Sexual and physical abuse and gynecologic disorders

K C Schliep; Sunni L Mumford; Erica B Johnstone; C Matthew Peterson; Howard T Sharp; Joseph B Stanford; Zhen Chen; Uba Backonja; Maeve E Wallace; Germaine M Buck Louis

doi:10.1093/humrep/dew153

General Gynecology · Pelvic Pain

Sexual and physical abuse and gynecologic disorders

Schliep KC, Mumford SL, Johnstone EB, Peterson CM, Sharp HT, Stanford JB, Chen Z, Backonja U, Wallace ME, Buck Louis GM

Published August 2016 Human reproduction (Oxford, England), 31(8), 1904-1912

DOI 10.1093/humrep/dew153 PMID 27334336 PMC PMC4974667

RRM Academy Synopsis

Past physical abuse is associated with pelvic adhesions at surgery

Women who reported past physical abuse were more likely to have pelvic scar tissue at surgery. This cohort study followed 471 women having pelvic surgery. Overall, abuse showed no link to endometriosis, ovarian cysts or fibroids.

Key Findings

Of 471 women, 202 (43%) reported sexual abuse and 185 (39%) reported physical abuse, each of some type.
Physical abuse history was associated with a higher risk of adhesions (adjusted RR 2.39, 95% CI: 1.18–4.85). Adhesions were the primary post-operative diagnosis in 33 women (7%).
Endometriosis (190 women, 40%): adjusted RR 1.00 (95% CI: 0.80–1.25) for sexual abuse and 0.83 (95% CI: 0.65–1.06) for physical abuse.
Ovarian cysts: adjusted RR 0.67 (95% CI: 0.39–1.15) sexual, 0.60 (95% CI: 0.34–1.09) physical. Fibroids: 1.25 (95% CI: 0.85–1.83) sexual, 1.36 (95% CI: 0.92–2.01) physical.
Mediation analysis found chronic pelvic pain (indirect effect RR 1.02, 95% CI: 0.96–1.09) and depression (0.91, 95% CI: 0.82–1.00) did not explain the adhesion finding.

Interpretation

The ENDO Study is an observational cohort. Results from a cohort like this show association in these women and cannot show that abuse causes adhesions. Women described abuse in an interview before surgery, and surgeons recorded diagnoses afterward. Only women having surgery took part. The adhesion finding rests on 33 women. The authors ran many comparisons, and about 5% could reach significance by chance. Sexual abuse questions covered age 14 and older, while physical abuse questions covered childhood and adulthood. The sample was predominately white. The authors call for more study of the adhesion finding.

RRM Context

Restorative reproductive medicine looks for the underlying cause of pelvic pain. In this cohort, abuse history was not associated with endometriosis. The authors name abdominal or pelvic surgery as the leading cause of pelvic adhesions. Adhesions are bands of scar tissue.

Our editorial summary of this paper, not the article's abstract.

Abstract

Study Question

Is sexual and/or physical abuse history associated with incident endometriosis diagnosis or other gynecologic disorders among premenopausal women undergoing diagnostic and/or therapeutic laparoscopy or laparotomy regardless of clinical indication?

Summary Answer

No association was observed between either a history of sexual or physical abuse and risk of endometriosis, ovarian cysts or fibroids; however, a history of physical abuse was associated with a higher likelihood of adhesions after taking into account important confounding and mediating factors.

What Is Known Already

Sexual and physical abuse may alter neuroendocrine-immune processes leading to a higher risk for endometriosis and other noninfectious gynecologic disorders, but few studies have assessed abuse history prior to diagnosis.

Study Design, Size, Duration

The study population for these analyses includes the ENDO Study (2007-2009) operative cohort: 473 women, ages 18-44 years, who underwent a diagnostic and/or therapeutic laparoscopy or laparotomy at 1 of the 14 surgical centers located in Salt Lake City, UT, USA or San Francisco, CA, USA. Women with a history of surgically confirmed endometriosis were excluded.

Participants/Materials, Setting, Methods

Prior to surgery, women completed standardized abuse questionnaires. Relative risk (RR) of incident endometriosis, uterine fibroids, adhesions or ovarian cysts by abuse history were estimated, adjusting for age, race/ethnicity, education, marital status, smoking, gravidity and recruitment site. We assessed whether a history of chronic pelvic pain, depression, or STIs explained any relationships via mediation analyses.

Main Results and the Role of Chance

43 and 39% of women reported experiencing sexual and physical abuse. No association was observed between either a history of sexual or physical abuse, versus no history, and risk of endometriosis (aRR: 1.00 [95% confidence interval (CI): 0.80-1.25]); aRR: 0.83 [95% CI: 0.65-1.06]), ovarian cysts (aRR: 0.67 [95% CI: 0.39-1.15]); aRR: 0.60 [95% CI: 0.34-1.09]) or fibroids (aRR: 1.25 [95% CI: 0.85-1.83]); aRR: 1.36 [95% CI: 0.92-2.01]). Conversely, a history of physical abuse, versus no history, was associated with higher risk of adhesions (aRR: 2.39 [95% CI: 1.18-4.85]). We found no indication that the effect of abuse on women's adhesion risk could be explained by a history of chronic pelvic pain, depression or STIs.

Limitations, Reasons for Caution

Limitations to our study include inquiries on childhood physical but not sexual abuse. Additionally, we did not inquire about childhood or adulthood emotional support systems, found to buffer the negative impact of stress on gynecologic health.

Wider Implications of the Findings

Abuse may be associated with some but not all gynecologic disorders with neuroendocrine-inflammatory origin. High prevalence of abuse reporting supports the need for care providers to screen for abuse and initiate appropriate follow-up.

Study Funding/Competing Interests

Supported by the Intramural Research Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development (contracts NO1-DK-6-3428, NO1-DK-6-3427, and 10001406-02). The authors have no potential competing interests.

Topics

General Gynecology Pelvic Pain Chronic Pelvic Pain

General Gynecology › Pelvic Pain › Chronic Pelvic Pain

Sunni L Mumford, Erica B Johnstone, C Matthew Peterson, Howard T Sharp, Joseph B Stanford, Zhen Chen, Uba Backonja, Maeve E Wallace, Germaine M Buck Louis, Karen C Schliep

S Mumford, E Johnstone, H Sharp, Joe Stanford, Joey Stanford, J Stanford, Z Chen, U Backonja, M Wallace, G Louis, K Schliep

PMID 27334336 27334336 DOI 10.1093/humrep/dew153 10.1093/humrep/dew153 Schliep et al. 2016, Schliep 2016

Sexual and physical abuse and gynecologic disorders

Past physical abuse is associated with pelvic adhesions at surgery

Key Findings

Interpretation

RRM Context

Abstract

Topics

By this author

Related research