Prevalence of hot flushes and night sweats around the world: a systematic review

Symptoms assessed in studies on perimenopausal depression: A narrative review

The menopausal transition constitutes a phase of major biopsychosocial changes associated with an elevated risk for the development of depression. Perimenopausal depression is highly prevalent and usually characterized by core symptoms of a major depressive disorder combined with menopausal complaints such as vasomotor symptoms or other physical complaints. However, a distinct definition of the condition is lacking. The aim of this review is to portray the symptoms assessed in studies on perimenopausal depression in order to provide relevant information on the current understanding of this condition. A literature search was conducted using the databases PubMed, Cochrane Library, and PsycINFO. A total of 37 studies were included. Various assessment tools have been used to measure symptoms related to perimenopausal depression. Fifteen symptoms were identified. Depressed mood was assessed across all studies. Low energy or sleep disturbances, as acknowledged symptoms of a major depressive disorder, were surveyed in most studies. However, the assessment of menopausal complaints was rather heterogeneous. While vasomotor symptoms were often measured, other menopausal symptoms such as mood swings or pain were investigated less frequently. Sexual problems were only rarely assessed. Studies on perimenopausal depression regularly include the assessment of core symptoms of a major depressive disorder, but the assessment of menopausal complaints is inconsistent. While certain symptoms are commonly measured, others are not assessed. Such inconsistencies underline an ambiguous understanding of perimenopausal depression, which in turn affects the evaluation and treatment of the condition. Thus, the use of the existing guidelines on perimenopausal depression is recommended.

Parabrachial neuron types categorically encode thermoregulation variables during heat defense

Heat defense is crucial for survival and fitness. Transmission of thermosensory signals into hypothalamic thermoregulation centers represents a key layer of regulation in heat defense. Yet, how these signals are transmitted into the hypothalamus remains poorly understood. Here, we reveal that lateral parabrachial nucleus (LPB) glutamatergic prodynorphin and cholecystokinin neuron populations are progressively recruited to defend elevated body temperature. These two nonoverlapping neuron types form circuits with downstream preoptic hypothalamic neurons to inhibit the thermogenesis of brown adipose tissues (BATs) and activate tail vasodilation, respectively. Both circuits are activated by warmth and can limit fever development. The prodynorphin circuit is further required for regulating energy expenditure and body weight homeostasis. Thus, these findings establish that the genetic and functional specificity of heat defense neurons occurs as early as in the LPB and uncover categorical neuron types for encoding two heat defense variables, inhibition of BAT thermogenesis and activation of vasodilation.

The Swiss Perimenopause Study - study protocol of a longitudinal prospective study in perimenopausal women

BACKGROUND

The perimenopause is associated with considerable biopsychosocial changes. The majority of women manage to adjust to these changes and cope well with the shift from reproductive to non-reproductive life. However, some women develop burdensome physical and psychological symptoms during the perimenopause. A strong link between menopausal complaints and depressed mood has been shown in this regard. To date, the decisive factors determining whether a woman will successfully achieve a healthy transition remain unclear. Thus, the purpose of this study is to investigate a range of theory-based markers related to health in perimenopausal women.

METHODS

The Swiss Perimenopause Study comprises a sample of 135 healthy perimenopausal women aged 40-56. A variety of health-related genetic, epigenetic, endocrinological, physiological, and psychosocial markers associated with the menopausal transition are investigated over a period of 13 months.

DISCUSSION

The Swiss Perimenopause Study will contribute to a better understanding of the biopsychosocial processes associated with the perimenopause, which should help to improve the clinical care of women undergoing the menopausal transition.

Impaired Quality of Life and Its Determinants among Postmenopausal Women of Slum Communities in Bhubaneswar, India

BACKGROUND

The severity of menopausal symptoms negatively impacts a woman's quality of life (QoL).

OBJECTIVE

The aim of the study was to assess the prevalence of menopause-related impaired QoL and determine its associated factors among postmenopausal women living in slum areas of Bhubaneswar, India.

MATERIALS AND METHODS

This cross-sectional study was conducted among 198 postmenopausal women aged 45-65 years during the year 2016-2017. The Menopause Rating Scale (MRS) was used to assess the prevalence and severity of menopausal symptoms.

RESULTS

Joint and muscular discomfort was the most prevalent moderate-to-severe symptom (90.4%), followed by hot flushes (72.8%), irritability (67.2%), and physical and mental exhaustion (64.2%). More than two-third (133, 67.2%) of women had impaired QoL (severe total MRS score ≥17). Multivariate logistic regression analysis revealed that impaired QoL was associated younger age (adjusted odds ratio [AOR]: 4.6, 95% confidence interval [CI]: 2.12-9.98), tobacco consumption (AOR: 2.0, 95% CI: 1.05-3.82), not being satisfied in relation with husband (AOR: 3.33, 95% CI: 1.84-6.06), not having autonomy in health-care decision-making in the family (AOR: 2.30, 95% CI: 1.12-4.73), history of reproductive tract infection (AOR: 4.57, 95% CI: 1.71-12.19), and earlier onset of menopause (AOR: 3.26, 95% CI: 1.18-8.96).

CONCLUSION

The point prevalence of menopause-related impaired QOL in postmenopausal women living in slums of Bhubaneswar was high. Incorporating these determinants in the existing strategies can be useful to improve the QoL of these women.

