Deciding about hormone therapy: validation of a model

OBJECTIVE

The purposes of this study were to (1) validate components of a decision process regarding adoption of hormone therapy and (2) compare the decision processes women used with respect to their evaluation of decision quality.

DESIGN

A sample of women participating in a population-based study of midlife women's health participated in individual in-depth interviews.

RESULTS

Content analysis of 30 recorded interviews provided evidence that each component of the decision process (precontemplation, contemplation, commitment, critical evaluation, and continuance) was replicated. Few additional codes were identified, and these could be subsumed under the phases of the original decision model.

CONCLUSIONS

Women's self-reported statuses on a screening questionnaire corresponded to the stages of the decision model coded from their interviews. What women actually decided to do (use hormone therapy or something else) was not associated with their decision process. Satisfaction with the decision, uncertainty about the decision, and other factors related to the decision were independent of the decision phases.

Luteal phase ovarian steroids, stress arousal, premenses perceived stress, and premenstrual symptoms

The purpose of this study was to examine the relationships among perceived stress, ovarian steroids (estradiol and pregnanediol), stress arousal indicators (cortisol, catecholamines) and premenstrual symptoms (turmoil, fluid retention). Women (N = 74) with low symptom severity (LS), premenstrual syndrome (PMS), or premenstrual magnification (PMM) symptom patterns provided daily urine samples over one cycle and recorded their symptoms and perceived stress levels in a health diary. Multiple regression analysis was used to test models of premenstrual symptoms in separate analyses for women with the LS and PMS symptom patterns and the LS and PMM symptom patterns. Data from the LS and PMS groups revealed that greater stress ratings accounted for turmoil symptoms and higher luteal phase cortisol levels for fluid retention symptoms. For LS and PMM groups, lower luteal phase norepinephrine levels, higher global stress ratings, and a more gradual drop in estradiol premenses accounted for turmoil symptoms. Premenses norepinephrine and epinephrine levels and premenses stress ratings accounted for fluid retention. These findings support an important relationship among perceived stress, stress arousal indicators, and premenstrual symptoms that differs for women with a PMS and PMM symptom pattern.

Women's images of midlife: observations from the Seattle Midlife Women's Health Study

Our purpose in conducting this study was to determine how a cohort of women born between 1935 and 1955 defined midlife, and what midlife events they viewed as important, distressing, and satisfying. A random sample of women enrolled in the Seattle Midlife Women's Health Study (n = 131) participated in a telephone interview about the meaning of midlife and important events occurring during the past year. They described midlife similarly to women from earlier birth cohorts with one important exception: the centrality of work and personal achievements in their lives. Contemporary midlife women's views of midlife reflect their roles in society.

Physician policies on the use of preventive hormone therapy

BACKGROUND

Current guidelines recommend that most postmenopausal women be offered preventive hormone therapy (PHT), but there have been no surveys of U.S. physicians' policies since these guidelines appeared. We sought to measure physicians' policies and attitudes about PHT and compare them with the American College of Physicians' guideline on the use of PHT.

METHODS

We used a stratified, randomized survey of gynecologists, family physicians, and general internists in Washington, Alaska, Montana, and Idaho.

RESULTS

Nearly all respondents reported strong belief in the benefits of PHT and felt that the vast majority of their patients should be offered PHT. Where they differed, gynecologists believed even more strongly in its benefits than other respondents. Physicians estimated that 3% of their patients with a uterus were on regimens without any progestin and 23% were on regimens including time without any hormones. Gynecologists ranked mammography first and PHT use second on a list of eight preventive services, while the other respondents ranked smoking cessation first and PHT fourth (P < .0001 for differences).

CONCLUSIONS

Among surveyed physicians, there was near unanimous adoption of policies favoring the recommendation of PHT. Gynecologists believed in it even more strongly than family physicians and general internists and ranked it as more important than counseling about smoking cessation.

