Impact of Deployment on Reproductive Health in U.S. Active-Duty Servicewomen and Veterans.

Military deployments occur in young, physically fit servicewomen, but injuries that commonly occur may impact postdeployment physical health and long-term quality of life. Gender differences in the approach to military physical training and the risk for injury have been described. 74 One study in deployed servicewomen found 36% sustained a musculoskeletal injury, most commonly affecting the knee or low back. 75 These injuries could lead to chronic pain and associated opioid dependence without early and appropriate intervention. Other adverse health conditions are associated with deployment history. According to some studies of OEF/OIF/OND Veterans, multisystem medically unexplained symptoms, such as fibromyalgia, irritable bowel syndrome, and chronic fatigue syndrome, among others, may be at least twice as prevalent among female (8.4%) versus male (4.2%) Veterans. 76 – 78 Several studies among civilian populations suggest that these conditions, broadly termed “chronic multisymptom illness,” may be associated with a higher risk of adverse reproductive health outcomes, 79 – 81 but there are limited studies of these associations among military personnel. Another understudied area, but one with significant risks for mental and reproductive health, is traumatic brain injury (TBI) in servicewomen. While women make up a minority of military-associated TBI diagnoses, they are more likely to experience long-term symptoms then men, 82 and may be more likely to experience their TBI through intimate partner violence rather than combat injury during their service years. 83 Postdeployment physical examinations need to include a level of concern for more “mild” physical injuries that may lead to differential outcomes for women, including pelvic floor disorders and sexual dysfunction, which impact long-term quality of life. Following the Iraq and Afghanistan wars, it became evident that women tend to respond differently to combat and injury versus their male counterparts, often based on predeployment stressors and histories of interpersonal trauma. 84 , 85 The Millennium Cohort Study included 17,481 women who served from 2001 to 2008 and study researchers found those who were deployed and had combat exposures were more likely to report mental health symptoms or diagnoses than nondeployed women (aOR, 1.91; 95% CI, 1.65–2.20). 86 Additionally, deployed women reporting combat exposures were more likely to report new-onset disordered eating (aOR, 1.78; 95% CI, 1.02–3.11) compared with women who deployed but did not report combat exposures. 87 These mental health issues can influence reproductive health risks and carry across their careers and into the VA. Of all women Veterans, those of reproductive age with mental health disorders experience the highest rates of VA healthcare utilization. 88 Trauma and stressors could impact pregnancy outcomes and this area remains understudied in women with deployment histories. One study found that deployment with combat exposure after childbirth was associated with a higher risk of maternal depression compared with nondeployed women (aOR, 2.01; 95% CI, 1.17–3.43), whereas deployment with combat exposure before childbirth was not associated with a statistically significant higher risk of maternal depression (aOR, 1.27; 95% CI, 0.83–1.95). 89 To address care needs unique to women Veterans, Shivakumar et al described the interrelated factors for optimal perinatal health, which include deployment and postdeployment factors (combat stressors, MST, etc.), pregnancy and postpartum factors (pregnancy intention, parity, risks of postpartum depression, etc.), and psychiatric conditions (PTSD, premilitary abuse, etc.). 90 Preconception consultation, both during active duty and into Veteran health services, is important to integrate military service exposures and weigh the risks and benefits of treatment options during pregnancy compared with the risk of worsening mental health during pregnancy and postpartum. Postdeployment reintegration for women can be challenging and adversely impact reproductive goals. In one study, women reported avoidance of speaking about their military experiences. They identified disrupted relationships with family and friends and difficulty reestablishing their household roles. Their coping methods varied, but included negative approaches (substance use, social isolation, and weight gain/loss) and positive choices, such as reaching out to military peers and engaging in therapy. 91 A small online survey found support groups and social networks for Veterans tend to be more accessible for men, especially those who experienced combat. Women and those without combat exposure may be more socially isolated than men following military service or deployment resulting in potential barriers to seeking help and service provision in this vulnerable population. 92 The negative coping strategies can be associated with high-risk sexual behaviors, unintended pregnancy, and subsequent adverse pregnancy outcomes; thus, the need for evidence on postdeployment reintegration strategies is important for reproductive health outcomes. Women Veterans are four times more likely to experience homelessness than civilian women and trauma experiences during military service, including MST, are known risk factors in this vulnerable population. 93 , 94 Homeless women experience a high rate of unintended pregnancy that can adversely affect their mental health and ability to obtain housing. 95 Prenatal homelessness is also an independent risk factor for adverse pregnancy outcomes, such as preterm birth. 96 Homeless women have low contraceptive utilization, are at high risk for sexual exploitation, and have a hard time prioritizing reproductive healthcare due to competing demands. 97 , 98 Women Veterans are highly reliant upon the VA for reproductive health needs; however, services vary widely across the country in non-VA homeless healthcare organizations. Integration of reproductive health screening into VA homeless services is essential to meet acute needs in this high-risk population.

