Psychosomatics 45:403-413, October 2004
© 2004 The Academy of Psychosomatic Medicine
Menopausal Symptoms and Psychological Distress in Women With and Without Tubal Sterilization
Grace Wyshak, Ph.D., M.S. HYG.
Received June 12, 2003; revision received Nov. 5, 2003; accepted Nov. 24, 2003. From the Department of Population and International Health, Harvard School of Public Health. Address correspondence to Dr. Wyshak, Department of Population and International Health, Harvard School of Public Health, 665 Huntington Ave., Boston, MA 02115; wyshak{at}hsph.harvard.edu (e-mail).
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ABSTRACT
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Data from self-administered mailed questionnaires were used to examine the relationship between menopausal and psychological/psychiatric factors in women age 45–50 years with and without tubal sterilization. In multivariate logistic regression analysis, tubal sterilization was associated with current flushing (odds ratio=8.78, 95% confidence interval [CI]=1.58–48.67) and current symptoms of psychological distress (odds ratio=3.37, 95% CI=1.27–8.95); psychological distress was associated with tubal sterilization (odds ratio=3.28, 95% CI=1.28–8.42) and with being perimenopausal (odds ratio=3.93, 95% CI=1.08–14.34). Sterilization was marginally associated with a history of physician-diagnosed depression (univariate age-adjusted odds ratio=2.24, 95% CI=0.90–5.60). The menopausal and psychological symptoms of women with tubal sterilization should be taken seriously and treated appropriately.
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INTRODUCTION
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Women age 40–50 years who are entering the perimenopausal period of their lives often experience affective symptoms, psychological distress, and menopausal symptoms, including vasomotor symptoms such as flushing, hot flashes, and night sweats and somatic symptoms such as vaginal dryness and breast tenderness, as well as alterations in their menstrual patterns. Published reports vary in their conclusions about the nature and extent of vasomotor symptoms and of psychological distress during the menopausal transition.1–11 At the same time a growing literature has documented the convergence of reproductive endocrine and central serotonergic systems in the regulation of a variety of behaviors.12 Decline in ovarian function, with associated decline in estrogen levels, remains a key factor in leading hypotheses about reproductive- and endocrine-associated affective symptoms and about mood disorders observed during the perimenopause.13 In a comprehensive review of the literature on hot flushes, Stearns et al.2 reported that hot flushes are the most common complaint of perimenopausal and postmenopausal women, yet the pathophysiology of hot flushes is not well understood. The temporal relation between changes in gonadal hormone concentrations and the onset of hot flushes has led to the assumption that the symptoms occur as a result of decreased estrogen or gonadotrophin concentrations. Stearns et al.2 further stated that alteration in the CNS thermoregulatory set-point might be mediated by changes in hormone concentrations that affect brain neurotransmitters. The perimenopause has been associated with a higher rate of depressive symptoms but no increased risk of major depression.8
This paper focuses on a subset of women, with and without tubal sterilization, who are of perimenopausal age (45–50 years). It has been reported that more women in the United States have undergone tubal sterilization than are using any other single method of contraception.14–16 The existence of a post-tubal-ligation syndrome of menstrual abnormalities has been debated for decades, and the evidence is inconclusive.15,16 Peterson et al.,15 conducted a large follow-up study to determine whether the likelihood of persistent menstrual abnormalities was greater among women who had tubal sterilization than among women who had not; they concluded that there was no difference between the groups in likelihood of persistent menstrual abnormalities. Westhoff and Davis17 reviewed the frequency, effectiveness, and clinical sequelae of tubal sterilization from U.S. health care statistics and reported that tubal sterilization was protective against ovarian cancer. Westhoff and Davis17 and Westhoff18 concluded that the procedure is highly effective and safe. Harlow et al.19 found no significant change in menstrual cycle characteristics and hormone levels among women with tubal sterilization. Whitmore20 commented briefly, in response to the conclusion that tubal sterilization may reduce the risk of epithelial ovarian cancer,21 that it is imperative to question how tubal ligation may alter normal physiology in premenopausal women and to examine the long-term effects of tubal ligation in accelerating osteoporosis and atherosclerosis. Cattanach and Milne22 reported that women have experienced abnormal uterine bleeding and/or menorrahagia, physical problems, and psychological and/or psychiatric problems after tubal sterilization and that tubal sterilization may lead to reduced ovarian function, but they provided no data on the extent of types of psychological and/or psychiatric problems experienced by women with tubal sterilization. Some patients with prodromal premature ovarian failure may present with hot flashes.23 Women with idiopathic premature ovarian failure expressed sadness and resignation about their menopausal symptoms.24