Healthcare Utilization and Prevalence of Symptoms in Women with Menopause: A Real-World Analysis

Objective

Self-reported studies estimated that as many as 50-75% of women experience symptoms during menopause; however, limited real-world clinical data are available to support this observation. The electronic databases of Maccabi Healthcare Services were used to describe the prevalence of menopause symptoms in Israel and to characterize patients with regard to socioeconomic status, comorbidities and use of healthcare services.

Methods

Females aged 45-54 years diagnosed with menopausal symptoms (N=17,046, cumulative incidence of 8% during the study period) were identified from the Maccabi Healthcare Services electronic database and matched to female members without menopause symptoms, one-to-one on birth year and enumeration area.

Results

Symptomatic peri- and post-menopausal women, and particularly those under 52 years, were more likely to have a higher prevalence of comorbid conditions such as depression, anxiety, osteoporosis and insomnia in the year following index. Correspondingly, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors and hypnotic drug use were significantly higher in symptomatic women as was healthcare utilization including hospitalization (OR=1.10; 95% CI=1.00-1.20), primary care visits (1.90; 1.73-2.08), gynecologist visits (24.84; 22.36-27.59) and hysterectomy procedures (2.26; 1.63-3.14).

Conclusion

Medically documented menopausal symptoms are associated with increased burden of disease (particularly among women diagnosed with menopausal symptoms prior to age 52 years), healthcare utilization and greater likelihood of undergoing hysterectomy within one year of diagnosis. This burden is expected to rise further as awareness and social acceptance of peri- and post-menopausal symptoms increase.

An examination of the relationship between sunlight exposure and hot flush in working women

We examined whether sunlight affects hot flushes in working menopausal women and explored effect modification by shift work and season. In this prospective cohort study, daily hot flush score (outcome) was measured by the 7-day North Central Cancer Treatment Group Daily Vasomotor Symptoms Diary. Daily duration of sunlight (≥2000 lux) was recorded by the HOBO MX2202 pendant. Both variables were measured in two 7-day data collection phases. T0 data were collected during the Australian Summer (December 2017, January and February 2018); and T1 data were collected in the Australian winter (June, July and August 2018). Linear mixed effects model was used. Shift work and season were both confounders and effect modifiers. To detect a median effect size of R² = 0.2, 34 women were required to achieve an effective sample size of 41. A total of 49 menopausal women were recruited, 11 shift and 38 day workers. Some 13 women had various missing observations. For shift workers, an hour increase in sunlight exposure was associated with a 1.4-point reduction in hot flush score (p = .016). This relationship was not significant for day workers (p = .185). The finding of this study suggests increased sunlight exposure might improve hot flushes in menopausal shift workers who are moderately bothered by hot flushes, but probably not in day workers. The possible role of shift-work associated circadian disruption on estrogen level in regard to elevated intensity and frequency of hot flush in menopausal women is discussed.

Association of menopausal symptoms with sociodemographic factors and personality traits

Aim of the study

To investigate the association of personality traits with the severity of vasomotor symptoms (VMS) in a predominantly Greek population.

Material and methods

A questionnaire-based study of women from the Menopause Clinic of a University Hospital in Athens, Greece. Sociodemographic parameters were documented through a structured interview. All women completed the Menopause Rating Scale (MRS) for the assessment of severity of menopausal symptoms, the Hot Flush Beliefs Scale (HFBS) for the assessment of how women were coping with their symptoms and the Big Five Inventory questionnaires for the assessment of personality traits. Associations between baseline parameters and menopausal symptoms were assessed with univariate and multivariate regression analyses.

Results

One hundred women were included. Employed women had lower MRS sub-scores (psychological p< 0.001, somatic p< 0.047, urogenital p< 0.008). Married women scored higher in the psychological and somatic domains. Women of university educational level coped significantly better with hot flushes (β coefficient [SE]: 0.72 [0.25], p< 0.01) and night sweats (0.57 [0.19], p< 0.01) than women of primary education, although the significance of these findings was not replicated when taking into account confounders. Regarding personality traits, women with low openness (-0.33 [0.11], p< 0.01) and empathy (-0.83 [0.37], p = 0.03) and high agreeableness (1.13 [0.21], p< 0.001) had more severe menopausal symptoms. In contrast, women with high agreeableness could better cope with their menopausal symptoms (-0.75 [0.36], p = 0.04). These associations were independent of sociodemographic factors.

Conclusions

Personality traits, especially agreeableness, openness and empathy are associated with menopausal symptoms and functionality in postmenopausal women. These associations might serve as indicators of women at risk of experiencing more severe VMS.

Complementary and alternative treatment methods for menopausal hot flashes used in Turkey

Objective

Study was planned to determine complementary and alternative treatment methods for menopausal hot flashes.

Methods

Women who reported their discomfort of hot flashes as a degree of discomfort of 4 or more according to the Visual Analogue Scale (VAS) were included in the study (n:356). In data collection, Questionnaire Form and Complementary and Alternative Medicine Approaches Scale were used.

Results

The average age of the women was 56.65±6.05 and the average age of menopause was 46.39±5.25. According to VAS, the average severity of hot flashes was 7.85±1.83.

Women with obesity and any chronic disease were more likely to have hot flashes. It was determined that 73.6% of women in the menopausal period were using Complementary and Alternative Medicine (CAM). It was determined that women were using herbal supplements, dietary supplements, mind-body practices and religious practices against the discomfort of hot flashes. 72% of women using CAM stated that the method used was effective.

Conclusion

Women who use CAM usually use it with information that is out of the knowledge of health profession and lack of information. It is recommended to carry out extensive studies for CAM methods and the mechanisms of action that women use.

Sexual Dysfunction in Menopausal Women

INTRODUCTION

Hormone-related changes in menopause may negatively affect sexual function.

