Fertile lifespan characteristics and all-cause and cause-specific mortality among postmenopausal women: the Rotterdam Study

Late reproduction is associated with extended female survival but not with familial longevity

RESEARCH QUESTION

Are age at last childbirth and number of children, as facets of female reproductive health, related to individual lifespan or familial longevity?

DESIGN

This observational study included 10,255 female participants from a multigenerational historical cohort, the LINKing System for historical family reconstruction (LINKS), and 1258 female participants from 651 long-lived families in the Leiden Longevity Study (LLS). Age at last childbirth and number of children, as outcomes of reproductive success, were compared with individual and familial longevity using the LINKS dataset. In addition, the genetic predisposition in the form of a polygenic risk score (PRS) for age at menopause was studied in relation to familial longevity using the LLS dataset.

RESULTS

For each year increase in the age of the birth of the last child, a woman's lifespan increased by 0.06 years (22 days; P = 0.002). The yearly risk for having a last child was 9% lower in women who survived to the oldest 10% of their birth cohort (hazard ratio 0.91, 95% CI 0.86-0.95). Women who came from long-living families did not have a higher mean age of last childbirth. There was no significant association between familial longevity and genetic predisposition to age at menopause.

CONCLUSIONS

Female reproductive health associates with a longer lifespan. Familial longevity does not associate to extended reproductive health. Other factors in somatic maintenance that support a longer lifespan are likely to have an impact on reproductive health.

Mothers of twins had higher old-age survival than mothers of singletons in Estonian 19th-century birth cohorts

STUDY QUESTION

Do the mothers of twins and singletons differ regarding post-partum and old-age mortality?

SUMMARY ANSWER

Twin deliveries were associated with higher post-partum maternal mortality than singleton deliveries, but the lifetime post-partum mortality risk was similar for mothers of twins and singletons; survival of twinners was higher than survival of the mothers of singletons after the 67th lifespan percentile.

WHAT IS KNOWN ALREADY

Twinning is typically associated with higher post-partum maternal mortality. The evidence about whether twinning incurs long-term survival costs of reproduction or is a trait pertinent to long-lived women is scarce and contradictory.

STUDY DESIGN, SIZE, DURATION

The study is based on the data of the Estonian Family Register (operating from 1926 to 1943) and involves 5565 mothers of twins and 119 613 mothers of singletons born between 1850 and 1899. The subset for comparing maternal lifespans included 1703-1884 mothers of twins and 19 747-36 690 mothers of singletons.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Post-partum maternal mortality was analyzed in the whole sample (including mothers of a single child) by logistic regression. Most of the analyses were performed in samples where each mother of twins was matched against mothers of singletons based on parity (or number of deliveries), urban versus rural and inland versus coastal origin, whether their lifespan was known, date of birth and age at first birth. Lifespans were compared in linear mixed models. Quantile regression was used to analyze age-dependent variations in maternal mortality rates. All models were adjusted for relevant biodemographic covariates.

MAIN RESULTS AND THE ROLE OF CHANCE

The twinning rate in the whole sample was 4.4%. During the year after giving birth, maternal mortality for twin deliveries was 0.75% (17/2273) and 0.37% (449/122 750) for singleton deliveries (OR = 2.05, 95% CI = 1.21-3.23). However, the lifetime post-partum mortality risk for mothers of twins (0.51%; 28/5557) and singletons (0.37%; 438/119 466) did not differ significantly (OR = 1.38, 95% CI = 0.91-1.98). The life spans of the mothers of twins and singletons did not differ in matched samples. Past the 67th lifespan percentile, the odds of survival were significantly higher for mothers of twins than mothers of singletons, as indicated by non-overlapping 95% confidence intervals.

LIMITATIONS, REASONS FOR CAUTION

Relatively low number of individuals (22 802-28 335) with known age at death in matched datasets due to discontinuation of the register after 1943.

WIDER IMPLICATIONS OF THE FINDINGS

The finding that mothers of twins had higher odds of old-age survival than mothers of singletons is consistent with the contention that twinners represent a non-random subset of women whose robust phenotypic quality allows them to outlive the mothers of singletons in old age.

STUDY FUNDING/COMPETING INTEREST(S)

The study was funded by the Estonian Research Council grants PRG1137, PRG2248, and PSG669. The authors declare no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Jidong ovarian aging cohort study: Objective, design, and baseline characteristics

BACKGROUND

Ovarian aging is a continuous process comprising a gradual decrease in both the quantity and the quality of the oocytes. A decline in ovarian function leads to chronic disease and physiological problems. The aim of this study is to establish a cohort for the purpose of examining the ovarian aging process and its relationship with health status and quality of life in women across all age groups.

