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Overview of VA research on

Women's Health

Introduction

Currently, there are 1.9 million living women Veterans, who make up 9.4 percent of the total Veteran population. 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.

Sex-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 (including posttraumatic stress disorder); 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 for chronic conditions including heart disease, diabetes, cancer, and osteoporosis, as well as screening for intimate partner violence and sexually transmitted diseases.

Reproductive health care includes maternity care, infertility evaluation and limited treatment, sexual problems, tubal ligation, urinary incontinence, and others. VA provides health care services to pregnant women Veterans, usually in the community but also directly through VA. All VA medical centers have a maternity care coordinator who assists with coordinating VA and community resources for prenatal care and delivery. 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

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"

2007: Published the first randomized multisite clinical trial of treatment for PTSD in women Veterans, 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

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

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

2016: 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

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, 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; 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 both the physical and mental health care needs of women returning from Iraq and Afghanistan, as well as women still on active duty. A new area of focus in post-deployment health has included traumatic brain injury in women.

VA's Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) program is a framework for VA studies. 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 sources 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.

In 2018, VA's National Center for PTSD announced a collaboration with the nonprofit organization PINK Concussions, encouraging women to donate their brains for the purpose of research of the effects of traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD).

The center hopes to learn how the female brain deals with TBI and PTSD. The effort is part of VA's Biorepository Brain Bank, a human tissue bank that collects, processes, stores, and gives out research specimens for future scientific studies.

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➤Military-era cohort studies

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

The study is looking at the lifetime and current incidence of conditions in women Vietnam-era Veterans, including PTSD, depression, diabetes, heart disease, and disability.

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

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.

Another paper using the data from the HealthVIEWS study, published in 2015, found that 20 percent of women Veterans who served in Vietnam have developed PTSD either during or after their service. By contrast, about 12 percent of those who served near Vietnam, and 14 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 have studied, and are continuing to study, the impact of these changes on women's health outcomes, their health care needs, and their utilization of VA's health care system.

Researchers with the VA Connecticut Health Care System analyzed administrative and clinical data—collected between 2007-2012—on more than 900,000 Veterans who served during Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New Dawn. They supplemented the data with a patient survey of nearly 700 female and male Veterans in the Women Veterans Cohort Study.

The goals of the study were to evaluate gender differences in diagnosis and treatment of medical and mental health conditions after deployment, and understand gender differences in military trauma exposures and post-deployment health

Among the findings of the study were 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. These findings have had significant impact on national women's health policy, including for maternity care and pain management.

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 is also looking at treatment patterns and barriers to care for women with those conditions. The new study is expected to be completed in 2019. The follow-up work has already resulted in significant findings that have informed VHA programs and services and implementation pilots related to cardiovascular risk and tailoring preventive strategies.

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➤Other national surveys of women Veterans

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 than those who were younger, nonwhite, Hispanic, and without a usual source of primary care, according to another 2015 paper. The more-engaged group was also 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, which was 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, lesbian-bisexual orientation, 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

Women and the Veterans Choice Program—The Veterans Choice Program (VCP) was launched in 2014 to give Veterans the option to receive care from a community provider. Women Veterans may disproportionately rely on VCP care because many sex-specific health services, such as mammography and maternity care, are not routinely provided in all VHA facilities.

A 2018 study by researchers from several VA facilities found that women experience several challenges with VCP care, and that improved care coordination is needed. Four major issues emerged from the study: eligibility information was limited and confusing; women had difficulty scheduling VCP appointments; VCP care results were not shared with women Veterans or their VHA providers in a timely manner; and many women had concerns with unpaid VCP bills.

The VA MISSION Act, signed into law in June 2018, will continue the goals of the VCP. The legislation combines seven VA community care programs, including VCP, into one program to reduce the complexity in administering those programs and to make more efficient use of VA resources.

Food insufficiency and access to care—A 2018 study by VA Greater Los Angeles Healthcare System found that food insufficiency is linked to delayed access to health care and worse health outcomes in women Veterans. Food insufficiency refers to not having enough food because of a lack of money or resources. Among surveyed women Veterans, 28 percent had food insufficiency. Being food insufficient was linked to a 16 percent higher chance of delaying or missing medical care. Women with food insufficiency were also more likely to screen positive for anxiety and depression and were more likely to be in fair to poor health.