AIM

The primary aim of this study was to evaluate sexual functioning in Polish women with the Female Sexual Function Index (FSFI). The secondary aim was to evaluate the major factors affecting sexual functions in middle-aged Polish women.

METHODS

The Menopause Rating Scale was used to assess the menopausal symptoms. The Polish translation of the FSFI was used to assess sexual function.

OUTCOMES

69.73% of respondents had sexual dysfunction according to FSFI (FSFI score ≤ 26.55).

RESULTS

80.61% of women experienced menopausal symptoms during the 4-week period of study. Psychological and urogenital symptoms were the most frequently reported among all the women enrolled in the study (78.23% and 77.21%). Sexual problems were observed in women who did not use hormone therapy (β = 0.09, t = -1.97, P = .048) and showed no somatic symptoms (β = 0.03, t = 2.95, P = .002).

CLINICAL IMPLICATIONS

It is important for health care providers to ask women about this problem and understand the factors that may influence sexual problems in menopause.

STRENGTHS & LIMITATIONS

A validated survey tool was used. The limitation was selection of participants in the clinical setting and sample population size.

CONCLUSION

Sexual problems were much more common in women who did not use hormone therapy and showed no somatic symptoms. Dąbrowska-Galas M, Dąbrowska J, Michalski B. Prevalence and Associated Risk Factors of Sexual Problems Among Polish Middle-Aged Women. Sex Med 2019;7:472-479.

A Neural Circuit Underlying the Generation of Hot Flushes

Hot flushes are a sudden feeling of warmth commonly associated with the decline of gonadal hormones at menopause. Neurons in the arcuate nucleus of the hypothalamus that express kisspeptin and neurokinin B (Kiss1^ARH neurons) are candidates for mediating hot flushes because they are negatively regulated by sex hormones. We used a combination of genetic and viral technologies in mice to demonstrate that artificial activation of Kiss1^ARH neurons evokes a heat-dissipation response resulting in vasodilation (flushing) and a corresponding reduction of core-body temperature in both females and males. This response is sensitized by ovariectomy. Brief activation of Kiss1^ARH axon terminals in the preoptic area of the hypothalamus recapitulates this response, while pharmacological blockade of neurokinin B (NkB) receptors in the same brain region abolishes it. We conclude that transient activation of Kiss1^ARH neurons following sex-hormone withdrawal contributes to the occurrence of hot flushes via NkB release in the rostral preoptic area.

Acupuncture or phy(F)itoestrogens vs. (E)strogen plus progestin on menopausal symptoms. A randomized study

The effect of acupuncture and phytoestrogens on climacteric symptoms was compared to the effect of hormone therapy (HT) with estrogen plus progestin. A total of 75 postmenopausal women with hot flushes were randomized to receive for 3 months conjugated estrogens/medroxyprogesterone acetate (0.30 mg/1.5 mg/d), acupuncture weekly or soy isoflavones (75 mg/2/d). Evaluations were performed prior to, at the end, and 3 months after treatments. Main outcomes were modification of the Greene's climacteric scale and menopause quality of life (MenQoL). The Greene's score significantly declined (p < .05) during HT (-5.6 ± 3.1), acupuncture (-6.9 ± 4.5) and phytostrogens (-3.4 ± 4.3) (p < .05 vs. HT). Mean Greene's vasomotor sub-score declined less during phytoestrogens than HT (-0.8 ± 2.0 vs. -2.0 ± 1.9; p < .05) and a ≥ 80% reduction was observed in 17.4% of women on phytoestrogens (p < .05 vs. HT), 44% of women on HT, and 41.7% of women on acupuncture. MenQoL score improved similarly (p < .05) during HT (-1.4 ± 1.3), acupuncture (-1.7 ± 1.0) and phytoestrogens (-1.0 ± 1.3). Three months after treatment end, benefits on MenQoL were conserved more following acupuncture than HT (p < .006). The present data indicate that acupuncture, and in lesser extent phytoestrogens, can be effective therapies for climacteric symptoms. Trial registration: EudraCT Number 2008-006053-4.

Vasomotor symptoms in women over 60: results from the Data Registry on Experiences of Aging, Menopause, and Sexuality (DREAMS)

OBJECTIVE

Frequency of vasomotor symptoms (VMS) in older women and the contributing factors are largely undefined. We measured the frequency of moderate-to-severe vasomotor symptoms (msVMS) in women ≥60 years of age and examined their characteristics to determine factors that may associate with VMS in older women.

METHODS

A cross-sectional survey was completed using the Menopause Health Questionnaire from the Data Registry on Experiences of Aging, Menopause, and Sexuality. Data were collected from women presenting for menopause consultation to Mayo Clinic, Rochester, MN, from January 1, 2006 to October 7, 2014. We created a binary variable where women were classified as having msVMS bother if they reported "quite a bit" or "extremely" compared with women reporting "not at all" or "a little bit." Women with and without msVMS were evaluated by menopause type, self-rated heath, current tobacco, caffeine, and alcohol use, as well as pertinent medication use. Associations between participant characteristics and msVMS were evaluated using logistic regression and a multivariable model with age as a covariate. Interactions between participant characteristics and age were also assessed.

RESULTS

Of the 4,956 women presenting for menopause consultation, 921 (18%) were ≥60 years old. Of these, 379 (41.2%) reported msVMS bother. Women with msVMS were more likely to have a history of nonspontaneous menopause and report their health as fair, versus good or excellent. Women reporting current use of hormone therapy (HT) (21%) were less likely to report msVMS compared with those not taking HT (P < 0.001).