METHOD

This protocol outlines a community-based, prospective long-term observational study involving 1676 women recruited from Caofeidian District in Tangshan City, Hebei Province, China. Data are gathered by the administration of questionnaires, doing physical examinations, performing blood biochemistry tests, and measuring levels of female hormones. The primary outcomes will be the occurrence of cardiovascular disease, osteoporosis, hypertension, diabetes, hyperlipidemia, and other chronic diseases, assessed according to established diagnostic criteria for each disease. The secondary outcome will be the decline in quality of life during the follow-up period, assessed by the modified Kupperman Index. The study comprises a baseline cross-sectional assessment and a follow-up evaluation. The participants will undergo face-to-face interviews as part of their regular medical examinations until 2026 or until the occurrence of outcome events.

DISCUSSION

The results of the prospective study will indicate the association between ovarian aging and the prevalence of chronic diseases as well as diminished quality of life among women across different age categories.

Lifetime cumulative effect of reproductive factors on ischaemic heart disease in a prospective cohort

OBJECTIVE

This study aimed to examine the association between lifetime oestrogen exposure and ischaemic heart disease (IHD), based on the hypothesis that higher lifetime oestrogen exposure is linked to lower cardiovascular risk.

METHODS

In 2004-2008, lifetime cumulative exposure to reproductive factors was assessed among postmenopausal females from the China Kadoorie Biobank using reproductive lifespan (RLS), endogenous oestrogen exposure (EEE) and total oestrogen exposure (TEE). EEE was calculated by subtracting pregnancy-related and contraceptive use duration from RLS, while TEE by adding up the same components except for lactation. Incident IHD during follow-up (2004-2015) was identified. Stratified Cox proportional hazards models estimated the HRs and 95% CIs of IHD for RLS, EEE and TEE.

RESULTS

Among 118 855 postmenopausal females, 13 162 (11.1%) developed IHD during a median follow-up of 8.9 years. The IHD incidence rates were 13.0, 12.1, 12.5, 13.8 per 1000 person-years for RLS Q1-Q4, 15.8, 12.6, 11.3, 12.1 per 1000 person-years for EEE Q1-Q4 and 13.7, 12.3, 12.2, 13.4 per 1000 person-years for TEE Q1-Q4. The highest quartile (Q4) of RLS and TEE were associated with lower risks of IHD (adjusted HR (aHR) 0.95, 95% CI 0.91 to 1.00 and 0.92, 95% CI 0.88 to 0.97, respectively) compared with the lowest quartile (Q1). Longer EEE showed progressively lower risks of incident IHD (aHR 0.93, 95% CI 0.88 to 0.97; 0.88, 95% CI 0.84 to 0.93; 0.87, 95% CI 0.83 to 0.92 for Q2-Q4 vs Q1).

CONCLUSIONS

Longer RLS, TEE and EEE were associated with lower risks of IHD among Chinese postmenopausal females.

Premature Menopause and All-Cause Mortality and Life Span Among Women Older Than 40 Years in the NHANES I Epidemiologic Follow-Up Study: Propensity Score Matching Analysis

Objective: Findings from studies of the long-term effect of premature menopause on risks of all-cause mortality in women are equivocal. We used the approach of propensity score matching to examine the causal association of premature menopause with all-cause mortality and life span among women older than 40 years. Methods: The data were from the National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study. We calculated the propensity score of premature menopause using a logistic regression model, then matched premature menopause with nonpremature menopause according to the score and the ratio of 1:1. We estimated mortality hazard ratios (HRs) and 95% confidence intervals (CIs) using Cox proportional hazard models. We also analyzed and plotted the relationship between age at menopause and reproductive life span with all-cause mortality and life span. Results: The mean age of 1,210 women was 55.4 ± 10.8 years at baseline. The unadjusted and adjusted HRs of all-cause mortality for women with premature menopause were 1.46 (95% CI: 1.08-1.96) and 1.53 (95% CI: 1.13-2.08), respectively, compared to nonpremature menopause. Nonlinear associations were found between age at menopause, reproductive life span, all-cause mortality, and life span. Menopausal age <37.5 years of age or reproductive life span <24 years increased the risk of all-cause mortality. Women with menopausal age <39 years of age or reproductive life span <24 years had a lower mean life span than the overall average of 76 years. Conclusions: Premature menopause significantly increased all-cause mortality risk and shortened life span in women. As women's age at menopause or reproductive life span increases, their overall life span also tends to increase.

