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M E D I C A L S U R V E I L L A N C E M O N T H L Y R E P O R T

smsmr

A publication of the Armed Forces Health Surveillance Center

SEPTEMBER 2013

Volume 20Number 9

Women’s Health Issue

P A G E 2 Depression and suicidality during the postpartum period ater irst timedeliveries, active component service women and dependent spouses, U.S.Armed Forces, 2007-2012

Tai Do, MD; Zheng Hu, MS; Jean Otto, DrPH, MPH; Patricia Rohrbeck, DrPH, MPH, CPH

P A G E 8 Female inertility, active component service women, U.S. Armed Forces,2000-2012

P A G E 1 3 Brie report: polycystic ovary syndrome, active component service women,U.S. Armed Forces, 2000-2012

P A G E 1 5 Pelvic inlammatory disease among emale recruit trainees, activecomponent, U.S. Armed Forces, 2002-2012

Patricia Rohrbeck, DrPH, MPH, CPH

P A G E 1 9

Surveillance snapshot: myomectomies and hysterectomies perormedor uterine ibroids at military health acilities, active component servicewomen, U.S. Armed Forces, 2000-2012

P A G E 2 0 Menorrhagia, active component service women, U.S. Armed Forces, 1998-

2012Kerri Dorsey, MPH

P A G E 2 5 Incident diagnoses o breast cancer, active component service women,U.S. Armed Forces, 2000-2012

P A G E 2 7 Correction

P A G E 2 8 Surveillance snapshot: births, active component service women, U.S.Armed Forces, 2001-2012

S U M M A R Y T A B L E S A N D F I G U R E S

P A G E 2 9 Deployment-related conditions o special surveillance interest

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M S M R Vol. 20 No. 9 September 201Page 2

inant, making the diagnosis o PPD diffi culor delayed. Some studies suggest that PPD ithe most common complication o childbearing.5 Te Centers or Disease Control andPrevention (CDC) reports that 8 to 19 percent o postpartum women report requenPPD symptoms.6 However, most studies werbased on sel-reported symptoms, whereas true diagnosis o PPD is based on a physicianevaluation o the patient’s entire medical history afer an initial positive screen or PPD.

Compared to the civilian populationactive component service women and dependent spouses o active component servicmen may experience unique stressors as paro the military environment.7 For active component women, these stressors may includworking longer into their pregnancy andworking longer hours during pregnancy.7 Inaddition, they may have to deploy as earlyas six months afer giving birth. Dependenspouses may not have the support o theiactive component spouses i the spouse ideployed during part or all o the pregnancydelivery, or postpartum period. Previou

research has reported that rates o PPD symptoms (based on screening results) amonactive component women range rom 11 to20 percent;7-9 estimates o rates in the civilian population range rom 8 to 15 percent.10,1

Similarly, suicidal ideation rates in the postpartum period have been ound to be highein active component women (15.4%) thanthose in the civilian population (5.3%).8,1

Additionally, Danielson et al. reported tharst time mothers who deployed within sixmonths afer giving birth had a 37 percenhigher incidence o mental health disorder

than those who deployed much later afedelivery.13

Previous studies o PPD and suicidaideation and attempts during the postpartum period among service women ocusedprimarily on screening results amonsmall populations. Tis report summarizecounts, percentages, and trends o inciden

Depression and Suicidality During the Postpartum Period After First Time DeliveriesActive Component Service Women and Dependent Spouses, U.S. Armed Forces, 2007-2012

Tai Do , MD (LCDR, USN); Zheng Hu, MS; Jean Otto, DrPh, MPH; Patricia Rohrbeck, DrPH, MPH, CPH (Maj, USAF)

Although suicide is a leading cause o death among new mothers during thepostpartum period, there has been limited research on sel-harm in the post-partum period and associated risk actors. One potential risk actor or sui-cidality (completed suicides, suicide attempts, and suicide ideation includingthoughts o sel harm) during the postpartum period is postpartum depression(PPD). In this study o women who gave birth or the rst time between 1 Janu-ary 2007 and 31 December 2011, 5,267 (9.9% o all who delivered) active com-ponent service women and 10,301 (8.2%) dependent spouses received incidentPPD diagnoses during the one year postpartum period; 213 (0.4%) servicewomen and 221 (0.2%) dependent spouses were diagnosed with incident sui-

cidality. Afer adjusting or the effects o other covariates, service women withPPD had 42.2 times the odds o being diagnosed with suicidality in the post-partum period compared to service women without PPD; dependent spouseswith PPD had 14.5 times the odds compared to those without PPD. Te nd-ings o this report suggest that a history o mental disorders was commonamong service women and dependent spouses with PPD in the postpartumperiod, and, in turn, PPD was a strong predictor or suicidality in the postpar-tum period. Tese results emphasize the importance o PPD screening duringthe postpartum period. Tey also suggest that additional ocused screening orsuicidal behavior among those already diagnosed with PPD may be warranted.

suicide deaths and attempts occur at alower rate during pregnancy and thepostpartum period than in the gen-

eral population o women.1 Nevertheless, ithas been estimated that there are approx-imately 3.5 to 11 postpartum suicides per100,000 pregnancies.2 Prior studies havedemonstrated that suicidal ideation is morecommon than suicide attempts or deathsrom suicide during pregnancy and thepostpartum period; suicidal ideation is

estimated to affect between 5 to 14 percento women.2 Overall, suicidality (completed sui-

cides, suicide attempts, and suicidal ide-ation including thoughts o sel harm)occurs at a higher rate during the perina-tal period among women with a history omental disorders.2 It has been documentedthat postpartum depression (PPD) can

adversely affect the mother-child relation-ship, child development, marital relation-ship, and mental health o the woman’spartner,3 but it is unclear i suicidality hassimilar effects on child development.

PPD is a potential risk actor or suicid-ality during the postpartum period. Accord-ing to the American Psychiatric Association:Diagnostic and Statistical Manual o MentalDisorders (DSM-IV), PPD is a type o majordepression disorder occurring within the rst

our weeks afer delivery.4

However, in clinicalpractice, it is accepted that a depression dis-order occurring within 12 months o deliv-ery is considered PPD. Some signs o PPDinclude disturbances in sleep, energy level,appetite, weight and libido.3 However, signsand symptoms that are reported or observedby amily members may be interpreted asthe usual impact o taking care o a newborn

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September 2013 Vol. 20 No. 9 M S M R Page

PPD and suicidality diagnoses during thepostpartum period among active com-ponent service women and dependentspouses over a six-year surveillance period.

M E T H O D S

Te surveillance period was 1 Janu-

ary 2007 to 31 December 2012. Te surveillance population included two cohorts;active component service women o allServices, and dependent spouses o activecomponent service members o all Serviceswho gave birth or the rst time between1 January 2007 and 31 December 2011.Females within each cohort were ollowedor a one year postpartum period. First-time births and diagnoses o incident PPDand suicidality were derived rom recordsroutinely maintained in the Deense Medi-cal Surveillance System (DMSS). DMSS

records document both ambulatoryencounters and hospitalizations o activecomponent members o the U.S. ArmedForces and their dependents, i eligible andenrolled in a RICARE health plan option,in xed military and civilian (i reimbursedthrough the Military Health System) treat-ment acilities. Diagnoses were indicatedby specic codes rom the InternationalClassication o Diseases, Ninth Revision,Clinical Modication (ICD-9-CM). Com-pleted suicide data or active component

service women were derived rom recordsprovided by the Armed Forces MedicalExaminer System (AFMES) and routinelymaintained by the DMSS. Te AFMES doesnot have records or causes o death amongdependent spouses so data on completedsuicides among dependents were not avail-able or this analysis.

For summary purposes, mental dis-order-specic diagnoses indicative o sin-gle major depressive disorder (ICD-9-CM:296.20-296.26), recurring major depres-sive disorder (ICD-9-CM: 296.30-296.36),

unspecied episodic mood disorder (ICD-9-CM: 296.9), depressive disorder notelsewhere classied (ICD-9-CM: 311), ormental disease postpartum complication(ICD-9-CM: 648.44) qualied a woman asa case o PPD. Each incident diagnosis oPPD was dened by: a hospitalization withan indicator diagnosis in the rst or second

diagnostic position; two outpatient visitswithin 180 days documented with indica-tor diagnoses (rom the same mental dis-order or mental health problem-speciccategory [V-coded behavioral health dis-orders])14 in the rst or second diagnosticpositions; or a single outpatient visit in apsychiatric or mental health care specialtysetting (dened by Medical Expense and

Perormance Reporting System [MEPRS]code: BF) with an indicator diagnosis in therst or second diagnostic position.

For surveillance purposes, completedsuicide was ascertained rom AFMES casu-alty records or service members who diedby suicide. Suicide attempt (SA) was ascer-tained rom records o hospitalizations andambulatory visits with external cause oinjury codes (E-codes) indicative o sel-inicted injury or poisoning (ICD-9-CM:E950-E958). Each incident diagnosis o SAwas dened by one hospitalization or one

ambulatory visit with an indicator diag-nosis in any diagnostic position. For eachaffected emale, only the rst sel-inictedinjury-specic encounter was used oranalyses regardless o the number o suchencounters during the surveillance period.Suicidal ideation (SI) was ascertained romrecords o hospitalizations and ambula-tory encounters with the ICD-9-CM codeindicative o suicidal ideation (ICD-9-CM:V62.84). An incident diagnosis o SI wasdened by one hospitalization with the

code V62.84 in the rst or second diagnos-tic position, or two ambulatory visits within180 days with the code in the rst or sec-ond diagnostic position, or one ambulatory visit in a psychiatric or mental health carespecialty setting (MEPRS code: BF) withthe indicator diagnostic code in the rst orsecond diagnostic position. Suicidality wasdened as any incident case o completedsuicide, SA, or SI.

