Exercise Treadmills: A Cause of Significant Hand Burns in Young Children.

A pediatric nurse practitioner and an occupational therapist were impressed by the number and severity of treadmill-related hand burns encountered in their outpatient burn clinic. They observed that treadmill burns appeared to be deeper compared with other contact hand burns. Literature review revealed that research was inadequate in this area. A retrospective chart review was conducted, and a total of 384 patients were found to receive treatments at a regional level 1 pediatric burn center for treadmill and contact hand burns from 2010 to 2014. Age distribution, severity, and negative outcomes were compared between treadmill hand burns and contact hand burns. Recommendations for primary caregivers to prevent treadmill hand burns were given. Treadmill burns were the second most common hand injury mechanism after stovetop burns. Both hot surface contact burns and treadmill burns were more frequently seen in patients 0 to 4 years of age. Treadmill hand burns were more severe than contact hand burns in depth of injury (24.5 vs 1.4% full thickness), need for operative intervention (6.4 vs 0.0%), mean number of burn appointments (4.9 vs 1.9), median time to skin closure (25.2 days vs 11.0 days), and median length of care (51.0 days vs 11.0 days). Treadmill hand burns were frequently seen, and they were more severe and required an increased level and duration of care in comparison with other contact hand burns.

Plasma 25-hydroxyvitamin D and risk of premenstrual syndrome in a prospective cohort study.

BACKGROUND: Moderate to severe premenstrual syndrome (PMS) affects 8-20 percent of premenopausal women. Previous studies suggest that high dietary vitamin D intake may reduce risk. However, vitamin D status is influenced by both dietary vitamin D intake and sunlight exposure and the association of vitamin D status with PMS remains unclear. METHODS: We assessed the relation of plasma 25-hydroxyvitamin D (25OHD), total calcium and parathyroid hormone levels with risk of PMS and specific menstrual symptoms in a case-control study nested within the prospective Nurses' Health Study II. Cases were 401 women free from PMS at baseline who developed PMS during follow-up (1991-2005). Controls were women not experiencing PMS (1991-2005), matched 1:1 with cases on age and other factors. Timed luteal phase blood samples were collected between 1996 and 1999 from cases and controls. We used conditional logistic regression to model the relation of 25OHD levels with risk of PMS and individual menstrual symptoms. RESULTS: In analyses of all cases and controls, 25OHD levels were not associated with risk of PMS. However, results differed when the timing of blood collection vs. PMS diagnosis was considered. Among cases who had already been diagnosed with PMS at the time of blood collection (n = 279), 25OHD levels were positively associated with PMS, with each 10 nmol/L change in 25OHD associated with a 13% higher risk. Among cases who developed PMS after blood collection (n = 123), 25OHD levels were unrelated to risk of PMS overall, but inversely related to risk of specific menstrual symptoms. For example, each 10 nmol/L increase was associated with a significant 21% lower risk of breast tenderness (P = 0.02). Total calcium or parathyroid hormone levels were unrelated to PMS. CONCLUSIONS: 25OHD levels were not associated with overall risk of PMS. The positive association observed among women already experiencing PMS at the time of 25OHD measurement is likely due to confounding by indication related to use of dietary supplements to treat menstrual symptoms. Results from prospective analyses, which were less likely influenced by this bias, suggest that higher 25OHD levels may be inversely related to the development of specific menstrual symptoms.

Intake of selected minerals and risk of premenstrual syndrome.

Iron, potassium, zinc, and other minerals might impact the development of premenstrual syndrome (PMS) through multiple mechanisms, but few studies have evaluated these relations. We conducted a case-control study nested within the prospective Nurses' Health Study II (1991-2001). Participants were free from PMS at baseline. After 10 years, 1,057 women were confirmed as PMS cases and 1,968 as controls. Mineral intake was assessed using food frequency questionnaires completed in 1991, 1995, and 1999. After adjustment for calcium intake and other factors, women in the highest quintile of nonheme iron intake had a relative risk of PMS of 0.64 (95% confidence interval (CI): 0.44, 0.92; P for trend = 0.04) compared with women in the lowest quintile. Women in the highest quintile of potassium intake had a relative risk of 1.46 (95% CI: 0.99, 2.15; P for trend = 0.04) compared with women in the lowest quintile. High intake of zinc from supplements was marginally associated with PMS (for intake of ≥25 mg/day vs. none, relative risk = 0.69, 95% CI: 0.46, 1.02; P for trend = 0.05). Intakes of sodium, magnesium, and manganese were unrelated to PMS risk. These findings suggest that dietary minerals may be useful in preventing PMS. Additional studies are needed to confirm these relations.

