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Newsletter Archive > Summer Issue 2002
Health Matters
for Women™
Summer 2002
HIGHLIGHT Top Killers of Women
The leading causes of death for U.S. women in 1999, according to
"Deaths: Leading Causes for 1999," CDC's comprehensive report on U.S. causes of death:
1. Heart disease
2. Cancer
3. Stroke
4. Chronic lower respiratory disease
5. Diabetes
6. Influenza and pneumonia
7. Accidents
8. Alzheimer's disease
9. Kidney disease
10. Septicemia
Data on leading causes of death are now available by age, gender, race and
Hispanic origin. Access the report at:
www.cdc.gov/nchs/about/major/dvs
/mortdata.htm
or contact the National Center for Health Statistics at 301-458-4636.
COVER STORY
Helping Women Understand Bleeding Disorders
Up to 2 million women in the United States may have an inherited bleeding disorder and not know it. Many of these women learn to live with
the problems their bleeding causes, such as heavy periods, and don’t realize that they could have a bleeding disorder. Other women may have
more serious bleeding problems such as hemorrhages after childbirth or surgery, and some have hysterectomies to end their heavy periods. With
proper diagnosis of their condition, women with bleeding disorders could avoid these complications and surgeries.
The most well-known bleeding disorder is hemophilia, because of its prevalence
among royal families in Europe. Hemophilia affects about 17,000 men in the United States and is rarely found in females. But the most common
bleeding disorder is von Willebrand disease (VWD), which affects about 1 to 2 percent of people in the United States.
The disease is named after Erik von Willebrand, who first described it in 1926
in a large Scandinavian family. It came to his attention because a young woman in the family had profuse bleeding during her menstrual period.
VWD is caused by a deficiency or defect in the body’s ability to make a protein, von Willebrand factor, that helps blood clot. It can range
from severe to mild in symptoms; 90 percent of people who have the disease have the mild form. VWD occurs equally in men and women, but women
are more likely to notice the symptoms because they have heavy or abnormal bleeding during their menstrual periods and after childbirth.
Although VWD is the most common cause of bleeding disorders in women, there
are other inherited bleeding disorders, so proper treatment requires an accurate diagnosis. CDC is working to find new ways to diagnose these
conditions and provide care for women who have them. Part of this effort involves increasing awareness of these disorders among women and
their doctors.
What Is a Bleeding Disorder?
Bleeding disorders occur when the blood does not clot properly. There are several possible causes: a person may have a shortage of platelets
or of any of the proteins called clotting factors, or the
platelets or clotting factors may not work correctly.
Symptoms vary depending on the bleeding disorder and its severity and might
include:
- menorrhagia: heavy bleeding during monthly periods
- unusually hard-to-control bleeding after minor injury, childbirth, or
surgery
- excessive bleeding from the gums after flossing, brushing, or having a
tooth removed
- frequent or prolonged nosebleeds
- easy bruising
While there is no cure for these disorders, once they are identified,
treatment is available to control symptoms.
Undiagnosed and Misunderstood
Why do so few women know about bleeding disorders? First, women may not report their symptoms. They may not feel comfortable talking about
heavy menstrual bleeding, which is, in essence, a relative and sometimes subjective term.
There are many gynecological and physical causes for menorrhagia, such as
endometriosis, thyroid problems, and cancer; however, the cause is not identified in half the cases. A recent CDC-Emory University survey
found that gynecologists rarely considered bleeding disorders as a cause of menorrhagia. However, recent research from Europe and CDC has
shown that 15 to 20 percent of women with menorrhagia have inherited bleeding disorders. CDC and the National Hemophilia Foundation have been
working to encourage gynecologists to consider bleeding disorders in women who have menorrhagia. As a result, the American College of
Obstetricians and Gynecologists recently recommended screening for VWD in these women (see inset).
In December 2001, the American College of Obstetricians
and Gynecologists recommended screening women with menorrhagia for VWD. Women who should be tested include:
- adolescents with severe menorrhagia. They should be tested before
hormone therapy is prescribed.