Pregnancy-induced physiological hypertrophic preconditioning attenuates pathological myocardial hypertrophy by activation of FoxO3a

Previous studies show a woman's pregnancy is correlated with post-reproductive longevity, and nulliparity is associated with higher risk of incident heart failure, suggesting pregnancy likely exerts a cardioprotection. We previously reported a cardioprotective phenomenon termed myocardial hypertrophic preconditioning, but it is unknown whether pregnancy-induced physiological hypertrophic preconditioning (PHP) can also protect the heart against subsequent pathological hypertrophic stress. We aimed to clarify the phenomenon of PHP and its mechanisms. The pluripara mice whose pregnancy-induced physiological hypertrophy regressed and the nulliparous mice underwent angiotensin II (Ang II) infusion or transverse aortic constriction (TAC). Echocardiography, invasive left ventricular hemodynamic measurement and histological analysis were used to evaluate cardiac remodeling and function. Silencing or overexpression of Foxo3 by adeno-associated virus was used to investigate the role of FoxO3a involved in the antihypertrophic effect. Compared with nulliparous mice, pathological cardiac hypertrophy induced by Ang II infusion, or TAC was significantly attenuated and heart failure induced by TAC was markedly improved in mice with PHP. Activation of FoxO3a was significantly enhanced in the hearts of postpartum mice. FoxO3a inhibited myocardial hypertrophy by suppressing signaling pathway of phosphorylated glycogen synthase kinase-3β (p-GSK3β)/β-catenin/Cyclin D1. Silencing or overexpression of Foxo3 attenuated or enhanced the anti-hypertrophic effect of PHP in mice with pathological stimulation. Our findings demonstrate that PHP confers resistance to subsequent hypertrophic stress and slows progression to heart failure through activation of FoxO3a/GSK3β pathway.

Interaction of reproductive tract infections with estrogen exposure on breast cancer risk and prognosis

BACKGROUND

Reproductive tract infections influenced a series of inflammatory processes which involved in the development of breast cancer, while the processes were largely affected by estrogen. The present study aimed to explore the associations of breast cancer risk and prognosis with reproductive tract infections and the modification effects of estrogen exposure.

METHODS

We collected history of reproductive tract infections, menstruation and reproduction from 1003 cases and 1107 controls and a cohort of 4264 breast cancer patients during 2008-2018 in Guangzhou, China. We used logistic regression model to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for risk; Cox model was applied to estimate the hazard ratios (HRs) and 95% CIs for progression-free survival (PFS) and overall survival (OS).

RESULTS

It was found that previous reproductive tract infections were negatively associated with breast cancer risk (OR = 0.80, 95%CI, 0.65-0.98), particularly for patients with more menstrual cycles (OR = 0.74, 95%CI, 0.57-0.96). Patients with previous reproductive tract infections experienced better OS (HR = 0.61; 95% CI, 0.40-0.94) and PFS (HR = 0.84; 95% CI, 0.65-1.09). This protective effect on PFS was only found in patients with more menstrual cycles (HR = 0.52, 95% CI:0.34-0.79, P_interaction = 0.015).

CONCLUSIONS

The findings suggested that reproductive tract infections may be protective for the initiation and development of breast cancer, particularly for women with a longer interval of lifetime estrogen exposure.

Association of life-course reproductive duration with mortality: a population-based twin cohort study

BACKGROUND

Although age at menopause has been linked to mortality, the association between the entire reproductive lifespan and mortality remains unclear.

OBJECTIVE

This study aimed to examine to what extent life-course reproductive duration is associated with all-cause mortality and explore the role of a healthy lifestyle and familial background in such an association.

STUDY DESIGN

A total of 11,669 women (mean age, 63.54 years) from the Swedish Twin Registry were followed for up to 19 years. Information on reproductive duration (the interval between ages at menarche and menopause) and lifestyle factors (including smoking, alcohol consumption, and physical activity; divided into unfavorable/intermediate/favorable) was collected on the basis of a structured questionnaire. Survival status was obtained from the Sweden Cause of Death Register. The data were analyzed using generalized estimating equation models, Laplace regression, and conditional logistic regression.