Access to mental health care—Women Veterans with mental health conditions are less likely to give high ratings for provider care quality, according to a Women's Health CREATE study published in 2018. Researchers surveyed more than 1,000 women across 12 VA facilities. Women with multiple positive screenings for mental health conditions were less likely to rate communication with their providers as high, compared with women without mental health conditions. Women with mental health conditions were significantly less likely to have high trust in their providers than women with no mental health conditions. The results show a need to improve communication with women Veterans with mental health conditions.

Another 2018 study found that a majority of study participants were happy with the timeliness of mental health care in VA. The researchers surveyed 419 women Veterans receiving care through VA. Of those women, 59 percent said they could always get an appointment for mental health care as soon as needed. Another 22 percent said they could usually get an appointment as soon as needed. Two problems negatively associated with mental health appointment timeliness were medical appointments that interfere with other activities and difficulty getting questions answered between visits. Most of the women in the study rated VA health care highly, and 93 percent said they would recommend VA health care to other women Veterans.

VA sees telemedicine as a good fit for providing women Veterans with access to mental health care, according to a 2018 study. The researchers interviewed leadership and clinical employees at VA facilities. Telemedicine was seen as a way to increase access to mental health care. In particular, staff saw telemedicine as a way of increasing same-gender care and access to providers with specialized training. This method of health care delivery is seen as especially helpful for rural women and those with other limiting circumstances. Interviewees saw women Veterans as being particularly poised to benefit from telemental health, considering their responsibilities associated with childcare, spousal care, and elder caregiving.

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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. As of late 2018, the WHRN had helped 40 women's health related grants get funded, and has overseen two VA-funded journal supplements devoted to women Veterans' health and health care. More than 250 VA investigators and clinicians have joined the Women's Health Research Consortium. The Women's Health Practice-based Research Network has grown from four initial sites to 60.

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➤Women Veterans and mental health

Disordered eating—Disordered eating can encompass a wide range of abnormal and unhealthy eating behaviors but does not include eating disorders such as anorexia and bulimia. A 2018 VA study by researchers from the VA Palo Alto Health Care System and the San Francisco VA Medical Center found that trauma related to conditions including depression and PTSD was associated with disordered eating in women Veterans, often in relation to negative feelings and emotions and thoughts of panic, fear, and anxiety. The study also found that disordered eating provided short-term but not long-term relief from negative feelings or emotions related to trauma, and a way to avoid unwanted attention from potential and past perpetrators of trauma.

The study researchers defined disordered eating as changing eating patterns in response to stress, using food to cope with stress, gaining or losing more weight than desired, or starting to become very interested in healthier eating in an excessive or otherwise unusual or harmful way. Another 2018 study by the same group found that while military sexual trauma is associated with eating disorders in women Veterans, combat exposure is not.

Yoga treatment for PTSD—In a 2015 study, researchers established the feasibility of using yoga to treat PTSD and depression symptoms in women Veterans who experienced military sexual trauma. This study of 42 female Veterans was conducted at the Atlanta VA Medical Center. The trauma-sensitive yoga treatment showed a trend toward reducing PTSD, depression, and chronic pain symptoms.

The researchers are now conducting a larger, four-year trial to test the effectiveness of this treatment. They are recruiting women Veterans seeking treatment for PTSD related to military sexual trauma who have chronic pain and trouble sleeping. They aim to evaluate the effectiveness of a trauma-sensitive yoga program compared with traditional cognitive processing therapy (CPT) in reducing PTSD symptoms.

The team will also try to find out if yoga is better than CPT at improving Veterans' quality of life and social functioning, and will examine the effect of yoga on the body's response to stress and the hyper-reactivity typical of PTSD. The study's estimated completion date is 2020.