For the PPD-dened outcome, adescriptive analysis was conducted or bothcohorts in relation to each demographic

and military characteristic o interest. Forthe suicidality-dened outcome, the rela-tive odds in relation to each demographicand military characteristic o interest wereestimated by a logistic regression modelthat included a covariate or each charac-teristic. Since the incidence o suicidal-ity was low (

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F I G U R E 3 a . Percentage of incident post-partum depression diagnoses within 12

months of first time delivery, by age group and

year of delivery, active component females,

U.S. Armed Forces, 2007-2011

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

2007 2008 2009 2010 2011

% o f i n c i d e n t p o s t p a

r t u m d e p r e s s i o n d i a g n o s e s

Year of delivery

18-20

21-24

25-30

31-40

>40

F I G U R E 3 b . Percentage of incident postpartum depression diagnoses within 12

months of first time delivery, by age group and

year of delivery, active component dependen

spouses, U.S. Armed Forces, 2007-2011

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

2007 2008 2009 2010 2011

% o f i n c i d e n t p o s t p a r t u m d e p r e s s i o n d i a g n o s e s

Year of delivery

18-20

21-24

25-30

31-40

>40

F I G U R E 2 a . Percentage of incident post-

partum depression diagnoses within 12

months of first time delivery, by service and

year of delivery, active component females,


0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

2007 2008 2009 2010 2011

% o f i n c i d e n t p o s t p a r t u m d e p r e s s

i o n d i a g n o s i s

Year of delivery

Army

Marine Corps

Navy

Coast Guard

Air Force

F I G U R E 2 b . Percentage of incident post-

partum depression diagnoses within 12

months of first time delivery, by servicea and

year of delivery, active component dependent

spouses, U.S. Armed Forces, 2007-2011

a

Refers to the service of the active component spouse.

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

2007 2008 2009 2010 2011

% o f i n c i d e n t p o s t p a r t u m d i a g n o s e s

Year of delivery

Army

Coast Guard

Navy

Air Force

Marine Corps

that Marine Corps, black, non-Hispanicrace/ethnicity, youngest age group (18-20 years), delivery outcome (stillbirth/unknown), PPD during the postpartumperiod, and history o any mental disor-der diagnosis were signicant indepen-dent predictors o suicidality within bothcohorts.

For the multivariate analyses, the oddsratio was adjusted or service, race/ethnic-ity, age, delivery outcome, and history omental disorder. Service women with PPDhad a higher odds or suicidality comparedto service women without PPD (OR=42.2,95% CI=28.8, 61.9). Risk actors predictingsuicidality or service women included service (Coast Guard), age (18-20 years), PPDduring the postpartum period, and historyo mental disorder diagnosis. Dependentspouses with PPD also had a higher odds or

suicidality compared to dependent spouseswithout PPD (OR=14.5, 95% CI=10.8, 19.4).Risk actors predicting suicidality or depen-dent spouses included race/ethnicity (black,non-Hispanic), age (18-20 years), deliveryoutcome (stillbirth/unknown), PPD duringthe postpartum period, and history o anymental disorder diagnosis.

E D I T O R I A L C O M M E N T

Tis report documents the counts, per-centages, and trends o PPD among women

in the active component and dependenspouses who gave birth or the rst time(per administrative medical records o thMilitary Health System) during the postpartum period. In addition to PPD, thereport also ocused on other actors predicting suicidality during the postpartumperiod or both cohorts. Overall, the percentages o incident PPD diagnoses among

service women and dependent spousewere within the range reported by the CDCor the general civilian population.6 Ingeneral, the incidence o PPD was consistently higher among service women thandependent spouses; o note, during thperiod, annual percentages o PPD slowlyincreased among service women but noamong dependent spouses.

Te report also documents that ser vice women in the Army, aged 18-20 yearsand with any prior mental disorder-relateddiagnoses were more likely than thei

counterparts to have PPD diagnoses aferst deliveries; dependent spouses o Armservice members and those with any priomental disorder-related diagnoses weralso at relatively high risk o PPD diagnoseafer rst deliveries. For dependent spousesthe incidence o PPD among age groupwas similar with an increase in womenolder than 40 since 2009. Tis may be due

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T A B L E 2 . Diagnosis of suicidalitya within 12 months following first time delivery, active component females and dependent spouses,


Active component females Dependent spouses

Total No. %Unadjusted OR

(95% CI)

Adjusted OR

(95% CI)Total No. %

Unadjusted OR

(95% CI)

Adjusted OR

(95% CI)

Total 53,264 213 0.40 . . 125,450 221 0.18 . .

Service

Army 19,582 105 0.54

3.2

(2.1, 5.0)

2.0

(1.3, 3.1) 61,765 150 0.24

2.8

(1.7, 4.6)

2.5

(1.5, 4.1)

Navy 13,510 50 0.372.2

(1.4, 3.6)1.6

(1.0, 2.7)25,382 33 0.13

1.5(0.8, 2.7)

1.6(0.9, 2.9)

Air Force 14,414 24 0.17 ref ref 19,332 17 0.09 ref ref

Marine Corps 4,571 28 0.613.7

(2.1, 6.4)2.3

(1.3, 4.1)17,811 21 0.12

1.3(0.9, 2.1)

1.4(0.7, 2.7)

Coast Guard 1,187 6 0.513.0

(0.7, 7.5)2.9

(1.2, 7.3)1,160 0 0.00 0.0 0.0

Race/ethnicity

White, non-Hispanic 25,842 98 0.38 ref ref 73,857 125 0.17 ref ref

Black, non-Hispanic 13,095 59 0.451.2

(0.9, 1.6)1.5

(1.1, 2.2)10,070 23 0.23

1.4(0.9, 2.1)

2.0(1.2, 3.1)

Other 14,327 56 0.391.0

(0.7, 1.4)1.2

(0.9, 1.7)41,523 73 0.18

1.0(0.8, 1.4)

1.4(1.1, 1.9)

Age

18-20 5,122 53 1.038.4

(4.2, 17.1)6.9

(3.3, 14.1)11,365 39 0.34

7.6(3.9, 15.7)

10.3(5.1, 20.8)

21-24 23,086 94 0.413.3

(1.7, 6.5)2.8

(1.4, 5.6)42,112 100 0.24

5.4(2.8, 10.4)

6.2(3.2, 11.9)

25-30 17,797 57 0.322.6

(1.3, 5.2)2.5

(1.2, 5.0)49,155 72 0.15

3.4(1.7, 6.5)

3.6(1.9, 7.0)

>31 7,259 9 0.12 ref ref 22,818 10 0.04 ref ref

Delivery outcome

Livebirth 50,175 194 0.39 ref ref 119,004 197 0.17 ref ref

Stillbirth/unknown 3,089 19 0.621.6

(1.0, 2.6)1.1

( 0.7, 1.8)6,446 24 0.37

2.3(1.5, 3.5)

1.7(1.1, 2.6)

Postpartum depression

No 47,997 34 0.07 ref ref 115,149 83 0.07 ref ref

Yes 5,267 179 3.4049.6

(34.3, 71.7)42.2

(28.8, 61.9)10,301 138 1.34

18.8(14.3, 24.7)

14.5(10.8, 19.4)

Any mental disorder diagnosisb

No 40,313 98 0.24 ref ref 114,670 147 0.13 ref ref

Yes 12,951 115 0.893.7

(2.8, 4.8)1.4

(1.0, 1.9)10,780 74 0.69

5.4(4.1, 7.1)

2.6(1.9, 3.5)

OR=Odds RatioaSuicidality includes suicide ideation, suicide attempt, and completed suicideb At least one recorded mental disorder diagnosis

to dependent spouses having children orthe rst time at a later age and experienc-

ing unique, age-associated stressors. In

contrast, service women may experience

unique stressors associated with serving

in the military, such as long duty hours

and a ast-paced duty environment. Addi-

tionally, dependent spouses may share the

burden o raising children with their hus-bands, whereas service women may ofen

be single parents without social support

during and afer pregnancy.

Te percentages o incident PPD diag-

noses among service women who returned

rom a deployment within 365 days prior

to delivery and those who did not were

similar, and the incidence o PPD amongthose who deployed within 365 days afe

delivery was lower than among those who

did not deploy. A history o recent deployment or the prospect o uture deploymenseemed to have no effect on the likelihoodthat a service woman would experience

postpartum depression; this nding may

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be due in part to a “healthy worker” effect

since service women who deploy are ofen

physically and mentally healthier than

those who do not deploy.

ime to diagnosis o PPD was di-

erent among the cohorts. Compared to

dependent spouses, service women were

diagnosed with PPD at later times dur-

ing their postpartum periods. Te nding

suggests that some service women may

delay seeking care due to lack o knowl-

edge regarding available services and/or

concerns that seeking care or a mental

disorder may adversely impact their mili-

tary careers.

In the multivariate analysis, PPD

diagnosis during the postpartum period

was the strongest independent predic-

tor o suicidality (i.e., with control o the

effects o service, race/ethnicity, age, deliv-

ery outcome, and history o mental disor-der diagnoses). Among service women,

young age (18-20 years), service in the

Coast Guard, and prior mental disor-

der diagnoses were other signicant pre-

dictors o suicidality; among dependent

spouses, young age (18-20 years), history

o a mental disorder diagnosis, black, non-

Hispanic race/ethnicity, and stillbirth/

unknown delivery outcome were signi-

cant predictors o suicidality.