RESULTS

In the generalized estimating equation model, compared with those with ≤34 reproductive years, the odds ratio (95% confidence interval) of all-cause mortality was 0.79 (0.68-0.90) for those with ≥40 reproductive years, which prolonged survival time by 0.84 (0.24-1.43) years. Women with ≥40 reproductive years plus a favorable lifestyle (odds ratio, 0.28; 95% confidence interval, 0.23-0.35) were at a lower risk of all-cause mortality than those with <40 reproductive years plus an unfavorable lifestyle. An additive interaction between ≥40 reproductive years and a favorable lifestyle on all-cause mortality was observed (attributable proportion, 0.584; 95% confidence interval, 0.016-1.151). The odds ratios in conditional logistic regression and generalized estimating equation models did not differ significantly (P=.67).

CONCLUSION

A longer reproductive lifespan is associated with reduced all-cause mortality and prolongs survival by 0.84 years. A favorable lifestyle may amplify the beneficial effect of longer reproductive lifespan on mortality. Familial background does not account for the observed association.

Polycystic ovary syndrome and leukocyte telomere length: cross-sectional and longitudinal changes

OBJECTIVE

Telomeres are DNA-protein complexes that protect chromosome ends from DNA damage and are surrogate biomarkers of cellular aging. Current evidence, almost entirely from cross-sectional observations, supports negative associations between leukocyte telomere length (LTL) and adverse lifestyle factors and cardiometabolic risk factors. Polycystic ovary syndrome (PCOS), the most common gynecological endocrine disorder, is associated with inflammation and oxidative stress, both factors associated with accelerated telomere attrition. We therefore hypothesized that LTL would be shorter and decrease more rapidly in women with PCOS in comparison to a control population.

DESIGN

This is a population-based cohort study comprising women of Northern Finland Birth Cohort 1966, with clinical examinations at ages 31 and 46. The sample included self-reported PCOS (age 31, n = 190; age 46, n = 207) and referent women (age 31, n = 1054; age 46, n = 1324) with data on LTL.

METHODS

The association between LTL and PCOS at ages 31 and 46 was analyzed by linear regression models adjusted for BMI, smoking, alcohol consumption and socioeconomic status at the corresponding age.

RESULTS

Women with PCOS had similar mean LTL at ages 31 and 46 (P > 0.4 for both). The mean LTL change between ages 31 and 46 did not differ between groups (P = 0.19). However, we observed a significant LTL attrition between ages 31 and 46 in the reference population (P < 0.001), but not in women with PCOS (P = 0.96).

CONCLUSIONS

This finding may suggest a difference in the LTL attrition rate in women with PCOS, an unexpected finding that might affect their risk of age-related disease. Further research is needed to clarify the underlying mechanisms.

Age at Menarche and Menopause, Reproductive Lifespan, and Risk of Cardiovascular Events Among Chinese Postmenopausal Women: Results From a Large National Representative Cohort Study

Background

At present, the association between age at menarche and menopause, reproductive lifespan, and cardiovascular disease (CVD) risk among Chinese postmenopausal women is not clear, and some related researches are contradictory.

Methods

A total of 6,198 Chinese postmenopausal women with a mean age of 63.6 years were enrolled at baseline in 2012-2015 and followed up for 5 years. A standardized questionnaire was used to collect relevant information by well-trained interviewers. Physical examination of the participants was performed by trained medical staff. CVD events were observed during follow-up. Cox proportional hazards models were used to estimate hazard ratios between reproductive characteristics and CVD events.

Results

Age at menarche was positively associated with CVD events (HR, 1.106; 95%CI, 1.047-1.167). There was a negative association between age at menopause and CVD risk in postmenopausal women with comorbidity (HR, 0.952; 95%CI, 0.909-0.996). Reproductive lifespan was negatively associated with CVD events (HR, 0.938; 95%CI, 0.880-0.999). The CVD risk increased by 10.6% for every 1-year increase in age at menarche. The CVD risk reduced by 6.2% for every 1-year increase in age at menopause in women with comorbidity. The CVD risk reduced by 3.8% for every 1-year increase in reproductive lifespan.

Conclusions

Based on the large prospective study with a nationally representative sample, Chinese postmenopausal women with late age at menarche and shorter reproductive lifespan have higher risk of CVD events.