- adult women with significant menorrhagia that cannot be explained by
other causes
- women who are about to have hysterectomies for excessive menstrual
bleeding
For more on the ACOG opinion, see the December 2001 Obstetrics &
Gynecology, (Volume 98, No. 6), "ACOG Committee Opinion #263. Von Willebrand's Disease in Gynecologic Practice."
|
CDC is also developing a short screening questionnaire to help doctors decide
which women with unexplained menorrhagia should be tested for a bleeding disorder. Researchers in CDC’s hematologic diseases branch are
evaluating the questionnaire with gynecologists and women and hope to make it available within the next year.
Testing and Treatment
Tests for bleeding disorders are performed on a blood sample, but the testing can be complicated and should be done at a specialized
laboratory by experienced coagulation specialists. Finding a laboratory with such expertise can be difficult. CDC is working to develop better
laboratory tests for VWD disease and other bleeding disorders.
An effective way for women to be tested and receive treatment for bleeding
disorders is through a hemophilia treatment center (HTC). CDC supports a network of 140 HTCs thoughout the United States. Although these
centers traditionally served men with hemophilia, they have expanded their services to include women with bleeding disorders.
HTCs provide comprehensive care for people with bleeding disorders. A team of
health-care providers offers services that include specialized laboratory testing, yearly assessments and referrals. A CDC survey of women
with VWD served by HTCs found that they were very satisfied with the care they received at them. CDC continues to work with its partners to
develop educational materials for women recently diagnosed with a bleeding disorder.
For more information about women and bleeding disorders, visit www.cdc.gov/ncidod/dastlr/hematology or contact CDC’s hematologic diseases branch at hdb@cdc.gov.
A Doctor Reaches Out
It’s routine for New York pediatrician Paula Elbirt to ask her girl
patients if their periods are heavy or if their gums bleed. She's looking for red flags for bleeding disorders, because she knows
first-hand they often go undiagnosed.
Until she was a young woman, Dr. Elbirt took her bleeds for granted. Her
periods may have lasted for two weeks, but so did her mother's. She and her mother both spat blood into the sink after brushing their
teeth and bled interminably when they nicked their legs shaving. "It was normal in my family," she says.
It wasn’t until her medical internship that a hematologist helped her
recognize that she had mild von Willebrand disease, a condition she never learned about in medical school. After she accidentally cut
herself with scissors, the hematologist watched Dr. Elbirt soak through gauze pad after pad waiting for the bleeding to stop. Then he
asked her questions about her bleeding and guided her toward testing for the disease.
Now, she takes care to control what she says is a very livable condition
with checkups from a hematologist and a periodontist and occasional use of the nasal spray Stimate. And she works to help boost
awareness of women’s bleeding disorders through her work with the National Hemophilia Foundation — and through careful screening of
her own young patients.
Courtesy National Hemophilia Foundation |
Bleeding Disorders: How Many Women?
Putting a number on the problem of bleeding disorders in women is not a simple matter. The most obvious symptom, abnormally heavy menstrual
bleeding, is almost always described subjectively, rather than measured through actual blood lost. Even when women do complain, their
internist, gynecologists or family practitioners may not think of a bleeding disorder as the cause. Testing is complicated and must be done by
specialists in sophisticated laboratories.
So it’s important for women who think they might have a bleeding disorder to
consider seeking a diagnosis from a hemophilia treatment center (HTC) that can perform the special testing and understands the different
treatments.
- 5 to 10 percent of U.S. women complain to their doctors about heavy
menstrual bleeding.
- Half of all menorrhagia cases go unexplained after other causes have been
ruled out.
- 1 to 2 percent of people in the United States — which means up to 2
million women — may have mild von Willebrand disease (VWD), the most common bleeding disorder.
- About 5 percent of hysterectomies — 30,000 per year — are performed
because of heavy bleeding. Some of these women probably have bleeding disorders that could have been controlled without surgery.
- Two studies in Europe and one in the United States have shown that up to 20
percent of women with menorrhagia may have an inherited bleeding disorder, most commonly VWD.
NEWS YOU CAN USE
Diabetes
Carrying the Burden
The burden of diabetes is especially heavy for women, and diagnosed cases among women have increased almost 50 percent in the past decade.
Pam Fernandes has conquered the fears that can stop
people with diabetes from taking responsibility for taking care of themselves. "Yes, this is a serious disease," she says.