Te limitations o these analyses

should be considered when interpretingthe results. Findings observed afer rst

time deliveries may not apply afer subse-

quent deliveries. Te endpoints o analy-

ses were ICD-9-CM diagnostic codes that

are indicators o the conditions o inter-

est or this report. However, some o the

ICD-9-CM indicator diagnoses used here,

particularly those not recorded as pri-

mary (rst-listed) diagnoses may not rep-

resent conrmed diagnoses or currently

symptomatic disease. Also, the diagnos-

tic codes used as endpoints o analysesdo not speciy the clinical severity o the

conditions o interest. Te ICD-9-CM

codes used to dene a disease outcome

may present issues. Since the diagnostic

code or suicide ideation was only added

to the ICD-9-CM in October 2005 and

was not routinely used prior to 2007, the

surveillance period was restricted to afer

January 2007. Tis approach assumed

that every provider during the surveil-

lance period was amiliar with the usage

o this specic code; i this assumption

was incorrect, the result may be an under-

estimation o cases. Another limitation

was assessment o effects prior to and afer

deployments. Relying on administrative

data to capture specic stressors associ-

ated with deployments may not be reli-

able. Tis report also relied on ICD-9-CM

codes entered into the subjects’ medical

records to determine i this was the rst

pregnancy or those in whom the analy-

sis assessed incident PPD and suicidality.

Service women and dependent spouses

may have had children prior to accession

and enrollment in the Military Health Sys-

tem; to the extent that subjects were mis-

classied as rst-time mothers, this reportwould have ailed to account or instances

in which PPD, other mental disorders, and

suicidality may have been associated with

previous pregnancies not captured by the

Military Health System.

In summary, the ndings o this

report suggest that a history o mental

disorders was common among service

women and dependent spouses with PPD,

and, in turn, PPD was a strong predictor

or suicidality in the postpartum period.

Tese associations were most commonlyound in younger age groups, but other

predictors or suicidality included black,

non-Hispanic race/ethnicity, Coast Guard

service, and stillbirth/unknown delivery

outcome.

Te ndings o this report emphasize

the importance o PPD screening during

the postpartum period. Mothers typically

have only one postpartum visit, approxi-

mately six weeks afer delivery, and may

not be seen again until their annual well-

woman check-ups. Additional screeningassessments o mothers, around the same

time as their inant well-baby visits, may

be indicated. Since service women were

diagnosed at a later time with PPD than

dependent spouses, this may also suggest

directing screening efforts or PPD to start

immediately afer delivery.

In addition to screening or PPD

screening or suicidality may also requir

a different approach. Postpartum women

when asked about suicidality outside th

context o depression, admitted to suicida

behavior or suicide ideation at a much

higher rate compared to when they were

asked about suicidality in the context o

depressed eelings.2 Tis suggests tha

additional ocused screening o suicida

behavior among those already diagnosed

with PPD may be warranted.

R E F E R E N C E S

1. Healey C, Morriss R, Henshaw C, et al. Selfharm in postpartum depression and referrals toa perinatal mental health team: an audit study

Arch Womens Ment Health. 2013;16(3):237-2452. Lindahl V, Pearson J L, Colpe L. Prevalence osuicidality during pregnancy and the postpartum

Arch Womens Ment Health. 2004;8:77-87.

3. Shari IL, Shaila M. Postpartum blues anddepression. Feburary 15, 2011. Found at: http:/www.uptodate.com/contents/postpartum-bluesand-depression?detectedLanguage=en&source=search_result&search=postpartum+blues&selectedTitle=1%7E6&provider=noProvider#H12

Accessed on: 18 July 2013.4. American Psychiatric Association. Diagnosti

And Statistical Manual of Mental Disorders4th ed. Washington, DC: American Psychiatri

Association; 1994.5. Wisner KL, Parry BL, Piontek CM. Postpartumdepression. N Engl J Med. 2000;347(3):194-1996. Center for Disease Control and PreventionReproductive health: depression among womeof reproductive age. Found at: http://www.cdcgov/reproductivehealth/Depression/. Accesseon: 7 August 2013.7. Appolonio KK, Fingerhut R. Postpartumdepression in a military sample. Mil Med. 2008173(11):1085-1091.8. O’Boyle AL, Magann EF, Robert E, Ricks JDoyle M, Morrison JC. Depression screening ithe pregnant soldier wellness program. SoutMed J. 2005;98(4):416-418.9. Rychnovsky J, Beck CT. Screening fopostpartum depression in military women withthe Postpartum Depression Screening Scale. MMed. 2006;171:1100-1104.10. Gold LH. Postpartum disorders in primarcare: diagnosis and treatment. Primary Care2002;29:27-41.11. Miller LJ. Postpartum depression. JAMA2002;287:762-765.12. Georgiopoulos AM, Bryan TL, Yawn BP

Houston MS, Rummans TA, Therneau TMPopulation-based screening for postpartumdepression. Obstet Gynecol. 1999;93(5 Pt 1)653-657.13. Danielson R. Childbirth, deployment anddiagnoses of mental disorders among activcomponent women. MSMR. 2010;17(11):17-21.14. Armed Forces Health Surveillance CenterMental disorders and mental health problemsactive component, U.S. Armed Forces, 20002011. MSMR. 2012;19(6):11-17.

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and durations o wartime deployments havbeen associated with increasing rates omenstrual disorders and inertility.13

Women in active military servicmay receive diagnostic services to identiyphysical causes o and some treatments oinertility (e.g., hormonal therapy, corrective surgery, antibiotics).14 However, thU.S. Military Health System does not pro vide non-coital reproductive therapies (e.garticial insemination, in vitro ertilization) except or service members who lostheir natural reproductive abilities due toillnesses or injuries related to active service

Tis report estimates requenciesrates, temporal trends, types o inertility

and demographic and military characteristics o inertility among active componenservice women in the U.S. Armed Forces.

M E T H O D S

Te surveillance population consistedo service women who served in the activcomponent o the Army, Navy, Air ForceMarine Corps, or Coast Guard at any timrom January 2000 through Decembe

2012. For this analysis, an incident case oinertility was dened as an individual whohad two outpatient health care encounters with inertility-related diagnoses (peICD-9 codes) listed in the rst or seconddiagnostic positions o the records o thosencounters (Table 1). I inertility-relateddiagnostic codes reported on relevanrecords were non-specic codes (ICD-9codes: 628, 628.8, 628.9), more specicinertility-related diagnostic codes (i.e., ano the remaining case-dening codes) wersearched in records o later encounters o

subject service members.For analysis purposes, individual

were considered incident cases o inertilityonly once during the surveillance periodAll data used or analyses were abstractedrom records routinely maintained inthe Deense Medical Surveillance System(DMSS) or health surveillance purposes.

Female Infertility, Active Component Service Women, U.S. Armed Forces, 2000-2012

Inertility is the inability to become pregnant afer one year o regular,unprotected sexual intercourse. Among active component service women,

16,807 received a diagnosis o emale inertility during the 13-year surveil-lance period. Te incidence rate o inertility diagnoses increased during theperiod, mainly due to increasing rates o inertility o unspecied origin.Inertility o tubal origin and anovulation were the most common speciedtypes o inertility. Incidence rates o inertility were highest among womenin their thirties; however, rates increased the most in women in their orties.Black, non-Hispanic women had the highest rates o inertility overall ando inertility o tubal and uterine origin. Te higher rates among women intheir thirties and orties may reect high and increasing rates o clinical careseeking or inertility among women who elect to delay pregnancy until olderages and an increase in treatment options or women who have been unable

to become pregnant.

clinical inertility is the ailure oa woman o childbearing age tobecome pregnant afer one year

o regular, unprotected sexual intercourse.Tere are other denitions that consider theage o the woman and the duration o theperiod o unprotected intercourse. Te rea-

sons or inertility can involve one or bothpartners, but, in some cases no cause canbe identied. Te most common causes oemale inertility are ovulation disorders,uterine or cervical abnormalities, allopiantube damage or blockage, endometriosis,and primary ovarian insuffi ciency (i.e., earlymenopause). Ovulation disorders, such aspolycystic ovary syndrome, prevent the ova-ries rom releasing eggs (i.e., anovulation).1,2,3

ubal inertility rom blocked or swol-len allopian tubes can be caused by previ-ous sexually transmitted inections, pelvic

inammatory disease (PID), and historyo a ruptured appendix or abdominal sur-gery.3-6 Uterine or cervical abnormalitiesinclude structural abnormalities or thegrowth o benign tumors called broids,which can interere with the passage andimplantation o the ertilized egg withinthe uterus.3,7 Endometriosis occurs when

endometrial tissue implants and grows out-side o the uterus affecting the unction othe emale genital organs.8

Advancing age is the most commonactor associated with inertility due toa decrease in ovarian unction and in thenumber and quality o eggs released. In

the United States many women are delay-ing pregnancies to their thirties and or-ties; approximately 20 percent o women inthe U.S. now have their rst child afer age35.3,9 Tis actor has led to age as a growingcause o inertility in the U.S. Tere are alsoseveral liestyle and environmental actorsthat can contribute to inertility. Stress,tobacco and alcohol use, being overweightor underweight, and strenuous, intenseexercise are modiable risk actors associ-ated with inertility.3