The United Nations defines “reproductive health as a state of complete physical, mental, and social well-being,” and not “merely the absence of reproductive disease or infirmity” 25 ( Fig. 1 ). Although most reproductive health problems arise during the reproductive years, “in old age, general health continues to reflect earlier reproductive life events.” 25 , 26 Reproductive services include pregnancy care, family planning, care for sexually transmitted infections (STIs), protection from and response to sexual and gender-based violence, preventive health services (gynecologic exams, HPV vaccination, bone screening, and cancer screening), and specialty care for infertility, sexual dysfunction, pelvic pain, and other pathology. 27 Specific to women Veterans, Katon et al categorized reproductive conditions to assess their frequency within the VA in FY2010. 28 The most common reproductive diagnoses identified in women younger than 45 years included menstrual and pain disorders, STIs and vaginitis, urinary conditions, and pregnancy-related diagnoses. As most deployments happen in reproductive-age women, the focus of this article is on needs for those younger than 45 years ( Table 1 ).

Reproductive health research in servicewomen and women Veterans is a high priority due to the minority status of women in the military and need to expand services. There is particular interest in the intersection of needs of women and National Institutes of Health (NIH) health disparity populations such as racial/ethnic minorities, rural residents, those from low socioeconomic strata, and gender minorities. Fortunately, available data do not reveal any direct causal relationships between deployments or combat and adverse reproductive outcomes, albeit based on studies with methodological limitations, including small study sizes, study design limitations, and residual or uncontrolled confounding including from mental and physical comorbidities. What is clear in previous research is that reproductive health and other health outcomes are not independent events, supporting the United Nations’ integrative definition of reproductive health 25 ( Fig. 1 ). The effect of deployment on mental and physical health is a large part of reproductive issues, such as sexual dysfunction and chronic pelvic pain. Adverse mental and physical health conditions may confound or mediate associations of military deployment-related exposures and reproductive health and lead to challenges in diagnosis and treatment of certain aspects of reproductive health for servicewomen and women Veterans. The trauma some women experience prior to their military enlistment is also a potential risk factor for other adverse life events, especially revictimization during or after their service, and yet data on best screening options for resilience and predeployment mental health are sparse. Education interventions on reproductive health and planning for both men and women during their service differ by military branch and need evidence-based standardization to mitigate high-risk sexual behaviors. Programmatic evaluation on efforts to decrease MST could be highly impactful, due to the clear associations with all adverse health outcomes. Development of healthcare provider training and implementation of comprehensive and integrative care coordination programs will make knowledgeable women’s healthcare providers more widely and readily available across military and Veteran services, resulting in engagement of women in essential preventive care. Finally, improving military or Veteran healthcare services will not address the civilian family planning legislative restrictions that led to geographic gaps across the United States in comprehensive reproductive health services. As current legislation shifts to more non-VA civilian health care funding, 23 many vulnerable women Veterans in rural settings will lack clinic or provider options for covered reproductive services. 24 Acknowledging the vital role reproductive health plays in a woman’s life and general health is necessary to integrate services across healthcare touchpoints.