"But it can be lived with." Insulin dependent since she was 4 and legally blind since she was 21, Fernandes has won U.S.
Olympic Committee Athlete of the Year and a silver medal at the 2000 Games in Sydney. Now she is also a spokesperson for the effects of
diabetes on women. |
To focus national attention on the impact of the disease on women, CDC has
published Diabetes and Women’s Health Across the Life Stages: A Public Health Perspective. A task force is developing a national
public health action plan and planning a first-ever national conference on diabetes and women’s health.
- Diabetes is a leading cause of death among middle-aged American women.
- Women’s risk factors for the disease are higher than men’s: they are
more likely to be overweight and inactive, and they more often live to be older.
- Among people with diabetes who have had heart attacks, women have lower
survival rates and quality of life than men.
- American Indian women are particularly vulnerable to diabetes.
- About 4.5 million women 60 or older have diabetes. But 25 percent of them
don’t know it. For a copy of the report or more information on women and diabetes, visit www.cdc.gov/diabetes
or call 877-CDC-DIAB.
Move It!
Boosting Physical Activity
We know that physical inactivity is a leading cause of preventable death in the United States and that regular exercise can reduce the
risk for heart disease, diabetes, obesity, some cancers, and musculoskeletal conditions.
Still, only one fourth of U.S. adults get the recommended 30 minutes of
moderate exercise five days a week or 20 minutes of vigorous activity three days a week. Almost 30 percent of adults report no regular
physical activity.
Here’s what communities can do to help people increase physical activity.
The Task Force on Community Preventive Services reviewed interventions for effectiveness and strongly recommends:
- large-scale community-wide campaigns that include media campaigns as well
as support groups, counseling, screening, education and walking trails;
- behavior-change programs tailored to individuals’ readiness for change or
interests, including teaching goal-setting, building social support and relapse prevention;
- school-based physical education programs with more activity or more time in
P.E.;
- social support interventions such as buddy systems or walking groups; and
- better access to walking trails and exercise facilities. Also recommended:
motivational signs near elevators to encourage people to take the stairs. Read the report at www.cdc.gov/mmwr/pdf/rr/rr5018.pdf. For more on the Task Force, visit www.thecommunityguide.org.
Safe Motherhood
Finding One Voice
An expansive concept of safe motherhood, one that includes the physical and emotional health of women before, during and after pregnancy,
emerged from a CDC-organized gathering in early September in Atlanta.
More than 300 attendees at the National Summit on Safe Motherhood came
together from many walks: they were scientists, obstetricians and pediatricians, policy makers and program managers, professors and students,
fertility specialists, childbirth educators and advocates for practices such as birthing centers, doulas, and breastfeeding. They discussed
everything from depression and domestic violence to cultural barriers and the lack of data about pregnancy-related complications and health.
And they left resolved to look for answers and take action to build a grassroots safe motherhood movement in the United States.
"Why in the world are we still having this
discussion in the 21st century?" former Congresswoman Patricia Schroeder asked the National Summit on Safe Motherhood. Schroeder
related her own near-death story of hemorrhage complicated by hepatitis C after the birth of her second child and said she hears too
many like it from women today. "Let's get the knowledge and get it out there." |
"Motherhood is a pretty universal experience that captures the
imagination and brings together a lot of single-issue interests," said Wanda Jones, head of the U.S. Department of Health and Human
Services Office on Women’s Health.
An expanded definition of safe motherhood could help focus research and policy
to further reduce the number of maternal deaths, which stopped declining in 1982. The current ratio is 9.9 maternal deaths per 100,000 live
births, but this risk is not equal for all groups of women. For example, African- American women are four times more likely to die of
pregnancy-related complications than non- Hispanic white women; Native American and Hispanic and Asian immigrant women twice as likely.
"This conference is a beginning, to bring people together to say with one
voice, 'This is important,'" said Lynne Wilcox, director of CDC's reproductive health program. "We must collaborate, we must take
action to make our voices heard, we must call for research and investigation into the issues that affect safe motherhood, and we must design
policy that supports the health of all pregnant women." For more information on safe motherhood, visit www.cdc.gov/nccdphp/drh/smh_aag.htm.
Fertility
Report Helps Women Decide
What are the chances of having a child with the help of assisted reproductive technology (ART)? Where can women go for the treatment?