Nearly 15 percent o active compo-

nent U.S. military members are women, owhom about 90 percent are o child-bearingage. Service women are at risk or inertil-ity based on the risk actors described previ-ously. obacco use, alcohol abuse, and PIDare relatively requent diagnoses among service women, and each condition affects er-tility.10-12 Furthermore, increasing numbers

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T A B L E 1 . ICD-9-CM codes for female infertility and pregnancy

F I G U R E 1 a . Annual incidence rates of

female infertility, overall and unspecified

origin, active component service women,


0.0

25.0

50.0

75.0

2 0 0 0

2 0 0 1

2 0 0 2

2 0 0 3

2 0 0 4

2 0 0 5

2 0 0 6

2 0 0 7

2 0 0 8

2 0 0 9

2 0 1 0

2 0 1 1

2 0 1 2

I n c i d e n c e r a

t e p e r 1 0 , 0

0 0 p e r s o n - y e a r s

Total

Unspecified origin

F I G U R E 1 b . Annual incidence rates o

female infertility of specified type, active

component service women, U.S. Armed

Forces, 2000-2012

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

2 0 0 0

2 0 0 1

2 0 0 2

2 0 0 3

2 0 0 4

2 0 0 5

2 0 0 6

2 0 0 7

2 0 0 8

2 0 0 9

2 0 1 0

2 0 1 1

2 0 1 2

I n c i d e n c e r a t e p e

r 1 0 , 0


Anovulation

Tubal origin

Other specified origin

Uterine origin

Pituitary-hypothalamic origin

Cervical/vaginal origin

ICD-9-CM codes Description

Infertility codes

628 Female infertility

628.0 Infertility associated with anovulation

628.1 Infertility of pituitary-hypothalamic origin

628.2 Infertility of tubal origin (block, occlusion, stenosis of fallopian tubes)

628.3 Infertility of uterine origin (congenital anomaly of uterus, nonimplantation)

628.4 Infertility of cervical or vaginal origin (anomaly or cervical mucuscongenital structural anomaly, dysmucorrhea)

628.8 Infertility of other specified origin

628.9 Infertility of unspecified origin

Pregnancy-related codes

V27.0-V27.9 Outcome of delivery

650.xx Normal delivery

640-679 where the 5thdigit is 1, 2, or 4 (excluding644.0, 644.1, 677.xx)

Pregnancy complications

Service women were counted as inci-dent cases o inertility i they were hospital-ized during the surveillance period and aninertility case-dening ICD-9 diagnosticcode was reported in the primary diagnos-tic position o the hospitalization record.o enable assessments o health care bur-dens associated with inertility, ambulatory visits and hospitalizations or inertilitywere analyzed separately. o assess occur-rences o pregnancy in women afer diag-noses o inertility, records o all medical

encounters within two years afer incidentinertility diagnoses were searched to iden-tiy those that included pregnancy-specicdiagnostic (ICD-9-CM) codes (Table 1).

R E S U L T S

During the 13-year surveillance period,16,807 active component service womenwere diagnosed with inertility. Te over-all incidence rate o inertility among activecomponent service members was 62.4 per10,000 person-years (p-yrs) (Table 2).

Incidence rates o inertility diagno-ses (all types) increased by 15 percent rom2005 to 2011 (mainly due to increasingrates o inertility o unspecied origin) butthen decreased by 15 percent in 2012; assuch, the rates in 2005 and 2012 were simi-lar (Figure 1a). Inertility o tubal origin and

inertility due to anovulation were the mostcommon specied types o inertility (inci-dence rates: 6.8 and 6.6 per 10,000 p-yrs,respectively). Te incidence rate o diagno-ses o unspecied inertility exceeded therates o diagnoses o each o the ve specic

types o inertility considered here; rates odiagnoses o each o the specied types oinertility declined during the surveillancperiod (Figure 1b, Table 2).

Among service women overall, rateo inertility diagnoses were highest amongwomen in their thirties and lowest amongthe youngest (

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T A B L E 2 . Incident counts and incidence rates of infertility by infertility type anddemographic and military characteristics, active component service women, U.S.

Armed Forces, 2000-2012

No. Rate % total/IRR% difference2000-2012

Total 16,807 62.4 6.2

Type of infertility % total

Tubal origina 1,823 6.8 10.8 -50.4

Anovulation 1,780 6.6 10.6 -49.4

Uterine originb 96 0.4 0.6 -81.3

Pituitary-hypothalamic origin 36 0.1 0.2 -100.0

Cervical/vaginal originc 15 0.1 0.1 -100.0

Other specified origin 454 1.7 2.7 -47.8

Unspecified origin 12,603 46.8 75.0 39.7

Age IRR

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September 2013 Vol. 20 No. 9 M S M R Page 1

F I G U R E 2 . Annual incidence rates of female infertility by age, active component service

women, U.S. Armed Forces, 2000-2012

0.0

20.0

40.0

60.0

80.0

100.0

120.0

2 0 0 0

2 0 0 1

2 0 0 2

2 0 0 3

2 0 0 4

2 0 0 5

2 0 0 6

2 0 0 7

2 0 0 8

2 0 0 9

2 0 1 0

2 0 1 1

2 0 1 2

I n c i d e n c e r a t e p e r 1 0 , 0 0 0 p e r s o n - y e a r s

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F I G U R E 4 . Annual incidence rates of female infertility by race/ethnicity and age, active

component service women, U.S. Armed Forces, 2000-2012

0.0

25.0

50.0

75.0

100.0

125.0

White, non-Hispanic Black, non-Hispanic Hispanic Asian/Pacific Islander Other/unknown

I n c i d e n c e r a t e p e r 1 0 , 0


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p

olycystic ovary syndrome (PCOS) isan endocrine disorder named or the

appearance o the ovaries – enlargedand with numerous, small cysts – in mostindividuals with the syndrome.1 PCOS ischaracterized by signs and symptoms that vary by individual and can present in differ-ent ways to a clinician. Te hallmark criteriaor this diagnosis are chronic anovulation(i.e., mature eggs are not released rom theovaries) and an excess in male hormones(i.e., androgens). In adolescence, the mostcommon maniestation o PCOS is inre-quent or prolonged menstrual periods, butthe patient may also experience overweight/obesity, excessive hair growth (hirsutism),and/or acne.1,2 In women o child bearingyears, inertility and unexplained weightgain are the most common reasons orseeking medical evaluation. Older womenwith undiagnosed or untreated PCOS maydevelop metabolic abnormalities such type2 diabetes or cardiovascular conditionssuch as heart disease and/or hypertension.3,4

reatment o PCOS is directed at man-agement o the signs and symptoms thatare o most concern to the individual (e.g.,

inertility, excessive hair growth, acne,weight gain). Early detection and treatmentcan also prevent some o the long term,serious complications o PCOS.

Tis report describes the counts, rates,and trends o diagnoses o PCOS amongactive component service women. Co-occur-ring conditions were also identied duringthe period beore and afer PCOS diagnoses.

M E T H O D S

Te surveillance population was activecomponent service women o the Army,Navy, Air Force, Marine Corps, and CoastGuard. Te surveillance period was 2000to 2012. Cases o PCOS were identiedrom the records routinely maintained inthe Deense Medical Surveillance System(DMSS). An incident case o PCOS was

T A B L E 1 . Incident counts and incidencerates of polycystic ovary syndrome,

active component service women, U.S. Armed Forces, 2000-2012

No. Ratea

Total 356 1.3

Ageb

>20 29 0.7

20-24 85 1.1

25-29 117 1.9

30-34 80 2.2

35-39 35 1.3

40-44 10 0.6

Race/ethnicity

White, non-Hispanic 185 1.4

Black, non-Hispanic 93 1.2

Hispanic 41 1.4

Asian/Pacific Islander 7 0.6

Other 30 1.5

Service

Army 131 1.4

Navy 78 1.2

Air Force 118 1.4

Marine Corps 10 0.7

Coast Guard 19 3.1

Rank

Junior enlisted 144 1.1

Senior enlisted 156 1.6

Junior of ficers 47 1.5

Senior of ficers 9 0.6

Occupation

Combat-specific 5 1.3

Armor/motor transport 13 1.4

Repair/engineering 45 1.0

Comm/intel 146 1.5

Health care 75 1.5

Other 72 1.2

Marital status

Married 212 1.8

Unmarried 115 0.9

Other 29 1.2

aIncidence rate per 10,000 person-yearsbThere were no cases identified in service

women aged 45 and older.

dened as two outpatient medical encoun-ters with a PCOS ICD-9-CM code (256.4)

listed in the primary or secondary diag-nostic position or one inpatient medicalencounter with the PCOS ICD-9-CM listedin the primary diagnostic position. Anindividual was considered a case once dur-ing the surveillance period.

Co-occurring conditions – i.e., condi-tions identied as commonly associated withPCOS as described previously – were identi-ed by searching medical records rom theyear prior to, and the year afer, the incidentdiagnosis o PCOS. In order to be countedas a co-occurring condition in the year

prior, the diagnosis had to be in the primarydiagnostic position. In order to be countedas a co-occurring condition in the year afer,the diagnosis had to be in the primary diag-nostic position or in the secondary positionwhen the primary diagnosis was PCOS. Ian individual had the co-occurring condi-tion beore the PCOS diagnosis, the samecondition was not counted in the periodafer the incident encounter or PCOS.

R E S U L T S

During the 13-year surveillance period356 individuals were identied as cases oPCOS among active component servicewomen (Table 1). Te overall incidencerate o PCOS was 1.3 per 10,000 person-years (p-yrs). Te annual incidence ratesincreased rom 2000 to 2006 and thenremained relatively stable or the nal sixyears o the surveillance period (Figure 1).

