Center for the Study 

of Healthcare 

Provider Behavior

A Systematic Review Update: 

Health Effects of Military Service 

on Women Veterans

Bevanne Bean-Mayberry MD, MHS

and 

Laurie Zephyrin MD, MPH, MBA

November 29, 2011
Center for the Study 

of Healthcare 

Provider Behavior

Background: Women in VA

Women

• Play an increasing role in military and veteran activities 

representing:

– 20% of new recruits

– 17% of reserve and guard forces

– 15% of active duty forces

 Represent one of the fastest growing groups of new VA 

healthcare users 

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Center for the Study 

of Healthcare 

Provider Behavior

Systematic Reviews on Women Veterans

• Women’s military experiences & responses to their experiences are 

often unknown or distinct from men

• The impact of those experiences on health status and healthcare 

needs is important for care delivery

• Systematic reviews of research evidence can inform health care 

decisions made by managers and policymakers

• 2 comprehensive synthesis of the scientific literature on women 

veterans’ health have been conducted (Goldzweig et al 2006, BeanMayberry et al 2011)

• However, the effects of deployment on reproductive health and 

trauma on post-deployment health have not received direct attention

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Center for the Study 

of Healthcare 

Provider Behavior

Acceleration of Women Veteran Literature over 

Time 

4

JGIM Special Issue 2006

contributed to the increase

More articles were identified 

in 2004-2008 than in the 

previous 25 years years
Center for the Study 

of Healthcare 

Provider Behavior

Objectives 

• To systematically assess the recent literature 

on women veterans’ health specific to 2 key 

questions for post deployment health

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Center for the Study 

of Healthcare 

Provider Behavior

Key Question 1

• What research has been published on the 

effects of deployment on post-deployment 

reproductive outcomes?

• “Reproductive effects” operationalized to 

– fertility issues, birth defects, menstrual effects,

– urinary tract infections, sexually transmitted 

infections

– reproductive cancers (e.g., cervical, ovarian) 

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Center for the Study 

of Healthcare 

Provider Behavior

Key Question 2

• What research has been published on posttrauma sequelae in OEF/OIF women veterans?

• Post trauma sequelae includes: 

– mental health problems, suicide and homicide

– cardiovascular disease, 

– risky health behaviors (i.e., tobacco use, hazardous 

alcohol use, substance abuse, assaultive behavior, 

and eating disorders), and other. 

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Center for the Study 

of Healthcare 

Provider Behavior

Methods

• Searched multiple scientific databases

– PubMed, PsychINFO, CINAHL, Social Science Abs

– Sample search strategy 

• veteran*[tiab] OR veteran*[mh] OR military personnel

• female* OR women* OR woman OR gender OR 

women's health

• gulf war OR persian gulf OR "desert storm" OR iraq* OR 

afghanistan OR OEF OR OIF OR "enduring freedom" OR 

afghan

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Center for the Study 

of Healthcare 

Provider Behavior

Methods

• Articles assessed: 

– original articles identified in comprehensive 

systematic reviews 

• 2004 synthesis by Goldzweig et al 

• 2008 synthesis by Bean-Mayberry et al 

– 1990-2010 updates using search strategy 

developed specific to key questions for this review

– search terms and Medical Subject Headings 

(MeSH) for the various search strategies used 

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Center for the Study 

of Healthcare 

Provider Behavior

Methods

• 2 team members performed a title screen of all 

articles by consensus

• 4 WH physicians performed a full screen of 

articles using set criteria

• Each article was summarized using standard 

abstract form and categorized into evidence 

tables 

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Center for the Study 

of Healthcare 

Provider Behavior

Methods

• Exclusions: 

• Some areas in the literature had been previously 

summarized in prior reviews or our WH reviews

– Agent Orange and Gulf War Syndrome

– Military sexual trauma

– Post traumatic stress disorder

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Center for the Study 

of Healthcare 

Provider Behavior

Goldzweig et al

N=182

Bean-Mayberry et al

N=195

New Search 

Key Question 1

N=1023

Full Article Review

N=57

Key Question 1

N=15

Key Question 2

N=29

Mental Health Trauma

N=13

Other Trauma

N=16

Not Relevant: N=11

Non-Systematic 

Review, Reference 

mined: N=2

Titles & Articles 

Reviewed

N=2359

Articles in prior review, 

Duplicate, Not Relevant 

N=2302

New Search 

Key Question 2

N=959

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Figure 1. Literature Flow 
Center for the Study 

of Healthcare 

Provider Behavior

Results by Key Questions

Category N

KQ1: Reproductive Effects 15

KQ2: Post Deployment Trauma Sequelae 29

- Mental Health 13

- Other Trauma 16

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Center for the Study 

of Healthcare 

Provider Behavior

Results: Reproductive Effects

Subject Area Key Findings:

Gynecological Cancer 8% Vietnam Veterans and 7.1% non-Vietnam Veterans 

reported a history of gynecologic cancers (breast , 

ovary, uterus, and cervix). Female Vietnam veterans 

have not experienced a higher prevalence of 

gynecologic cancer since the conflict.

