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Overview of VA research on

Women's Health

Introduction

Currently, there are 2 million living women Veterans, who make up nearly 9.4 percent of the total Veteran population. By 2018, women are expected to account for 10 percent of all Veterans.

At each VA medical center nationwide, a Women Veterans program manager is designated to advise and advocate for women Veterans. These program managers help coordinate services for eligible women for both primary and specialized care.

Gender-specific primary care programs include cervical cancer and breast cancer screening, birth control, prescription counseling, human papillomavirus vaccine, and menopausal support such as hormone replacement therapy.

Mental health programs geared specifically for women include evaluation and assistance for issues including depression, mood, and anxiety disorders; intimate partner and domestic violence; sexual trauma; parenting and anger management; and marital, caregiver, or family-related stress.

Special services are available to women who have experienced military sexual trauma (MST). VA provides free, confidential counseling and treatment for mental and physical health conditions related to MST.

VA also manages and screens chronic conditions including heart disease, diabetes, cancer, glandular disorders, osteoporosis, and fibromyalgia, as well as sexually transmitted diseases such as HIV/AIDS and hepatitis.

Reproductive health care includes maternity care, infertility evaluation and limited treatment; sexual problems, tubal ligation, urinary incontinence, and others. VA is prohibited by legislative authority from providing either in-vitro fertilization or abortion services.

VA also offers special programs providing services for homeless women Veterans and victims of domestic violence. The department also offers help to women Veterans who are interested in education and training, employment assistance, and vocational rehabilitation.

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Selected Major Accomplishments

1992: Formally targeted women Veterans' health issues as a research priority and conducted a series of studies on their health care needs

1993: Established the Women's Health Sciences Division within the National Center for Posttraumatic Stress Disorder

1998: Released the "Women Vietnam Veterans Reproductive Outcomes Health Study,'" which found that women who had served in Vietnam had a statistically significant increase in the prevalence of children with birth defects, relative to women Veterans of the same era who had not deployed to Vietnam

2005: Held the first VA women's health research agenda-setting conference with a broad focus on biomedical, clinical, rehabilitation and health services research

2006:

• Published results from a large study showing that women patients in VA had "as heavy a burden of physical and mental illness as do men in VA, and are expected to require comparable intensity of health care services"
• First special journal supplement on Women Veteran research is published

2007: First randomized multisite clinical trial of treatment for PTSD in women Veterans is published, demonstrating the value of prolonged exposure therapy as a treatment for this population

2009:

• Initiated the largest health study ever of Vietnam-era women Veterans
• Conducted research on care-delivery models that has informed VA programs and policies on comprehensive care for women Veterans.

2010:

• Created the Women's Health Practice Based Research Network to include more women in VA studies, expand research on women Veterans, sharpen the focus on their health needs, and improve their care and health
• Held women's health research conference on building the evidence base to improve health care outcomes

2012: Secretary's Women Veterans Task Force issues report, "Strategies for Serving our Women Veterans"

2013:

• Found that women aged 50 to 74 face no extra risk of breast cancer if they get a screening mammogram every two years instead of every year
• Established the Women Veterans Healthcare CREATE to increase research impacts on health and care of women Veterans through partnered research
• 2014: Held women' health research conference focused on research-clinical partnerships to enhance intervention, impact and implementation

2016:

• Friends of VA Medical Care and Health Research (FOVA) holds Congressional Briefing on Women Veterans Health Research
• Conducted the 6th systematic review of research evidence since 2006 related to the health and care of women Veterans (Mapping the Evidence: Sex Effects in High Impact conditions for Women Veterans)
• Special journal supplement in The Gerontologist published, titled "Women Veterans in the Women's Health Initiative"
• Women's Health QUERI funded: Enhancing Mental and Physical Health of Women through Engagement and Retention (EMPOWER)

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New, Ongoing, and Published Research

Women Veterans' participation in VA research increased sharply beginning in the early 1980s, due to policy changes in response to Public Law 98-160.

In the early 1990s, VA formally targeted women Veterans' health issues as a research priority and conducted a series of studies on their health care needs, including research on differences in health care delivery to female and male Veterans. In the last decade, more VA-based research on women's health and health care has been funded than ever before, and an extensive, continually expanding evidence base on women Veteran health and health needs has been established.

Today, VA researchers are looking at a broad range of health issues related to women Veterans, including gender differences in health status and health care; risk and resilience factors; mental and behavioral health; the impacts of military service, era of service and combat; sexual trauma; gynecological and reproductive care; access to care: improving the quality and delivery of care; and women Veterans' experiences of and preferences for care. Recent research is also addressing issues related to intimate partner violence and homelessness among women Veterans, as well as special needs of specific populations of women (e.g., rural dwellers, minorities, and LGBT Veterans).

Deployment and post-deployment health research, in particular, is now a major portion of the VA women's health research portfolio, extending VA's knowledge of the health care needs of women returning from Iraq and Afghanistan, as well as women still on active duty.

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➤ Military-era cohort studies

Health of Vietnam-Era Women's Study—The HealthVIEWS: Health of Vietnam Era Women's Study, conducted by VA's Cooperative Study Program (CSP No. 579), was a study of approximately 10,000 women who served in the U.S. military during the Vietnam War. It included those who served in Vietnam, those who served in countries near Vietnam, and those who served primarily in the United States. It has been the most comprehensive study to date of the mental and physical health of women Vietnam-era Veterans.