The Influence of Female Reproductive Factors on Longevity: A Systematized Narrative Review of Epidemiological Studies

Purpose: This systematized review presents a synthesis of epidemiological studies that examine the association between female reproductive factors and longevity indicators. Methods: A comprehensive literature search was conducted using four bibliographic databases: OVID Medline, Web of Science, PubMed, and Google Scholar, including English language articles published until March 2022. Results from the search strategy yielded 306 articles, 37 of which were included for review based on eligibility criteria. Results were identified within the following nine themes: endogenous androgens and estrogens, age at first childbirth, age at last childbirth, parity, reproductive lifespan, menopause-related factors, hormone therapy use, age at menarche, and offspring gender. Results: Evidence that links reproductive factors and long lifespan is limited. Several female reproductive factors are shown to be significantly associated with longevity, yet findings remain inconclusive. The most consistent association was between parity (fertility and fecundity) and increased female lifespan. Age at first birth and parity were consistently associated with increased longevity. Associations between age at menarche and menopause, premature menopause, reproductive lifespan, offspring gender and longevity are inconclusive. Conclusion: There is not enough evidence to consider sex a longevity predictor. To understand the mechanisms that predict longevity outcomes, it is imperative to consider sex-specific within-population differences.

Genetics of Menopause and Primary Ovarian Insufficiency: Time for a Paradigm Shift?

This review summarizes the existing information concerning the genetic background of menopause and primary ovarian insufficiency (POI). There is overwhelming evidence that majority of genes are involved in double-strand break repair, mismatch repair, and base excision repair. The remaining loci were involved in cell energy metabolism and immune response. Gradual (or in case of rapid POI) accumulation of unrepaired DNA damage causes (premature) cell death and cellular senescence. This in turn leads to exhaustion of cell renewal capacity and cellular dysfunction in affected organs and eventually to aging of the entire soma. Similar erosion of the genome occurs within the germ cell line and the ovaries. Subsequently, the systemic "survival" response intentionally suppresses the sex-steroid hormonal output, which in turn may contribute to the onset of menopause. The latter occurs in particular when age-dependent DNA damage accumulation does not cease. Both effects are expected to synergize to promote (premature) ovarian silencing and install (early) menopause. Consequently, aging of the soma seems to be a primary driver for the loss of ovarian function in women. This challenges the current dogma which implies that loss of ovarian function initiates aging of the soma. It is time for a paradigm shift!

Association of the length of oestrogen exposure with risk of incident stroke in postmenopausal women: Insights from a 20-year prospective study

BACKGROUND

To examine the relationship between the length of oestrogen exposure and risk of incident stroke. Also, the additive value of each model was compared for assessing oestrogen exposure and stroke risk in postmenopausal women.

STUDY DESIGN AND SETTING

Prospective study of 5632 post-menopausal women without a prior history of stroke from 1996 through 2016 in Australian Longitudinal Study on Women's Health. Data on surrogate measures of oestrogen exposure were used to derive five indices of oestrogen exposure including reproductive lifespan (RLS) (age at menopause-age at menarche), endogenous oestrogen and total oestrogen exposure (which included menopausal hormone therapy (MHT use)). The relationships between the length of oestrogen exposure (quartiles) and incident stroke events were examined using multivariable adjusted Cox proportional hazard regression and their predictive accuracy were compared using area under the Receiver Operating Characteristic Curve.

RESULTS

The mean (SD) for RLS was 37.9(4.3) years. A shorter RLS (≤34 years) was associated with a higher risk of incident stroke after adjustment (HR: 1.85, 95%CI: 1.08, 3.15), compared with 38-40 years. There was 7% decrease in risk of stroke per 1-year increase in RLS (HR: 0.93, 95%CI: 0.89, 0.97). Even though the combination of endogenous oestrogen and exogenous hormones aimed to provide more accurate length of oestrogen exposure, the results showed that each model had similar goodness of fit and did not improve the model of just using RLS as a predictor of incident stroke.

CONCLUSIONS

A shorter RLS (≤34 years) was associated with higher risk of incident stroke compared to medium RLS. Endogenous oestrogen and of total oestrogen exposure (which included MHT use) did not improve the model of just using RLS as a predictor of incident stroke.

Duration of estrogen exposure during reproductive years, age at menarche and age at menopause, and risk of cardiovascular disease events, all-cause and cardiovascular mortality: a systematic review and meta-analysis

BACKGROUND

Little is known about the estrogen exposure measurement and mutual effect of age at menarche and age at menopause in the risk of cardiovascular disease (CVD) events.