PMS after 40: persistence of a stress-related symptom pattern

The purpose of this study was to compare women over 40 years of age with premenstrual syndrome (PMS) to women with a low-severity (LS) symptom pattern with respect to physiologic indicators of stress arousal and response, stress hormone arousal, stressful life circumstances, anger, self- and social control, and interpersonal sensitivity. Women with PMS experienced more negative life events, more difficulty with anger, and more concerns about self- and social control, than women with an LS pattern. These experiences were coupled with increased physiologic arousal and stress responses (skin conductance and muscle tension levels) and relatively higher norepinephrine levels than for women with an LS pattern, but with dampened cardiovascular responses to stressors. As they age, women with a PMS symptom pattern demonstrate persistent differences in stress arousal and response from women with an LS pattern.

Sleep, psychological distress, and stress arousal in women with fibromyalgia

The purpose of this investigation was to compare self-reported sleep quality and psychological distress, as well as somnographic sleep and physiological stress arousal, in women recruited from the community with self-reported medically diagnosed fibromyalgia (FM) to women without somatic symptoms. Eleven midlife women with FM, when compared to 11 asymptomatic women, reported poorer sleep quality and higher SCL-90 psychological distress scores. Women with FM also had more early night transitional sleep (stage 1) (p < 0.01), more sleep stage changes (p < 0.03) and a higher sleep fragmentation index (p < 0.03), but did not differ in alpha-EEG-NREM activity (a marker believed to accompany FM). No physiological stress arousal differences were evident. Less stable sleep in the early night supports a postulate that nighttime hormone (e.g., growth hormone) disturbance is an etiologic factor but, contrary to several literature assertions, alpha-EEG-NREM activity sleep does not appear to be a specific marker of FM. Further study of mechanisms is needed to guide treatment options.

Pathways to depressed mood for midlife women: observations from the Seattle Midlife Women's Health Study

The purpose of this study was to develop and test a multidimensional model of depressed mood experienced by women during midlife. Three pathways to depressed mood were tested for their explanatory power, including menopausal transition, stressful life context, and health status pathways in a multiethnic sample (N = 337). Multiple measures for each variable in the three paths included the CESD and SCL 90 depression scales, menopausal changes questions, vasomotor symptoms rated in a daily health diary. Life Events Scale, Attitudes toward Menopause and Attitudes toward Aging Scales, and chronic health problems and perceived health ratings. The stressful life context pathway was most influential in accounting for depressed mood. Health status had a direct effect on depressed mood and an indirect effect through stress. The menopausal changes pathway had little explanatory power. These results support the need for clinicians to look beyond menopausal status to the broader context of midlife women's lives.

Changing women's health, changing nursing practice

Women's health is a field of study and health care that is of the highest concern for nurses, both from a professional and personal standpoint. It is imperative that those in nursing practice, education, and research be knowledgeable about, prepared for, able to advocate for, and participate in the transformation of health care policy and practice. The changing health care patterns and changing health care delivery system influencing the future of women's health are discussed. Recommendations for nursing practice, education, and research are proposed to advance women's health care.

Symptom experiences of midlife women: observations from the Seattle Midlife Women's Health Study

Symptoms experienced by perimenopausal women are varied with little agreement about their nature, cause or stability.

OBJECTIVE

To describe the type and stability of symptoms experienced by midlife women.

METHODS

A community-based sample of 301 women ages 35-55 (Mean 41.1; S.D. = 4.2), had at least one menstrual period in the past year, and took no ovarian hormones. Women completed a daily symptom diary for at least one cycle for 3 consecutive years. Symptoms were rated from zero to four. The 5 premenses days were targeted for consistency and as those most symptomatic. Twenty-eight symptoms commonly reported as perimenopausal were factor analyzed using principal components analysis with varimax rotation. Test-retest reliability and stability estimates were calculated according to the method of Heise (Heise, D. Am Sociol Rev 1969; 34: 93-101) that accounts for expected change over time.