Te incidence rates o PCOS were high-est in service women aged 30 to 34 and lowestin the youngest and oldest age groups(Table 1).Incidence rates were similar among all race/ethnicities except or Asian/Pacic Islanders,whose rate was hal that o other racial/eth-nic groups. Compared to their counterparts,rates o PCOS were highest among servicewomen in the Coast Guard and lowest in theMarine Corps. Rates were similar among allranks except or senior offi cers, who had the

lowest rate. Incidence rates did not vary muchby occupation. Te incidence rate o PCOSamong married women was notably highethan those or unmarried women and thoscategorized as other.

Polycystic Ovary Syndrome, Active Component Service Women, U.S. Armed Forces2000-2012

Brief Report

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Pelvic Inflammatory Disease Among Female Recruit Trainees, Active ComponentU.S. Armed Forces, 2002-2012

Patricia Rohrbeck, DrPH, MPH, CPH (Maj, USAF)

p

elvic inammatory disease (PID) is

a emale specic inammatory pro-cess, which affects the uterus, allo-

pian tubes, and other reproductive organs.1

Te inammation is the result o a bacterialinection commonly caused by Chlamydiatrachomatis, Neisseria gonorrhoeae, entericorganisms, or anaerobic organisms.1 Whenthe bacteria ascend rom the cervix throughthe uterus to the upper genital tract, whichincludes the endometrium, uterine wall,uterine serosa and broad ligaments, allo-pian tubes, ovary, and pelvic peritoneum,the resulting inammation is reerred to as

PID.1,2 Symptoms vary and can range rom

mild to severe.1,2 Since PID comprises aspectrum o inammatory disorders, thereis no denitive diagnostic test available; lap-aroscopy can be used, but is ofen not read-ily available.3 Te clinical diagnosis o PIDis based on symptoms and physical ndings

Pelvic inammatory disease (PID) is a bacterial inection causing an inam-matory reaction in the upper genital tract. It can be treated with antibiotics,but since it is ofen asymptomatic, women ofen delay seeking health care,which may result in long-term sequelae such as inertility. Among 161,501emale recruits who began basic training between January 2002 and Decem-ber 2011, 1,750 (1.1%) met the surveillance case denition or PID duringthe 12 months ollowing completion o their basic military training. Teoverall incidence rate (11.2 per 1,000 person-years) showed a stable trendduring the surveillance period, with the exception o a decline or emalesaccessed in 2011. Te unadjusted rates were higher among women who werenot screened or chlamydia during basic training. Compared to their respec-tive counterparts, rates were higher in service women aged 17-20, o black,

non-Hispanic race/ethnicity, married, in the Army, and who had a chlamydiadiagnosis afer basic training. Te lowest rates were among women 25 yearsand older, other race/ethnicity, and in the Coast Guard. Te ndings in thisreport may warrant urther evaluation o the long-term impact o chlamydiascreening programs or recruit trainees on PID and PID-related sequelaeamong service women.

associated with the disease, even though

many episodes go unnoticed because casesare ofen asymptomatic or not recognizedby the health care provider.3

Te main etiologic agent or PID ischlamydia, and when compared to PID dueto Neisseria gonorrhoeae inection, chla-mydial inections are associated with lowerrates o clinical symptoms.2 Mild to moder-ate symptoms o PID ofen result in womendelaying care, and the length o timerom onset o symptoms to seeking careis highest among women with chlamydiainection.4 Since chlamydia induces an

inammatory reaction resulting in perma-nent scarring o the allopian tubes, higherrates o inertility are associated with PIDdue to chlamydia.2 Cohorts o women whodelayed seeking care overall showed higherrates o inertility, as well as recurrent PID,and chronic pelvic pain.4 Standard treat-ment or PID consists o oral antibiotics;

however, any damage which has alreadyoccurred to the reproductive organs due to

delayed care cannot be reversed.5 Since antibiotics are readily avail

able to treat PID, mortality outcomes arrare among otherwise healthy women.2

Most cases o PID are managed in outpatient settings, and hospitalizations are onlyrecommended i the woman is severely illpregnant, does not respond to or cannotake antibiotic treatment, or needs to bemonitored due to potential complications.Even though it has been diffi cult to accurately estimate rates o PID among civilianbecause it is a non-reportable disease and iofen misdiagnosed or asymptomatic, hospitalizations and initial visits to physiciansoffi ces by women aged 15 to 44 years havedeclined since 1998.6

Racial disparities have been notedamong PID cases in ambulatory and hospitalized settings, suggesting that blackwomen have two to three times higher disease rates than white women.6 Within thactive duty U.S. military population, incidence rates o PID remained stable between2002 and 2011 at approximately 11.2 pe

1,000 person-years, with high-risk subgroups among the 17-24 year olds, andemales in the Army and o black, non-Hispanic race/ethnicity.7

Due to tissue inammation, PID ofenresults in tubal scarring which can lead tomajor sequelae such as inertility and ectopic pregnancy.2 Tese sequelae ofen occulong afer the initial PID diagnosis; additionally, risk or sequelae increases withreoccurrence o PID encounters.2 As result, prevention efforts or PID sequelahave ocused on preventing the major caus

o PID – chlamydia inection. Compared tothe civilian population, U.S. service womenare at higher risk or sexually transmitted inections (SIs).6,8 Within the U.Smilitary, rates o SIs are highest amongrecruit trainees.8 As a result, the Servicebegan implementing recruit trainee chlamydia screening programs, except or th

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diagnostic code during a medical encoun-ter (hospitalization or ambulatory visit)with: 1) a primary (rst-listed) diagnosis oPID during a single medical encounter; 2)a secondary (not rst-listed) diagnosis oPID during a single medical encounter plusdiagnoses with signs or symptoms consis-tent with PID in each diagnostic positionantecedent to PID; or 3) a PID diagnosis in

any diagnostic position during two medicalencounters that occurred between one and60 days apart.

Diagnoses o chlamydia inection dur-ing the 12-month surveillance period andprior to incident PID diagnoses were iden-tied rom conrmed Reportable MedicalEvents (RMEs). Recruit trainees were cat-egorized as having been screened or chla-mydia based upon their respective services’screening polices at the time o entry intobasic training. Each recruit trainee wasassigned a code o “yes” or “no” based upon

this categorization. Female service mem-bers in the Navy and Marines were screenedduring the entire surveillance period. Since

T A B L E 1 . Diagnostic codes (ICD-9-CM) considered indicative of acute pelvic

inflammatory disease

Acute gonococcal infections of the upper genitourinary tract 098.10, 098.16, 098.17

Gonococcal peritonitis 98.86

Chlamydia trachomatis infection of peritoneum 099.56

Acute or unspecified inflammatory disease of pelvic organs andtissues (salpingitis and oophoritis, peritonitis, pelvic cellulitis)

614.0, 614.2, 614.3, 614.5,

614.8, 614.9

Acute or unspecified inflammatory diseases of uterus 615.0, 615.9

Chronic pelvic inflammatory disease098.30, 098.36, 098.37,

098.39, 614.1, 314.7, 615.1

Army. Recruit trainee chlamydia screeningwas implemented by the Navy and MarineCorps prior to 2000, by the Coast Guardin 2004, and by the Air Force in 2005;the Army screens emales upon arrivalat their rst duty location i aged 25 oryounger. Bloom et al. compared PID ratesamong emale Navy and Army recruits andobserved that crude incident PID rate was

61 percent higher among Army recruits.9 Te authors suggest that the increased riskor PID may in part be attributed to Armyrecruits experiencing higher recurrencerates or chlamydia as a result o not beingscreened at entry-level military service.9 Due to increased risk or SI, particularlychlamydia inection, emale recruit train-ees may consequently be at higher risk orPID during their rst 12 months on activeduty afer their basic training period i notscreened immediately upon entry.

Te objective o this report is to esti-

mate the incidence o pelvic inammatorydisease (related to chlamydia inection)and unspecied pelvic inammatory dis-ease (hereafer reerred to as PID) diag-nosed during medical encounters o ormerrecruit trainees during their initial 12months on active duty ollowing comple-tion o basic training.

M E T H O D S

Te surveillance population was activecomponent emales, aged 17 to 42, in allservices, who entered basic military train-ing between January 2002 and Decem-ber 2011. Coast Guard data prior to 2007were incomplete and thus excluded romthe report. Additionally, each emale hadto have successully completed her train-ing requirements and to have remainedon active duty or at least 12 months aferbasic training. Te surveillance period orPID or this population consisted o the12 months ollowing completion o basic

training. Incident diagnoses o PID wereidentied rom ICD-9-CM diagnosticcodes recorded during hospitalizations andambulatory medical encounters (Table 1).

Te MSMR PID case denition wasapplied or this analysis.7 An incidentcase o PID was dened as an individualwith a case-dening acute or chronic PID

the Army does not have a Recruit Chlamydia Screening Policy, all emales in theArmy in this surveillance population werecategorized as not screened. Recruits whostarted basic military training with thCoast Guard on or afer 1 April 2004, andrecruits in the Air Force who started theitraining on or afer 1 December 2005 werescreened and categorized accordingly.

R E S U L T S

Between January 2002 and December 2011, 223,642 emales entered basitraining on active duty, all services. O therecruit population, 200,508 (89.7%) completed their training, but 39,007 (19.5%did not remain on active duty or at least 12months ollowing basic training and wereeliminated rom the study. Te surveillancpopulation consisted o 161,501 emal

service members, and 1,750 (1.1%) met thsurveillance case denition or PID; o thtotal number o cases, 1,719 (98.2%) were

F I G U R E 1 .