Higher rates of PTSD in women Veterans—Women Veterans have a higher prevalence of PTSD than civilian women or male Veterans. A 2018 study by VA Puget Sound Health Care System researchers found that this may be due to a number of factors. In this study of more than 20,000 people, women Veterans had a PTSD rate of 11 percent, compared with 6 percent for female civilians and 5 percent for male Veterans. Number of trauma types, type of trauma, and social factors taken together may explain the higher prevalence.

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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. VA research is also exploring ways of improving trauma sensitive primary care for women Veterans with histories of sexual trauma and expanding access to new treatments that will improve the health and functioning of women with MST—specifically through home-based psychotherapy and an evidence-based coping skills program.

Sexual trauma can prompt eating problems in returned Veterans—A 2017 study led by investigators at VA Salt Lake City Health Care System found an association between military sexual trauma (MST) and eating disorders in Veterans.

Researchers reviewed close to 600,000 medical records belonging to Afghanistan and Iraq Veterans who used the VA health care system during the period 2004–2014. Nearly two-thirds of those records belonged to women. After adjusting for variables like age, military service, and other mental health disorders, the researchers concluded that the chance of developing an eating disorder was two-times higher for Veterans who had experienced MST, especially in male Veterans. (See the section on "Women Veterans and mental health" above for more studies on disordered eating.) 

Female Veterans with PTSD as a result of MST are twice as likely to have suicidal thoughts as those with PTSD from any other cause, according to a 2018 study led by researchers from the VA Eastern Colorado Health Care System. In addition, those who identified military sexual trauma as the source of their PTSD were at least three times as likely to have suicidal thoughts as those who said their PTSD was specifically related to combat or deployment. According to the researchers, their results show the importance of addressing PTSD that is specifically related to military sexual trauma.

Interpersonal processes may contribute to suicidal ideation among women Veterans with a history of MST, according to a 2017 study by the VA Rocky Mountain Mental Illness Research, Education and Clinical Center. Among a group of women who had experienced MST, perceived burdensomeness, thwarted belongingness, and fearlessness about death were each linked with suicidal ideation. The results show that treatment should assess interpersonal and psychological effects rather than focusing just on psychiatric symptoms, say the researchers.

Homelessness linked to military sexual trauma—Veterans who had experienced MST are at greater risk of homelessness, according to researchers at the VA Salt Lake City Health Care System and VA's National Center for PTSD. In 2016, the team found that 1.6 percent of Veterans who were exposed to sexual trauma during their service were homeless within 30 days of leaving the military. That rate went up to 4.4 percent within one year and was 9.6 percent after five years. That is double the rate for Veterans who had not experienced military sexual trauma.

The study also found that men who went through MST experienced higher rates of homelessness than women who had similar experiences.

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➤Intimate partner violence

Intimate partner violence (IPV), often called domestic violence, occurs when a current or former intimate partner, such as a boyfriend, girlfriend, or spouse, harms, threatens to harm, or stalks his or her partner. VA has documented that women Veterans are at higher risk for IPV compared with women who have not served in the military, and that some of the forms of violence they experience are quite severe.

Women who have been through IPV may experience short-term health effects such as physical injuries, or long-term health effects such as obesity; problems with their heart, stomach, or digestive systems; chronic pain; sexual health problems; and other stress-related difficulties, such as headaches. They may also experience mental health issues like depression, substance misuse, posttraumatic stress disorder, and thoughts of hurting themselves.

Screening for intimate partner violence—VA uses a four-item screening tool called HITS (Hurt, Insult, Threaten, Scream) to detect 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.

VA now uses the tool in its national Social Work, Women's Health Services, and Women's Mental Health Services programs, and many VA employees have been trained in its use. The tool can be used in primary care, during mental health assessments, or during emergency department visits. Because women do not tend to spontaneously disclose IPV but are often willing to talk about it when asked, the HITS tool gives women an opportunity to disclose what may be happening to them and sends the message that it is important to discuss the subject and that someone at VA is available to talk to about it.

The VA New England Healthcare System is now testing an electronic version (E-HITS) of the tool, linked to VA's Electronic Health Record system.