RESULTS

Twenty-five of the 28 symptoms loaded on five factors labeled dysphoric mood, vasomotor, somatic, neuromuscular, and insomnia together accounting for 51.7% of the variance. Test-retest reliability estimates were highest for dysphoric mood (r = 0.78) and somatic (r = 0.70) symptoms. The reliability for the other three clusters ranged from r = 0.65 to r = 0.53). The stability of the clusters across 3 years was high for dysphoric mood, neuromuscular, and insomnia. The vasomotor and somatic clusters had the most change between years 1 and 3.

DISCUSSION

These results indicate that dysphoric mood is not a part of vasomotor symptoms or insomnia or other somatic symptoms suggesting an origin for vasomotor symptoms apart from the other symptoms. The stability of dysphoric mood across 3 years suggests a chronic situation possibly due to high stress, overwork, or an ongoing emotional illness. The stability of the neuromuscular and insomnia symptoms suggests underlying chronic physical conditions. The reduction in stability of vasomotor symptoms may reflect the changing nature of hormones as women approach menopause. Finally, the low stability of somatic symptoms suggests that they represent acute episodic illnesses. Together the identification of five distinct symptom clusters with varying stability over 3 years suggests that they are due to different underlying mechanisms and are not all attributed to the changing hormone patterns associated with the menopausal transition. Many other events in a midlife woman's life can account for these symptoms including life stress and acute and chronic illnesses.

Increased urine catecholamines and cortisol in women with irritable bowel syndrome

OBJECTIVES

There are few data on the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis in individuals with chronic GI symptoms. The current study was designed to describe and compare urine catecholamine (norepinephrine, epinephrine) and cortisol levels in women diagnosed with irritable bowel syndrome (IBS-patients), women who report similar symptom levels but had not sought health care services (IBS-nonpatients; IBS-NP), and asymptomatic (control) women.

METHODS

Seventy-three women (24 IBS; 24 IBS-NP; 25 controls) were interviewed for demographic, GI, gynecological, and psychological data and then followed for two menstrual cycles with a daily health diary. Urine samples were obtained in the evening and morning at specific phases across two menstrual cycles.

RESULTS

Women in the IBS group had significantly higher PM and AM urine norepinephrine levels. Urine epinephrine and cortisol levels were also generally higher in women with IBS. Differences in neuroendocrine indicators of arousal were not accounted for by differences in demographic variables, lifestyle characteristics, menstrual distress, or average daily measures of anxiety or depression.

CONCLUSIONS

Increases in indicators of sympathetic nervous system activation in women seeking health care for IBS may reflect greater symptom distress or may contribute to increased symptom distress.

Patterns of depressed mood in midlife women; observations from the Seattle Midlife Women's Health Study

To differentiate women who experience patterns of depressed mood with respect to their perceptions of menopausal changes and those that were part of everyday life, women (N=347) from the Seattle Midlife Women's Health Study were studied. Women participated in in-depth interviews, kept symptom diaries, and responded to mailed health updates. Data for years 1 and 2 on the Center for Epidemiologic Studies Depression Scale revealed four patterns of depressed mood: consistent depressed mood, emerging depressed mood, resolving depressed mood, and absence of depressed mood. Discriminant function analyses differentiated women with consistent, emerging, and resolving depressed mood from those with absence of depressed mood. Patterns of depressed mood were related to stressful life context, past/present health status, and social learning about midlife. Menopausal status did not differentiate women with patterns of depressed mood from those without depressed mood. Vasomotor symptoms, history of premenstrual syndrome, and postpartum blues helped differentiate women with consistently depressed mood from those recovering from depressed mood.