To my knowledge, before our 2000 study,25 there was little in the literature about vasomotor and other perimenopausal symptoms among women with tubal sterilization and about the possible association between tubal sterilization and affective symptoms. Motivated by anecdotal reports that sterilization may lead to earlier menopause, earlier menopausal symptoms, and more menstrual distress than would be expected, we investigated these concerns among sterilized women. Data based on the self-reports of college-educated women age 40–44 years at time of reporting, i.e., of premenopausal age, indicated that women in this age group with tubal sterilization had a significantly higher risk of menopausal symptoms than did women in this age group with no tubal sterilization.25
The current follow-up study included the previously studied group of women with tubal sterilization, whose age at the time of the follow-up was 45–50 years, and a group of women of similar age without tubal sterilization who were randomly selected from the original overall study group.25 The purpose of the current study was twofold: 1) to reexamine the women with tubal sterilization, who were now closer to the perimenopausal age range of 45–54 years,1,26 with respect to menopausal status, vasomotor and somatic symptoms, and changes in menstrual patterns associated with the perimenopausal period and 2) to examine the association of tubal sterilization with psychological distress, including current affective symptoms and history of physician-diagnosed depression. The follow-up is important for several reasons. An important research question was whether women age 40–44 years with tubal sterilization, who differed in menopausal symptoms from women in the same age group who did not have tubal sterilization, continue to differ as they reached age 45–50 years, closer to the perimenopausal period. Do the differences between the two groups become less or greater or stay the same as the length of time from the tubal sterilization increases? Further, in the previous study, no conclusions could be drawn about the hypothesis that women with tubal sterilization would have earlier natural menopause than women without tubal sterilization, and this hypothesis was further considered in the follow-up.
In addition, the relationship of mental health and well-being with tubal sterilization is a new area of investigation that was not covered in the earlier study. The current study was also intended to provide new information about reproductive- and endocrine-associated affective symptoms.
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METHOD
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In a previous study we investigated the prevalence of tubal sterilization and the relation between tubal sterilization and menstrual disturbances and menopausal symptoms in women in the premenopausal years—age 40–44 years at the time of reporting—by comparing women with and without tubal sterilization.25 The women were first identified and surveyed in 1982 and surveyed again in a 15-year follow-up conducted in 1996–1997. They were alumnae of 10 colleges and universities, including the "Seven Sister" colleges (Barnard, Bryn Mawr, Mount Holyoke, Radcliffe, Smith, Vassar, and Wellesley), Springfield College, University of Southern California, and University of Wisconsin.27 The main purpose of this longitudinal study was to investigate the long-term health of women who had been athletes in college, compared to their nonathletic classmates.28,29
From data obtained in the 15-year follow-up, the association of tubal sterilization and menopausal symptoms was first examined in a subset of women age 40–44 years.25 In the current study the previously identified women with tubal sterilization (N=56), currently age 45–50 years, and a randomly selected group of women of similar age without tubal sterilization were queried again. The women without tubal sterilization were selected from the same database as the tubal sterilization group—the women who participated in the 1996–1997 study and were the subjects in the study published in 2000.25 From the group of women without tubal sterilization in the previous study (N=460), one of five women was randomly selected, for a total of 92 women. Questionnaires were sent to all 56 women who had had tubal sterilization and to the 92 randomly selected women without tubal sterilization, a total of 148 women. The ratio of cases to controls was 1:1.6. A total of 116 women—45 with tubal sterilization and 71 without tubal sterilization—responded to the questionnaire. Questionnaires for two women in the tubal sterilization group and five in the group without tubal sterilization were returned because of the lack of a follow-up address or an incorrect address. Excluding the women who did not receive questionnaires, the response rate was 116/141, or 82.3%. The response rate for the entire group selected for inclusion was 116/148, or 78.3%—80.3% for women with tubal sterilization and 77.2% for the women without tubal sterilization.