CONCLUSIONS

A substantial number of women seen in a specialty menopause clinic were over age 60 years and reported msVMS, highlighting that VMS may be disruptive in women over a decade past the natural age of menopause.

The Role of Lifestyle in Developing and Maintaining Vasomotor Symptoms: A Cross-Sectional Study among Iranian Postmenopausal Women

OBJECTIVE

Lifestyle patterns are not only related to healthy life but also could be related to modifying menopausal symptoms. Considering the lack of data, the present study aimed to evaluate the relationship between lifestyle and vasomotor symptoms among Iranian postmenopausal women.

MATERIALS AND METHODS

The present cross-sectional questionnaire-based study was conducted among 302 eligible postmenopausal women referring to Shahroud health centers (Shahroud, Iran) during June 2017 and October 2018. The Iranian standard questionnaire on women health project (Saba questionnaire) was used for data collection. Our data were analyzed using the SPSS software (version 18). Descriptive statistics, Chi-square test, Fisher's exact test, and multiple logistic regression were used to address sociodemographic characteristics among our participants and the relations between lifestyle and vasomotor symptoms.

RESULTS

We found a significant relation between daily dairy units (P = 0.05), daily vegetable units (P = 0.01), weekly use of solid oils (0.01), and hot flush. The relation between daily vegetable units and urinary incontinence was also statistically significant (P = 0.02). When we use multiple logistic regression, we found significant predictive relations between daily vegetable unit status (P = 0.01), weekly use of solid oils (P = 0.04), body mass index (P = 0.03), and hot flush.

CONCLUSION

The study provided findings to support the probable relation between some of lifestyle-related variables and vasomotor symptoms in postmenopausal women.

Is core temperature the trigger of a menopausal hot flush?

OBJECTIVE

Menopausal hot flushes negatively impact quality of life and may be a biomarker of cardiovascular and metabolic disease risk; therefore understanding the physiology of hot flushes is important. Current thinking is that a small elevation (∼0.03-0.05C) in core temperature surpasses a sweating threshold (that is reduced in the menopause), sweating is activated, and a hot flush ensues. Nevertheless, more recent studies examining thermoregulatory control question whether core temperature per se can explain the trigger for a hot flush. The primary aim of this study was to assess the contribution of increases in core temperature on the occurrence of menopausal hot flushes.

METHODS

For this purpose, 108 hot flushes were objectively assessed in a laboratory setting in 72 symptomatic postmenopausal women (aged 45.8 ± 5.1 years; body mass index 25.9 ± 4.5 kg/m) from five previously reported studies. Women rested, wearing a tube-lined suit (or trousers), which was perfused with 34C water. A subset then underwent mild heat stress (48°C water). Sweat rate, skin blood flow, blood pressure, heart rate, skin, and core temperature were measured continuously throughout. A hot flush was objectively identified during rest (spontaneous hot flush) or mild heating as an abrupt increase in sternal sweat rate. Further, a subset of symptomatic postmenopausal women (n = 22) underwent whole-body passive heating for 60 minutes to identify core temperature thresholds and sensitivities for sweat rate and cutaneous vasodilation, which were compared to a subset of premenopausal women (n = 18). Data were analyzed using t tests and/or general linear modeling, and are presented as mean (95% confidence interval).

RESULTS

In the 20 minutes before a spontaneous hot flush, core temperature increased by 0.03 ± 0.12C (P < 0.05), but only 51% of hot flushes were preceded by an increase in core temperature. During mild heating, 76% of hot flushes were preceded by an increase in core temperature. The temperature thresholds for sweating were similar, but the vasodilatory threshold was higher in postmenopausal compared with premenopausal women (37.1 ± 0.2 vs 36.8 ± 0.3°C; P = 0.06).

CONCLUSION

We provide new evidence that menopausal hot flushes are unlikely triggered by an increase in core temperature. These findings provide important information about the physiology of hot flushes that have implications for treatment and management options for menopausal hot flushes.

Menopausal hot flashing and endothelial function in two vascular beds: findings from a cross-sectional study of postmenopausal women

OBJECTIVE

We sought to examine the association of menopausal hot flashing with vascular reactivity in two different vascular beds in the same cohort of postmenopausal women and explore the relationship between hot flashing and cardiovascular disease (CVD) risk profile.

METHODS

A cross-sectional study of 79 healthy postmenopausal women, 23 of whom have never had menopausal hot flashes and 56 of whom have reported hot flashes. Endothelial function at a microvascular level was measured with Laser Doppler Imaging with Iontophoresis which assesses the response to both acetylcholine (Ach, endothelium dependent) and sodium-nitroprusside (SNP, endothelium independent). Reactive Hyperemia Index (RHI) was measured with peripheral arterial tonometry as a marker of endothelial function mainly at a macrovascular level. Metabolic biomarkers including insulin sensitivity were assessed.

RESULTS

Women with hot flashes had enhanced microvascular response to Ach by ∼30% (P = 0.04) and to SNP by ∼31% (P = 0.02), but lower RHI by ∼13% (P = 0.05) compared with women without flashes. Hot flashing was associated with enhanced response to SNP and lower RHI after adjustment for confounders and conventional CVD risk factors. Women with hot flashes were more insulin resistant than nonflashers (HOMAIR: 1.9 (1.2-2.6) vs 1.4 (0.8-1.9), P = 0.03).