OBJECTIVES

To evaluate estrogen exposure measurement and describe mutual effect of age at menarche and age at menopause in the risk of CVD events.

SEARCH STRATEGY

Systematic review of literature in PubMed, Embase and Web of Science for studies published up to 28 June 2020.

SELECTION CRITERIA

Observational studies related to estrogen exposure measurement, including mutual effect of age at menarche and age at menopause and risk of CVD events.

DATA COLLECTION AND ANALYSIS

Synthesis of evidence was conducted by reviewing individual estimates, followed by meta-analysis. The study received no external funding.

MAIN RESULTS

A total of 75 studies were included in synthesis of evidence, of which 17 studies were included in meta-analysis. Reproductive lifespan (age at menopause - age at menarche), endogenous estrogen exposure and total estrogen exposure were used for estrogen exposure measurement. Reproductive lifespan was by far the most commonly used method for estrogen exposure measurement. A shorter reproductive lifespan was associated with a higher risk of CVD events; the pooled relative risk (95% CI) was 1.31 (1.25-1.36) for stroke events. Robust epidemiological studies with measurement of estrogen exposure and associated health risk would strengthen the evidence.

CONCLUSIONS

Reproductive lifespan was the most commonly used method for estrogen exposure measurement in epidemiological studies. A shorter reproductive lifespan was associated with a higher risk of CVD events, particularly stroke.

TWEETABLE ABSTRACT

A systematic review and meta-analysis found that women with a shorter reproductive lifespan have a higher risk of stroke events.

Association between gravidity and risk of metabolic syndrome: Results of Tabari cohort study

BACKGROUND AND AIMS

The purpose of the present study was to investigate the association of gravidity and age at first pregnancy with metabolic syndrome in a large-scale, population-based cohort study in Iran.

METHODS

The present secondary analysis was conducted on a subset of the population (5739 women with at least one pregnancy) enrolled in the Tabari cohort study. Reproductive history was collected using a structured questionnaire. The relationship of gravidity and age at first pregnancy with metabolic syndrome and its components was analyzed using the logistic regression model.

RESULTS

The results showed that after adjustment for confounding variables, the odds of having metabolic syndrome was not significantly associated with age at first pregnancy (P = 0.269) and gravidity (P = 0.504). However, there was an association between hypertension and age at first pregnancy (OR = 0.32, 95% CI = 0.12-0.82; P = 0.03). Additionally, waist circumference was also associated with gravidity (OR = 2.17, 95% CI = 1.37-3.35).

CONCLUSION

As the findings indicated, age at first pregnancy and gravidity were not associated with the odds of having metabolic syndrome. However, a relationship was found between first pregnancy at the age of >35 years and the decreased risk of hypertension. Gravidity was also found to be a dose-dependent risk factor for increased waist circumference.

Objectives, design and main findings until 2020 from the Rotterdam Study

The Rotterdam Study is an ongoing prospective cohort study that started in 1990 in the city of Rotterdam, The Netherlands. The study aims to unravel etiology, preclinical course, natural history and potential targets for intervention for chronic diseases in mid-life and late-life. The study focuses on cardiovascular, endocrine, hepatic, neurological, ophthalmic, psychiatric, dermatological, otolaryngological, locomotor, and respiratory diseases. As of 2008, 14,926 subjects aged 45 years or over comprise the Rotterdam Study cohort. Since 2016, the cohort is being expanded by persons aged 40 years and over. The findings of the Rotterdam Study have been presented in over 1700 research articles and reports. This article provides an update on the rationale and design of the study. It also presents a summary of the major findings from the preceding 3 years and outlines developments for the coming period.

Time Trends in Survival Following First Hemorrhagic or Ischemic Stroke Between 1991 and 2015 in the Rotterdam Study

Background and Purpose—

The introduction of stroke units and the implementation of evidence-based interventions have been a breakthrough in the management of patients with stroke over the past decade. Survival following stroke is an important indicator in monitoring stroke burden. Recent data on survival by stroke subtype in the general population is scarce. We assessed (1) recent temporal time trends in survival; (2) age-standardized death rates; (3) survival probabilities at 6 months, 1, 2, and 3 years following first hemorrhagic or ischemic stroke.

Methods—

Within the population-based Rotterdam Study between 1991 and 2015, we assessed time trends in survival among 162 with first-ever hemorrhagic and 988 patients with first-ever ischemic stroke across 3 time periods (1991–1998; 1999–2007; 2008–2015) using time-varying Cox regression model and calculated age-standardized death rates according to the European 2010 census population.