The Harvard School of Public Health Human Subjects Committee has approved this study since its inception.
Questionnaire
The women were mailed a detailed questionnaire. Much of the content of the questionnaire was derived from the well-validated and widely used instrument that was used in the Nurses' Health Study.30 The questionnaire included questions on medical history and physician-diagnosed illnesses; occupation and living arrangements; current exercise or athletic activity; weight gain or loss; diet; family history of cancer, cardiovascular disease, diabetes, smoking, alcohol and drug problems, and other medical conditions; medications taken; physical activities; reproductive history; menstruation; and menopause. Detailed questions about perimenopausal and menopausal symptoms were included.
The questionnaire also included questions from the Medical Outcomes Study 36-Item Short-Form Health Survey31 on self-assessment of general health, mental health, and well-being. These questions cover perceptions of vitality and affective symptoms of psychological distress. Psychological distress is measured by five mental health items that address four major mental health dimensions (anxiety, depression, loss of behavioral/emotional control, and psychological well-being).31 The questions are phrased, "In general, how much of the time during the past 4 weeks ...?" The five mental health items are "... have you been a nervous person?" "... have you felt down-hearted and blue?" "... have you felt so down in the dumps that nothing could cheer you up?" "... have you been a happy person?" and "... have you felt calm and peaceful?"
The four items relating to vitality are "... did you feel full of pep?" "... did you have a lot of energy?" "... did you feel worn out?" and "... did you feel tired?" The responses are scored on the following 7-point Likert-type scale: all of the time, most of the time, a good bit of the time, some of the time, a little of the time, hardly any of the time, and none of the time.
A variable of high or low psychological distress was created from the nine items. Directionality for four items—calm, happy, energy, and pep—was considered. For each participant, responses to the nine items were summed (possible score range=9–63). The distribution of the sums was dichotomized at the median. High psychological distress was indicated by a total score of 46 or less; low psychological distress by a score of 47 or higher. Thus, low scores denoted high distress.
The rationale for using the nine items was based on the conceptual framework of the Medical Outcomes Study 36-Item Short-Form Health Survey, which summarized the health phenomena—physical and mental—captured by these scales.31 The mental component scale included the five items from the mental health scale, which capture both functioning and well-being, and the four vitality items, which capture well-being.
Statistical Analysis
Statistical analytic methods included descriptive statistics, comparisons among groups, age-adjusted univariate logistic regression, multivariate logistic regression, and the backward selection method for multivariate logistic regression to determine factors associated with 1) tubal sterilization and 2) current symptoms affecting mental health and well-being (hereafter referred to as psychological distress), and 3) lifetime prevalence of physician-diagnosed depression. Both tubal sterilization and depression were used as dependent or outcome variables to allow for the possibility of "reverse causation," that is, tubal sterilization may lead to depression, or depression may lead to tubal sterilization. Predictor variables that may be related either to tubal sterilization or to psychological distress included age, reproductive history, menopausal status, menopausal symptoms, and social and behavioral factors, such as alcohol consumption, smoking, current exercise, body mass index, and whether the subject was an athlete in college.