The five-year study looked at the lifetime and current incidence of conditions in women Vietnam-era Veterans, including PTSD, depression, diabetes, heart disease, and disability. VA researchers have published several analyses based on the overall study, some involving smaller subsets of the overall study group.

Causes of death in Vietnam Veterans—The first paper published as a result of this study, in 2014, found that women Veterans of that era had a lower risk of death from all causes combined and from diabetes, heart disease, chronic obstructive pulmonary disease, and diseases of the nervous system, compared with other American women of their age.

Women Veterans who served in the United States and in Vietnam did have a higher rate of dying in motor vehicle accidents compared to other American women, just as male Veterans do compared to other men. In addition, nurses who served in Vietnam had twice the risk of death from pancreatic cancer, and nearly five times the risk of brain cancer, compared with nurses who served only in the United States.

PTSD in women Vietnam Veterans—Another paper using the data from the HealthVIEWS study, published in 2015, found that 20.1 percent of women Veterans who served in Vietnam have developed PTSD either during or after their service. By contrast, 11.5 percent of those who served near Vietnam, and 14.1 percent of those who served in the United States, have developed PTSD at some time during their lives.

According to the research team, the prevalence of PTSD for women who served in Vietnam was higher than previously documented, and Vietnam service significantly increased the chances of developing PTSD relative to service in the United States. The results suggest that the mental health effects of Vietnam-era service among women Veterans are long-lasting.

Women Iraq and Afghanistan Veterans Cohort Study—The proportion of women in the military, their roles, and their exposure to combat changed dramatically during the wars in Iraq and Afghanistan. VA researchers are studying the impact of these changes on women's health outcomes, their health care needs, and their utilization of VA's health care system.

From November 2007 through October 2012, researchers with the VA Connecticut Health Care System analyzed administrative and clinical data on more than 900,000 Veterans, and surveyed nearly 700 female and male Veterans. The goals of the study were to:

- evaluate sex differences in diagnosis and treatment of medical and mental health conditions after deployment

- To understand sex differences in military trauma exposures and post-deployment health

The team found that women Veterans of the Iraq and Afghanistan wars have higher outpatient utilization and pharmacy and outpatient costs than male Veterans. In addition, the study provided a foundation for additional research related to pain and musculoskeletal conditions in women Veterans. More than 25 papers have been published since 2009 based on the study, in the areas above but also on other medical and mental health outcomes, reproductive health, PTSD, and substance use.

In July 2014, VA began a follow-up study of this cohort designed to identify the predictors of painful musculoskeletal conditions, mental health conditions, and cardiovascular disease in these women. The team will also look at treatment patterns and barriers to care for women with those conditions. The new study is expected to be completed in 2018.

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➤ Other national surveys of women Veterans

Women Veterans' characteristics, needs, and experiences—In 2008 and 2009, VA conducted a nationwide telephone survey of a sample of women Veterans that included both those who used VA for their health care and those who did not.

The objectives of the survey were to characterize the demographics, health care needs, and VA experiences of U.S. Veterans; to determine how health care needs and barriers to VA health care use differ among women Veterans of different periods of military service; and to assess the preferences of women Veterans for potential actions to address barriers to VA care.

Researchers spoke to 3,611 women Veterans, and found that 19 percent had delayed health care or had unmet health care needs during the previous 12 months. Factors that predicted delaying or going without care included limited knowledge of VA care; the perception that VA providers were not sensitive to gender issues; a history of military sexual assault; and greater distance to VA facilities.

VA Women's Overall Mental Health Assessment of Needs (WOMAN) study—In the first population-based national study of mental health among women Veterans using VA care, researchers with the VA Women's Overall Mental Health Assessment of Needs (WOMAN) study surveyed nearly 6,300 women in 2012 to learn more about the prevalence of various mental health conditions in women Veterans, and about their use of VA care and their mental health care needs. Several papers have been published based on this survey.

A 2015 paper based on the survey showed that most women Veterans (84 percent) who perceived a need for mental health care received that care, and nearly all (91 percent) of their care was provided through VA. However, only half reported that their mental health care met their needs completely or very well. Gender-related experiences, including the availability of female providers, women-only treatment settings, women-only treatment groups, and gender-related comfort were each associated with significantly increased odds of perceived mental health access.

Women who were more engaged with their health care rated their mental health care as higher quality, according to another 2015 paper, and were more likely to receive care in accordance with their preferences with respect to the availability of female providers, women-only treatment settings, and women-only treatment groups.

This study also provided the first national estimate for the prevalence of intimate partner violence (IPV) among women Veterans using VA, published in 2016. Investigators found that nearly 1 in 5 women in VHA primary care had experienced IPV in the past year, with an elevated risk among younger, sexual minority, and low socioeconomic status women.

Characteristics of rural women Veterans—In 2014, VA's Office of Rural Health and the University of Colorado published a first-of-its-kind study of the population demographics and health care needs of female Veterans enrolled in VA care.

The study found that women Veterans living in rural and highly rural areas were older and more likely to be married than their urban counterparts. Diagnostic rates were about equal across the groups for several mental health conditions, hypertension, and diabetes. However, anxiety not related to posttraumatic stress was significantly lower for highly rural Veterans.