Dietary B vitamin intake and incident premenstrual syndrome.

BACKGROUND: Thiamine, riboflavin, niacin, vitamin B-6, folate, and vitamin B-12 are required to synthesize neurotransmitters that are potentially involved in the pathophysiology of premenstrual syndrome (PMS). OBJECTIVE: The objective was to evaluate whether B vitamin intake from food sources and supplements is associated with the initial development of PMS. DESIGN: We conducted a case-control study nested within the Nurses' Health Study II cohort. Participants were free of PMS at baseline (1991). After 10 y of follow up, 1057 women were confirmed as cases and 1968 were confirmed as controls. Dietary information was collected in 1991, 1995, and 1999 by using food-frequency questionnaires. RESULTS: Intakes of thiamine and riboflavin from food sources were each inversely associated with incident PMS. For example, women in the highest quintile of riboflavin intake 2-4 y before the diagnosis year had a 35% lower risk of developing PMS than did those in the lowest quintile (relative risk: 0.65; 95% CI: 0.45, 0.92; P for trend = 0.02). No significant associations between incident PMS and dietary intakes of niacin, vitamin B-6, folate, and vitamin B-12 were observed. Intake of B vitamins from supplements was not associated with a lower risk of PMS. CONCLUSIONS: We observed a significantly lower risk of PMS in women with high intakes of thiamine and riboflavin from food sources only. Further research is needed to evaluate the effects of B vitamins in the development of premenstrual syndrome.

Adiposity and the development of premenstrual syndrome.

BACKGROUND: Moderate to severe premenstrual syndrome (PMS) affects 8%-20% of premenopausal women and causes substantial levels of impairment, but few modifiable risk factors for PMS have been identified. Adiposity may impact risk through the complex interaction of hormonal and neurochemical factors, but it is not known if adiposity increases a woman's risk of developing PMS. We have addressed these issues in a prospective study nested within the Nurses' Health Study 2. METHODS: Participants were a subset of women aged 27-44 and free from PMS at baseline, including 1057 women who developed PMS over 10 years of follow-up and 1968 controls. Body mass index (BMI), weight change and weight cycling were assessed biennially via questionnaire. RESULTS: We observed a strong linear relationship between BMI at baseline and risk of incident PMS, with each 1 kg/m(2) increase in BMI associated with a significant 3% increase in PMS risk (95% confidence interval [CI] 1.01-1.05). After adjustment for age, smoking, physical activity, and other factors, women with BMI ≥ 27.5 kg/m(2) at baseline had significantly higher risks of PMS than women with BMI < 20 kg/m(2) (p(trend) = 0.003). A large weight change between age 18 and the year 1991 was significantly associated with PMS risk, whereas weight cycling during this period was not. BMI was positively associated with specific symptoms, including swelling of extremities, backache, and abdominal cramping (all p < 0.001). CONCLUSIONS: Our findings suggest that maintaining a healthy body mass may be important for preventing the development of PMS. Additional studies are needed to assess whether losing weight would benefit overweight and obese women who currently experience PMS.

Timing of alcohol use and the incidence of premenstrual syndrome and probable premenstrual dysphoric disorder.

BACKGROUND: Relatively little is known about factors that influence the initial development of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD), although these conditions are common in reproductive age women and are associated with substantial impairment. Previous studies have observed higher alcohol use in prevalent PMS/PMDD patients compared with controls, but it is unknown if drinking predisposes women to developing these disorders or is instead influenced by symptom experience. METHODS: To address this, we conducted a case-control study nested within the prospective Nurses' Health Study II (NHS2). Participants were a subset of women aged 27-44 and free from PMS at baseline (1991), including 1057 women who developed PMS over 10 years of follow-up, 762 of whom also met criteria consistent with PMDD, and 1968 control women. Alcohol use at various time periods, before and after onset of menstrual symptoms, was assessed by questionnaire. RESULTS: Overall, alcohol use was not strongly associated with the incidence of PMS and probable PMDD. Relative risks (RR) for women with the highest cumulative alcohol use vs. never drinkers were 1.19 (95% confidence interval [CI] 0.84-1.67) for PMS and 1.28 (95% CI 0.86-1.91) for PMDD, although results did suggest a positive relationship in leaner women (p trend=0.002). Women who first used alcohol before age 18 had an RR of PMS of 1.26 (95% CI 0.91-1.75) compared with never drinkers; the comparable RR for PMDD was 1.35 (95% CI 0.93-1.98). CONCLUSIONS: These findings suggest alcohol use is not strongly associated with the development of PMS and PMDD, although early age at first use and long-term use may minimally increase risk.