Results—

In the hemorrhagic stroke group, a total of 144 deaths occurred during 386 person-years. Following a hemorrhagic stroke, we observed similar mortality rates over the years with 30 per 100 person-years in 2015 compared with 25/100 person-years in 1991. Similarly, compared with the earliest study period (1991–1998), mortality rates remained unchanged in the latest study period (2008–2015; hazard ratio, 0.97 [95% CI, 0.61–1.57]; P =0.93). In the ischemic stroke group, a total of 711 deaths occurred during 4897 person-years. We observed a decline in mortality rates in 2015 (11 per 100 person-years) compared with 1991 (29/100 person-years). This translated to favorable trends in the latest study period 2008 to 2015 (hazard ratio, 0.71 [95% CI, 0.56–0.90]; P <0.01).

Conclusions—

Survival following ischemic stroke has improved over the past decade, while no change was observed in survival following hemorrhagic stroke.

Ages at menarche and menopause, and mortality among postmenopausal women

OBJECTIVES

Although both age at menarche and age at menopause may independently affect the risk of cardiovascular diseases and all-cause mortality, their joint association with mortality is less clear. The objectives of this study were to address the relationship between ages at menarche and at menopause with mortality among postmenopausal women.

STUDY DESIGN

The study included 75,359 U.S. postmenopausal women aged 50-78 years from the Prostate, Lung, Colorectal, and Ovarian (PLCO) cohort. Information on ages at menarche and menopause was self-reported and collected at baseline, by questionnaire.

MAIN OUTCOME MEASURES

All-cause, cardiovascular and cancer mortality.

RESULTS

After a median follow-up of 13 years, we identified 7826 deaths among 75,359 women in the PLCO cohort. Compared with women with an age at menarche of 12-13 years and an age at menopause of 45-54 years, the adjusted hazard ratios (95% confidence interval) for all-cause mortality for women with early menarche (≤11 years) and menopause (≤44 years) and those with late menarche (≥14 years) and menopause (≥55 years) were 1.20 (1.09, 1.32) and 0.82 (0.71, 0.96), respectively. This association remained significant in a sensitivity analysis that excluded women who did not undergo natural menopause. The indexes for the additive effect of the combined association showed no excess risk due to an interaction.

CONCLUSIONS

Early menarche and early menopause seemed to have an exactly additive effect on all-cause mortality. The findings suggest that it is important to evaluate ages at both menarche and menopause rather than to consider either variable on its own in assessing the risk of mortality.

Mid-life fertility: Challenges & policy planning

This review highlights the challenges, priority areas of research and planning, strategies for regulation of services and the need to develop guidelines and laws for fertility treatments during mid-life. The success rate of all treatments is poor in advanced age women because of declining ovarian reserve and natural fertility. There is often a need of third-party involvement which has its own ethical, legal and medical issues. Welfare of children born to older women and early death of parents are important concerns. Most of the new techniques such as the pre-implantation genetic diagnosis, oocyte augmentation, use of stem cells or artificial gametes, ovarian tissue preservation and ovarian transplantation are directed to improve, preserve or replace the declining ovarian reserve. These techniques are costly and have limited availability, safety and efficacy data. Continued research and policies are required to keep pace with these techniques. The other important issues include the patients' personal autonomy and right of self-determination, welfare of offspring, public vs. private funding for research and development of new technologies vs. indiscriminate use of unproven technology. It is important that mid-life fertility is recognized as a distinct area of human reproduction requiring special considerations.

The relation of age at menarche with age at natural menopause: a population study of 336 788 women in Norway

STUDY QUESTION

Is age at menarche associated with age at menopause or with duration of the reproductive period (interval between menarche and menopause)?

SUMMARY ANSWER

The association of age at menarche with age at menopause was weak and non-linear, and the duration of the reproductive period decreased by increasing age at menarche.

WHAT IS KNOWN ALREADY

It remains uncertain whether age at menarche is associated with age at menopause. Some studies report that women with early menarche also have early menopause. Other studies report that women with early menarche have late menopause, or they report no association. The duration of the reproductive period may be an indicator of the cumulative endogenous exposure to estrogens and progestogens during life course and is associated with risk of breast cancer and endometrial cancer.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study of 336 788 women, aged 48-71 years, in the BreastScreen Norway during the years 2006-2014 was performed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Information about age at menarche and menopausal status was obtained by self-administered questionnaires. We used time to event approaches to estimate the associations.