Rural and highly rural Veterans were also less likely to visit VA for woman-specific care than were urban women Veterans. Those in highly rural areas were less likely to visit for mental health care, compared with urban women.

The authors recommended VA expand its use of telehealth, peer support, and other methods to better reach rural women Veterans, especially for woman-specific care and mental health care.

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➤ Improving access to quality care

Barriers to comprehensive health care—In 2010, Congress directed VA to conduct an independent study of the barriers to comprehensive health care for women who are Veterans. The study, published in 2015, highlighted areas in which the VA health care system can invest effort and resources to influence women Veterans' decisions to seek care through VA.

These areas included improving VA's ability to communicate with women Veterans, especially disabled women Veterans. They also included enhancing VA's services specifically for women, especially by providing female providers on demand (which is VA policy) and having more women-only clinics. The study also suggested that more VA providers be trained in gender sensitivity issues.

Mission of the Women's Health CREATE—VA research has been critical to understanding the organization and quality of VA care for women Veterans and has played a key role in efforts to transform care within VA and inform the development of a national implementation plan for comprehensive women Veteran care. VA's Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) program is a relatively new framework for VA studies. Under the CREATE initiative, VA funds sets of related studies around a high-priority topic. The investigators work closely with each other and with other VA partners (program offices, clinicians and policymakers), with the goal of rapidly putting research results into practice.

The goal of the Women's Health CREATE, established in 2013, is to use research to accelerate the implementation of comprehensive care for women Veterans, and to focus on fundamental issues in how VA delivers care to women Veterans in the context of national VHA policy.

A set of five studies linked to this effort focuses on the following areas:

• Understanding the determinants of barriers and facilitators to using VA care, in particular attrition and retention of women Veterans in VA health care;
• examining the impacts of comprehensive care on the quality of women Veteran's health;
• testing an evidence-based quality improvement approach to tailoring medical homes for women Veterans;
• supporting women's health providers in distance community based outpatient clinics;
• examining the quality and coordination of outsourced or community care for women Veterans.

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➤ Women's Health Research Network

To bolster support for investigators conducting women's health services research, as well as recruitment and inclusion of women Veterans in a wider array of studies, VA HSR&D launched the Women's Health Research Network (WHRN) in 2010. The network's two partnered components are the Women's Health Research Consortium, which provides training and mentorship to researchers focusing on women's health research, and the Women's Health Practice-based Research Network, which supports clinical research networks that test VA-based women's health-related interventions and studies that require recruitment of women Veterans at multiple sites.

The WHRN fosters research development in six strategic priority areas: access/rural health, primary care/prevention, mental health, post-deployment health, complex chronic conditions, and reproductive health. The Women's Health Practice-based Research Network has grown from four initial sites to 60 as of fall 2016.

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➤ Women Veterans and mental health

Prolonged-exposure therapy better than patient-centered therapy—In a large 2007 study of women Veterans and active-duty personnel, VA researchers learned that prolonged-exposure therapy—a type of cognitive behavioral therapy in which therapists help patients recall their traumas under safe, controlled conditions—was more effective in reducing PTSD symptoms than a supportive intervention called present-centered therapy.

Partly as a result of this study, VA launched a nationwide effort to train more clinicians in prolonged-exposure therapy.

Women in combat at same risk of PTSD as men—A 2015 study by VA researchers and researchers with the University of California, San Francisco, School of Medicine found that women who serve in combat are at the same risk as men of developing PTSD.

The study looked at more than 2,300 pairs of men and women deployed to Iraq and Afghanistan who were matched based on variables such as combat exposure, age, race, military occupation, marital status, and pay grade.

After following the pairs for an average of seven years, the research team found that 6.7 percent of the women and 6.1 percent of the men in the study developed PTSD. The difference was not statistically significant.

Accordingly, the researchers concluded that gender alone is not an indicator of PTSD risk, and that future research and treatment should focus on the types of traumatic experiences people have been exposed to, rather than any inherent gender differences in the development of PTSD.

Brain study on PTSD likelihood—The Brain Sciences Center is an interdisciplinary research institute and training center located at the Minneapolis VA Health Care System. The center focuses on the mechanisms underlying the active, dynamic brain in both health and disease.

The center's investigators are using neuroimaging and genotyping in a study that will attempt to determine which women Veterans are most likely to develop PTSD following exposure to potentially traumatic events,

Women Veterans with and without PTSD will be asked to complete diagnostic interviews, and undergo a noninvasive type of brain scan called magnetoencephalography. They will also be asked to provide a blood sample for genetic analysis.

Gender differences in care for Iraq and Afghanistan Veterans—In 2015, researchers from VA's National Center for PTSD and its Center of Excellence for Research on Returning War Veterans explored gender differences in attitudinal barriers to and facilitators of care for 278 Iraq and Afghanistan Veterans and examined the relationship of those factors with VA mental health service use among male and female Veterans with probable mental health conditions.

They found negligible gender differences in attitudes about VA care and their perceived fit in the VA setting: however, men reported slightly more negative beliefs about mental illness and mental health treatment than women. In addition, for women, positive perceptions of VA care were associated with an increased likelihood of seeking mental health treatment.