Endometrial effects of tibolone in elderly, osteoporotic women.

OBJECTIVE: To investigate endometrial effects of tibolone administered to postmenopausal women for 3 years. METHODS: Postmenopausal women (N=3,519) aged 60-85 years (mean 68 years) with a uterus and with osteoporosis were randomly assigned to receive tibolone orally, 1.25 mg per day, or identical placebo. We evaluated effects on endometrial thickness in all women, and examined endometrial histology in 635 participants considered to be at increased risk for abnormalities (with unexpected vaginal bleeding or endometrial thickness more than 4 mm). RESULTS: During the first year of study, mean endometrial thickness increased 1 mm in women receiving tibolone (P<.001), but no further increases were noted during the next 2 years. Diagnostic biopsies among 499 women receiving tibolone and 136 who were receiving placebo showed cumulative incidences of endometrial hyperplasia less than 1%. Among the 15% of women whose biopsy showed an endometrial polyp (similar rate in tibolone and placebo), those receiving tibolone were more than twice as likely to show hyperplasia within the polyp. A marginal increase in grade 1 endometrioid adenocarcinoma (P=.06 compared with placebo) was found among women receiving tibolone. Prevalences of vaginal bleeding during the study were 10.8% in the tibolone group and 2.8% in the placebo group (P<.001). CONCLUSION: Tibolone treatment during 3 years minimally increased endometrial thickness, hyperplastic polyps, endometrial carcinoma, and vaginal bleeding.

Cigarette smoking and the development of premenstrual syndrome.

Moderate to severe premenstrual syndrome (PMS) affects as many as 20% of premenopausal women. Although smoking may be more common in women with PMS, it is unknown whether smoking is involved in PMS etiology. In 1991-2001, the authors conducted a case-control study nested within the prospective Nurses' Health Study II. Participants were US women aged 27-44 years and free of PMS at baseline, including 1,057 who developed PMS over 10 years and 1,968 reporting no diagnosis of PMS and only minimal menstrual symptoms during this time. Smoking at various ages was assessed by questionnaires. After adjustment for oral contraceptives and other factors, current smokers were 2.1 times as likely as never smokers to develop PMS over the next 2-4 years (95% confidence interval: 1.56, 2.83). Total pack-years and smoking during adolescence and young adulthood were also independently associated with a higher risk of PMS. For example, the relative risk for women who started smoking before age 15 years, compared with never smokers, was 2.53 (95% confidence interval: 1.70, 3.76). Results suggest that smoking, especially in adolescence and young adulthood, may increase risk of moderate to severe PMS. These findings may provide an additional incentive for young women to avoid cigarette smoking.

A simple method of assessing premenstrual syndrome in large prospective studies.

OBJECTIVE: To evaluate a simple method of assessing incident premenstrual syndrome (PMS) in large prospective studies. STUDY DESIGN: Participants included 135 Nurses' Health Study II members who first reported PMS by questionnaire in 2001 and 371 who never reported PMS (1989-2001). All completed a retrospective menstrual symptom questionnaire in 2002. We used responses to classify cases and noncases into diagnostic groups for comparison. Logistic regression was used to assess the effect of using various case and noncase classifications on risk estimates in analyses of age, calcium intake and PMS. RESULTS: The menstrual symptom occurrence, timing and severity in women meeting established PMS criteria as assessed by retrospective questionnaire were essentially identical to those who also reported prospective symptom charting (our "gold standard"). Relative risks calculated using these 2 case groups were similar, while results using less restrictive case and noncase definitions were substantially attenuated. CONCLUSION: Prospective reporting of initial PMS diagnosis followed by a short retrospective symptom questionnaire to confirm symptom experience can identify cases in large prospective studies and appears sensitive enough to identify risk factors for incident PMS.