Reproductive planning is essential for active-duty servicewomen to avoid unintended pregnancy at the time of deployment or other service commitments, as well as ensuring pregnancy occurs when a woman’s health is optimized. Despite this need, approximately 59% of active-duty pregnancies are unintended, resulting in 12% of all U.S. servicewomen experiencing an unintended pregnancy each year. 43 Unintended pregnancy remains an issue in recent conflicts during deployment, with one longitudinal study reporting 10.8% of women in an OIF Army combat brigade requiring medical evacuation for pregnancy reasons. 44 Women experiencing an unintended pregnancy during deployment who desire abortion care typically must also receive a medical evacuation and pay for the procedure out of pocket unless it is a result of rape or incest, or if continuation of the pregnancy endangers the woman’s life. 45 As women denied a wanted abortion are more likely to experience economic hardship and insecurity in subsequent years than those who receive desired abortion care, 46 further research on the effects of restrictive military policies and insurance coverage is needed. Additionally, a study of women Veterans who received care in the VA found a history of deployment was associated with increased need for abortion services in the previous 5 years (aOR, 2.50; 95% CI, 1.04–6.02). 47 Opportunities to support reproductive planning persist as women transition into Veteran services. The most effective means to improve reproductive planning is through consistent use of contraception. A survey study of active-duty servicewomen and Veterans with a deployment history found that 63% of respondents reported contraception use during deployment for pregnancy prevention and/or noncontraceptive benefits, such as menstrual suppression. 48 Method access varied somewhat with women reporting difficulty obtaining LARC methods or being discouraged from use, while those on short-acting methods, such as the contraceptive ring, found continuation difficult due to insufficient supplies at their deployment location. Even with abstinence during deployment, these issues place women at risk for unintended pregnancy during leave or postdeployment times when immediate access to care may be challenging. Once women establish care in the VA, all contraceptive methods are covered, but access to LARC methods is based on provider experience. Women Veterans with a history of substance use disorders and mental health needs have decreased uptake of LARC methods and adherence to short-acting contraceptive methods as compared with other women Veterans. 49 , 50 Women Veterans who report of a history of MST and those with a DWHP are most likely to access the methods of their choice. 51 Women Veterans who experience homelessness are more likely to utilize LARC methods than housed women Veterans (9.3 vs. 5.4%; p > 0.001) within the VA. Despite this finding, ongoing efforts to prioritize reproductive planning are needed, due to the high prevalence of chronic health conditions in this population. 34 Ensuring women Veterans who are transitioning into the VA postdeployment are screened for reproductive health needs may decrease access barriers and risk of unintended pregnancy in a vulnerable time period. The American Society for Reproductive Medicine defines infertility as failure to conceive within 12 months of unprotected intercourse, unless medical history, age, or physical findings prompt an earlier evaluation. Approximately 10% of U.S. women aged 15 to 44 years in the general population have difficulty getting pregnant or staying pregnant. 52 The effects of deployment on fertility are not well established, despite concerns for environmental risks and combat injuries. One study of Iraq and Afghanistan women Veterans found an increased risk of infertility associated with mental health diagnoses while controlling for deployment history. 5 Another reported the risk of infertility diagnoses increased with deployment length and recommended consideration of shorter assignment times for women. 53 In response to Veteran concerns and thelimited and variable research findings, the VA established an infertility policy to expand basic coverage for fertility evaluation and treatment including in vitro fertilization procedures, if the Veteran’s cause of infertility is service connected. 54 Establishing service connectivity is difficult, except in the rare setting of a physical trauma impacting reproductive organs, as data do not support an association between deployment and diagnosed infertility. Painful menses or dysmenorrhea and endometriosis are common diagnoses in women Veterans in the VA. 28 It is difficult to establish the effects of deployment and combat exposure on these disorders or the timing of their onset, except that many women who use contraception during deployment may do so for menstrual suppression related to symptoms that started prior to their assignment. 48 Menstrual symptoms during deployment appear to vary by race and ethnicity with one survey study finding a range, with 6% of African American women and up to 21% of Asian American women reporting severe dysmenorrhea. 