CONCLUSIONS

Our data support the association of hot flashing with greater insulin resistance and lower macrovascular response. The paradoxical enhanced microvascular response in hot flashers could be the result of the net effect of thermoregulatory and nonnitric oxide-related pathways rather than of endothelial integrity.

Influence of Menopausal Status on the Symptom Experience of Women Before Breast Cancer Surgery

BACKGROUND

Breast cancer treatments can change women's hormonal milieu and alter their symptom experience. Little is known about associations between menopausal status and menopausal symptoms in women with breast cancer before surgery.

OBJECTIVE

The purpose of this study was to evaluate for differences in occurrence, severity, and distress of symptoms between premenopausal and postmenopausal women before breast cancer surgery.

METHODS

A total of 312 women with breast cancer completed the Menopausal Symptoms Scale, a self-report measure that evaluated the occurrence, severity, and distress of 46 common symptoms associated with menopause. Regression analyses were used to evaluate for between-group differences in these symptoms.

RESULTS

Of the 312 patients enrolled, 37.4% (n = 116) were premenopausal, and 62.6% (n = 196) were postmenopausal. In the multivariate analysis that adjusted for 7 covariates, premenopausal patients reported higher occurrence rates for urinary frequency (P = .006) and reported lower occurrence rates for joint pain/stiffness (P = .011), difficulty falling asleep (P = .025), and vaginal dryness (P = .002). A significant interaction was found between age and menopausal status for hot flashes (P = .002), wake during the night (P = .025), and headache (P = .040).

CONCLUSION

Regardless of menopausal status, women reported high occurrence rates for several menopausal symptoms. Associations between some symptom occurrence rates and menopausal status depended on the patients' age.

IMPLICATIONS FOR PRACTICE

As part of a preoperative symptom assessment, clinicians need to consider a woman's menopausal status and salient demographic and clinical characteristics. The identification of women with a higher symptom burden will assist with more effective management.

A Classic Herbal Formula Guizhi Fuling Wan for Menopausal Hot Flushes: From Experimental Findings to Clinical Applications

A classic herbal formula Guizhi Fuling Wan (GFW) has been used for managing menopausal hot flushes (MHFs), but the evidence across different study types has not been systematically summarized. This project investigated the clinical effects, phytochemistry, pharmacodynamics, and potential mechanisms of actions of GFW on the causative target proteins potentially driving MHFs. Twenty English and Chinese databases were searched for relevant clinical and experimental studies. A total of 12,988 studies were identified, of which 46 were included. Seven clinical studies demonstrated GFW had no statistically significant changes in the frequency and severity of MHFs; however, it could improve peripheral blood flow in the fingertips, jaw, and toes. Thirty-five studies on phytochemistry identified 169 chemical compounds of GFW. Four experimental studies revealed GFW's therapeutic effects (e.g., normalize calcitonin gene-related peptide [CGRP] level) and potential target protein/cytokine (estrogen receptor beta [ESR2] with genetic variation, CGRP receptor, and interleukin-8) on MHFs. Therapeutic effects across different study types were inconsistent, possibly due to the dose difference and genotype variety of ESR2 in the human population. Further clinical and experimental studies, as well as biochemical investigation on the mechanisms of actions of GFW, are recommended.

What's in a name: are menopausal "hot flashes" a symptom of menopause or a manifestation of neurovascular dysregulation?

Hot flashes have typically been classified as "symptoms of menopause" that should be tolerated or treated until they resolve. However, mounting evidence points to hot flashes as a manifestation of one or several underlying pathophysiological processes. Associations exist between the presence, timing of onset, severity, and duration of hot flashes, and the risk of several neurological (affecting sleep, mood, and cognition) and cardiovascular conditions. In addition, four consistent patterns of vasomotor disturbances have been identified across different countries, making it unlikely that these patterns are solely explained by socioeconomic or cultural factors. The changing hormonal environment of menopause may unmask differences in the autonomic neurovascular control mechanisms that put an individual woman at risk for chronic conditions of aging. These differences may have a genetic basis or may be acquired across the life span and are consistent with the variability of the clinical manifestations of aging observed in women after bilateral oophorectomy. It is time to investigate the pathophysiological mechanisms underlying the four patterns of vasomotor symptoms more closely, and to shift from describing hot flashes as symptoms to be tolerated to manifestations of an underlying autonomic neurovascular dysregulation that need to be addressed.

Complementary and alternative medicine for natural and treatment-induced vasomotor symptoms: An overview of systematic reviews and meta-analyses

BACKGROUND AND PURPOSE

Vasomotor symptoms (VMS) are very common in menopausal populations and cancer patients and can cause physical and mental discomfort. We aim to summarize the findings of systematic reviews and meta-analyses (SRs/MAs) that assessed the effectiveness of complementary and alternative medicines(CAMs)on VMS to provide solid evidence for future practice.

METHODS

PubMed, Embase, the Cochrane Library, and Web of Science were searched from inception to May 2019 to identify relevant SRs/MAs. The methodological quality of SRs/MAs and evidence levels of the outcomes were assessed.

RESULTS

A total of 29 SRs/MAs were reviewed. Evidence has shown that acupuncture, hypnosis, paced respiration, cognitive behavioural therapy, genistein, soy isoflavones, S-equol, combined preparations of black cohosh, and omega-3 supplements could significantly reduce VMS. The methodological quality of the SRs/MAs was moderate or high.

CONCLUSION

CAMs might be beneficial for reducing VMS, but the evidence levels were not high. Several priorities for future practice were identified.

Resistance training for hot flushes in postmenopausal women: A randomised controlled trial

OBJECTIVES

To investigate the effect of 15 weeks of resistance training on the frequency of moderate to severe hot flushes in postmenopausal women.