Use of electric blankets and association with prevalence of endometrial cancer.

The objective of this study was to assess the relationship between electric blanket use and prevalence of endometrial cancer for women. Information relating to women enrolled in the Women's Health Initiative Observational Data Set (n=93 676) used to test the relationship factors associated with endometrial cancer included older age at screening, younger age at last menstrual period, region of domicile (highest prevalence in the South), less than a high school education, lower income, body mass index >25 kg/m, low parity, unopposed use of estrogen, never use of estrogen plus progesterone, past alcohol use, higher percentage of daily calories from fat and any electric blanket use. Following a univariate identification of factors significantly related to endometrial cancer, stepwise logistic regression analysis was performed for those factors with P values of less than 0.001 in the univariate analysis. Using electric blankets was associated with a 15% higher prevalence of endometrial cancer than never having used electric blankets (odds ratio=1.15, 95% confidence interval: 1.03-1.27). After controlling for variables significantly associated with endometrial cancer, use of electric blankets for 20 years or more was associated with 36% higher prevalence of endometrial cancer (odds ratio=1.36, 95% confidence interval: 1.16-1.59). Although we were unable to determine the duration of electric blanket use before diagnosis of endometrial cancer, we found that women using electric blankets for 20 years or more had a significantly higher prevalence.

Incidence of cervical cytological abnormalities with aging in the women's health initiative: a randomized controlled trial.

OBJECTIVE: To estimate the incidence of cytological abnormalities and cervical cancer and to determine the effect of oral estrogen and progestin on cervical cytology among postmenopausal women participating in a multi-institution clinical trial. METHODS: The study was a longitudinal analysis of a prospective cohort of 16,608 postmenopausal women (aged 50-79 years) participating in the Women's Health Initiative (WHI) clinical trial of estrogen plus progestin. Eligible participants had a cervical smear within 1 year before randomization and at 3- and 6-year follow-ups. Outcomes measured were low-grade and high-grade squamous intraepithelial lesions (LSIL, HSIL) and cervical cancer at follow-up years 3 and 6. RESULTS: Of 15,733 eligible participants with a uterus, 7,663 were assigned to placebo and 8,070 to estrogen plus progestin. At baseline, 318 women (2%) had low-grade abnormalities on cervical cytology. The annual incidence rate of any new cytological abnormality in the estrogen plus progestin group was significantly higher than that in the placebo group (hazard ratio 1.4, 95% confidence interval [CI] 1.2-1.6). Independent risk factors for HSIL and cervical cancer over a 6-year follow-up (after stratifying for baseline cytologic abnormalities) included sexual activity in the past year while not being married or living as married (hazard ratio 3.5, 95% CI 1.5-8.3). Risk factors did not include age or use of estrogen plus progestin. CONCLUSION: Use of estrogen plus progestin was associated with increased incidence of any cytologic abnormality, although it had no impact on the incidence of HSIL or cervical cancer. Sexually active older women who are not married or living as married may benefit from continued cervical cancer screening. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, www.clinicaltrials.gov, NCT00000611.

Cushing syndrome with secondary adrenal insufficiency from concomitant therapy with ritonavir and fluticasone.

We present 2 cases of Cushing syndrome with secondary adrenal insufficiency from concomitant use of ritonavir and inhaled corticosteroids in children with human immunodeficiency virus infection. These cases highlight the need for special consideration when treatment with an inhaled/intranasal corticosteroid is indicated in children receiving antiretroviral therapy.

Calcium and vitamin D intake and risk of incident premenstrual syndrome.

