Objective
Epidemiologic research suggests that psychosocial stress may increase fibroid risk, , but associations with symptom severity, which often influence clinical management decisions, have been underexamined. We aimed to examine the associations between adverse childhood experiences (ACEs) and symptom severity and symptom effect on health-related quality of life (HRQL) among women undergoing hysterectomy for the treatment of leiomyomas (fibroids).
Study Design
We recruited and consented 103 women from 2018 to 2021 into the Fibroids, Observational Research on Genes and the Environment (FORGE) study who were seeking evaluation of fibroids at the Medical Faculty Associates in Washington, DC. Eligible women were nonpregnant, premenopausal, ≥18 years of age, and intending to undergo hysterectomy at the George Washington University Hospital. The presence of fibroids was confirmed by pathology reports. The George Washington University Institutional Review Board approved the study. Participants provided written informed consent before enrollment. For exposure classification, we used an ACE module consisting of 8 ACE categories related to child abuse and household challenges. Questions referred to experiences within the first 18 years of life. Responses were binary. We summed ACE categories to create a cumulative score (range, 0–8); a higher score indicated greater exposure. For outcome classification, we used the Uterine Fibroid Symptom and Quality of Life (UFS-QOL) 37-item questionnaire, assessing the severity of symptoms and effect of symptoms on 6 HRQL categories for women undergoing surgery for fibroids. The 5-level Likert scale responses were summed to create composite scores and standardized to a 0 to 100 scale; a lower symptom severity score indicated fewer symptoms, whereas a higher HRQL score indicated better quality of life. We ran quasi-Poisson regressions (log-link) to examine associations between ACE scores and UFS-QOL composite scores, adjusting for age, race and ethnicity, and education (n=89). Statistical significance was set at the 2-sided alpha of 0.05.
Results
Most participants were Black (73%); about half had private insurance (55%) and a college degree (49%) ( Supplemental Table 1 ). Cumulative ACE and symptom severity scores were higher among Black women than non-Black women ( P ≤.03). Moreover, symptom severity varied by education, with the most severe symptoms reported among those with the least education ( P =.02) ( Supplemental Tables 2 and 3 ). In models that included all ACE categories, history of substance abuse in the household was associated with greater symptom severity (relative risk [RR], 1.31; 95% confidence interval [CI], 1.07–1.61) and marginally associated with worse HRQL (RR, 0.74; 95% CI, 0.55; P =1.00). In addition, history of sexual abuse was associated with worse HRQL (RR, 0.67; 95% CI, 0.48–0.92). The results were similar when we modeled each ACE category separately ( Figure ).
Conclusion
Our study has added to the growing evidence that early life exposures to chronic stress may influence gynecologic health, including symptom-related quality of life. These findings warrant replication because of study limitations, including the cross-sectional study design, potential recall bias on events that occurred in childhood, and the modest sample size. Nonetheless, our data point to the need to investigate how psychosocial stressors contribute to fibroid risk, including the disproportionate burden on Black women.
Acknowledgments
We acknowledge Dr Gaby Moawad, MD, Dr Maria (Vicky) Vargas, MD, and Dr Catherine Wu, MD for their assistance with participant recruitment. We acknowledge Roshni Rangaswamy, BS, Samar Ahmad, MPH, Brianna VanNoy, MPH, Dan Dinh, MPH, Tahera Alnaseri, MPH, and Olivia Wilson, BS who contributed to participant recruitment, data collection, and database management.
