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Association of Powder Use in the Genital Area With Risk of Ovarian Cancer

Educational Objective
To understand whether there is an association between powder use in the genital area and ovarian cancer.
1 Credit CME
Key Points

Question  Is use of powder in the genital area associated with the risk of developing ovarian cancer?

Findings  In this analysis that pooled data from 4 cohorts with a total of 252 745 women, the hazard ratio for the association between self-reported ever use vs never use of powder in the genital area and incident ovarian cancer was 1.08 (95% CI, 0.99-1.17).

Meaning  Among women from 4 prospective cohorts, there was not a statistically significant association between use of powder in the genital area and ovarian cancer, but the study may have been underpowered to identify a small increase in risk.


Importance  The relationship between use of powder in the genital area and ovarian cancer is not established. Positive associations reported in case-control studies have not been confirmed in cohort studies.

Objective  To estimate the association between use of powder in the genital area and ovarian cancer using prospective observational data.

Design, Setting, and Participants  Data were pooled from 4 large, US-based cohorts: Nurses’ Health Study (enrollment 1976; follow-up 1982-2016; n = 81 869), Nurses’ Health Study II (enrollment 1989; follow-up 2013-2017; n = 61 261), Sister Study (enrollment 2003-2009; follow-up 2003-2017; n = 40 647), and Women’s Health Initiative Observational Study (enrollment 1993-1998; follow-up 1993-2017; n = 73 267).

Exposures  Ever, long-term (≥20 years), and frequent (≥1/week) use of powder in the genital area.

Main Outcomes and Measures  The primary analysis examined the association between ever use of powder in the genital area and self-reported incident ovarian cancer. Covariate-adjusted hazard ratios (HRs) and 95% CIs were estimated using Cox proportional hazards models.

Results  The pooled sample included 252 745 women (median age at baseline, 57 years) with 38% self-reporting use of powder in the genital area. Ten percent reported long-term use, and 22% reported frequent use. During a median of 11.2 years of follow-up (3.8 million person-years at risk), 2168 women developed ovarian cancer (58 cases/100 000 person-years). Ovarian cancer incidence was 61 cases/100 000 person-years among ever users and 55 cases/100 000 person-years among never users (estimated risk difference at age 70 years, 0.09% [95% CI, −0.02% to 0.19%]; estimated HR, 1.08 [95% CI, 0.99 to 1.17]). The estimated HR for frequent vs never use was 1.09 (95% CI, 0.97 to 1.23) and for long-term vs never use, the HR was 1.01 (95% CI, 0.82 to 1.25). Subgroup analyses were conducted for 10 variables; the tests for heterogeneity were not statistically significant for any of these comparisons. While the estimated HR for the association between ever use of powder in the genital area and ovarian cancer risk among women with a patent reproductive tract was 1.13 (95% CI, 1.01 to 1.26), the P value for interaction comparing women with vs without patent reproductive tracts was .15.

Conclusions and Relevance  In this analysis of pooled data from women in 4 US cohorts, there was not a statistically significant association between use of powder in the genital area and incident ovarian cancer. However, the study may have been underpowered to identify a small increase in risk.

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Article Information

Corresponding Author: Katie M. O’Brien, Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC, 27709 (obrienkm2@niehs.nih.gov).

Accepted for Publication: November 16, 2019.

Author Contributions: Dr O’Brien had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Joint senior authors: Drs Sandler and Wentzensen.

Concept and design: O'Brien, Tworoger, Sandler, Wentzensen.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: O'Brien, Weinberg, Trabert, Wentzensen.

Critical revision of the manuscript for important intellectual content: O'Brien, Tworoger, Harris, Anderson, Trabert, Kaunitz, D'Aloisio, Sandler, Wentzensen.

Statistical analysis: O'Brien, Tworoger, Harris, Trabert.

Obtained funding: Sandler.

Administrative, technical, or material support: O'Brien, Tworoger, Harris, Kaunitz, D'Aloisio.

Supervision: Sandler, Wentzensen.