Women can look to CDC’s fifth annual Assisted Reproductive Technology
Success Rates report for the answers. The ART report summarizes national trends and gives success rates from 370 fertility clinics around
the country to help consumers make informed decisions.
- Overall, about one in four ART cycles resulted in the birth of a baby for
women who used their own eggs, a slight increase in success rate from 1998.
- Success rates decrease markedly with age after 35.
- Approximately 37 percent of all ART deliveries were of multiple infants
(twins or more), compared with less than 3 percent for the general population.
- More than 30,000 babies were born as the result of assisted reproductive
technology procedures carried out in 1999.
"ART holds out the promise of having a child, but it can be a long and
expensive process," said Lynne Wilcox, director of CDC’s reproductive health program. "People need all the information they can
get to make an informed decision."
The full report is available at www.cdc.gov/nccdphp/drh/art.htm or 770-488-5372.
Another CDC study shows ART use rapidly on the rise, raising concerns about
the potential health problems of the many twins, triplets, and higher-order multiples and their mothers. More than half of ART babies are
multiples. Multiple-infant pregnancies are often higher risk and the infants are more often low birth weight than single births.
Find the report at: www.cdc.gov/mmwr/preview/mmwrhtml/mm5105a2.htm.
Violence
Looking at Homicide Numbers
During the 1980s and 1990s, rates of intimate partner homicide decreased by 47 percent, researchers at CDC found in a first-ever analysis
of 1991-1998 data from the Federal Bureau of Investigation. Homicides against men decreased 68 percent and against women 30 percent.
Some key findings:
- one in three women murdered is killed by a current or former spouse or
boyfriend.
- The rate of intimate partner homicide increases with the population size of
the community.
- Rates among blacks were 4.6 times higher than among whites.
- Among women, rates were highest among those 20 to 39 years old. The report
calculates national intimate partner homicide rates for racial groups, by state, by month, by size of community, and other factors. See
the report at: www.cdc.gov/mmwr/preview/mmwrhtml/ss5003a1.htm.
If You're Tanned, You're Toast
Tanned skin is damaged skin. There's no other way to say it. Any change in skin color after time outdoors - whether suntan or sunburn -
means damage from the sun's UV rays. And just a few serious sunburns can increase your risk of skin cancer. One million people will get some
kind of skin cancer this year. Don't be one of them. Protect the skin you're in.
Choose Your Cover
Skin Cancer: CDC's Choose Your Cover Campaign targets young people to change social norms about skin protection and tanned skin. Visit www.cdc.gov/chooseyourcover.
INTERNATIONAL
Pregnancy a Big Risk for Afghan Refugees
Pregnancy and childbirth were the leading cause of death among Afghan refugee women of reproductive age in Pakistan refugee camps,
according to a CDC study published in The Lancet in February. Of the babies born to these mothers who died, 60 percent were stillborn or died
early in infancy.
The study by CDC’s reproductive health program with the International Rescue
Committee (IRC) says that better access to health care might have prevented the deaths of many of the Afghan mothers and babies who died in
Pakistani refugee camps in 1999 and 2000.
Death rates for Afghan women were lower in the refugee settlements, showing
that IRC basic health services reduce mortality. But high fertility, low literacy and limited mobility may conspire to make pregnancy and
childbirth a dangerous endeavor for these women.
Recommendations include multivitamins with folate and iron, more and
better-trained lay midwives, treatment of complications such as malaria, better access to obstetric and postpartum care, contraceptives for
women who do not wish to become pregnant, and better surveillance for maternal deaths.
Afghanistan is the source of the largest and most long-standing refugee
population in the world. The study — one of the first to document reproductive health status in refugees and the first reproductive-age
mortality study in a refugee setting — aims to help fill a gap in knowledge about refugee maternal and child health.
"Given that the leading cause of death among women living in stable camps
with established health care services was maternal mortality, we anticipate that the burden of maternal mortality will be even greater among
new refugees, women living in Afghanistan and women returning to Afghanistan, where health care services are reported to be in seriously short
supply," according to the article.