Two-tailed t tests were used for comparisons of means; the chi-square test was used to test the significance of differences in percentages. Univariate logistic regression analyses were done to determine which variables should be included in the multivariate model. Multivariate logistic regression analyses using a backward selection procedure were carried out to select significant independent variables and make adjustments for covariates and possible confounding factors. The logistic regression models tested for the significance of interactions among variables. The criterion for inclusion in the backward selection multivariate logistic regression models was p 0.05. Odd ratios and 95% confidence intervals (CIs) are presented in the tables. Goodness of fit was assessed with the Hosmer-Lemeshow test. Statistical analyses were completed with SAS.32
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RESULTS
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Table 1 and Table 2 present descriptive data for the 116 women who participated in the study. Table 3 presents the results of logistic regression analyses.
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TABLE 1. Characteristics of Subjects in a Study of Menopausal Symptoms and Psychological Distress in Women With and Without Tubal Sterilization a
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TABLE 2. Characteristics of Subjects in a Study of Menopausal Symptoms and Psychological Distress in Women With and Without Tubal Sterilization, by Presence of Psychological Distress and History of Depressiona
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TABLE 3. Logistic Regression Analyses of Characteristics Associated With Tubal Sterilization, Psychological Distress, and History of Depression Among 116 Women With and Without Tubal Sterilization
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The women were classified into groups according to three variables: 1) tubal sterilization (yes/no), 2) current symptoms of psychological distress (high/low), and 3) history of physician-diagnosed depression (yes/no).
Tubal sterilization was associated with psychological distress (multivariate odds ratio=3.37, 95% CI=1.27–8.95) and with current flushing (multivariate odds ratio=8.78, 95% CI=1.58–48.67). Compared with women without tubal sterilization, women with tubal sterilization were more likely to have sexual intercourse one or more times a week (multivariate odds ratio=2.49, 95% CI=1.01–6.14), to have less stress in their lives (multivariate odds ratio=0.35, 95% CI=0.13–0.92), and to have more live births (multivariate odds ratio=1.76, 95% CI=1.10–2.83).
Psychological distress was associated with tubal sterilization (multivariate odds ratio=3.28, 95% CI=1.28–8.42), being perimenopausal (multivariate odds ratio=3.93, 95% CI=1.08–14.34), a history of depression (multivariate odds ratio=4.20, 95% CI=1.27–13.93), a stressful life (multivariate odds ratio=6.42, 95% CI=2.47–16.68), and living with a spouse or partner (multivariate odds ratio=3.39, 95% CI=1.06–10.83).
Physician-diagnosed depression was associated with surgical menopause (multivariate odds ratio=8.52, 95% CI=1.84–39.42), current vaginal dryness (multivariate odds ratio=4.80, 95% CI=1.30–17.69), and psychological distress (multivariate odds ratio=5.31, 95% CI=1.60–17.58). Living with a spouse or partner seemed to be a protective factor (multivariate odds ratio=0.28, 95% CI=0.09–0.91). The association between tubal sterilization and depression was marginal in the univariate logistic analysis (odds ratio=2.24, 95% CI=0.90–5.60) but not in the multivariate model (Table 3).
The lifetime prevalence of physician-diagnosed depression and current symptoms of psychological distress were highly correlated; 75% of the women with a history of depression scored high on current symptoms of psychological distress, but only 42% of those without a history of depression scored high on current symptoms of psychological distress. Among those scoring high on current (past 4 weeks) psychological distress, 32% had a history of physician-diagnosed depression; among those scoring low on psychological distress, 10% had a history of depression (Table 2).
The mean age at tubal sterilization was 36.8 years (SD=4.0, median=37). Twenty-four women reported a history of physician-diagnosed depression; the mean age at first episode was similar in those with or without tubal sterilization (mean=38.3 years, SD=5.5, median=38.5). Nine women had surgical menopause; the mean age at surgery was 39.9 years (SD=5.8, median=40). Of the women with both a lifetime history of depression and a tubal sterilization (N=13), eight had the tubal sterilization before the first episode of depression, and five after. Of those with a history of depression and surgical menopause (six women), four had depression before surgery, one after, and one at about the same time (data not shown).