Intimate partner violence and mental health—IPV has a strong association with mental health symptoms. Women Veterans are at a particularly high risk for both IPV and mental health conditions. A 2017 study by researchers at the Corporal Michael J. Crescenz VA Medical Center in Philadelphia found that female VA patients who screened positive for IPV in the past year were more than twice as likely to have a mental health diagnosis, compared to those who screened negative. More than half of women Veterans who experienced IPV had a mental health diagnosis, compared to a third of those who had not experiences IPV. The connection between mental health diagnoses and IPV was significant for each category of IPV: psychological, physical, and sexual violence.

Intimate partner violence and head injury in women Veterans—VA researchers conducted a study in 2017 that found evidence IPV is widespread in women Veterans who were screened for a traumatic brain injury through VA. IPV was also found to be connected to several treatable health problems like depression and substance use disorder.

Researchers surveyed 127 women Veterans who had participated in a larger study that examined reintegration among Iraq and Afghanistan Veterans who had been screened for TBI in the VA. The survey showed 63 percent of study participants who had been screened for TBI reported IPV sometime in their lives. Women who reported IPV were also more likely to have a diagnosis of back pain (48.6 percent) and substance use disorder (12.2 percent) than those who did not.

Approximately 10 percent of women Veterans who served in Afghanistan or Iraq and use the VA for health care services screen positive for deployment-related TBI. These women are also much more likely to have experienced IPV at some point in their lifetimes.

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.

Homelessness and intimate partner violence—Women Veterans who experience intimate partner violence are much more likely to also experience housing instability, found a 2018 study. Looking at the electronic health records of more than 8,000 women, the researchers found that women who screened positive for intimate partner violence were three times more likely to face housing instability. Women who had experienced intimate partner violence in the last year were even more likely to face housing instability if they were African American, had screened positive for military sexual trauma, or had a substance use disorder. Receiving compensation for a disability from military service and being married made it less likely that women would face housing instability.

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➤Reproductive health of women Veterans

For VA, the area of reproductive health includes pre-conception care, maternity care, cancer care, management of menopause, sexually transmitted disease care, 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.

Impact of sexual assault and combat trauma on fertility—A team of investigators at the Iowa City VA Health Care System is investigating the relationship between sexual assault, combat-related trauma, and infertility in male and female Veterans. Through telephone surveys, the team is attempting to better understand the complex relationships between trauma exposures and infertility. The study is expected to be completed in 2019.

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.

A 2017 study by members of the same research team found that PTSD is a risk factor for two common pregnancy complications: gestational diabetes and preeclampsia. Gestational diabetes is the development of diabetes in the mother during pregnancy, and preeclampsia is characterized by increased blood pressure and protein in the urine—a sign of kidney problems. The team found that the risk of both conditions is 30 to 40 percent higher in Veterans with PTSD.

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 is looking 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 and mental health conditions of women Veterans

Women Veterans who faced childhood adversity as likely as men to have abuse problems—Childhood adversity increases the risk for alcohol and drug disorders among Veterans, and women Veterans are as likely as men to have those types of problems, according to a 2018 study led by researchers from the VA Greater Los Angeles Healthcare System. In the general population, however, women who had undergone adversity during childhood are less likely than men to have such problems. Childhood adversity is defined as having experienced problems such as emotional or physical abuse or neglect, or household dysfunction such as a parent's problematic substance use, incarceration, mental illness, or suicide

Value of chiropractic care—In 2017, a VA Western New York Healthcare System study found that chiropractic care can improve outcomes for some female Veterans with low back pain. After an average of eight chiropractic treatments, women saw an average of 27 percent improvement in pain, based on a back-pain questionnaire. The researchers concluded that chiropractic care may be of value for pain management in this population.

Prosthetic needs of women Veterans—The majority of prosthetics are mostly designed for men. For example, nearly all of the commercially available prosthetic feet are male, meaning they are larger and wider than female feet. VA researcher are working on assessing the prosthetic needs of women Veterans, from both a functional and cosmetic standpoint.

An ongoing study by VA and DOD is working to gauge prosthetic use patterns and needs of Veterans and service members with upper-limb amputation. In 2017, the study funding was expanded to include all women Veterans with transradial amputation. The study now includes sub-aims to specifically address the needs of women Veterans. This includes gathering comprehensive data on women Veterans with upper-limb amputation, describing their patterns of prosthetic use, and identifying unmet needs. The study will compare satisfaction with prostheses by gender to determine whether changes need to be made to better serve women Veterans.