Sexual Function Gulf War Veterans with chronic fatigue symptoms had 

worse sexual dysfunction than female veterans without 

chronic fatigue syndrome (60% vs 10%, p=.002). Many 

subjects with chronic fatigue had Axis I psych. disorders. 

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Center for the Study 

of Healthcare 

Provider Behavior

Results: Reproductive Effects

Subject Area Key Findings:

Conception and 

Pregnancy

In a self reported questionnaire, pregnancy outcomes 

for Gulf War exposed conceptions and non-deployed 

conceptions were similar. However, spontaneous 

abortions and ectopic pregnancies were higher for Gulf 

War veterans who conceived post-war.

A similar study using survey methods of men and 

women veterans deployed and non-deployed during 

Gulf War found no differences in birth weight 

outcomes, risk for ectopic pregnancy, stillbirth or 

miscarriage.

Note: Response rates for both studies were 50-51%.

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Center for the Study 

of Healthcare 

Provider Behavior

Results: Reproductive Effects

Subject Area Key Findings:

Birth Defects Comparison of the overall risk of birth defects in Gulf 

War Veterans vs. non-deployed Veterans among 

infants born at military hospitals revealed no increase 

in birth defects among children of Gulf War Veterans, 

and no association between service in Gulf War and 

prevalence of birth defects for male or female veterans

A Hawaii based study on prevalence of congenital 

anomalies in the first year of life found the prevalence 

of birth defects similar for conceptions occurring before 

the Gulf War and during and after the Gulf War.

In a national, population based case control study 

assessing 30 major birth defects, there was no 

significant association for any of those birth defects 

and military service since 1990.

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Center for the Study 

of Healthcare 

Provider Behavior

Results: Reproductive Effects

Subject Area Key Findings:

General Health and 

Gynecology 

Deployed female veterans reported more general and 

gender specific health problems than women not 

deployed, including abnormal paps (10.4% vs. 4.9%)

Women and men deployed had similar common 

complaints, but women made more visits to sick call 

and one-quarter of these visits related to gynecologic 

issues.

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Center for the Study 

of Healthcare 

Provider Behavior

Results: Post Trauma Sequelae

Subject Area Key Findings:

Mental Health –

Depression & Suicide

Deployed men and women with combat exposures had the 

highest rates of onset of depression. Compared to nondeployed men and women, combat deployed men and women 

were at increased risk of depression.

Veteran men are at greater risk for suicide than veteran women, 

however, the male to female ratio in VA is less (3:1) than the 

general population (4:1).

Among veteran suicide decedents, male and female veterans 

had higher firearm suicide rates than non-Veterans.

Suicide rates among VA patients were 66% higher than among 

the general US population. Male VA patients had a suicide rate 

43/100,000 person-years vs. 23/100,000 person years in males 

in general population, and for female VA patients, 10/100,000 

person-years vs. 5/100,000 person-years.

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Center for the Study 

of Healthcare 

Provider Behavior

Results: Post Trauma Sequelae

Subject Area Key Findings:

Mental Health 

Needs & Utilization

In a study of soldiers deployed to Iraq or Afghanistan 

through 2004, both female soldiers and enlisted 

soldiers has significantly greater risks for psychiatric 

hospitalization as compared to male and non-enlisted 

counterparts.

Among veterans with newly diagnoses PTSD, only 

9.5% attended nine or more VA mental health sessions 

in 15 weeks or less in the first year of diagnosis. 

Veterans with mental health diagnoses, particularly 

PTSD, had significantly greater utilization of nonmental health medical services. Female sex and lower 

rank were also independently associated with greater 

utilization.

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Center for the Study 

of Healthcare 

Provider Behavior

Results: Post Trauma Sequelae

Subject Area Key Findings:

Other Trauma –

Spinal Cord Injury

Unique barriers to care for SCI veterans include 

geographical distance. Data were limited for women due 

to small subgroup (2%) for utilization, TBI history and 

functional scores, and TBI prevalence in military hospitals. 

Alcohol & 

Substance Abuse

Alcohol misuse was greater among OEF/OIF young men 

compared to non-OEF/OIF men and either group of 

women.

In OEF/OIF women veterans who had positive PTSD 

Symptoms, 47% screened positive for high-risk drinking.

Re-admission rates for inpatient drug treatment differs 

among men and women. While sexual and physical 

abuse were potent predictors for women, substance 

abuse, aggression, and cognitive impairment were 

predictors for men.

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Center for the Study 

of Healthcare 

Provider Behavior

Results: Post Trauma Sequelae

Subject Area Key Findings:

General Health First time deployments were associated with more 

increased post-deployment distress in both men and 

women, but the association between deployment length 

and distress was only seen in men.

Women deployed with combat exposures were 1.78x 

more likely to develop disordered eating and 2.35x more 

likely to lost an extreme amount of weight compared to 

women who deployed but reported no combat exposure.