MAIN RESULTS AND THE ROLE OF CHANCE

Median age at menopause was 51 years in most menarche groups. Women with menarche at age 16 years or age ≥ 17 years had menopause 1 year later [median: 52 years, interquartile range (IQR): 49-54 years] than women with menarche at age 13 years (median: 51 years, IQR: 49-54 years, reference) (crude hazard ratio (HR) = 0.95; 95% CI: 0.93-0.97 and 0.95; 95% CI: 0.92-0.99, Pnon-linearity < 0.001). The reproductive period decreased with increasing age at menarche (Pnon-linearity < 0.001), and women with menarche at age ≤ 9 years had 9 years longer median reproductive period than women with menarche at age ≥ 17 years (median: 43 versus 34 years). Adjustment for year of birth did not change the HR estimates notably.

LARGE SCALE DATA

Not applicable.

LIMITATIONS, REASONS FOR CAUTION

Information about age at menarche and age at menopause was based on self-reports. Particularly for age at menarche, the long time interval between the event and data collection may have caused imprecise reporting.

WIDER IMPLICATIONS OF THE FINDINGS

Our study suggests that age at menarche is a strong indicator for the duration of women's reproductive period. Our findings should encourage studies of the independent role of duration of the reproductive period on the risk of breast cancer and endometrial cancer, since these cancers have been associated with exposure to estrogens and progestogens.

STUDY FUNDING/COMPETING INTEREST(S)

The present study was funded by the Norwegian Cancer Society [Grant number 6863294-2015]. The authors declare no conflicts of interest.

High Androgens in Postmenopausal Women and the Risk for Atherosclerosis and Cardiovascular Disease: The Rotterdam Study

CONTEXT

Polycystic ovary syndrome (PCOS) is closely linked to hyperandrogenism (HA). In PCOS, HA has been associated with metabolic disturbances that increase the risk for cardiovascular disease (CVD).

OBJECTIVE

To assess the association of high serum androgen levels, as a postmenopausal remnant of PCOS, with the prevalence of atherosclerosis and incidence of CVD in postmenopausal women.

DESIGN

The Rotterdam Study, a prospective population-based cohort study. Median follow-up was 11.36 years.

SETTING

General community.

PARTICIPANTS

A total of 2578 women aged >55 years. Exclusion criteria were missing informed consent or follow-up data, perimenopausal status, and menopause by surgical intervention or at an unnatural age (age <40 or >62).

INTERVENTION

None.

MAIN OUTCOMES AND MEASURES

Linear, logistic, and Cox regression models assessed the association of top quartiles (P75) of serum testosterone, free androgen index (FAI), dehydroepiandrosterone, and androstenedione and sex hormone-binding globulin with coronary artery calcium, carotid intima-media thickness (IMT), pulse wave velocity, peripheral artery disease, and incidence of coronary heart disease (CHD), stroke, and CVD.

RESULTS

Mean age (standard deviation) was 70.19 (8.71) years, and average time since menopause was 19.85 (9.94) years. Highest quartile FAI was associated with higher pulse wave velocity (β [95% confidence interval (CI)], 0.009 [0.000 to 0.018]). Highest quartile dehydroepiandrosterone [β (95% CI), -0.008 (-0.015 to -0.001)] and androstenedione [β (95% CI), -0.010 (-0.017 to -0.003)] levels were associated with a lower IMT. We found no association between high androgen levels and incident stroke, CHD, or CVD.

CONCLUSION

Postmenopausal high androgen levels were not associated with an elevated risk for CVD. Cardiovascular health in women with PCOS might be better than was anticipated.

The Rotterdam Study: 2018 update on objectives, design and main results

The Rotterdam Study is a prospective cohort study ongoing since 1990 in the city of Rotterdam in The Netherlands. The study targets cardiovascular, endocrine, hepatic, neurological, ophthalmic, psychiatric, dermatological, otolaryngological, locomotor, and respiratory diseases. As of 2008, 14,926 subjects aged 45 years or over comprise the Rotterdam Study cohort. Since 2016, the cohort is being expanded by persons aged 40 years and over. The findings of the Rotterdam Study have been presented in over 1500 research articles and reports (see www.erasmus-epidemiology.nl/rotterdamstudy ). This article gives the rationale of the study and its design. It also presents a summary of the major findings and an update of the objectives and methods.