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DISCUSSION
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The findings of high odds ratios for the association of tubal sterilization with flushing (odds ratio=8.78) and with psychological distress (odds ratio=3.37) provide strong evidence in accord with the clinical observations of Cattanach and Milne,22 who reported that women experienced psychological and/or psychiatric problems subsequent to tubal sterilization, and of Joffe and Cohen,13 who stated, "Decline in ovarian function, with associated estrogen decline, remains a leading hypothesis about the reproductive-endocrine-associated affective symptoms and mood disorders observed during the perimenopause."
Psychological distress was associated with perimenopause, with adjustment for other factors (odds ratio=3.93). Lifetime history of physician-diagnosed depression was marginally and inconclusively associated with tubal sterilization. These results are in accord with those of Kim and Viguera,8 who reported that the perimenopause has been associated with a higher rate of depressive symptoms but with no increased risk of major depression.
The results confirmed the finding of our earlier study that women who had tubal sterilization had more flushing than women without tubal sterilization and provided suggestive evidence that women with tubal sterilization had earlier natural menopause (due to small numbers, the results were marginally significant). The results for surgical menopause supported the finding of Rulin et al.33 that women with tubal sterilization are slightly but significantly more likely to have surgical menopause (4.55% versus 2.17% of women without tubal sterilization in the study by Rulin et al.). In the current study the difference between the sterilized and nonsterilized women in likelihood of having tubal sterilization was not significant (age-adjusted odds ratio=1.2).
Although the results are robust and in accord with the biological and psychiatric literature, the study had some limitations. The data were based on self-reports of history and symptoms; however, the participants were well-educated, upper-middle-class women who were likely to be reliable reporters of their medical history. The findings may not be generalizable to the population at large. At the time of the inquiry, the women had a mean age of 47.8 years (range 45–50); those in the sterilized group had the procedure at least 6 and one-half years before the study (i.e., they were first identified as having been sterilized in 1996–1997 survey). The first episode of physician-diagnosed depression occurred before tubal sterilization in some women and after tubal sterilization in others; therefore, in this study, causal associations cannot be determined. Longitudinal data on reproductive and psychiatric history may be needed to determine whether a causal relationship exists.
An additional construct relevant to tubal sterilization is regret about having had the procedure.17 Women have been reported to experience regret about tubal sterilization, in the context of the desire for more children and the desire to have the procedure reversed. For example, on the basis of data from a large national sample, Chandra14 reported that almost 25% of women with a tubal ligation in 1995 desired a reversal of the operation. The desire for a reversal of the operation may occur when women enter into a new partnership. The current study did not inquire about regret.
Nevertheless, the findings from this epidemiological, observational study have face and construct validity, are internally consistent, and have biological plausibility. These results, based on epidemiologic data, may contribute to the neuroscientific understanding of the estrogen-serotonin interaction in women.2,13 As Joffe and Cohen13 stated: "It remains unclear whether there is a subpopulation that is at risk of perimenopausal symptoms (i.e., a differential behavioral sensitivity) or whether certain clinical and biological characteristics of the perimenopausal process cause depression in a more direct fashion." This paper has identified a subset of women, i.e., those who have undergone tubal sterilization and who experienced menopausal symptoms and psychological distress to a greater degree than nonsterilized women.
That further research is needed may be best epitomized from 1) the clinical and pathophysiological perspective and 2) the psychiatric perspective. In reference to the clinical and pathophysiological perspective, Stearns et al.2 wrote, "Thus, preclinical and clinical observation suggest cross-talk between gonadal hormones, especially oestrogen, and the thermoregulatory set-point, located in the anterior portion of the hypothalamus. The set-point might be dependent on a balance of at least two serotonin receptors, and a change in the balance could induce a vasomotor physiological response to hot or cold stimuli to dissipate the heat. How oestrogen affects this delicate balance, and whether the hormone acts directly or indirectly, is unknown." In reference to the psychiatric perspective, Joffe and Cohen13 wrote: "Contrary to popular lore, research has not revealed a consistent association between female reproductive hormones and psychiatric symptoms, but rather supports a more complicated interplay between biological and psychological diathesis and psychosocial factors." Rubinow et al.12 sum up the overall area in which further research is needed: "Why do different individuals respond differently to ostensibly the same stimulus?"