55 Similar to infertility, dysmenorrhea and endometriosis are associated with mental health diagnoses when controlling for deployment history. 5 As these disorders may lead to chronic pain and poor quality of life, mental health associations are not surprising, and screening women postdeployment and at VA enrollment could lead to early interventions, such as pelvic floor physical therapy, which decrease risk of long-term disability. Data on the postdeployment needs related to cervical cancer and STI screening are limited, but closely linked to high-risk sexual behaviors and MST prevalence in deployed women Veterans. High-risk sexual behaviors in active-duty military personnel include inconsistentcondom use, multiple partners, and alcohol consumption. 56 Many studies on STI rates in active-duty personnel included military recruits whose exposures represent pre-enlisting behaviors. One study specific to deployment found active duty servicewomen deployed to Iraq and Afghanistan had higher gonorrhea and chlamydia rates than their male peers. 57 Predeployment education on high-risk sexual behaviors and provision of condoms in the field could decrease risk of exposure and the potential for long-term adverse outcomes of chronic pelvic pain and infertility. 58 Studies of active-duty military personnel suggest an increased rate of cervical dysplasia compared with civilian populations; yet methodologic differences, including use of retrospective billing data, differences in screening and follow-up rates, and inclusion of all military insurance beneficiaries, limit direct comparisons. 59 – 61 Published studies predominantly occurred in the era prior to routine vaccination against HPV and, as cervical dysplasia can occur several years after a high-risk exposure, updated studies are needed to estimate the current prevalence. Regardless, ensuring active-duty servicewomen and women Veterans are fully vaccinated and up to date on cervical cancer screening across their career transitions will decrease risk of progression to cervical cancer in a potentially higher-risk population. Female sexual function is complex and multifaceted, and trauma and mental health diagnoses, such as PTSD, incurred during deployment and combat exposure are closely associated with sexual dysfunction. 62 , 63 Women Veterans in the VA who experienced combat frequently report sexual health issues, with low libido as the most common. 64 Blais et al 65 explored associations between sexual dysfunction and suicidal ideation in servicewomen and women Veterans. Symptoms consistent with PTSD and depression and lower sexual function were all associated with suicidal ideation, specifically difficulties with sexual arousal (aOR, 0.87, 95% CI, 0.79–0.97) and sexual satisfaction (aOR, 0.85, 95% CI, 0.75–0.96). As sexual health impacts relationship satisfaction and overall quality of life, screening for dysfunction and early interventions may decrease progressive mental health risks. Additionally, universal MST screening in the VA is one important intervention to engage women in treatment and address the complex relationships between sexual trauma, PTSD, and sexual dysfunction. Deployment conditions and environment impact feminine hygiene practices in the field and can lead to ongoing postdeployment health issues, including urinary symptoms and urinary tract infections (UTIs). 66 While data on whether there is a true increased risk of UTIs are limited, 66 , 67 subjective symptoms of dysuria or pruritus that might also be a result of vaginitis can impact work and quality of life. 68 Many servicewomen are reluctant to seek care and may risk progression to kidney disease with untreated infection. 68 As part of predeployment training, the Women’s Health Promotion Program was developed to educate servicewomen on hygiene in austere environments, including use of a female urinary diversion device. One year after program implementation, the rates of urinary and vaginal infections had declined. 69 Additionally, self-treatment kits for urinary and vaginal infections show promise, 70 but may not adequately treat the cause of ongoing symptoms. Addressing any genitourinary symptoms postdeployment should be a priority to avoid any further delay in appropriate care. Military experiences may put women Veterans at risk for chronic urinary issues, as urinary conditions remain a top diagnosis of women Veterans seeking care within the VA. 28 , 71 Pelvic floor disorders encompass urinary incontinence, fecal incontinence, and pelvic organ prolapse which typically occur in older women, but may be related to pregnancy and delivery. Military deployments and combat exposures could theoretically increase risk of urinary incontinence and prolapse due to strenuous training, heavy lifting, and activities necessitating recurrent Valsalva techniques. Despite these service-associated risks, data on these associations are limited 72 and are confounded by other risk factors by the time women are Veterans. 71 , 73 Investing in pelvic floor physical therapists in the VA with experience in traumasensitive care can prevent progression of many pelvic floor disorders and improve the quality of life for women Veterans experiencing symptoms across their lifespan.