Incidence rates of pelvic inflammatory disease during 12 months following

basic training, active component females, U.S. Armed Forces, 2002-2012

01 Jan 2004, start of

Coast Guard Recruit

Chlamydia Screening

Program

01 Dec 2005, startof Air Force Recruit

Chlamydia Screening

Program

Year in which service member began recruit training

0.0

5.0

10.0

15.0

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 I n c i d e n c e r a t e p e r 1 , 0 0 0 p e r s o n - y e a r s

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T A B L E 2 .

Incidence rates (per 1,000 person-years) of acute/unspecified pelvic

inflammatory disease during 12 months following basic training, active component

females, U.S. Armed Forces, 2002-2012

No.Incidence rate

(unadjusted)

Incidence rate

ratio

Total 1,750 11.2 .

Service

Army 879 14.8 1.7

Navy 374 8.7 1.0

Air Force 333 8.6 Ref

Marine Corps 157 11.8 1.4

Coast Guard 7 4.4 0.5

Age

17-20 1,233 11.5 1.3

21-24 380 11.1 1.2

25+ 137 9.1 Ref

Race/ethnicity

Black, non-Hispanic 585 16.3 1.6

White, non-Hispanic 786 9.9 Ref

Hispanic 229 10.4 1.1

Other 150 7.8 0.8

Education

High school or less 1,643 11.4 1.3 College degree 107 8.7 Ref

Marital status

Married/other 301 14.3 1.3

Single 1,449 10.7 Ref

Chlamydia screening during basic training

Yes 719 9.2 Ref

No 1,031 13.3 1.4

Chlamydia Reportable Medical Event (RME) during 12 months following basic training

Yes 222 25.4 2.4

No 1,528 10.4 Ref

classied as acute PID and 31 (1.8%) wereclassied as chronic PID (data not shown).Overall incidence rates remained stablewith slight uctuations over the surveil-lance period (range: 10.2 per 1,000 per-son-years [p-yrs] to 14.9 per 1,000 p-yrs),with the exception o a decline or emalesaccessed in 2011 (5.1 per 1,000 p-yrs) (Fig-ure 1). O the 1,750 cases, 50.2 percentwere in the Army; 44.9 percent were white,non-Hispanic; and 70.5 percent were aged

17-20. For 93.9 percent, the highest levelo educational achievement was less than acollege degree, and 82.8 percent were single(Table 2).

During the 12-month surveillanceperiod ollowing basic training, the over-all incidence rate o PID was 11.2 per1,000 p-yrs (Table 2). Compared to their

rate to Navy women aged 25 and older (Figure 2). Overall, PID rates were lower in eachservice or women aged 25 and older, withthe exception o the Coast Guard whichhad the lowest rate among service womenaged 18-20 and the highest rate among ser vice women aged 21-24 (Figure 2). Femalein the Air Force had the lowest rate amongall services in the 25 and older age group

(Figure 2).Overall, when the rates were stratied

by service, the Army had the highest incidence rate, which was 2.4 times higher thanthe rate o the Coast Guard (Table 2). During the surveillance period, the rates uctuated among services without indicating atrend (Figure 3).

About 87.3 percent o PID case(n=1,528) had no conrmed reportablemedical event diagnosis o chlamydiinection prior to their initial PID diagnosis (Table 2).

E D I T O R I A L C O M M E N T

Tis report documents a stable trendin PID incidence among service womenwho began military service between 2002and 2011 during their initial 12 monthon active duty afer basic military trainingwith the exception o a decline among thosaccessed in 2011. Te overall incidence rat

F I G U R E 2 .

Incidence rates of pelvic

inflammatory disease during 12 month

following basic training by service and age

group, active component females, U.S

Armed Forces, 2002-2012

respective counterparts, unadjusted rateswere higher among women who were notscreened or chlamydia during basic train-ing, aged 17-20 years, black, non-Hispanicrace/ethnicity, married/other (includingdivorced and widowed), in the Army, andwho had a chlamydia inection afer basictraining (Table 2). Te lowest rates wereamong women 25 years and older, o otherrace/ethnicity (included Asian/PacicIslander, American Indian/Alaskan Native,

other, unknown), and in the Coast Guard(Table 2).

When the rates in each service branchwere stratied by age, the Army had thehighest rates o PID in each age group(Figure 2). Women in the Marines had thesecond highest rates or the younger agegroups (18-20, 21-24), but had a similar low

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

17-20 21-24 25+

I n c i d e n c e r a t e p e r 1 , 0 0 0 p e r s o n - y e a r s

Army

Navy

Air Force

Marine Corp

Coast Guard

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F I G U R E 3 .

Annual incidence rates ofpelvic inflammatory disease during 12months following basic training by service,active component females, U.S. ArmedForces, 2002-2012

aCoast Guard data was not available until 2007

o PID during the surveillance period washigher among known high-risk sub-pop-ulations (women aged 17-20 years, black,non-Hispanic, and in the Army). Overalland demographic-specic rates were highercompared to those previously reported inmilitary populations.7,9

Rates o PID were higher in the Armythan the other Services. As previouslystated, service women in the Army are

not routinely screened or chlamydia untilthey arrive at their rst duty assignment,which may cause women with asymptom-atic chlamydia to wait 12 months to receivechlamydia screening. At the same time,the Army incidence rate o PID was only25.4 percent higher than the rate amongMarines, who undergo screening or chla-mydia during recruit training. Tis obser- vation suggests that high-risk behavior maypersist afer screening and education, orthat episodes o PID prior to military service may have made some o these women

more susceptible to recurrences o PID.Medical history prior to military servicewas not available, so it is unknown howmany women may have had PID prior tomilitary service.

One risk actor or PID in studies ocivilian populations was single marital sta-tus. In this study, the incidence rate among

those categorized as married/other was33.6 percent higher than the rate o sin-gle service women. Bloom et al. ound thesame trend in their study but were unableto explain these ndings.9 Married womenwith one sexual partner are considered atlow risk or acquiring sexually transmittedinections and PID, but Lee et al. ound thati this group has intercourse six or more

times per week, they had a higher risk orPID (RR: 3.2, 95% CI: 1.4-7.2) comparedto similar women having intercourse lessthan once per week.10 Tis suggests ur-ther investigation o sexual behaviorsamong service women to determine pos-sible explanations or why married/otherwomen are at higher risk or PID than sin-gle service women.

Tese results should be interpretedin consideration o several limitations.Women o black, non-Hispanic race (whohad a higher rate o PID) comprised a

larger proportion o women in the Army(27.3%) than in the other services (5.7-20.7%) (data not shown). As a result, vari-ation in racial/ethnic composition mayaccount or some o the difference in PIDrates among the Services. Nevertheless,Bloom et al. reported higher rates o PIDamong women in the Army than the Navy,even afer adjustment or race/ethnicity.9 PID rate discrepancies among the servicebranches may also be affected by differ-ences in case management.

Even beore the offi cial start date othe chlamydia screening program in someServices, screening had begun. As a result,some recruit trainees who were categorizedas unscreened actually had been screened,and the chlamydia positive ones were likelytreated or their inection. Early screeningand treatment may have lowered the risko subsequent PID and may have conse-quently lowered the overall rate o PID inall unscreened recruit trainees. Tis mayhave reduced the difference in PID inci-dence rates between those women and

those identied as screened.Additionally, this study ocused on

a disease that can be diffi cult to diagnoseand may remain asymptomatic or longperiods. Reporting bias or non-healthcareseeking behavior among service womenmay have been responsible or an underes-timate o PID cases and the incidence rates

and risk ratios. Even though all Servicesexcept or the Army, had begun chlamydiascreening in basic training or emales by2006, overall rates or PID during the sur veillance period remained stable with thexception o a decline or emales accessedin 2011. Tis overall stable trend was pre viously documented or active componenservice women, even though at a lowe

rate.7 Te ndings in this report may warrant urther evaluation o the long-termimpact o chlamydia screening programor recruit trainees on PID and PID-relatedsequelae among service women.

Author affi liation: Armed Forces Health Surveillance Center (Maj Rohrbeck).

R E F E R E N C E S

1. Gaydos CA. Chapter 29: Chlamydi

trachomatis. In: Goldman MB, Troisi R, RexrodeKM, ed. Women & Health. 2nd ed. London, UKElsevier, Inc.; 2012:445-460.2. Zenilman JM. Chapter 23: SexuallyTransmitted Diseases. In: Nelson KE, WilliamCM, ed. Infectious Disease EpidemiologyTheory and Practice. 2nd ed. Boston, MA: Jonesand Bartlett; 2007:963-1020.3. Centers for Disease Control and PreventionSexually transmitted diseases treatmenguidelines, 2010: pelvic inflammatory diseaseFound at: www.cdc.gov/std/treatment/2010/pidhtm. Accessed on: 30 April, 2013.4. Taylor BD, Ness RB, Darville T, HaggertCL. Microbial correlates of delayed care fopelvic inflammatory disease. Sex Transm Dis2011;38(5):434-438.