Appendix
| Characteristic | Total (N=103) |
|---|---|
| Age | |
| Mean (SD) | 44.7 (5.14) |
| Median (IQR) | 45.1 (32.1–59.9) |
| Age categories | |
| 20–33 | 3 (3) |
| 34–43 | 38 (37) |
| 44–60 | 62 (60) |
| Race and ethnicity | |
| Black or African-American | 75 (73) |
| White | 18 (18) |
| Other | 10 (10) |
| Highest education completed | |
| Up to high school or GED degree | 24 (23) |
| Some college or technical or associate degree | 29 (28) |
| Bachelor’s or graduate degree | 50 (49) |
| Insurance type | |
| Private | 57 (55) |
| Public or government | 46 (45) |
| Household income ($) | |
| Up to $60,000 | 28 (27) |
| >$60,000 | 64 (62) |
| Missing | 11 (11) |
| Variable | Total (N=103) | Bachelor’s or graduate degree (n=50) | Some college or technical or associate degree (n=29) | Up to high school or GED degree (n=24) | P value a | Black or African-American (n=75) | Non-Black (n=28) | P value a |
|---|---|---|---|---|---|---|---|---|
| ACE cumulative score | ||||||||
| Mean score (SD) | 2.73 (2.22) | 3.32 (2.55) | 3.18 (1.98) | 2.73 (2.22) | .106 | 3.04 (2.32) | 1.88 (1.72) | .031 |
| Missing | 9 (9) | 1 (3) | 7 (29) | 9 (89) | 6 (8) | 3 (11) | ||
| ACE categories | ||||||||
| Mental illness in the household | ||||||||
| Mean proportion (SD) | 0.351 (0.480) | 0.345 (0.484) | 0.278 (0.461) | 0.351 (0.480) | .742 | 0.324 (0.471) | 0.423 (0.504) | .370 |
| Missing | 6 (6) | 0 (0) | 6 (25) | 6 (6) | 4 (5) | 2 (7) | ||
| Substance abuse in the household | ||||||||
| Mean proportion (SD) | 0.433 (0.498) | 0.483 (0.509) | 0.667 (0.485) | 0.433 (0.498) | .031 | 0.521 (0.503) | 0.192 (0.402) | .003 |
| Missing | 6 (6) | 0 (0) | 6 (25) | 6 (6) | 4 (5) | 2 (7) | ||
| Incarcerated household member | ||||||||
| Mean proportion (SD) | 0.216 (0.414) | 0.276 (0.455) | 0.500 (0.514) | 0.216 (0.414) | .001 | 0.282 (0.453) | 0.0385 (0.196) | .010 |
| Missing | 6 (6) | 0 (0) | 6 (25) | 6 (6) | 4 (5) | 2 (7) | ||
| Parents divorced | ||||||||
| Mean proportion (SD) | 0.433 (0.498) | 0.483 (0.509) | 0.611 (0.502) | 0.433 (0.498) | .114 | 0.479 (0.503) | 0.308 (0.471) | .135 |
| Missing | 6 (6) | 0 (0) | 6 (25) | 6 (6) | 4 (5) | 2 (7) | ||
| Intimate partner violence | ||||||||
| Mean proportion (SD) | 0.292 (0.457) | 0.536 (0.508) | 0.278 (0.461) | 0.292 (0.457) | .002 | 0.314 (0.468) | 0.231 (0.430) | .429 |
| Missing | 7 (7) | 1 (3) | 6 (25) | 7 (7) | 5 (7) | 2 (7) | ||
| Physical abuse | ||||||||
| Mean proportion (SD) | 0.232 (0.424) | 0.357 (0.488) | 0.176 (0.393) | 0.232 (0.424) | .176 | 0.290 (0.457) | 0.0769 (0.272) | .028 |
| Missing | 8 (8) | 1 (3) | 7 (29) | 8 (8) | 6 (8) | 2 (7) | ||
| Emotional abuse | ||||||||
| Mean proportion (SD) | 0.510 (0.503) | 0.483 (0.509) | 0.529 (0.514) | 0.510 (0.503) | .938 | 0.514 (0.503) | 0.500 (0.510) | .902 |
| Missing | 7 (8) | 0 (0) | 7 (29) | 7 (7) | 5 (7) | 2 (7) | ||
| Sexual abuse | ||||||||
| Mean proportion (SD) | 0.305 (0.463) | 0.379 (0.494) | 0.235 (0.437) | 0.305 (0.463) | .549 | 0.357 (0.483) | 0.160 (0.374) | .067 |
| Missing | 8 (8) | 0 (0) | 7 (29) | 8 (8) | 5 (7) | 3 (11) |
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