BACKGROUND: Premenstrual syndrome (PMS) is one of the most common disorders of premenopausal women. Studies suggest that blood calcium and vitamin D levels are lower in women with PMS and that calcium supplementation may reduce symptom severity, but it is unknown whether these nutrients may prevent the initial development of PMS. METHODS: We conducted a case-control study nested within the prospective Nurses' Health Study II cohort. Participants were a subset of women aged 27 to 44 years and free from PMS at baseline in 1991, including 1057 women who developed PMS over 10 years of follow-up and 1968 women reporting no diagnosis of PMS and no or minimal menstrual symptoms. Intake of calcium and vitamin D was measured in 1991, 1995, and 1999 by a food frequency questionnaire. RESULTS: After adjustment for age, parity, smoking status, and other risk factors, women in the highest quintile of total vitamin D intake (median, 706 IU/d) had a relative risk of 0.59 (95% confidence interval, 0.40-0.86) compared with those in the lowest quintile (median, 112 IU/d) (P = .01 for trend). The intake of calcium from food sources was also inversely related to PMS; compared with women with a low intake (median, 529 mg/d), participants with the highest intake (median, 1283 mg/d) had a relative risk of 0.70 (95% confidence interval, 0.50-0.97) (P = .02 for trend). The intake of skim or low-fat milk was also associated with a lower risk (P<.001). CONCLUSIONS: A high intake of calcium and vitamin D may reduce the risk of PMS. Large-scale clinical trials addressing this issue are warranted. Given that calcium and vitamin D may also reduce the risk of osteoporosis and some cancers, clinicians may consider recommending these nutrients even for younger women.

Menopausal symptoms and treatment-related effects of estrogen and progestin in the Women's Health Initiative.

OBJECTIVE: To estimate the effects of estrogen plus progestin (E+P) therapy on menopausal symptoms, vaginal bleeding, gynecologic surgery rates, and treatment-related adverse effects in postmenopausal women. METHODS: Randomized, double-blind, placebo-controlled trial of 16,608 postmenopausal women, ages 50-79 (mean +/- standard deviation 63.3 +/- 7.1) years, with intact uterus, randomized to one tablet per day containing 0.625 mg conjugated equine estrogens plus 2.5 mg medroxyprogesterone acetate (n = 8,506) or placebo (n = 8,102), and followed for a mean of 5.6 years. Change in symptoms and treatment-related effects were analyzed at year 1 in all participants. Bleeding and gynecologic surgery rates were analyzed through study close-out. RESULTS: Baseline symptoms did not differ between the treatment groups. More women assigned to E+P than placebo reported relief of hot flushes (85.7% versus 57.7%, respectively; odds ratio 4.40; 95% confidence interval 3.40-5.71), night sweats (77.6% versus 57.4%; 2.58; 2.04-3.26), vaginal or genital dryness (74.1% versus 54.6%; 2.40; 1.90-3.02), joint pain or stiffness (47.1% versus 38.4%; 1.43; 1.24-1.64), and general aches or pains (49.3% versus 43.7%; 1.25; 1.08-1.44). Women asymptomatic at baseline who were assigned to E+P more often developed breast tenderness (9.3% versus 2.4%, respectively; 4.26; 3.59-5.04), vaginal or genital discharge (4.1% versus 1.0%; 4.47; 3.44-5.81), vaginal or genital irritation (4.2% versus 2.8%; 1.52; 1.27-1.81), and headaches (5.8% versus 4.7%; 1.26; 1.08-1.46) than women on placebo. Estrogen plus progestin treatment prevented the onset of new musculoskeletal symptoms. Vaginal bleeding was reported by 51% of women on E+P and 5% of women on placebo at 6 months; most bleeding was reported as spotting. Gynecologic surgeries (hysterectomy and dilation and curettage) were performed more frequently in women assigned to E+P (3.1% versus 2.5% for hysterectomy, hazard ratio = 1.23, P = .026; 5.4% versus 2.4% for dilation and curettage, hazard ratio = 2.23, P < .001). CONCLUSION: Estrogen plus progestin relieved some menopausal symptoms, such as vasomotor symptoms and vaginal or genital dryness, but contributed to treatment-related effects, such as bleeding, breast tenderness, and an increased likelihood of gynecologic surgery.

Uterine and vaginal effects of unopposed ultralow-dose transdermal estradiol.