Miscellaneous In a study of health care use and satisfaction, women with 

combat exposure (compared to those without combat 

exposure) described more problems with VHA staff.

Hospitalization data on soldiers evacuated from war zones 

showed diagnostic differences by gender, although the 

majority of evacuees were male (90%). 

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Center for the Study 

of Healthcare 

Provider Behavior

Limitations

• Possible missing articles on women veterans

• Search terms may not have been specific for 

research on reproductive effects or postdeployment trauma

• Publication bias

• Some studies used small samples, had poor 

responses rates, or relied only on patient selfreports limiting generalizability 

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Center for the Study 

of Healthcare 

Provider Behavior

Summary 

• Differential effects from military service are apparent but 

the volume and quality of the research is modest

• More research is needed on the reproductive health 

effects of military service 

– The evidence is clearly mixed regarding the effects on 

pregnancy and birth outcomes 

– The range of reproductive issues is also limited 

– Gynecological problems and access to services in the field 

appear to be a recurrent issue

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Center for the Study 

of Healthcare 

Provider Behavior

Summary cont.

• Post trauma sequelae highlight the following:

– Early TBI data show an initial preponderance of men, 

ongoing evaluation is needed to understand what, if 

any, gender issues will be important

– Alcohol use in recently returning women veterans 

may present a greater risk at lower levels of 

consumption in patients with other risk conditions

– Health care use by gender and diagnosis require 

ongoing follow up because data are mixed

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Study Implications

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Center for the Study 

of Healthcare 

Provider Behavior

Future Implications

• Specific areas that need to be more fully developed in women 

veterans’ research should serve as targets for future research 

in VA......

– More research is needed on a range of reproductive health issues

• Pregnancy outcomes

• Gynecological diagnoses

• Access to services

– Current knowledge on post-deployment trauma issues 

should expand 

• To explore ways in which veteran, provider or practice settings can 

incorporate evidenced based treatments & evaluate outcomes

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Improving Reproductive Health 

Services

• Upcoming policies

– Maternity Care Coordination Handbook

– Infertility Handbook

– Emergency Contraception Rights of Conscience (ROC) Information 

Letter (IL)

• Maternity care

– 2010 Caregiver Law

– Newborn care

– Childcare pilots

– VA/DoD Pregnancy Guidelines

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Understanding Women Veterans

• National Survey of Women Veterans 2008

– 3,500+ participants thru telephone interviews

– Findings: access, quality perception, barriers

– Next Scientific Survey of Women Veterans: 2012

• Research: Women’s Health Evaluation Initiative

– Data on demographics and use of VHA care

– Effects of military service on women’s lives

– Women Vietnam Veterans Study

– OEF/OIF Cohort Study

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Women’s Health Transformation Initiative

Sub-initiative of New Models of Care

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Improved Care Coordination

 Emergency room care

• Assessment tool development

• Ongoing provider/staff education

• Planned completion: 9/2013

 Breast cancer 

• Tracking of abnormal test results

• Breast Cancer Clinical Case Registry

• Planned completion: 9/2013

 Teratogenic identification of drugs

• Planned completion: 9/2013
Accomplishments: 2008 Present

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 Comprehensive primary care for women

Veterans implemented

 144 full-time Women Veterans Program Managers (WVPMs) installed at VA 

facilities nationwide

 VHA Handbook 1330.01 revised: Health Care Services for Women Veterans 

 Enhancing mental health, homeless services for women Veterans through 

collaboration across program offices

 Provider education in Women’s Health developed and delivered

 Ramped-up communications to and about women Veterans
Center for the Study 

of Healthcare 

Provider Behavior

VA Women’s Health Links

• Health Effects of Military Service on Women Veterans

• http://www.hsrd.research.va.gov/publications/esp/womenvets.cfm

• Systematic Review of Women Veterans Health 

Research

• http://www.hsrd.research.va.gov/publications/esp/womenshealth.pdf

• VA Evidence Synthesis Program 

http://www.hsrd.research.va.gov/publications/esp/

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Center for the Study 

of Healthcare 

Provider Behavior

WH Synthesis Team

• Fatma Batuman MD

• Bevanne Bean-Mayberry MD, MHS

• Caroline Goldzweig MD, MSPH

• Christine Huang MD

• Isomi Miake-Lye BA

• Paul Shekelle MD, PhD

• Donna Washington MD, MPH

• Elizabeth Yano PhD, MSPH

• Laurie Zephyrin, MD, MPH, MBA

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Center for the Study 

of Healthcare 

Provider Behavior

Thank you

• VA Greater Los Angeles Evidence Synthesis Program & Southern 

California/RAND Evidence-based Practice Center 

• VA Greater Los Angeles HSR&D Center Staff 

• VA HSR&D Service, Washington, DC

• Women Veterans Health Strategic Healthcare Group (WVHSHG), 

Washington, DC

• VA Center for Information Dissemination and Education Resources 

(CIDER)

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