STUDY DESIGN

Postmenopausal women with at least 4 moderate or severe hot flushes or night sweats per day day were randomized to a 15-week resistance training intervention or unchanged physical activity. Participants did not exercise regularly at baseline and had not used any therapy for hot flushes two months prior to study entry. The resistance training was performed three times per week and the program contained 8 exercises performed with 8-12 repetitions in 2 sets. Loads were set individually from eight-repetition maximum-strength tests and increased progressively.

MAIN OUTCOME MEASURES

The primary outcome was change in mean moderate or severe hot flushes per day from baseline to week 15, assessed with symptom diaries. Secondary outcomes included change in hot flush score and time spent on physical activity.

RESULTS

Between November 19, 2013, and October 26, 2016, 65 women were enrolled; 58 completed the trial and were included in the analyses. The mean age was 55 and the mean number of moderate or severe hot flushes per day at baseline was 7.1; there were no baseline differences between groups. The frequency of hot flushes decreased more in the intervention group than in the control group (mean difference -2.7, 95% CI -4.2 to -1.3). The mean percentage change was -43.6% (-56.0 to -31.3) in the intervention group and -2.0% (-16.4-12.4) in the control group.

CONCLUSION

A 15-week resistance-training program decreased the frequency of moderate and severe hot flushes among postmenopausal women and could be an effective and safe treatment option to alleviate vasomotor symptoms.

Non-hormonal strategies for managing menopausal symptoms in cancer survivors: an update

Vasomotor symptoms, particularly hot flushes (HFs), are the most frequently reported symptom by menopausal women. In particular, for young women diagnosed with breast cancer, who experience premature ovarian failure due to cancer treatments, severe HFs are an unsolved problem that strongly impacts on quality of life. The optimal management of HFs requires a personalised approach to identify the treatment with the best benefit/risk profile for each woman. Hormonal replacement therapy (HRT) is effective in managing HFs but it is contraindicated in women with previous hormone-dependent cancer. Moreover, many healthy women are reluctant to take HRT and prefer to manage symptoms with non-hormonal strategies. In this narrative review, we provide an update on the current available non-oestrogenic strategies for HFs management for women who cannot, or do not wish to, take oestrogens. Since isoflavones have oestrogenic properties and it is not known if they can be safely consumed by women with previous hormone-dependent cancer, they were excluded. Selective serotonin reuptake inhibitors/selective serotonin-norepinephrine reuptake inhibitors, as well as other neuroactive agents, some herbal remedies and behavioural strategies are considered.

Sex-Specific Physiology and Cardiovascular Disease

Sex differences in cardiovascular diseases can be classified as those which are specific to one sex and those that differ in incidence, prevalence, etiology, symptomatology, response to treatment, morbidity, and mortality in one sex compared to the other. All sex differences in cardiovascular conditions have their basis in the combined expression of genetic and hormonal differences between women and men. This chapter addresses how understanding basic mechanisms of hormone responses, imaging diagnostics, and integration of genomics and proteomics has advanced diagnosis and improved outcomes for cardiovascular conditions, apart from those related to pregnancy that are more prevalent in women. These conditions include obstructive coronary artery disease, coronary microvascular dysfunction, spontaneous coronary artery dissection, diseases of the cardiac muscle including heart failure and takotsubo cardiomyopathy, and conditions related to neurovascular dysregulation including hot flashes and night sweats associated with menopause and effects of exogenous hormones on vascular function. Improvement in technologies allowing for noninvasive assessment of neuronally mediated vascular reactivity will further improve our understanding of the basic etiology of the neurovascular disorders. Consideration of sex, hormonal status, and pregnancy history in diagnosis and treatment protocols will improve prevention and outcomes of cardiovascular disease in women as they age.

Diet, menopause and the risk of ovarian, endometrial and breast cancer

Menopause, the permanent cessation of the menstrual cycle, marks the end of a woman's reproductive lifespan. In addition to changes in sex hormone levels associated with menopause, its timing is another predictor of future health outcomes such as duration of the presence of vasomotor symptoms (VMS) and the risk of hormone-related cancers. With ageing of the population, it is estimated that worldwide 1·2 billion women will be menopausal by the year 2030. Previously the effects of reproductive factors (e.g. parity, age at menarche, pregnancy) and socio-demographic factors on intermediate and long-term health outcomes of menopause have been widely documented. However, little is known about whether diet could have an impact on these. Therefore, we review current evidence on the associations of diet with menopause, presence of VMS and the risk of hormone-related cancers such as ovarian, endometrial and breast cancer. Dietary factors could influence the lifespan of the ovaries and sex-hormones levels, hence the timing of natural menopause. Few studies reported an association between diet, in particular soya consumption, and a reduced risk of VMS. Sustained oestrogen exposure has been associated with a higher risk of hormone-related cancers and thus high-fat and meat diets have been linked with an increased risk of these cancers. However, to better understand the mechanistic pathways involved and to make stronger conclusions for these relationships, further studies investigating the associations of dietary intakes and dietary patterns with menopause, presence of VMS and the risk of hormone-related cancers are required.