Conflict of Interest Disclosures: Dr Tworoger reported receipt of grants from the US Department of Defense Ovarian Cancer Research Program (OCRP) and the National Institutes of Health (NIH) both during the conduct of the study and outside the submitted work. Dr Anderson reported receipt of grants from the National Heart Lung Blood Institute (NHLBI) during the conduct of the study. Dr Kaunitz reported provision of consultancy services to the University of Florida, which receives research funding from companies involved with products related to contraception and treatment of menopausal symptoms; personal fees for consultancy services from Pfizer (injectable contraception), AMAG (treatment of genital atrophy), Mithra (contraceptive and menopausal hormone products), and Merck (implantable and vaginal ring contraception), but no companies involved with sales of powder; royalties from UpToDate; and funding for clinical trials through the University of Florida from Medicines 360 (intrauterine devices), Allergan (treatment of uterine fibroids), Myovant (treatment of uterine fibroids), and Endoceutics (treatment of genital atrophy). No other disclosures were reported.

Funding/Support: This work was supported by the Intramural Research Program of NIH, National Institute of Environmental Health Sciences (Z01-ES044005 to Dr Sandler); the Intramural Research Program of the National Cancer Institute; US Department of Defense OCRP (W81XWH-12-1-0561); NIH (UM1 CA186107, P01 CA87969, UM1 CA176726, and R01 CA67262 [Nurses’ Health Study {NHS} and Nurses’ Health Study II {NHSII}]); NHLBI, NIH/US Department of Health and Human Services (HHSN268201600018C, HHSN268201600001C, HHSN268201600002C, HHSN268201600003C, and HHSN268201600004C [Women’s Health Initiative Observational Study {WHI-OS}]); and the National Institute of Environmental Health Sciences (Sister Study [SIS]). Dr Harris is supported by an NIH grant (K22 CA193860). Statistical analysis services from Westat (Durham, North Carolina) were provided through a support contract from the National Institute of Environmental Health Sciences with Social and Scientific Systems (Durham, North Carolina).

Role of the Funder/Sponsor: None of the sponsors had a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Information: Statistical analyses were replicated by Westat, an independent contractor (Durham, North Carolina).

Additional Contributions: We would like to thank the participants and staff of the participating cohorts for their valuable contributions as well as the following state cancer registries for their help in the NHS/NHSII: Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Deleware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kentuckyy, Louisiana, Maine, Maryland, Massachusetts, Michigan, Nebraska, New Hampshire, New Jersey, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Virginia, Washington, and Wyoming. The authors acknowledge the Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, as the home of the NHS and the following investigators from the WHI, from the NHLBI, Bethesda, Maryland, Jacques Rossouw, MD, Shari Ludlam, MPH, Joan McGowan, PhD, Leslie Ford, MD, and Nancy Geller, PhD; Fred Hutchinson Cancer Research Center, Seattle, Washington, Garnet Anderson, PhD, Ross Prentice, PhD, Andrea LaCroix, PhD, and Charles Kooperberg, PhD; Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, JoAnn E. Manson, MD, DrPH (); MedStar Health Research Institute/Howard University, Washington, DC, Barbara V. Howard, PhD; Stanford Prevention Research Center, Stanford, California, Marcia L. Stefanick, PhD; The Ohio State University, Columbus, Rebecca Jackson, MD; University of Arizona, Tucson/Phoenix, Cynthia A. Thomson, PhD, RD; University at Buffalo, Buffalo, NY, Jean Wactawski-Wende, PhD; University of Florida, Gainesville/Jacksonville, Marian Limacher, MD; University of Iowa, Iowa City/Davenport, Jennifer Robinson, MD MPH; University of Pittsburgh, Pittsburgh, Pennsylvania, Lewis Kuller, MD, DrPH; Wake Forest University School of Medicine, Winston-Salem, North Carolina, Sally Shumaker, PhD, and Mark Espeland, PhD; and University of Nevada, Reno, Robert Brunner, PhD. None of aforementioned individuals received compensation for their role in this article.

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