Older women and their images of health: a replication study

Older women view themselves as healthy despite the fact that they suffer from chronic illnesses and some functional limitations. The study presented in this article replicates the work of Woods and associates by asking, "What does being healthy mean to you?" to a sample of 10 older women aged 70 to 91 years. The images presented by older women were remarkably consistent with the images presented by the younger cohort. As found in the original Woods et al study, there were nine dimensions that were reflective of the eudaemonistic model of health.

The impact of marital status and quality on family functioning in maternal chronic illness

Married individuals tend to enjoy greater health and well-being than nonmarried. However, investigators disagree about whether this is related to the quality of the marriage or to participation in the socially accepted role of marriage. In the present study, we examined the roles of marital quality and marital status as predictors of the family's adjustment processes in the context of maternal chronic illness. We found that the family functioning of single women and unhappily married women was similar and that happily married women enjoyed higher levels of family functioning and family coping. Unhappily married women reported more illness demands, particularly on their time and energy, than did happily married or single women. We suggest it is the quality of the marital interaction, and not the role benefits of marriage, that facilitates family adjustment under conditions of maternal chronic illness.

Social pathways to premenstrual symptoms

The purpose of this study was to explore feminine and menstrual socialization, expectations about experiencing symptoms, and the stressful nature of women's lives among women with three perimenstrual symptom patterns. Social learning and stress theory provided a theoretical framework for understanding why some menstruating women experience premenstrual syndrome or premenstrual magnification symptom patterns. Data about socialization, stressful life context, expectations about symptoms, depressed mood, and other health-related and demographic indicators were obtained from an interview. Subsequent daily recordings in a health diary for two or more menstrual cycles provided data with which to classify women's symptoms across the menstrual cycle as a low severity symptom (LS, n = 73), premenstrual syndrome (PMS, n = 36), or premenstrual magnification (PMM, n = 62) pattern. Stepwise discriminant function analysis demonstrated that stressful life context, menstrual socialization, and expectations about symptoms related to menstruation differentiated women with an LS from those with a PMS or PMM symptom pattern. In addition, depressed mood differentiated the three groups.

Cancer research: future agendas for women's health

This report reviews the national research priorities for women's health, focusing on future research needed to address women's experiences with cancer. The agenda for cancer research was considered in light of recent efforts of the Office of Women's Health Research of the National Institutes of Health to help set an agenda to guide future work. Nursing's contribution to developing science to support women's health care is also addressed.

Women and depression

As Western society increases in complexity and becomes more reliant on technology, women who thrive as integrators in interactional modes will face new dilemmas. Many women will view these changes as challenges, but for many other women, who view these changes as threats, the response will be depression. We lay a foundation to an understanding of depression in women, evaluating the current concept of depression and pointing out its limitations. We then review the traditional theories of women's increased vulnerability to depressive disorders, which have failed to explain adequately this phenomenon. A more recent theory of women's depression, based on the self-in-relation theory of women's development, is offered as an alternative.

Women with chronic illness: their views of their families' adaptation

Although research has characterized the effects of chronic illness on patients and their spouses, little work has addressed the effects of a woman's chronic illness on her family. We tested a model of family functioning during a woman's chronic illness. Data were obtained from standardized questionnaires from 48 women who resided with an adult partner and one or more school age children and had breast cancer, diabetes, or fibrocystic breast disease. Path analysis indicated that the women experienced more demands associated with their illness as the time since their initial diagnosis lengthened. The number of demands associated with the illness in turn produced problems with marital adjustment. Introspective coping behaviors were used more frequently by families in which the woman experienced high marital adjustment but depressed mood than by families in which the woman was not depressed but experienced marital difficulties. Women's relationships with their children were positively influenced by better marital adjustment, and women who had positive relationships with their children described their children's relationships with their peers as positive. Family functioning was optimum when the family frequently engaged in introspective coping behavior, when the woman had a low level of depressed mood, and when marital adjustment was positive.