CDC SPOTLIGHT
CDC's Injury Center
Tracking and Tackling Violence Against Women
As part of its work to protect Americans from harm caused by injuries, CDC’s National Center for Injury Prevention and Control also
focuses on intentional violence such as homicide, suicide, rape, and violence among youth. The injury center’s work to prevent intimate
partner violence and sexual violence are of particular relevance to women’s health.
Surveillance
Developing accurate ways to monitor the problems is a big challenge, and CDC's Uniform Definitions and Recommended Data Elements for
intimate partner violence, published in 2000, aims to improve and standardize the data on violence against women. Underreporting is a problem
because of embarrassment, denial, or fear, and because incidents that are reported may not be recorded as intimate partner or sexual violence
or make it into the medical record. Even semantics is at issue, with date rape, domestic abuse, battering, marital rape, stalking, and rape
being used inconsistently to describe forms of intimate partner and sexual violence.
This under-reporting and lack of standardization mask the problem and
contribute to confusion and lack of consensus. But Uniform Definitions is quickly becoming the recognized standard, and five states are
now piloting tracking systems. CDC conducts an ongoing National Violence Against Women Survey with the U.S. Department of Justice. And new
surveys to help states more accurately gauge the problems will guide policy and allow comparison among states.
Research
CDC supports research into causes, risk factors, consequences, and prevention strategies. For example, the injury center is working to find
out what social norms support or discourage intimate partner and sexual violence and which risk factors can be changed. Then it will use that
information to help communities build campaigns to make violence against women unacceptable and intolerable.
CDC is funding projects — several of them targeted for specific racial and
ethnic populations — in communities across the country to tackle the problems. In just one example of these very different projects, the
Austin, Texas, school district and the University of Texas are teaching children, teachers, and parents how to eliminate bullying and sexual
harassment in elementary schools. Rooted in the belief that social acceptance of violence in personal relationships is a cause of domestic
violence, the Expect Respect program teaches kids to expect to be treated with respect by their peers.
Intimate Partner and Sexual Violence
- One review showed that as many as 20 percent of women experience intimate
partner violence during pregnancy.
- Each year more than 10 million American children witness intimate partner
violence in their families.
- About half of all rapes and sexual assaults against women are committed by
friends and acquaintances, and 26 percent are by intimate partners.
- Of rape victims who reported the offense to law enforcement, about 40
percent were under age 18, and 15 percent were younger than 12.
- Victims of rape often suffer long-term symptoms including chronic
headaches, sleep disturbance, recurrent nausea, decreased appetite, eating disorders, sexual dysfunction, and suicide attempts. Sexual
assault increases the odds of substance abuse by a factor of 2.5.
Sexual Violence Against People With Disabilities
- Of the people with disabilities who have been sexually victimized, 72 to 82
percent are female.
- Among women with disabilities, reported rates of sexual violence range from
51 to 79 percent. Most cases involve multiple episodes of sexual contact.
- Most perpetrators are male (88 to 98 percent) and are someone the victim
knows.
Decades of Injury Prevention and Research
CDC began studying home and recreational injuries in the
early 1970s and violence prevention in 1983. From these early
activities grew a national program to reduce injury, disability,
death, and costs associated with injuries outside the workplace.
In June 1992, CDC established the National Center for Injury
Prevention and Control (NCIPC).
This summer, NCIPC marks 10 years of commitment to
coalescing and defining the field of injury prevention and
control.
Contact the National Center for Injury Prevention and
Control at Mailstop K65, 4770 Buford Highway NE, Atlanta,
GA 30341-3724; 770-488-1506; or OHCINFO@cdc.gov.
Visit CDC's injury Web site at www.cdc.gov/ncipc.
Check out CDC’s 2001-02 Injury Fact Book
(www.cdc.gov/ncipc/fact_book/) with comprehensive
chapters highlighting statistics and interventions on intentional
and unintentional injury topics. |
PREVENTION WORKS
PRAMS Collects Pregnancy Data
How soon do pregnant women seek prenatal care? How do they feel about their pregnancies? How many smoke or drink alcohol? How many
are counseled to breastfeed? And how might these variables relate to one another?
PRAMS — the Pregnancy Risk Assessment Monitoring System — collects such
data and makes it available to states to plan and evaluate their health programs. The goal: improve the health of mothers and infants by
reducing adverse outcomes such as low birth weight, infant death, and health problems for women and their babies. The data help identify
groups of women and infants who are at high risk for health problems.