Pain's relationship to PTSD and major depressive disorder—Previous research has shown that Veterans from prior eras show higher rates of co-occurring PTSD, major depressive disorder (MDD), and pain. Another 2013 Mid-Atlantic MIRECC study sought to examine these conditions in Iraq and Afghanistan war era Veterans. The study found that Veterans with PTSD or MDD were more likely to have chronic pain, with the highest rates of pain in those with both PTSD and MDD. Women Veterans were more likely to report back pain, muscle aches, and headaches than male Veterans, but the relationships between gender and specific diagnosis rates were not significant.

Social support and mental health symptoms—A study by the Women's Health Sciences Division of the National Center for PTSD found that social support reduces the risk of service members' developing posttraumatic stress symptoms. Support from military peers was associated with fewer posttraumatic stress symptoms in men, while civilian support was a more important factor for women service members. While higher levels of support from friends and family outside the military led to lower depression severity in both men and women, the relationship was stronger for women.

Understanding the mental health needs of women Veterans—Mental health services for women vary widely across the VA health care system. Understanding women's needs and priorities is essential to guiding the implementation of patient-centered health services. In a 2015 study, VA researchers surveyed 484 women using VA mental health services. The survey revealed depression, pain management, coping with chronic general medical conditions, sleep problems, weight management, and PTSD as the key priorities of women seeking mental health care through VA. The Veterans surveyed also said that having mental health care specialized specifically for women was extremely important.

Suicide rates in female Veterans—Recent years have seen an increase in suicides in the United States, and this trend is especially evident in the Veterans population. A recent study found that In 2000, female Veterans were nearly four times more likely than non-Veterans females to commit suicide. By 2010, they were nearly five times more likely. Between 2000 and 2010, the suicide rate among non-Veteran females increased by 13 percent. Over that same time period, the suicide rate in female Veterans increased by 40 percent. Suicide rates were also higher for female than male Veterans.

Notably, however, the study also found that the risk of suicide among Veterans who use VHA services did not increase at the same rates as among the overall population. Female Veterans who used VHA services were at significantly lower risk of suicide than those who did not use these services. Female Veterans who used VHA services were 1.5 to two times more likely to commit suicide than non-Veteran women—a marked improvement over the fivefold increase seen among women Veterans at large. Combating Veteran suicide is a high priority within VA; the department provides awareness and education campaigns, a 24-hour crisis line, and suicide prevention coordinators at all VA medical centers to try to prevent Veteran deaths.

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➤ Women and military sexual trauma

Since the late 1990s, VA research has been at the forefront of advancing knowledge about the prevalence and impact of military sexual trauma (MST), which includes both sexual harassment and sexual assault, on the health and functioning of women Veterans.

Fourfold increase in PTSD rate among women with MST—In women Veterans who had experienced MST, a 2012 study by researchers with the San Francisco VA Health Care System found a greater than fourfold increase in PTSD compared to women Veterans who had not experienced such trauma. (In men, the study found a nearly threefold increase in PTSD after MST.)

Increased rate of suicide in women with MST—MST is associated with a wide range of health and mental health conditions among both male and female Veterans, including depression, anxiety, eating disorders, and homelessness. Women and men who reported MST have an increased risk of suicide, according to a 2015 study by a team led by researchers from VA's National Center for PTSD and VA's Serious Mental Illness Treatment Resource and Evaluation Center. The results have informed the agency's approaches to MST and suicide prevention.

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➤ Intimate partner violence

Women and intimate partner violence—VA uses a four-item screening tool called HITS (Hurt, Insult, Threaten, Scream) to detect intimate partner violence (IPV) within the previous year among female Veterans. A study led by researchers from VA's National Center for PTSD, published in 2015, used the tool to determine the level of IPV among women Veterans. They found approximately 37 percent of the 160 Veterans studied reported they had experienced violence with an intimate partner in 2012. They also found a strong association between IPV and mental health issues, and with alcohol misuse.

Another study by many of the same researchers, also published in 2015, looked at the possibility of extending the HITS screening tool to add questions about sexual violence; they found that including such questions may be clinically beneficial and enables them to better identify cases of sexual violence.

Counseling preferences among women who have undergone IPV—National Center for PTSD researchers surveyed a national sample of 226 women Veterans who had reported experiencing IPV during their lifetime. Their findings were published in 2016. These women preferred counseling that focuses on physical safety and emotional health, and gave a lower priority to learning about community resources available to them.

They also preferred that counseling focus specifically on enhancing their coping skills and managing mental health symptoms. In addition, they want counseling to be individualized and preferred an option to meet with a counselor immediately after disclosing their IPV experiences. Of paramount importance to them, according to the researchers, were affordable services and attention to privacy concerns.

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➤ Homelessness and women Veterans

Homeless Veterans and children—A 2015 study by researchers with the VA Connecticut Health Care System and Yale University found that 30 percent of female and 9 percent of male homeless Veterans have children in their custody, raising concerns about the parenting environment for these children. Among Veterans with unstable housing, 45 percent of women and 18 percent of men had children in custody. Psychotic disorders were found in 11 percent of homeless Veterans with children in custody.

The researchers suggested that those who provide care for homeless Veterans need to consider the practical and ethical implications of serving homeless parents and their children, with a particular focus on VA's supported-housing program.

