observed events, and the Brier score or plots of calibration. Adding all female-specific risk factors simultaneously increased the c-index for the Pooled Cohort Equation - Atherosclerotic Cardiovascular Disease, Qrisk2, and PREDICT models to 0.712, 0.715, and 0.720, respectively.
CONCLUSIONS
Although several female-specific factors have been shown to be early indicators of CVD risk, these factors should not be used to reclassify risk in women aged 45 to 69 years when considering whether to commence a blood pressure or lipid-lowering medication.
Hysterectomy, removal of the uterus, is a commonly performed surgery for gynaecological morbidities. Emerging evidence indicates that hysterectomy performed before age 45 (early hysterectomy), is associated with considerable risks to women’s health. While most evidence on hysterectomy is from high-income settings, national surveys from India report high prevalence of early hysterectomy in specific regions, as well as higher prevalence amongst women in rural areas and with less education. The median age at hysterectomy in India is close to ten years before the onset of natural menopause. India has recently introduced national guidelines to address early hysterectomy, but large evidence gaps on the causes and consequences remain – which in turn limits the potential effectiveness of interventions at the clinical, health system and community level.
Methods
SAHELI is a Team Science study that will examine: (i) individual, social and health system determinants of early hysterectomy; (ii) women’s treatment pathways to hysterectomy and for gynaecological morbidity in general; and (iii) the consequences of undergoing hysterectomy on women’s physical, mental, economic and social well-being across the life course. This mixed-methods study includes population surveys amongst women in ages 25–49 in three high-prevalence states; qualitative health systems research to trace treatment journeys with women, health care providers and other stakeholders; evidence syntheses; and knowledge translation activities to ensure findings inform co-produced strategies and interventions. The study is grounded in a feminist epidemiology approach, aiming to examine individual and structural causes of vulnerability and prioritising the views of women, particularly in knowledge translation.
Conclusions
SAHELI, implemented by an all-women, multi-disciplinary team, is the first study in India to examine the causes and consequences of hysterectomy in a life course approach. We aim to influence interventions, policy and future research on women’s health, particularly access to quality gynaecological care and comprehensive health services through the life course.
Citations (47)
... Longitudinal research, including diverse patient cohorts, needs to become the main focus to solve present research shortcomings and eliminate healthcare equality gaps. Research findings about gynecological pain suffer from a lack of diversity in participants because most studies exclude patients from different racial backgrounds, as well as ethnically diverse and lower-income groups [54]. Future research must establish a diverse participant base to analyze how the genetic structure, combined with environmental conditions and differences in healthcare service accessibility, modifies both sensation detection and therapeutic results and patient outcomes. ...
... Twenty-two people with lived experience of either recurrent early pregnancy loss or stillbirth were nominated by relevant health consumer organisations to take part in the study, including two who had experienced both recurrent early pregnancy loss and stillbirth and five who had experienced bereavement as well as another pregnancy complication, such as gestational diabetes or a hypertensive disorder of pregnancy (see Fig. 1). Upon follow up, seven people agreed to take part in the recurrent early pregnancy loss focus groups, nine agreed to take part in the stillbirth focus groups, three were unable to be contacted and two preferred to attend the focus group related to hypertensive disorders of pregnancy (reported elsewhere [31]). All participants identified as women (see Table 1). ...
... Adding female specific risk factors, such as a history of GDM or HDP, to contemporary CVD risk calculators for women aged 45-69 does not appear to improve the ability to identify the women most at risk of CVD [4]. However, because GDM and HDP occur several years or even decades before the development of CVD, there is an opportunity to institute or continue preventive healthcare after pregnancy to reduce this risk [5]. ...
... The symptoms of menopause and the consequences they have on health are intimately tied to one another. 4,5 Cognitive issues are more prevalent around the time of menopause, which is characterized by a decrease in hormone levels, particularly estrogen, according to the findings of researchers. 6 An increased risk of cardiovascular disease, parkinsonism, depression, osteoporosis, hypertension, weight gain, diabetes in midlife, cognitive difficulties and dementia (including AD), and hypertension is associated with an early drop in estrogen levels in women. ...
... Mixed diets containing 90% of protein from a variety of plant foods and only 10% from animal sources can meet protein needs similarly to typical Western diets, which are significantly higher in animal protein [90,91]. High intake of animal protein, particularly from processed meat, has been associated with an increased risk of T2DM [92], whereas this risk does not appear to extend to plant proteins [85,86]. In fact, higher plant protein intake may even improve metabolic health [93]. ...
... Osteoporosis can be termed as a skeletal deformity in which there is a decrease in density (mass/volume) of a normally mineralized bone resulting in an elevated risk of fractures 1,2 . This is primarily caused by an increased production of osteoclast cells (components that degrade bone), low oestrogen hormone levels, old age and excessive tobacco consumption 3,4 . This phenomenon is prevalent in including hot flashes, vulvovaginal atrophy, and sexual dysfunction 5,6 . ...
... В настоящее время миома матки диагно стируется у 70 % пациентов гинекологического профиля. Частота выявления миомы матки неуклонно растет, что связано с внедрением более совершенных и доступных методов ди агностики [1][2][3]. Ведущая симптоматика забо левания включает длительные и / или обиль ные маточные кровотечения, анемию, абдо минальный болевой синдром, симптоматику со стороны органов малого таза, нарушение репродуктивной функции в виде бесплодия и невынашивания [4; 5]. Эти проявления нега тивно влияют на физическую активность, пси хологическое благополучие, воздействуют на социальные, интимные отношения и снижают качество жизни в целом [6][7][8]. ...
... 13 There are reports suggesting that several reproductive factors in women, such as age at menarche, number of children, miscarriages, stillbirths, age at menopause, and reproductive hormones, may be associated with the risk of COPD. 13,14 From an anatomical perspective, women are generally known to have differences in lung and thoracic shape and respiratory muscle usage compared to men. Specifically, the smaller airway area leading to increased respiratory resistance and the smaller lung capacity resulting in decreased ventilation efficiency may require higher respiratory effort during peak exercise compared to men. 15 This could potentially be related to the heightened symptom awareness observed in COPD patients. ...
... Recent data seem to confirm that a correct therapeutic flow-chart, as suggested by available recommendations, can optimize the reproductive chances in women with PCOS allowing to reach a long-term fecundability like or slightly higher in comparison with women without the disease [7,8]. ...
... While midlife has been reported as a vulnerable timeframe, recent studies have shown that it is also highly dynamic and amenable to meaningful change [43]. Therefore, midlife is a critical window as a target of interventions, as several limitations commence at midlife, such as reduced estrogen and behavioral changes (changes in diet, exercise and sleep patterns due to age), with visible health trajectories which persist into late adulthood [44]. ...