In conclusion, although tubal sterilization is a widely used method of contraception and is considered a safe and effective procedure, women who have undergone tubal sterilization have more vasomotor symptoms and affective symptoms than women who have not had a tubal sterilization. The findings of this study suggest that health care providers—primary care providers, obstetricians and gynecologists, and psychiatrists and other mental health providers—should be aware that this subgroup of women may present with symptoms that are not expected in women of their age, should take these symptoms seriously, and manage and treat them appropriately.
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ACKNOWLEDGMENTS
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The author thanks the alumnae offices of the participating colleges and universities for help in locating the study subjects and Colleen Clark for help in the preparation and distribution of the questionnaire. This work was funded partly by the Cambridge Mustard Seed Foundation and by a donation from Dr. Jill Ker Conway.
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REFERENCES
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- Bastian LA, Smith CM, Nanda K: Is this woman perimenopausal? JAMA 2003; 289:895–902[Abstract/Free Full Text]
- Stearns V, Ullmer L, Lopez JF, Smith Y, Isaacs C, Hayes DF: Hot flushes. Lancet 2002; 360:1851–1861[CrossRef][Medline]
- Greendale GA, Lee NP, Arriol ER: The menopause (seminar). Lancet 1999; 353:571–580[CrossRef][Medline]
- Torpy JM, Cassio L, Glass RM: Perimenopause: beginning of menopause (patient page). JAMA 2003; 289:940[Free Full Text]
- Bosworth HB, Bastian LA, Kuchibhatla MN, Steffens DC, McBride CM, Skinner CS, Rimer BK, Siegler IC: Depressive symptoms, menopausal status, and climacteric symptom in women at midlife. Psychosom Med 2001; 63:603–608[Abstract/Free Full Text]
- Bromberger JT, Meyer PM, Kravitz HM, Sommer B, Cordal A, Powell L, Ganz PA, Sutton-Tyrell K: Psychologic distress and natural menopause: a multiethnic community study. Am J Public Health 2001; 91:1435–1442[Abstract/Free Full Text]
- Freeman EW, Sammel MD, Grisso JA, Battistini M, Garcia-Espagna B, Hollander L: Hot flashes in the late reproductive years: risk factors for African American and Caucasian women. J Womens Health Gend Based Med 2001; 10:67–76[CrossRef][Medline]
- Kim HG, Viguera AC: Psychiatric symptoms associated with the female reproductive cycle, in Psychiatry Update and Board Preparation, Massachusetts General Hospital. Edited by Stern TA, Herman JB. New York, McGraw-Hill, 2000, pp 197–205
- Joffe H, Hall JE, Soares CN, Hennen J, Reilly CJ, Carlson K, Cohen LS: Vasomotor symptoms are associated with depression in perimenopausal women seeking primary care. Menopause 2002; 9:392–398[CrossRef][Medline]
- Harlow BL, Cohen LS, Otto MW, Spiegelman D, Cramer DW: Prevalence and predictors of depressive symptoms in older premenopausal women: the Harvard Study of Moods and Cycles. Arch Gen Psychiatry 1999; 56:418–424[Abstract/Free Full Text]
- Harlow BL, Wise LA, Otto MW, Soares CN, Cohen LS: Depression and its influence on reproductive endocrine and menstrual cycle markers associated with perimenopause: the Harvard Study of Moods and Cycles. Arch Gen Psychiatry 2003; 60:29–36[Abstract/Free Full Text]