Gender differences in the Veteran homelessness population—According to a 2014 study, homeless female Veterans were younger, had shorter homelessness and incarceration histories, and were less likely to have substance use disorders than men. They were more likely to have PTSD despite being less likely to have been exposed to combat. Female homeless Veterans were much more likely to have dependent children with them. They were also more likely to plan to live with family members in supported housing.

For Veterans admitted to Housing and Urban Development-VA Supportive Housing program, the study found no gender differences in rates of people leaving the program or permanent housing outcomes. Case managers were faster to admit female Veterans to supported housing, reported better working relationships, and provided more employment and income services compared with male Veterans. The study suggests that female Veterans have certain strengths that could aid them if they face homelessness, but that special attention may be needed to noncombat trauma and family-oriented services.

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➤ Reproductive health of women Veterans

For VA, the area of reproductive health includes pre-conception care, maternity care, cancer care, and management of menopause, sexually transmitted diseases, and other related conditions. Among other lines of research, VA researchers are studying the interaction of reproductive health with mental health and medical conditions, and the ways in which women Veterans' military experiences can influence their reproductive health. For example, researchers are examining the impact of sexual assault and combat-related trauma on fertility and reproductive health.

PTSD and the risk of preterm birth—Pregnant women with PTSD are significantly more likely to give birth prematurely, according to a 2015 study by researchers with VA's National Center for PTSD, the March of Dimes Prematurity Research Center, and other organizations. The study looked at all births among VA patients from 2000 to 2009. Of the more than 16,000 births included, more than 3,000 were by mothers with a diagnosis of PTSD, nearly 2,000 of whom had been diagnosed with the illness in the year prior to their giving birth.

The researchers found that if the Veteran had active symptoms of PTSD in the year prior to the baby's delivery, her risk of spontaneous premature delivery increased by 35 percent. Women who had not experienced symptoms in the year before giving birth had no higher risk of early delivery than women without PTSD. The investigators called for more research to determine whether treating PTSD symptoms early in pregnancy can reduce the risk of preterm birth.

Pregnant Veterans and VA care—The number of women Veterans of childbearing age enrolling to receive VA health care is increasing. A 2015 study led by a researcher with the VA Puget Sound Health Care System in Seattle looked at Veterans who had the opportunity to use the prenatal benefits provided by the department, and found that 75 percent of those eligible did not use that care.

The 25 percent of pregnant Veterans who did use VA for prenatal care tended to be younger and more likely to have depression and PTSD. They were also more likely to use VA care after their babies were delivered.

The researchers concluded that among those Veterans who chose not to use their pregnancy benefits, their pregnancy was an important point at which many stopped receiving care from VA. This raises questions about their continuity of care, and whether VA can retain these women as patients.

In the next phase of the work, researchers will survey women at 13 VA health care facilities across the country, ranging from rural areas to urban hubs. Veterans will be interviewed during pregnancy and after giving birth about their experiences with pregnancy, mental health, and maternity care coordination.

The research team will also interview VA primary care, gynecologic and mental health providers, as well as community obstetricians caring for pregnant Veterans under VA's fee-basis program.

Percentage of women using VA maternity benefits is increasing— In 2010, VA maternity benefits were expanded to include seven days of infant care, which may entice more women to use this benefit. A team of VA researchers looked at pregnant Veterans enrolled in VA for care who had delivered babies between 2008 and 2012, and found that the overall delivery rate increased by 44 percent over the study period, from 12.4 to 17.8 deliveries per 1,000 women Veterans.

A majority of those using maternity benefits were age 30 or over and had a service-connected disability. The team concluded that VA must increase its capacity to care for pregnant Veterans and ensure that care coordination systems are in place to address the needs of pregnant Veterans with service-connected disabilities.

Study of women Veterans' experiences during pregnancy—In 2016, researchers with the VA Central Massachusetts Healthcare System and the University of Massachusetts Medical School launched the Center for Maternal and Infant Outcomes Research in Translation (COMFORT) study, to better understand the needs and experiences of women Veterans during pregnancy and following childbirth.

The three-year study will look at ways to improve prenatal maternity and postpartum care coordination and follow-through for Veterans receiving VA care and care from providers designated by VA. It will also focus on mental health issues, such as postpartum depression, which has never been measured before in women Veterans.

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➤ Other medical conditions of women Veterans

Mammograms every two years appear OK—A 2013 study led by a VA investigator and involving more than 934,000 women found that women aged 50 to 75 face no extra risk of breast cancer if they get a screening mammogram every two years instead of every year. The new evidence also indicated that the less frequent screening meant less overall risk of false positives.

Not every health provider abides by the recommendations of this research. VA itself encourages all women between ages 50 and 75 to get mammograms every two years. Women ages 40 to 50 and those older than 75 should talk with their providers about the risks and benefits of having mammograms and make a decision based on their individual risk factors.

Low-dose aspirin shows action against breast cancer in lab tests—A 2015 study, conducted at the Kansas City (Mo.) VA Medical Center, found that low-dose aspirin can impair the ability of breast cancer cells to renew themselves.

The team tested breast cancer cells in mouse models, and found that a daily dose of low-dose aspirin almost halved tumor growth in the mice's tumors by altering the molecular signature in breast cancer cells—and those cells it failed to kill were unable to grow.