5. Centers for Disease Control and PreventionSexually transmitted diseases (STDs)pelvic inflammatory disease (PID) treatmentguidelines, research, and updates. Found atwww.cdc.gov/std/PID/treatment.htm. Accesseon: 30 April, 2013.6. Centers for Disease Control and Prevention2011 sexually transmitted diseases surveillance- STDs in women and infants: public healtimpact. Found at: www.cdc.gov/std/stats11womenandinf.htm Accessed on 30 April 2013.7. Armed Forces Health Surveillance Center

Acute pelvic inflammatory disease, activcomponent, U.S. Armed Forces, 2002-2011MSMR. 2012 Jul;19(7):11-13.8. Goyal V, Mattocks KM, Sadler AG. High-risbehavior and sexually transmitted infections among

U.S. active duty service women and veterans.Womens Health. 2012;21(11):1155-1169.9. Bloom MS, Hu Z, Gaydos JC, Brundage JFTobler SK. Incidence rates of pelvic inflammatordisease diagnoses among Army and Navyrecruits: potential impacts of chlamydia screeningpolicies. Am J Prev Med. 2008;34(6):471-477.10. Lee NC, Rubin GL, Grimes DA. Measureof sexual behavior and the risk of pelviinflammatory disease. Obstet Gynecol. 199Mar;77(3):425-430.

0.0

5.0

10.0

15.0

20.0

25.0

2 0 0 2

2 0 0 3

2 0 0 4

2 0 0 5

2 0 0 6

2 0 0 7

2 0 0 8

2 0 0 9

2 0 1 0

2 0 1 1

I n c i d e n c e r a t e p e r 1 , 0


Army

Navy

Air Force

Marine Corps

Coast Guard

Year of entry into recruit training

a

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Surveillance Snapshot: Myomectomies and Hysterectomies Performed for UterineFibroids at Military Health Facilities, Active Component Service Women, U.S. ArmedForces, 2000-2012

F I G U R E 1 . Incident counts and incidence rates of myomectomiesa performed at military health facilities for women with diagnoses o

uterine fibroids, active component, U.S. Armed Forces, 2000-2012

Among active component service women diagnosed with uterine broids, a total o 1,583 myomectomies were perormed inmilitary treatment acilities (MFs) during the surveillance period o 1 January 2000 through 31 December 2012 (overall rate: 58.8per 100,000 person years [p-yrs]) (Figure 1). Te annual numbers and rates o myomectomies decreased slightly in 2011 and 2012,(rates: 55.6 and 53.5 per 100,000 p-yrs ,respectively) but the numbers and rates were relatively stable during the surveillance period.Inpatient myomectomies (n=1,443; rate: 53.6 per 100,000 p-yrs) greatly outnumbered outpatient procedures (n=140; rate: 5.2 per

100,000 p-yrs) during the surveillance period.A total o 4,038 service women diagnosed with broids underwent hysterectomies perormed at MFs during the surveillance

period (rate: 150.9 per 100,000 p-yrs) (Figure 2). During the period, the annual rates o hysterectomies perormed as inpatient proce-dures showed a stable, then declining trend. Afer peaking in 2005 (rate: 157.7 per 100,000 p-yrs), the rate o inpatient hysterectomiesdeclined to 94.7 per 100,000 p-yrs in 2012. By contrast, hysterectomies perormed as outpatient procedures increased during thesurveillance period. In 2000, the rate or outpatient hysterectomies was 3.5 per 100,000 p-yrs. By 2012 the rate or outpatient hyster-ectomies was 37.5 per 100,000 p-yrs.

F I G U R E 2 . Incident counts and incidence rates of hysterectomies performed at military health facilities for women with diagnoses of uterine

fibroids, active component, U.S. Armed Forces, 2000-2012

a An individual could have one myomectomy per year.

0.0

20.040.0

60.0

80.0

100.0

120.0

140.0

160.0

180.0

0

50

100

150

200

250

300

350

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

N o .

Inpatient Outpatient Rate: Inpatient Rate: Outpatient

0.0

10.0

20.0

30.0

40.0

50.0

60.070.0

0

20

40

60

80

100

120140

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

N o .

Inpatient Outpatient Rate inpatient Rate outpatient

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Menorrhagia, Active Component Service Women, U.S. Armed Forces, 1998-2012

Kerri A. Dorsey, MPH

menorrhagia, also known as

heavy menstrual bleeding or

abnormal ovulatory bleeding,

is common among women o reproductive

age. Te CDC estimates that menorrhagiaaffects about one in ve American women

each year;1 urthermore, in a nationwide

sample o U.S. women, 13 percent sel-

reported menorrhagia.2

Te clinical criteria or menorrha-

gia usually speciy that excessive bleeding

(greater than 80 milliliters per period, per-

haps with large blood clots) occurs during

menstrual periods that last seven days or

longer over several consecutive, monthly

cycles. Such periods may interere with

daily activities.3 Possible etiologies (causes)o menorrhagia include endocrine (hor-

monal) disorders (e.g., polycystic ovary

syndrome), structural abnormalities o the

uterus (e.g., polyps, broids, or cancer),

inectious agents (i.e., those causing endo-

metritis), disorders o blood clotting (e.g.,

von Willebrand Disease), systemic illness

Menorrhagia (excessive menstrual bleeding) is relatively common among

women o reproductive age and may be caused by a wide range o differentconditions. Menorrhagia symptoms can interere with work and quality olie and may result in iron deciency anemia due to chronic blood loss. Tisanalysis o active component service women o the U.S. Armed Forces oundthat, during the surveillance period o 1998 through 2012, the crude inci-dence rate o menorrhagia was 6.2 cases per 1,000 person years. Annual inci-dence rates rose steadily throughout the period. Compared to their respectivecounterparts, rates were highest in women who were aged 40 to 49 or wereo black, non-Hispanic ethnicity. Among women with menorrhagia whoserecords documented co-occurring conditions, the most common such con-ditions were uterine disorders (e.g., broids) and ovarian cysts. Less than one

percent o cases had underlying bleeding disorders documented. O womenhospitalized with the diagnosis o menorrhagia, 79 percent underwent hys-terectomy during their hospitalizations. Limitations o the analysis and pos-sible uture studies are discussed.

(e.g., liver or kidney disease), intrauterine

devices, and medications.3,4

Untreated menorrhagia is a known

cause o iron deciency anemia (IDA)

because o chronic blood loss. Disorders omenstruation and other abnormal bleeding

diagnoses were identied in 15 percent o

incident IDA cases among active duty ser-

vice women.5 In a civilian study o women

with physician-diagnosed menorrhagia,

58 percent o the women with menorrha-

gia reported a past history o anemia and

our percent had received a blood transu-

sion.6 Symptoms caused by menorrhagia

can interere with work and the quality o

lie o the individual. Among premeno-

pausal women, menorrhagia is the rea-son or approximately 12 to 20 percent o

all gynecological medical encounters.7,8

Healthcare costs and all-cause total work

loss were signicantly higher in women

with idiopathic menorrhagia compared

to a matched cohort o women without

menorrhagia.9 O women with idiopathic

menorrhagia almost 85 percent underwen

surgical treatment (e.g., endometrial abla

tion or hysterectomy).9

Approximately 14 percent o activ

duty service members are women10 and

majority o these women are o reproductiv

age (15-44 years) (Source: Deense Medica

Epidemiology Database [DMED]). As mor

women enter the military it is important to

describe and understand the gynecologica

issues that may affect them and their readi

ness to serve. Managing a normal menstrua

period where access to bathroom acilities i

limited, such as during training, shipboard

or in an operational theater, can be diffi cult

Women have reported an increase in men

strual-related symptoms when access to res

room acilities was limited.11 Navy women

reported an increase in heavy menstrua

bleeding afer they began serving onboard

a ship.12 According to a recent publication

women service members who deployed o

nine months or longer were more likely to

receive a diagnosis o disorders o men

struation (which include menorrhagia

than women who were deployed or shorte

periods.13

Tis report describes the demographidistribution, requency, rates, trends and

comorbid conditions o menorrhagi

among active component women rom

1998 to 2012.

M E T H O D S

Te surveillance period was rom Jan

uary 1, 1998 through December 31, 2012

Te surveillance population consisted o

all service women who served in the activecomponent o the U.S. Armed Forces a

any time during the surveillance period

Records o inpatient hospitalizations and

outpatient encounters or menorrhagi

as well as demographic characteristics o

the study population were obtained rom

the Deense Medical Surveillance System

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T A B L E 2 . Incident counts and incidence

rates of menorrhagia, active component

service women, U.S. Armed Forces,

1998-2012

aIncidence rate per 1,000 person-years

No. Rate

Total 18,631 6.2

Age

17-19 859 2.6

20-29 5,477 3.1

30-39 7,126 10.1 40-49 4,998 23.1

50-55 169 9.2

>55 2 0.7

Race/ethnicity

White, non-Hispanic 7,891 5.2

Black, non-Hispanic 7,586 8.9

Hispanic 1,574 4.9

Asian/Pacific Islander 511 4.0

Other 1,069 4.9

Rank

Junior enlisted 8,448 4.2

Senior enlisted 6,753 13.4

Junior of ficer 1,721 4.9

Senior of ficer 1,707 10.4

Service

Navy 3,570 4.8

Army 8,097 7.6

Marine Corps 608 3.6

Air Force 5,849 6.0

Coast Guard 507 7.6

Occupation

Combat-specific 243 5.4

Armor/motor transport 521 5.0

Pilot/aircrew 135 2.9

Repair/engineer 2,446 5.1

Comm/intel 7,946 7.0

Health care 4,165 7.2

Other 3,175 5.0

(DMSS) database which contains electronic

medical records or all active component

service members. Te Teater Medical Data

Store (MDS), which maintains records or

medical encounters o service members

that occurred during operational deploy-

ments, and medical air transport (medical

evacuation) data were evaluated indepen-

dently or unique menorrhagia encounters.Te earliest MDS records are rom 2005;

thereore, encounters occurring between

2005 and 2012 were captured. Medical air

transport data was evaluated rom 2002

to 2012. Case denition and incidence

rules were not applied to the cases identi-

ed rom in-theater treatment and medi-

cal transport data, and such cases were not

included in the overall analysis.