OBJECTIVE: To investigate uterine effects of unopposed ultralow-dose transdermal estradiol administered to postmenopausal women for 2 years. METHODS: Postmenopausal women (n = 417), aged 60-80 years, with a uterus and with bone mineral density that was normal for age (z score >or=-2.0) were randomly assigned to receive unopposed transdermal estradiol (14 microg per day) or identical placebo patch. We evaluated effects on endometrial histology, vaginal bleeding, and vaginal epithelial cell maturation. RESULTS: At baseline, estradiol and placebo groups were similar in age (67 +/- 5 years) and in median baseline serum estradiol level (4.8 pg/mL, interquartile range 2.7, 8.0 pg/mL). In the estradiol group, median estradiol level increased to 8.6 pg/mL, (interquartile range 4.4, 13.9 pg/mL, P < .001). In the estradiol group, focal atypical endometrial hyperplasia developed in 1 woman, and adenosarcoma of the uterus developed in 1 woman. The placebo group had no endometrial hyperplasia. Endometrial proliferation occurred in 8.5% of the estradiol group and in 1.1% of the placebo group (P = .06). Incidence of vaginal bleeding was 12.4% in the estradiol group and 8.6% in the placebo group (P = .3). Vaginal epithelial cells showed greater maturation in the estradiol group than in the placebo group (P < .001) but less than typically observed with standard doses of estrogen. CONCLUSION: During 2 years of treatment with ultralow-dose unopposed estradiol, treatment and placebo groups had similar rates of endometrial hyperplasia, endometrial proliferation, and vaginal bleeding. This therapy apparently causes little or no endometrial stimulation. LEVEL OF EVIDENCE: I.

Premenstrual syndrome, premenstrual dysphoric disorder, and beyond: a clinical primer for practitioners.

The management of adverse premenstrual symptoms has presented a difficult challenge for clinicians. However, based on numerous well-designed research studies over the last decade, we now have diagnostic criteria for the severe form of the syndrome, premenstrual dysphoric disorder, and a variety of evidence-based therapeutic strategies. This review presents a comprehensive, practical description of what the clinician needs to know to diagnose and treat adverse premenstrual symptoms at all levels of severity. Diagnostic criteria are described in detail, including a discussion of the distinction between premenstrual dysphoric disorder and premenstrual syndrome (PMS). The rationale for including prospective symptom calendars as a routine part of the diagnostic evaluation of severe symptoms is presented. The differential diagnosis of cyclic symptoms, including depression and anxiety disorders, menstrual migraine, and mastalgia, and an approach for the management of each of these problems are presented. A treatment approach is recommended that matches the treatment to the degree of problems the woman is experiencing. Serotonin reuptake inhibitors are the treatment of choice for severe symptoms, and most women with PMS/premenstrual dysphoric disorder will respond to intermittent, luteal phase-only therapy. Ovulation suppression should be reserved for women who do not respond to other forms of therapy. The role of oophorectomy is limited, and guidelines for its use are presented.

The natural history of primary dysmenorrhoea: a longitudinal study.

OBJECTIVE: To describe the prevalence, severity, course and predictive factors of primary dysmenorrhoea in women of all reproductive ages. DESIGN: Prospective mailed surveys in 1985 and 1991. SETTING: University of Iowa, College of Nursing. POPULATION: We began with a stratified sample of 996 nurses who graduated between 1963 and 1984. We analysed data from 404 women who responded to both surveys, but denied endometriosis, pelvic inflammatory disease or uterine fibroids. METHODS: Participants were surveyed twice at an interval of six years (response rates 73% and 78%) regarding menstrual cycle characteristics. For analysis, dysmenorrhoea was dichotomised as none/mild or moderate/severe. We analysed predictive factors using chi2 tests and stepwise logistic regression. MAIN OUTCOME MEASURE: Severity of dysmenorrhoea. Menstrual cramps as experienced when not taking medication to prevent discomfort were rated on a four-point scale: 0 = no dysmenorrhoea, 1 = minimal (can work, somewhat uncomfortable), 2 = moderate (can work, but quite uncomfortable) or 3 = severe dysmenorrhoea (miss work, have to be in bed). RESULTS: In 1985, 80% of respondents were >25 years old and 60% were parous. There were few changes over six years in the prevalence of mild (51% to 53%), moderate (22% to 20%) or severe dysmenorrhoea (4% to 2%). After adjusting for dysmenorrhoea in 1985, each live birth during follow up (OR = 0.20, 95% CI = 0.08 to 0.53) and older age (OR = 0.92, 95% CI = 0.86 to 0.98) were associated with less dysmenorrhoea in 1991. CONCLUSIONS: Primary dysmenorrhoea affects most women throughout the menstrual years. Dysmenorrhoea severe enough to cause absence from work occurs in less than 5% of women. Although improvement and worsening are equally likely for all women, improvement is more likely in women who bear children.