The researchers believe that daily doses of low-dose aspirin would be effective both for patients after chemotherapy, and as a preventative measure.

Characteristics of women undergoing cardiac catheterization—Through the CART-CL (Clinical Assessment Reporting and Tracking System for Cath Labs) program, VA researchers track the quality of cardiac catheterization at 77 VA laboratories nationwide. Cardiac catheterization is used to diagnose and treat cardiovascular conditions. Researchers use the data to improve VA's clinical performance.

A 2015 study by researchers with the VA Ann Arbor Healthcare system and the University of Michigan used CART-CL data to look at nearly 86,000 Veterans who underwent the procedure at a VA facility between October 2007 and September 2012. Nearly 3,200 of those Veterans were women.

The researchers found that women Veterans who underwent the procedure tended to be younger and more obese than men, and that they were more likely to have PTSD or depression. They were also significantly less likely to have obstructive coronary disease, and consequently were less likely to have been prescribed heart medications.

However, their long-term health outcomes were about the same as those of their male counterparts. According to the research team, the findings suggest that a significant percentage of women Veterans may have chest pain that is not attributable to obstructive coronary artery disease, and that further research is needed into the reasons for that chest pain.

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➤ Women Veterans' aging

Women's Health Initiative Results—VA research, in collaboration with VA Women's Health Services, supported a secondary analysis of more than 3,700 women Veterans who participated in the national NIH Women's Health Initiative (WHI). These findings were published in a special 2016 supplement of The Gerontologist. The findings, which point to worse health and quality of life for Veterans, include:

• Older women Veterans enrolled in the Women's Health Initiative had a 13 percent higher all-cause mortality relative to non-Veteran women.
• In a comparison of the longitudinal trajectories of physical activity and sedentary behavior between Veteran and non-Veteran women, Veterans had higher baseline physical activity than non-Veterans, but they had greater declines in physical activity over time.
• Veteran status was associated with higher prevalence of protective factors that may have helped preserve cognitive functioning initially. However, findings ultimately revealed more pronounced cognitive decline among women Veterans.
• In examining the impact of chronic conditions on physical function among Veterans and non-Veteran women with diabetes, among women with diabetes, having any additional chronic condition accelerated the decline in physical function—an effect that was even more pronounced among Veterans.

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More on Our Website

• VA study shows women Veterans using maternity benefits at increasing rate, VA Research Currents, April 1, 2014
• Partnership key to caring for women Veterans, VA Research Currents, Aug. 13, 2014
• Rural women Veterans demographic report available, VA Research Quarterly Update, Fall 2014
• Phase 2 of women Veterans cohort study begins, VA Research Quarterly Update, Winter 2015
• Women Veterans with better military social support report better physical health, regardless of PTSD status, VA Research Currents, March 11, 2015
• Partnership key to caring for women Veterans, VA Research Currents, Aug. 13, 2014
• Rural women Veterans demographic report available, VA Research Quarterly Update, Fall 2014
• Phase 2 of women Veterans cohort study begins, VA Research Quarterly Update, Winter 2015
• Sexual dysfunction a common problem in Veterans with PTSD, VA Research Currents, March 24, 2015
• Research: Daily aspirin could block growth of breast, other cancers, VA Research Currents, May 21, 2015
• Women warriors at no greater risk for PTSD than men, study finds, VA Research Currents, Aug. 20, 2015
• Expanding the focus on women Veterans, VA Research Currents, Dec. 1, 2015
• Gender differences in chronic pain, VA Research Quarterly Update, Winter 2016
• Video: Women's Health
• Video: 2010 Women's Health Research Conference
• Women's Health Research, VA Office of Research and Development
• Spotlight on Research into Women Veterans' Health, VA Health Services Research and Development
• VA Women's Health Research Network
• CREATE: Women Veterans Healthcare

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Selected Scientific Articles by Our Researchers

Toward a VA Women's Health Research Agenda: Setting Evidence-based Priorities to Improve the Health and Health Care of Women Veterans. Yano EM, Bastian LA, Frayne SM, Howell AL, Lipson LR, McGlynn G, Schnurr PP, Seaver MR, Spungen AM, Fihn SD. A paper summarizing the process and outcomes of the first national VA Women's Health Research Agenda setting conference, outlining VA's research priorities for biomedical, clinical, rehabilitation, and health services research. J Gen Intern Med. 2006 March;21(Suppl 3): S93-S101.

Cognitive behavioral therapy for posttraumatic stress disorder in women: a randomized controlled trial. Schnurr PP, Friedman MJ, Engel CC, Foa EB, Shea MT, Chow BK, Resick PA, Thurston V, Orsillo SM, Haug R, Turner C, Bernardy N. Prolonged exposure is an effective treatment for PTSD in female Veterans and active-duty military personnel. It is feasible to implement prolonged exposure across a range of clinical settings. JAMA, 2007 Feb 28;297(8):820-30

Using research to transform care for women Veterans: advancing the research agenda and enhancing research-clinical partnerships. Yano E, Bastian L, Bean-Mayberry B, Eisen S, Frayne S, Hayes P, Klap R, Lipson L, Mattocks K, McGlynn G, Sadler A, Schnurr P, Washington DL. Outcomes of the 2010 VA Women's Health Services Research Conference, which sought to significantly advance the state and future direction of VA women's health research and its potential impacts on practice and policy. Womens Health Issues. 2011 Jul-Aug;21(4 Suppl):S73-83.

