Applying causal inference methods to gynecologic and cardiovascular health Julia Deegan DiTosto

Format:

Book

Thesis/Dissertation

Author/Creator:

DiTosto, Julia Deegan, author.

Contributor:

University of Pennsylvania. Epidemiology and Biostatistics., degree granting institution.

Language:

English

Subjects (All):

Epidemiology.

Health sciences.

Biostatistics.

Obstetrics.

0766.

0566.

0380.

0308.

Local Subjects:

Epidemiology.

Health sciences.

Biostatistics.

Obstetrics.

0766.

0566.

0380.

0308.

Genre:

Academic theses

Physical Description:

1 online resource (218 pages)

Contained In:

Dissertations Abstracts International 87-12B

Place of Publication:

Ann Arbor : ProQuest Dissertations and Theses, 2026

Language Note:

English

Summary:

Non-malignant gynecologic conditions-including uterine fibroids and polycystic ovary syndrome (PCOS)-affect millions of individuals during their reproductive years yet remain critically understudied. Diagnoses are frequently delayed by years, introducing substantial measurement error in epidemiologic research and perpetuating diagnostic disparities across populations. Emerging evidence suggests these conditions may be independently associated with atherosclerotic cardiovascular disease (ASCVD), though the robustness of these relationships and the cardiovascular impact of gynecologic treatments remain poorly characterized. Standard observational analyses are vulnerable to systematic biases including confounding, selection bias, and immortal time bias, potentially obscuring true causal relationships. This dissertation applies causal inference methods to investigate the intersection between gynecologic and cardiovascular health through simulation studies and real-world evidence. First, we conducted simulations quantifying how exposure misclassification from delayed or missed fibroid diagnoses affects epidemiologic effect estimates. We demonstrated that varying ascertainment sensitivity introduces substantial bias that differs by symptom status and across racialized groups. Second, using a large administrative claims database, we examined the association between fibroids and incident ASCVD over 10 years through an age-matched cohort design. Individuals with fibroids had a nearly 2-fold increased ASCVD risk, remaining robust after accounting for measurement error. Third, we applied the target trial framework to emulate a hypothetical randomized trial comparing surgical fibroid removal-myomectomy or hysterectomy-to no surgery. By implementing sequential monthly "trials," we estimated 5-year ASCVD risk while addressing time-varying confounding and immortal time bias, finding hysterectomy modestly associated with increased risk and myomectomy with decreased risk of ASCVD. Fourth, using similar methods, we compared metformin, oral contraceptive pills, combination therapy, and neither among individuals with PCOS. Results suggested metformin and combination therapy, compared with neither, were protective against ASCVD, with no harmful association for oral contraceptives alone. Together, these studies provide the first comprehensive causal assessment of cardiovascular risk in gynecologic populations and the implications of first-line treatments. By explicitly addressing methodological challenges through the target trial framework, this dissertation establishes principled approaches for evaluating health outcomes in gynecologic research, a historically underfunded area of reproductive health

Notes:

Source: Dissertations Abstracts International, Volume: 87-12, Section: B.

Advisors: Caniglia, Ellen C.; Mumford, Sunni L. Committee members: Lewey, Jennifer; Zee, Jarcy

Ph.D. University of Pennsylvania 2026

Vendor supplied data

Local Notes:

School code: 0175

ISBN:

9798247980445

Access Restriction:

Restricted for use by site license