Hormone replacement therapy and prevention of chronic conditions

Nowadays, postmenopausal women are largely undertreated. Analysis of conflicting results among different studies suggests that hormone replacement therapy (HRT) can prevent osteoporosis and cardiovascular disease in symptomatic, early postmenopausal women. In fact, climacteric symptoms are related to an increased risk of chronic conditions, including hypertension and cardiovascular disease. Different scientific societies have pointed out that patient selection, timing of initiation, and the choice of the type and dose of HRT used are the major determinants of the ultimate effect of HRT on women's health and quality of life in selected women. HRT may prevent chronic conditions when started in symptomatic women before the age of 60 years or within 10 years of the onset of the menopause, taking into consideration the characteristics and risk profiles of each given woman. The bulk of scientific evidence from preclinical, clinical, epidemiological, and also randomized studies indicates that wisely selected HRT is generally useful and rarely dangerous. Following simple and well-established rules, HRT benefits outweigh all of the possible risks. Progestogen choice can make the difference in terms of cardiovascular disease benefits.

Body image, satisfaction with sexual life, self-esteem, and anxiodepressive symptoms: A comparative study between premenopausal, perimenopausal, and postmenopausal women

Menopause is an important life transition in women, and it is associated with significant physical and psychological changes. This study aimed at examining how the menopausal transition influences body image and satisfaction with sexual life. To this aim, body image dissatisfaction, sexual dissatisfaction, and self-esteem were compared in three groups of women with distinct menopausal status (premenopausal n = 142, perimenopausal n = 66, or postmenopausal n = 149), while controlling for depressive and anxiety symptoms and BMI. Using ANOVA between these three groups, we observed that dissatisfaction with body image was significantly higher in the perimenopausal sample compared with its premenopausal counterpart. In the postmenopausal sample, body image improved, as this group displayed body image scores close to the premenopausal level. In addition, sexual dissatisfaction was significantly increased in the perimenopausal and postmenopausal samples, which is compatible with the concept that higher body appreciation positively predicted sexual function. We conclude that body image dissatisfaction reaches a maximum during the perimenopausal phase, before returning to a level nearly identical between the premenopausal and the postmenopausal phases.

The bidirectional relationship between vasomotor symptoms and depression across the menopausal transition: a systematic review of longitudinal studies

OBJECTIVE

To explore the nature of the bidirectional relationship between vasomotor symptoms (VMS) and depression, and to determine whether hot flashes and night sweats differentially affect the association between VMS and depression through their effect on sleep disruption.

METHODS

Multiple databases were searched from 1961 until July 31, 2016, and a manual search of reference lists of identified articles was conducted. Sixteen articles that involved 10,008 participants were identified and analyzed.

RESULTS

The methods of analyses and measurement of VMS and depression varied across the studies. Two studies explored the bidirectional association, but only one was significant in both directions (odds ratio [OR] depression to VMS 3.06, 95% confidence interval [CI] 1.43-6.58; OR VMS to depression 8.88, 95% CI 2.57-30.68). In both cases, the association between VMS leading to depressive symptoms was stronger than the opposite. Eleven studies examined VMS leading to depression, but only five showed a significant effect (OR 1.57-1.81, P ≤ 0.02). Treating VMS and depressive symptoms as continuous variables (n = 3) diminished the relationship. Three studies showed a significant association of depression leading to VMS (OR 1.62-1.94, P ≤ 0.01). We found little evidence for a specific effect of night sweats on the association between VMS and depressive symptoms. The effect might not be related to sleep disruption.

CONCLUSIONS

There is a bidirectional association between VMS and depressive symptoms. The menopausal transition appears to increase the risk of recurrent episodes of depression that might not be explained only by VMS. Further investigation is needed to explain the differential effect of night sweats and hot flashes on depression.

Menopausal-Related Symptoms in Women One Year After Breast Cancer Surgery

CONTEXT

Approximately 60% to 100% of women with breast cancer experience at least one menopausal-related symptom. Little is known about associations between menopausal status and symptoms in women 12 months after breast cancer surgery.

OBJECTIVES

The purpose of this study was to evaluate for differences in occurrence, severity, and distress of symptoms between pre- and postmenopausal women 12 months after breast cancer surgery.

METHODS

Women with breast cancer (n = 327) completed the Menopausal Symptoms Scale, which evaluated the occurrence, severity, and distress of 46 common menopausal-related symptoms. Regression analyses were used to evaluate between-group differences in the seven symptoms that occurred in 30% and more of the sample (i.e., hot flashes, night sweats, depression, daytime sweats, joint pain or stiffness, wake during the night, and numbness or tingling).

RESULTS

Of the 327 patients with breast cancer, who completed the 12-month assessment, 35.2% were premenopausal and 64.8% were postmenopausal before surgery. In the conditional models, when significant interactions were found, the differences in symptom occurrence rates between pre- and postmenopausal patients depended on their age.

CONCLUSION

Regardless of menopausal status, women reported relatively high occurrence rates for several menopausal symptoms. Associations between symptom occurrence rates and menopausal status depended on the patient's age. During the development of a survivorship care plan, clinicians need to assess symptom burden within the context of a woman's menopausal status and salient demographic and clinical characteristics. This approach will assist with the prescription of more effective interventions.

Cultural issues in menopause: an exploratory qualitative study of Macedonian women in Australia

OBJECTIVE

This study explored the attitudes to, and experience of, menopause among Macedonian women living in Australia, including attitudes and responses to hormone therapy (HT) and complementary therapies, as well as related psycho-sexual, relationship and other midlife issues.

METHODS

Using qualitative methodology, the study was based on seven unstructured, nondirective group discussions. Natural social groups were recruited, meeting wherever each group felt most at home. A total of 81 participants ranged in age from 45 to 75 years. The women included both first-generation immigrants and women born in Australia to Macedonian parents. A bilingual Macedonian researcher conducted the fieldwork.