Gender differences in combat-related stressors and their association with postdeployment mental health in a nationally representative sample of U.S. OEF/OIF Veterans. Vogt D, Vaughn R, Glickman ME, Schultz M, Drainoni ML, Elwy R, Eisen S. Female Iraq and Afghanistan service members may be as resilient to combat stress as men. Future research is needed to evaluate gender differences in the longer-term effects of combat exposure. J Abnorm Psychol. 2011 Nov;120(4):797-806.

Gender differences in military sexual trauma and mental health diagnosis among Iraq and Afghanistan Veterans with posttraumatic stress disorder. Maguen S, Cohen B, Ren L, Bosch J, Kimerling R, Seal K. MST is associated with an increased prevalence of mental health disorders comorbid with PTSD. Womens Health Issues. 2012 Jan-Feb;22(1):e61-6.

Gender differences in traumatic experiences and mental health in active duty soldiers redeployed from Iraq and Afghanistan. Maguen S, Luxton DD, Skopp NA, Madden E. Findings of significant gender differences in demographic variables, exposure to combat, and military sexual trauma. J Psychiatr Res. 2012 Mar; 46(3):311-6.

Outcomes of screening mammography by frequency, breast density, and postmenopausal hormone therapy. Kerilkowske K, Zhu W, Hubbard R, Geller B, Dittus K, Braithwaite D, Wemli K, Miglioretti D, O'Meara ES. Women aged 50 to 74 years who undergo biennial screening mammography have similar risk of advanced-stage disease and lower cumulative risk of false-positive results than those who undergo annual mammography. JAMA Intern Med. 2013;173(9);807-816.

Health Services research on women Veterans: a critical partner on the road to patient-centered care. Atkins D. Women's experience of military service and war differs from that of men in ways that have lasting effects on their needs as Veterans. J Gen Intern Med. 2013 Jul;28 suppl 2:S498-9.

The role of military social support in understanding the relationship between PTSD, physical health, and healthcare utilization in women Veterans. Lehavot K, Der-Martirosian C, Simpson TL, Shipherd JC, Washington DL. Maintaining the social support of military peers after active duty is associated with better physical health among women Veterans, regardless of whether they have PTSD. J Trauma Stress. 2013 Dec;26(6)772-5.

Five-year trends in women Veterans' use of VA maternity benefits, 2008-2012. Mattocks KM, Frayne S, Phibbs CS, Yano EM, Zephyrin L, Shryock H, Haskell S, Katon J, Sullivan JC, Weinreb L, Ulbricht C, Bastian LA. Over a 5-year period, the volume of women Veterans using VHA maternity benefits increased by 44 percent. Womens Health Issues. 2014 Jan-Feb;24(1):e37-42.

Gender differences in the effects of deployment-related stressors and pre-deployment risk factors on the development of PTSD symptoms in National Guard Soldiers deployed to Iraq and Afghanistan. Polusny MA, Kumpula MJ, Meis LA, Erbes CR, Arbisi PA, Murdoch M, Thuras P, Kehle-Forbes SM, Johnson AK. Elevated PTSD symptoms among female service members were not explained simply by gender differences in pre-deployment or deployment-related risk factors. J Psychiatr Res, 2014 Feb;49:1-9

HealthVIEWS: mortality study of female US Vietnam era Veterans, 1965-2010. Kang HK, Cypel Y, Kilbourne AM, Magruder KM, Serpi T, Collins JF, Frayne SM, Furey J, Huang GD, Kimerling R, Reinhard MJ, Schumacher K, Spiro A 3^rd. Women Vietnam- era Veterans had lower mortality risk from all causes combined and from several major causes, such as diabetes mellitus, heart disease, chronic obstructive pulmonary disease, and nervous system disease relative to comparable US women. Am J Epidemiol. 2014 Mar 15;179(6):721-30.

Rural women Veterans demographic report: defining VA users' health and health care access in rural areas. Brooks E, Dailey N, Bair B, Shore J. Improved service options for women's specific care and mental health visits may help rural women Veterans access care. J Rural Health. 2014 Spring;30(2):146-52.

Posttraumatic stress disorder and risk of spontaneous preterm birth. Shaw JG, Asch SM, Kimerling R, Frayne SM, Shaw KA, Phibbs CS. Mothers with active PTSD were significantly more likely to suffer spontaneous preterm birth with an attributable two excess preterm births per 100 deliveries. Obstet Gynecol. 2014 Dec;124(6):1111-9.

Attitudes about the VA health-care setting, mental illness, and mental health treatment and their relationship with VA mental health service use among female and male OEF/OIF veterans.

Fox AB, Meyer EC, Vogt D. There is a need for tailored outreach to address unique barriers to mental health treatment for female and male Iraq and Afghanistan Veterans. Psychol Serv. 2015 Feb;12(1):49-58.

Accuracy of an intimate partner violence screening tool for female VHA patients: a replication and extension. Iverson KM, King MW, Gerber MR, Resick PA, Kimerling R, Street AE, Vogt D. Including a sexual IPV item into VA's HITS tool to detect past-year intimate partner violence may be clinically beneficial. J Trauma Stress. 2015 Feb;28(1):79-82.