- Rubinow DR, Schmidt PJ, Roca CA: Estrogen-serotonin interactions: implications for affective regulation. Biol Psychiatry 1998; 44:839–850[CrossRef][Medline]
- Joffe H, Cohen LS: Estrogen, serotonin, and mood: where is the therapeutic bridge? Biol Psychiatry 1998; 44:798–811[CrossRef][Medline]
- Chandra A: Surgical sterilization in the United States: prevalence and characteristics, 1965–95. Vital Health Stat 1998; 23(20):1–33
- Peterson HB, Jeng G, Folger SG, Hillis SA, Marchbanks PA, Wilcox LS: The risk of menstrual abnormalities after tubal sterilization. N Engl J Med 2000; 343:1681–1687[Abstract/Free Full Text]
- Gentile G, Kaufman S, Helbig D: Is there any evidence for a post-tubal ligation syndrome? Fertil Steril 1998; 69:179–186[CrossRef][Medline]
- Westhoff C, Davis A: Tubal sterilization: focus on the US experience. Fertil Steril 2000; 73:913–922[CrossRef][Medline]
- Westhoff C: Tubal sterilization—safe and effective (editorial). N Engl J Med 2000; 343:1724–1726[Free Full Text]
- Harlow BI, Missmer SA, Cramer DW, Barbieri RL: Does tubal sterilization influence the subsequent risk of menorrhagia or dymenorrhea? Fertil Steril 2002; 77:754–760[CrossRef][Medline]
- Whitmore SE: Tubal ligation, hysterectomy, and risk of ovarian cancer (letter). JAMA 1994; 271:1235–1237
- Hankinson SE, Hunter DJ, Colditz GA, Willett WC, Stamfer MJ, Rosner B, Hennekens CH, Speizer FE: Tubal ligation, hysterectomy, and risk of ovarian cancer: a prospective study. JAMA 1993; 270:2813–2818[Abstract/Free Full Text]
- Cattanach JF, Milne BJ: Post-tubal sterilization problems correlate with ovarian steroidogenesis. Contraception 1988; 38:541–550[CrossRef][Medline]
- Anasti JN: Premature ovarian failure: an update. Fertil Steril 1998; 70:1–15[Medline]
- Orshan SA, Furniss KK, Forst C, Santoro N: The lived experience of premature ovarian failure. J Obstet Gynecol Neonatal Nurs 2001; 30:202–208[CrossRef][Medline]
- Visvanathan N, Wyshak G: Tubal ligation, menstrual changes, and menopausal symptoms. J Womens Health Gend Based Med 2000; 9:521–527[CrossRef][Medline]
- McKinlay SM, Brambilla DJ, Posner JG: The normal menopause transition. Maturitas 1992; 14:103–115[CrossRef][Medline]
- Frisch RE, Wyshak G, Albright NL, Albright TE, Schiff I, Jones KP, Witschi J, Shiang E, Koff E, Marguglio M: Lower prevalence of breast cancer and cancers of the reproductive system among former college athletes compared to non-athletes. Br J Cancer 1985; 52:885–891[Medline]
- Wyshak G, Frisch RE: Breast cancer among former college athletes compared to non-athletes: a 15-year follow-up. Br J Cancer 2000; 82:726–730[CrossRef][Medline]
- Wyshak G: Women's college physical activity and self-reports of physician-diagnosed depression and of current symptoms of psychiatric distress. J Womens Health Gend Based Med 2000; 10: 355–362
- Colditz GA, Manson JE, Hankinson SE: The Nurses' Health Study: a 20-year contribution to the understanding of health among women. J Womens Health 1997; 6:49–62[Medline]
- Ware JE Jr: SF-36 Health Survey: Manual and Interpretation Guide. Boston, Health Institute, New England Medical Center, 1997
- SAS Statistical Analysis System. Cary, NC, SAS, 1987
- Rulin MC, Davidson AR, Philliber SG, Graves WL, Cushman LF: Long-term effect of tubal sterilization on menstrual indices and pelvic pain. Obstet Gynecol 1993; 82:118–121[Medline]
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ABSTRACT
INTRODUCTION