Journal supplement on sex/gender differences in VA—A 2019 supplement to the peer-reviewed journal Women’s Health Issues, sponsored by the VA Cooperative Studies Program, examines sex and gender differences in U.S. Veterans’ health conditions and responses to treatments.

Articles in the supplement include commentaries providing historical context and recommendations for research attentive to sex/gender differences, examinations of how existing VA research addresses these differences, analyses of health and health behaviors among men and women enrolled in cohort studies of Gulf War-era Veterans, and studies on sex/gender differences in specific areas of health, from trauma and suicide to smoking and obesity.

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➤Aging in women Veterans

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 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.
• Additional chronic conditions accelerated a decline in physical function in both Veterans and non-Veteran women with diabetes—with the effect being even more pronounced among Veterans.

Yoga may help with menopause symptoms—A 2017 study by researchers at the Durham VA Medical Center in North Carolina found that yoga may reduce vasomotor symptoms such as hot flashes and psychological issues such as anxiety and mood disturbances in women going through menopause. The researchers searched through previous studies and found one review and three randomized controlled trials on the subject but cautioned that more research with larger numbers and control groups is needed.

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More on Our Website

• Relationship impairment due to PTSD and depression has opposite effect on treatment-seeking in men and women, VA Research Currents, Jan. 23, 2019
• When it comes to using birth control, intention and attitude matter, VA Research Currents, Nov. 28, 2018
• Study: Demanding, fast-paced military lifestyle may cause women to adopt poor eating habits, VA Research Currents, June 27, 2018
• A new battlefront: female Veterans comprise fastest-growing segment of homeless Veteran population, VA Research Currents, March 21, 2018
• Study to focus on women with limb loss, VA Research Currents, Feb. 8, 2018
• How intimate partner violence affects women Veterans: a chat with our experts, VA Research Quarterly Update, Winter 2018
• Impact of sexual assault and combat trauma on fertility in Veterans, VA Research Quarterly Update, Winter 2018
• Trauma-sensitive yoga for female Veterans with PTSD who experienced military sexual trauma, VA Research Quarterly Update, Winter 2018
• Research links multiple forms of trauma with eating disorders in female Vets, VA Research Currents, July 20, 2017
• Gestational diabetes and preeclampsia rates higher in women with PTSD, VA Research Currents, April 26, 2017
• Exploring the link between trauma and disordered eating for female Vets, VA Research Currents, Feb. 2, 2017
• Homelessness among U.S. male and female Veterans linked to military sexual trauma. VA Research Quarterly Update, Winter 2017
• Research yields insight on sexual misconduct in the military going back to World War II, VA Research Currents, Sept. 7, 2016
• Diet and cardiovascular disease in women, VA Research Quarterly Update, Spring 2016
• Video: Women's Health
• 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

Mental health screening results associated with women Veterans' ratings of provider communication, trust, and care quality. Chanfreau-Coffinier C, Gordon HS, Schweizer CA, Bean-Mayberry BA, Darling JE, Canelo I, Yano EM. Women Veterans screening positive for mental health conditions were less likely to give high ratings for provider communication, trust, and care quality. Women Health Issues. 2018 Sep-Oct;28(5):430-438.

Do trauma type, stressful life events, and social support explain women veterans' high prevalence of PTSD? Lehavot K, Goldberg SB, Chen JA, Katon JG, Glass JE, Fortney JC, Simpson TL, Schnurr PP. Number of trauma types, type of trauma, and social factors may together help explain women Veterans' higher PTSD prevalence compared to women civilians, but do not fully account for differences between men and women Veterans. Soc Psychiatry Psychiatr Epidemiol. 2018 Sep;53(9):943-953.

Examining women Veteran's experiences, perceptions, and challenges with the Veterans Choice Program. Mattocks KM, Yamo EM, Brown A, Casares J, Bastian L. The study highlights challenges women experience in VCP care and the need for improved care coordination. Med Care. 2018 Jul;56(7):557-560.