Characteristics and outcomes of women Veterans undergoing cardiac catheterization in the Veterans Affairs healthcare system: insights from the VA CART program. Davis MB, Maddox TM, Langner P, Plomondon ME, Rumsfeld JS, Duvernoy CS. Women Veterans undergoing catheterizations are younger, have more obesity, depression, and PTSD, less obstructive coronary artery disease, and similar long-term outcomes, compared with men. Circ Cardiovasc Qual Outcomes, 2015 Mar;8(2 Suppl 1):S39-47.

A partnered research initiative to accelerate implementation of comprehensive care for women Veterans: the VA women's health CREATE. Yano E. Practicing partnered research through new approaches to multilevel engagement holds significant promise for forming strategies for more rapidly integrating rigorous science into quality improvement. Med Care. 2015 Apr;53(4 Suppl 1):S10-4.

Access to mental health care among women Veterans: is VA meeting women's needs? Kimerling R, Pavao J, Greene L, Karpenko J, Rodriguez A, Saweikis M, Washington DL. Women VA users demonstrate very good objective access to mental health services. Med Care. 2015 Apr;53(4 Suppl 1):S97-S104.

Creating a roadmap for delivering gender-sensitive comprehensive care for women Veterans: results of a national expert panel. deKleijn M, Lagro-Janssen AL, Canelo I, Yano E. Study using expert panel methods to arrive at consensus on top priority recommendations for improving delivery of sex-sensitive comprehensive care in VA settings. Med Care. 2015 Apr;53(4 Suppl 1):S156-64.

Aspirin blocks growth of breast tumor cells and tumor-initiating cells and induces reprogramming factors of mesenchymal to epithelial transition. Malty G, De A, Das A, Banerjee S, Sarkar S, Banerjee SK. Aspirin not only prevents breast tumor cell growth in vitro and tumor growth in nude mice models, but also significantly reduces the self-renewal capacity and growth of breast tumor-initiating cells and delays the formation of a palpable tumor. Lab Invest. 2015 Jul;95(7):702-17.

Prenatal care for women Veterans who use Department of Veterans Affairs Health Care. Katon JG, Washington DL, Cordasco KM, Reiber GE, Yano EM, Zephyrin LC. Pregnant women Veterans who use VA prenatal benefits are a high-risk group. Womens Health Issues. 2015 Ju-Aug:25(4):377-81.

Longitudinal assessment of gender differences in the development of PTSD among US military personnel deployed in support of the operations in Iraq and Afghanistan. Jacobson IG, Donoho CJ, Crum-Cianflone NF, Maguen S. Women do not have a significantly different risk for developing PTSD than men after experiencing combat. J Psychiatr Res. 2015 Sep;68:30-6.

Characteristics and use of services among literally homeless and unstably housed U.S. Veterans with custody of minor children. Tsai J, Rosenheck RA, Kasprow WJ, Kane V. A substantial proportion of homeless Veterans served by VA have severe mental illness and children in custody, which raises concerns about the parenting environment for their children. Psychatr Serv. 2015 Oct;66(10):1083-90.

Prevalence of posttraumatic stress disorder in Vietnam-era women Veterans: the health of Vietnam-era women's study (HealthVIEWS). Magruder K, Serpi T, Kimerling R, Kilbourne AM, Collins JF, Cypel Y, Frayne SM, Furey J, Huang GD, Gleason T, Reinhard MJ, Spiro A, Kang H. The prevalence of PTSD for women Veterans serving in Vietnam is higher than previously documented. JAMA Psychiatry. 2015 Nov;72(11):1127-34.

Intimate partner violence and current mental health needs among female Veterans. Iverson KM, Vogt D, Dichter ME, Carpenter SL, Kimerling R, Street AE, Gerber MR. There is a strong connection between past-year IPV and mental health conditions among female Veterans. J Am Board Fam Med. 2015 Nov-Dec;28(6):772-6.

Military sexual trauma and suicide mortality. Kimerling R, Makin-Byrd K, Louzon S, Ignacio RV, McCarthy JF. Military sexual trauma represents a clinical indicator for suicide in VA. Am J Prev Med. 2015 Dec 14. (Epub ahead of print)

Female Veterans' preferences for counseling related to intimate partner violence: informing patient-centered interventions. Iverson KM, Stirman SW, Street AE, Gerber MR, Carpenter SL, Dicter ME, Bair-Merritt M, Vogt D. Women prioritize counseling that focuses on physical safety and emotional health, with learning about community resources being a relatively lower priority. Gen Hosp Psychiatry. 2016 May-Jun;40:33-8.

Patient activation and mental health care experiences among women Veterans. Kimerling R, Pavao J, Wong A. Patient activation may pay an important role in promoting engagement with mental health care. Adm Policy Ment Health. 2016 Jul;43(4):506-13.

Prevalence of intimate partner violence among women Veterans who utilize Veterans Health Administration primary care. Kimerling R, Iverson KM, Dichter ME, Rodriguez AL, Wong A, Pavao J. The high prevalence of past-year IPV among women beyond childbearing years, the majority of whom primarily rely on VHA as a source of health care, reinforces the importance of screening all women for IPV in VHA primary care settings. J Gen Intern Med. 2016 Aug;31(8):888-94.

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