A woman was considered a case o

menorrhagia i she had a record o a hospi-

talization with an ICD-9-CM code or men-orrhagia in the primary diagnostic position

or records o two outpatient encounters

with a dening ICD-9-CM code in any

diagnostic position within a 180 day period

(Table 1). An individual who met the case

denition or an incident case could be

counted again as an incident case i more

than 365 days had passed without any

health care encounters or menorrhagia.

Denominators or rates were calcu-

lated by summing the person-time or all

emale active component service mem-

bers who served during the surveillance

period. For each menorrhagia case identi-

ed, the record o the incident encounter

was searched to identiy co-occurring diag-noses o those conditions and common

symptoms ofen associated with menorrha-

gia. Te records or inpatient cases o men-

orrhagia were analyzed to determine the

most common procedures that were per-

ormed during the same hospitalizations.

R E S U L T S

During the 15 year surveillance period,

16,150 different active component servicewomen (2.4% o all women who served

during the period) were identied as inci-

dent cases o menorrhagia on at least one

occasion. Among these women there were

18,631 incident cases o menorrhagia diag-

nosed (crude rate o 6.2 per 1,000 person-

years [p-yrs]) (Table 2). Annual incidence

rates more than doubled during the 15-yea

surveillance period rom 3.7 per 1,000

p-yrs in 1998 (n=511) to 9.4 per 1,000

p-yrs in 2012 (n=1,975) (Figure 1). Inpa

tient hospitalizations accounted or 13 per

cent (n= 2,440) o these cases and 16,19

were outpatient cases (data not shown). In

addition to the cases diagnosed in xedmedical acilities, during the period o 200

to 2012 MDS records documented 2,595

medical encounters or menorrhagia dur

ing deployment to an operational theater

An additional 48 women were evacuated

rom theater, between 2002 and 2012 due

to menorrhagia (data not shown).

Description ICD-9-CM codes

Menorrhagia

Excess menstruation 626.2

Puberty menorrhagia 626.3

Premenopausal menorrhagia 627.0

Co-occurring conditions

Uterine leiomyoma, polyps, or disorders of uterus 218.0-218.9, 621.0-621.2, 622.7-622.9

Ovarian cyst 620.x

Adenomyosis, endometriosis 617.0, 617.1, 617.9

Infections of female genital organs(e.g., gonorrhea, chlamydia, cervicitis)

098.10 ,098.16 ,098.17, 098.86, 099.56,099.41, 099.53, 616.0, 112.1, 131,131.0, 131.00, 131.01, 131.9

Endocrine disorders(e.g., disorders of thyroid, ovaries, pituitary)

242.x-244.x, 253.1, 256.1, 256.4, 256.8,256.9, 246.x

Dysplasia, hyperplasia 621.3x, 622.1x

Neoplasms of female genital organs180.x-183.x, 219.x, 220, 221.x, 233.1-233.3x, 239.5

Pelvic inflammatory disease 614.x, 615.0, 615.9

Coagulation disorders/other hemorrhagic conditions286.0-286.9, 286.5x, 287.1-287.9,387.3x, 287.4x

Systemic illnesses 571.4x, 571.5, 571.8, 571.9, 585.x

T A B L E 1 . ICD-9-CM codes for menorrhagia and co-occurring conditions

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race/ethnicity, overall incidence rates o

black, non-Hispanic women were the high

est in every age group except or women

50 to 55 years, or whom Hispanic servic

women had the highest rates. (Figure 4).

Service women in the Army and Coas

Guard had the highest overall rates o men

orrhagia among the services (Table 2). T

annual incidence rates o menorrhagia in

each o the Services generally increased

during the surveillance period (Figure 5 ).

Service women in health care had the

highest overall incidence rate among th

occupational groups (7.19 per 1,000 p-yrs

during the surveillance period (Table 2)

Annual incidence rates increased or all o

the occupational groups during the period

(data not shown).

A majority (73.9%) o menorrhagi

cases did not have a co-occurring condi

tion recorded during the incident encoun

ters. Nevertheless, 15.4 percent o all the

cases o menorrhagia had a co-occurring

diagnosis o uterine leiomyoma/polyp

or disorders o the uterus documented in

the record o the incident encounter (Table

3). Te other most common co-occurring

diagnoses were ovarian cysts (3.4% o

cases), adenomyosis/endometriosis (2.5%)

and inections o the emale genital organ

(2.0%). Each o the remaining conditions o

interest was ound in less than two percen

o the records o incident encounters omenorrhagia. Te records o approximately

18 percent o the women with menorrha

gia documented the presence o associated

symptoms such as dysmenorrhea (painu

periods), and 8 percent reected diagnose

o anemia, including iron deciency ane

mia and post hemorrhagic anemia (data no

shown).

O the 2,440 women who were hos

pitalized or menorrhagia, the records o

those hospitalizations documented th

perormance o a hysterectomy in 79.4 percent o the cases (n=1,918) (Table 4). Addi

tional procedures associated with thes

hospitalizations included removal o on

or more ovaries and/or allopian tube

(22.7% [n=549]), cystoscopy (20.5%), and

operation involving the vagina/cul-de-sa

(13.0%).

F I G U R E 2 . Annual incidence rates of

menorrhagia by age, active component

service women, U.S. Armed Forces, 1998-

2012

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1 9 9 8

1 9 9 9

2 0 0 0

2 0 0 1

2 0 0 2

2 0 0 3

2 0 0 4

2 0 0 5

2 0 0 6

2 0 0 7

2 0 0 8

2 0 0 9

2 0 1 0

2 0 1 1

2 0 1 2

I n c i d e n c e r a t e p

e r 1 , 0 0 0 p e r s o n - y e a r s

17-19

20-29

30-39

40-49

50-55

>55

F I G U R E 3 . Annual incidence rates of

menorrhagia by race/ethnicity, active

component service women, U.S. Armed

Forces, 1998-2012

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

1 9 9 8

1 9 9 9

2 0 0 0

2 0 0 1

2 0 0 2

2 0 0 3

2 0 0 4

2 0 0 5

2 0 0 6

2 0 0 7

2 0 0 8

2 0 0 9

2 0 1 0

2 0 1 1

2 0 1 2

I n c i d e n c e r a t e p e

r 1 , 0 0 0 p e r s o n - y e a r s

Black, non-Hispanic

White, non-Hispanic

Other

Hispanic

Asian/Pacific Islander

F I G U R E 1 . Annual incident counts and incidence rates of menorrhagia, active component

service women, U.S. Armed Forces, 1998-2012

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

0

250

500

750

1,000

1,250

1,500

1,750

2,000

2,250

1 9 9 8

1 9 9 9

2 0 0 0

2 0 0 1

2 0 0 2

2 0 0 3

2 0 0 4

2 0 0 5

2 0 0 6

2 0 0 7

2 0 0 8

2 0 0 9

2 0 1 0

2 0 1 1

2 0 1 2

I n c i d e n c e r a t e p e r 1 , 0 0

0 p e r s o n - y e a r s ( l i n e )

N o

. ( b a r s )

Service women aged 40 to 49 years hadtwice the overall rate o menorrhagia as ser-

vice women in their thirties (23.1 per 1,000

p-yrs and 10.1 per 1,000 p-yrs, respectively)

and over seven times the rate among ser-

vice women in their twenties (3.1 per 1,000

p-yrs) (Table 2). During the surveillance

period, annual incidence rates o menor-

rhagia increased in every age group except

those aged 55 or more (Figure 2). Te largestincrease was among women in their orties

(1998 rate: 15.0 per 1,000 p-yrs; 2012 rate:

33.2 per 1,000 p-yrs).

Black, non-Hispanic women had the

highest total rates o menorrhagia (overall

rate: 8.9 per 1,000 p-yrs) compared to all

other racial/ethnic categories (Table 2, Fig-

ure 3). Stratiying the data by age group and

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F I G U R E 5 . Annual incidence rates o

menorrhagia by service, active componen

service women, U.S. Armed Forces, 1998

2012

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

1 9 9 8

1 9 9 9

2 0 0 0

2 0 0 1

2 0 0 2

2 0 0 3

2 0 0 4

2 0 0 5

2 0 0 6

2 0 0 7

2 0 0 8

2 0 0 9

2 0 1 0

2 0 1 1

2 0 1 2

I n c i d e n c e r a t e p e r 1 , 0 0 0

p e r s o n - y e a r s

Army

Coast Guard

Air Force

Navy

Marine Corps

Description No. % total

Uterine leiomyoma, polyps, or disorders of uterus 2,862 15.4

Ovarian cyst 631 3.4

Adenomyosis, endometriosis 468 2.5

Infections of the female genital organs (e.g., gonorrhea, chlamydia, cervicitis) 364 2.0Endocrine disorders (e.g., disorders of thyroid, ovaries, pituitary) 221 1.2

Dysplasia, hyperplasia 135 0.7

Neoplasms of female genital organs 110 0.6

Pelvic inflammatory disease 39 0.2

Bleeding disorder (i.e., coagulation disorders/ other hemorrhagic conditions) 38 0.2

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