RESULTS

Participants typically claimed they lacked information about menopause in their native language, and their knowledge of HT was highly variable. Some women only felt comfortable approaching Macedonian doctors. Others reported an easing of symptoms when they revisited their homeland. Deeply religious participants claimed their faith helped them through this phase of life, and that they were as likely to consult a priest as a doctor. A recurring theme was that Macedonian men tended to regard their wives differently after menopause, sometimes treating them as "non-sexual." Women regarded this shift in male attitudes as a precipitating factor in domestic violence, extramarital affairs and divorce. Symptoms such as hot flashes and mood swings were associated with negative attitudes toward menopause.

CONCLUSIONS

Culturally determined attitudes appear to affect the perception and experience of menopause. Other influencing factors include migration, women's roles, marital status, religion, use of herbal and traditional remedies, social situation, access to information, knowledge and experience of menopausal symptoms.

Experiences of menopause, self-management strategies for menopausal symptoms and perceptions of health care among immigrant women: a systematic review

OBJECTIVE

To systematically review the published literature relating to experiences of menopause, self-management strategies for menopausal symptoms and health-care needs among immigrant women.

METHODS

A systematic literature search of English-language publications was performed using Medline, Embase, PsychInfo, Cinahl and Scopus. Twenty-four papers reporting on 19 studies met our inclusion criteria and investigated immigrant women's experiences of menopause and/or their self-management strategies for menopausal symptoms and/or their perceptions of menopause-specific health care.

FINDINGS

Of the 19 studies, 15 reported symptoms experienced during the menopausal transition. Three studies included questions regarding self-management strategies for menopausal symptoms and four enquired about perceptions of menopause-specific health care. Although the heterogeneity of the studies makes comparison difficult, their findings are broadly consistent. Immigrant women reported more vasomotor symptoms and other physical symptoms and poorer mental health than non-immigrant women. The few studies that investigated self-management strategies for menopausal symptoms found that these were influenced by culture and those that assessed perceptions of menopause-specific health care found that they were mostly dissatisfied with the care they had received.

CONCLUSION

More research is needed to improve understanding of how immigrant women manage the menopausal transition and how to provide culturally relevant menopause-specific health care.

Tai Chi Exercise for the Quality of Life in a Perimenopausal Women Organization: A Systematic Review

BACKGROUND

Improvement of the quality of life in perimenopausal women has recently become an important global health issue. Extensive research reports provide evidence of Tai Chi for the quality of life, but no systematic review has individually investigated Tai Chi as a main intervention on the quality of life in perimenopausal women.

OBJECTIVE

To assess clinical evidence of Tai Chi for the quality of life in perimenopausal women.

METHODS

Studies related to the effect of Tai Chi on the quality of life in perimenopausal women in the databases of China and abroad were searched. RevMan version 5.2 software was used, and the Medical Outcomes Study 36-item short form health survey (SF-36) and bone mineral density (BMD) were selected as evaluation indices.

RESULTS

Five trials were included. The results of this study showed that Tai Chi had a significant effect on bodily pain, general health, vitality, mental health of SF-36, and the spine dimension of BMD, as supported by the following data: bodily pain (Standard Mean Difference [SMD] = -3.63; 95% confidence interval [CI] [-6.62, -0.64]; p = .02); general health (SMD = -5.08; 95% CI [-7.60, -2.56]; p < .0001); vitality (SMD = -5.67; 95% CI [-8.54, -2.81], p = .0001); mental health (SMD = -2.51; 95% CI [-4.82, -0.20], p = .03); and spine dimension of BMD (SMD = -0.06; 95% CI [-0.10, -0.01]; p = .01). However, Tai Chi had no effect on physical function, emotional health, social function, role-physical of SF-36, and the hip dimension of BMD, as supported by the following data: physical function (SMD = -1.79; 95% CI [-5.15, 1.57]; p = .30); emotional health (SMD = -2.90; 95% CI [-7.23, 1.43], p = .19]; social function (SMD = -2.23, 95% CI [-5.08, 0.61], p = .12; role-physical (SMD = - 1.18; 95% CI [-4.84, 2.47], p = .53; and hip dimension of BMD (SMD = -0.01; 95% CI [-0.03, 0.01]; p = .31).

LINKING EVIDENCE TO ACTION

This systematic review found significant evidence for Tai Chi improving bodily pain, general health, vitality, mental health of SF-36, and the spine dimension of BMD in patients with perimenopausal syndrome. Findings suggest that Tai Chi might be recommended as effective and safe adjuvant treatment for patients with perimenopausal syndrome. More high-quality randomized controlled trials are urgently needed to confirm these results.

ASSOCIATION OF AGE AT MENOPAUSE WITH POST-MENOPAUSAL SYMPTOMS, MENARCHE AGE AND OTHER REPRODUCTIVE FACTORS AMONG RURAL FEMALES IN SHIMLA, HIMACHAL PRADESH

This study analysed the association between menopause, menarche and number of live births using cross-sectional primary data for 75 post-menopausal rural women from Shimla in the Indian state of Himachal Pradesh. The mean/median ages at menarche of the 75 women were 14.23/14 years, and those at menopause 45.35/45 years. There were no significant differences in these values between women in the age groups 40–55 and 56–65 years. Age at menopause was found to be significantly associated with age at menarche and maternal age at birth of the first and last child, but not with menopausal symptom severity score. The majority of the 75 post-menopausal women (70.7%) had very mild or no menopausal symptoms. Three principal components were identified that explained 72.43% of the underlying variation in menopausal symptoms.