The United States women's health research agenda analysis and critique

This article describes the process used to develop a United States women's health research agenda and the published critiques of that agenda. Consideration of methods to develop knowledge about women's health from a feminist standpoint raises questions about the process and products of research that can have emancipatory ends for women.

Fatigue as a response to environmental demands in women's lives

Fatigue is a significant health care problem of interest to professionals in many disciplines. Yet, it is poorly understood. Fatigue, as an indicator of adaptation, is examined in relationship to internal and external environmental demands in women's lives. From a secondary analysis of data collected from a large group of women in a Northwest urban community in the U.S., it was found that internal demands such as depression or anxiety are more significantly related to fatigue and vitality than external demands such as negative life events or employment status.

Menopause--challenges for future research

Menopause is a transition in women's lives with biological, personal, social, and cultural dimensions that together influence women's health. Scientists have not yet integrated the perspectives of multiple disciplines to provide a full account of women's experiences. Studies are underway to assess the effects of hormonal therapies used to treat symptoms that may be related to menopause or to prevent future disease. These studies will provide information women need to weigh the benefits and risks associated with hormone therapy. Although the biological dimensions of menopause warrant further study, the behavioral, social, and cultural dimensions also merit further attention. Moreover, there has been limited use of integrative perspectives, and as a result, the possibilities of cultural effects on biological processes of midlife remained understudied. The concerns of women who have been invisible, e.g., women of color, need to be brought into focus. Challenges in developing or refining methods for human research lie in studies that span the traditional disciplinary boundaries to create a more complete account of menopause and health.

Depressed mood and self-esteem in young Asian, black, and white women in America

During the last two decades, investigators have explored the relationship between women's life conditions and their mental health. Some have related women's socially disadvantaged status, or their socialization to a traditional feminine role, to depression and low self-esteem. Others have emphasized the consequences of women's roles, or the balance of social demands and resources, on their well-being. More recently, feminist scholars have proposed a developmental account of depression. We tested a model comparing the effects of personal resources, social demands and resources, socialization, and women's roles, on self-esteem and depressed mood in young adult Asian, Black, and White women in America. Women who resided in middle-income and racially mixed neighborhoods were interviewed in their homes. Personal resources were indicated by education and income and social resources by unconflicted network size as measured by Barrera's (1981) Arizona Social Support Interview Schedule. Social demands were assessed by conflicted network size as measured by the Barrera scale and by the Positive Life Events and Negative Life Events scales from Norbeck's (1984) revision of the Sarason Life Events Scale. Women's roles included employment, parenting, and partnership with an adult (e.g., marriage). Self-esteem was assessed with the Rosenberg Self Esteem Scale (Rosenberg, 1965) and depressed mood with the Center for Epidemiologic Studies Depression scale (Radloff, 1977). Although models for Asian, Black, and White women differed, social network and social demands as well as personal resources were common to each group as predictors of self-esteem and depression.

Arousal and stress response across the menstrual cycle in women with three perimenstrual symptom patterns

The purpose of this study was to compare arousal levels and stress response across menstrual cycle phases in women with three perimenstrual symptom patterns. Women with low symptom severity (LS, N = 28), were compared with those with a premenstrual syndrome (PMS, N = 15) and premenstrual magnification (PMM, N = 19) pattern across postmenses and premenses phases. Each woman was assessed during relaxation and in response to mental task and symptom imaging stressors during a postmenses and premenses day. Results of baseline skin conductance (SCL), electromyogram (EMG), and finger temperature (T) demonstrated arousal premenses in women with the PMS pattern, but not in women with the LS pattern. In addition, women with the PMS pattern experienced increased EMG and SCL response to stressors premenses. Women with the PMM pattern experienced a rise in finger temperature premenses, opposite the pattern of the women with LS or PMS. These results support development of symptom management strategies to reduce arousal and modulate stress response for women with PMS who seek help for their symptoms. In addition, the difference in arousal and stress response observed in women with PMS and PMM support development of different symptom management strategies for these two groups of women.