CDC and state health departments collect this state-specific, population-
based data on what women do before, during, and just after pregnancy. PRAMS surveys ask about, for instance, unintended pregnancy,
contraceptive use, tobacco and alcohol use, physical abuse, prenatal care, and HIV counseling. States work from birth certificate records to
survey, by mail and telephone, women who have recently had live births.
To find out more about PRAMS, visit www.cdc.gov/nccdphp/drh/srv_prams.htm. PRAMS is funded in 32 states and New York City.
PRAMS Informs Stop-Smoking SCRIPT
In Alabama, 1995 PRAMS data showed 28 percent of mothers smoked shortly
before, 16 percent during, and 24 percent shortly after pregnancy, with higher rates among pregnant women receiving Medicaid.
So the Alabama Department of Public Health, collaborating with the
University of Alabama-Birmingham, used PRAMS data to win a $2.5 million grant from the National Heart, Lung, and Blood Institute. The
goal: lower Alabama’s infant mortality and low birth weight by reducing smoking among pregnant women who receive prenatal care in
county health clinics.
The five-year randomized trial documented the effectiveness of an
education program pregnant smokers received during regular prenatal visits. The control group received the usual stop-smoking
encouragement and literature. The experimental group received SCRIPT (Smoking Cessation-Reduction in Pregnancy Trial), which includes a
video, self-help manual and counseling session. The trial was the largest sample of Medicaid patients whose smoking was confirmed on
entry by testing for cotinine, a metabolite of nicotine and an indicator of smoking status.
Among the first 800 participants, almost twice as many (17 percent) quit
than in the control group (9 percent). Another 20 percent who received the program cut their smoking by half or more. Quit rates were
also cotinine confirmed.
PRAMS has been invaluable, especially having data distributed by race
and by age, method of payment and low birth rate, according to Denise Donald, R.D.H., smoking cessation coordinator for the Alabama
Department of Public Health’s women and children division, who says she keeps the PRAMS data handy at all times. |
Mammograms
Following the Debate
The U.S. Department of Health and Human Services (HHS), the National Cancer Institute (NCI) and the U.S. Preventive Services Task
Force (USPSTF) have reaffirmed the value of mammography for women 40 and older.
"The federal government makes a clear recommendation to women on
mammography: If you are 40 or older, get screened for breast cancer with mammography every one or two years," said HHS Secretary Tommy G.
Thompson at a press conference in February.
The statement followed several months of debate about the evidence that
mammograms prevent deaths from breast cancer. A report last fall in The Lancet said that the trials that proved mammograms'
effectiveness in preventing deaths were flawed and that the benefits may not necessarily outweigh the risks, such as biopsy surgeries after
false positives. More than 250 articles have been published over the years in this ongoing debate, and most reviewers have come to the
conclusion that mammography is effective.
"It is absolutely essential to look beyond the debate over the
limitations of current data and to accelerate the development of better screening tools," said NCI Director Andrew von Eschenbach, M.D.,
in the NCI's statement in January. NCI pledged to make evaluating new data on mammography a high priority and to charge forward with research
on early detection.
CDC's mission in cancer is to translate research into practical prevention and
control programs and promote them widely to the public. One example is CDC’s National Breast and Cervical Cancer Early Detection Program,
which provides Pap smear and mammography screening to women who could otherwise not afford it.
DATES THAT MATTER
First Conference of the National
Center on Birth Defects and
Developmental Disabilities
September 17-19, Atlanta
www.cdc.gov/ncbddd/conference.htm
CDC/ATSDR Women’s Health
Conference, Advancing the
Health of Women: Prevention
Practice and Policy
October 7-9, Atlanta
404-639-7230
June is National Safety Month
National Men’s Health Week
June 10-16
National Prevention of Eye Injuries
Awareness Week
June 28-July 8
National Therapeutic Recreation
Week
July 13-19
World Breastfeeding Week
August 1-7
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— Yvonne Green, Director CDC/ATSDR Office of Women's Health
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This page last reviewed May 6, 2004: Historical Document
URL: http://www.cdc.gov/women/newsltr/02summ.htm
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