Access to care and health outcomes among women Veterans using Veterans Administration health care: association with food insufficiency. Narain K, Bean-Mayberry B, Washington DL, Canelo IA, Darling JE, Yano EM. The prevalence of food insufficiency among women Veterans was associated with delayed access to health care and worse health outcomes. Womens Health Issues. 2018 May-Jun;28(3):267-272.

Military sexual trauma is associated with eating disorders, while combat exposure is not. Breland JY, Donalson R, Li Y, Hebenstreit CL, Goldstein LA, Maguen S. The high rates of military sexual trauma and eating disorders highlight a need for continued work. Psychol Trauma. 2018 May;10(3):276-281.

Recent intimate partner violence and housing instability among women Veterans. Montgomery AE, Sorrentino AE, Cusack MC, Bellamy SL, Medvedeva E, Roberts CB, Dichter ME. For women Veterans, intimate partner violence interventions should assess for both physical and psychological housing needs, and housing interventions should coordinate with intimate partner violence programs to address common barriers to resources. Am J Prev Med. 2018 Apr;54(4):584-590.

Suicide ideation in female survivors of military sexual trauma: the trauma source matters. Blais RK, Monteith LL. Women who identified military sexual trauma as the source of their PTSD symptoms were more than two times more likely to identify suicide ideation as those who described non-military sexual trauma events as the source. Suicide Life Threat Behav. 2018 Apr 20. (Epub ahead of print)

Timely access to mental health care among women veterans. Brunner J, Schweizer CA, Canelo IA, Leung LB, Strauss JL, Yano EM. Findings suggest that overall experience of care is associated with timely access to mental health care, and that such access may be amenable to improvements related to clinic hours or mechanisms for answering patients questions between visits. Psychol Serv. 2018 Apr 5. (Epub ahead of print)

Deployment and preterm birth among US Army soldiers. Shaw JG, Nelson DA, Shaw KA, Woolaway-Bickel K, Phibbs CS, Kurina LM. Timing of pregnancy in relation to deployment is a novel risk factor for spontaneous preterm birth. Am J Epidemiol. 2018 Apr 1;187(4):687-695.

The use of telemental health to meet the mental health needs of women using Department of Veterans Affairs services. Moreau JL, Cordasco KM, Young AS, Oishi SM, Rose DE, Canelo I, Yano EM, Haskell SG, Hamilton AB. Stakeholders saw telemental health as a good fit for helping to address the perceived needs of women Veterans, especially in addressing the geographical barriers experienced by rural women and those with a limited ability to travel. Womens Health Issues. 2018 Mar-Apr;28(2):181-187.

Identifying women Veterans with unhealthy alcohol use using gender-tailored screening. Hoggatt KJ, Simpson T, Schweizer CA, Drexler K, Yano EM. Gender tailored binge-drinking questions may improve detection of women's unhealthy alcohol use. Am J Addict. 2018 Mar;27(2):97-100.

The impact of childhood sexual abuse on women's sexual health: a comprehensive review. Pulverman CS, Kilimnik CD, Meston CM. Mindfulness-based sex therapy and expressive writing treatments are particularly effective in treating sexual dysfunction in women with a history of childhood sexual abuse. Sex Med Rev. 2018 Apr;6(2):188-200.

Differences by Veteran/civilian status and gender in associations between childhood adversity and alcohol and drug use disorders. Evans EA, Upchurch DM, Simpson T, Hamilton AB, Hoggett KJ. Childhood adversity alters the gender gap in alcohol use disorders and drug use disorder risk, and in ways that are different for Veterans compared with civilians. Soc Psychiatry Psychiatr Epidemiol. 2018 Apr;53(4):421-435.

Trauma exposure and disordered eating: a qualitative study. Breland JY, Donalson R, Dinh JV, Maguen S. Trauma exposure can be associated with disordered eating; disordered eating can provide short-term, but not long term, relief from the effects of trauma; and disordered eating can provide a way to avoid unwanted attention from potential and past perpetrators of trauma. Women Health. 2018 Feb:58(2):160-174.

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