Ages at menarche and menopause, hormone therapy, and the risk of depression

Association between parity and female mortality: the mediative role of depressive symptoms

STUDY QUESTION

Is parity associated with all-cause and cause-specific mortality among women in a nationally representative cohort of the US population, and does depression mediate this association?

SUMMARY ANSWER

Nulliparous women have a higher risk of all-cause and cause-specific mortality, with depression partially mediating the relationship between parity and women's all-cause and cause-specific mortality.

WHAT IS KNOWN ALREADY

Parity, a significant state in reproductive life, has enduring implications for women's health. There is also a complex relationship between depression, a prevalent mental and emotional disorder, and female fertility. Previous studies have elucidated the relationships between parity and depression, both of which are associated with mortality. However, findings from studies examining parity and women's mortality have been inconsistent. Moreover, few studies have investigated whether the effect of parity on mortality is mediated by depression.

STUDY DESIGN, SIZE, DURATION

We conducted a cross-sectional study using data from seven cycles of the National Health and Nutrition Examination Survey (NHANES) spanning 2005-2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study cohort comprised adult women with available parity and survival follow-up data. Parity data were self-reported and sourced from the Reproductive Health Questionnaire. Depression scores were derived from the Patient Health Questionnaire 9, and cause-specific deaths were identified using the International Statistical Classification of Diseases, 10th Revision (ICD-10). Weighted multivariable Cox regression was applied to analyze the association between parity, depression, and mortality. Weighted linear regression was performed to examine the relationship between parity and depression. Mediation analyses were employed to determine whether and to what extent depression mediated the effect of parity on mortality.

MAIN RESULTS AND THE ROLE OF CHANCE

Our study ultimately encompassed 16 962 American women. Following multivariable adjustment, compared to nulliparous women, those with one to three live births exhibited a 17% and 33% reduction in all-cause and cancer mortality, respectively (all-cause mortality: HR = 0.83, 95% CI = 0.69-0.99, P = 0.040; cancer mortality: HR = 0.67, 95% CI = 0.45-0.99, P = 0.045). Women with more than four live births demonstrated lower all-cause mortality and mortality from other (not cancer or cardiovascular disease) diseases (all-cause mortality: HR = 0.73, 95% CI = 0.58-0.93, P = 0.011; other diseases mortality: HR = 0.66, 95% CI = 0.47-0.91, P = 0.013). No correlation was detected between parity and the risk of cardiovascular disease mortality among women. Furthermore, depression was found to partially mediate the impact of parity on all-cause mortality and mortality from other diseases in women.

LIMITATIONS, REASONS FOR CAUTION

Firstly, a single index of parity was used as an exposure factor, and other reproductive factors such as birth spacing, age at first birth, and mode of delivery were not taken into account. Secondly, despite accounting for important potentially confounders in our analysis, such as BMI, smoking status, and educational level, the influence of unmeasured confounders (e.g., social class, latent reproductive system diseases) on reproductive behavior or mortality cannot be dismissed. Thirdly, women's vulnerability to depression fluctuates across reproductive stages, and the effect of depression on female fertility varies over time. Due to data constraints, we were unable to obtain information on women's mental health status at different reproductive stages. Fourthly, due to the data accessibility limitations of NHANES, we were unable to specifically explore the relationship between parity and different specific types of cancer, a limitation that may obscure potential correlations. Additionally, despite our efforts to control for various confounding factors in subgroup analyses, the smaller sample sizes in some subgroups may limit the statistical power, affecting the ability to detect effects. Finally, studies exploring the association between parity and depression are cross-sectional designs, making it difficult to infer causality. These results should be interpreted with caution, and further research is warranted to corroborate our findings.

WIDER IMPLICATIONS OF THE FINDINGS

Our study underscores the elevated risk of all-cause and cause-specific mortality in nulliparous women and reveals that depression partially mediates the negative correlation between parity and women's all-cause mortality and mortality from other diseases. These results should be interpreted with caution, and further investigation is needed to support our findings.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the National Key Research and Development Program of China (2023YFC2705700), the Key Research & Developmental Program of Hubei Province (2022BCA042), and the Interdisciplinary Innovative Talents Foundation from Renmin Hospital of Wuhan University (JCRCWL-2022-001). The authors declare that they have no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A.

The psychological side of menopause: evidence from the comorbidity network of menopausal, anxiety, and depressive symptoms

OBJECTIVE

Numerous studies have uncovered a correlation between menopausal, anxiety, and depressive symptoms. How these symptoms interrelate and influence each other, however, remains unclear. This study aimed to identify the associations between menopausal, anxiety, and depressive symptoms using network analysis.

METHODS

The participants comprised 423 women ( Mage = 49.21 ± 4.01 y; range, 40-60 y) recruited from a menopause clinic at a tertiary hospital in Beijing, China. Demographic characteristics and menopausal, anxiety, and depressive symptoms were obtained through self-report questionnaires. Two networks were established: a partial correlation network and a Bayesian network.

RESULTS

The menopausal symptom of nervousness exhibited a robust association with anxiety symptoms in both networks. Within the partial correlation network, the depressive symptom of tiredness emerged as a pivotal symptom, facilitating the co-occurrence of menopausal and depressive symptoms. Bayesian network analysis exhibited that the depressive symptom of a loss of interest was related to certain menopausal symptoms through depressive symptoms of tiredness and motor problems, both serving as critical links between menopausal symptoms and depression. Notably, four menopausal symptoms-arthralgia/myalgia, formication, sexual complaints, and urinary tract infection-appeared independent of other menopausal, anxiety, and depressive symptoms.

CONCLUSIONS

Both psychological (eg, fatigue) and somatic (eg, hot flashes, headaches, and dizziness) menopausal symptoms demonstrate strong associations with depression. In providing optimal support for women's health during menopause, psychological interventions aimed at depression, particularly among those experiencing a loss of interest or pleasure in activities, should complement conventional therapies.

Bidirectional associations between dietary diversity and depressive symptoms in Chinese adult women: A retrospective cohort study

OBJECTIVE

This study aimed to examine the bidirectional associations between dietary diversity and clinical depressive symptoms in adult women, and influencing factors of clinical depressive symptoms.

METHODS

This longitudinal study included a total of 22,385 participants, each of whom underwent at least two data collections. We used convenience sampling to recruit women from a health management center of a general hospital in southern China from April 2015 to December 2021. They completed an online self-reported health questionnaire, which included demographic characteristics, lifestyle information, the Dietary Diversity Scale (DDS), and the Patient Health Questionnaire-9.

RESULTS

New-onset depressive symptoms and low dietary diversity were observed in this study among 1285 and 3223 participants, respectively. Negative associations were observed between baseline low dietary diversity and new-onset depressive symptoms (P < 0.05) and between baseline depressive symptoms and low dietary diversity (P < 0.001). Cross-lagged panel analysis indicated that dietary diversity negatively and prospectively predicted depressive symptoms, but vice versa (P < 0.05). Strong evidence of a nonlinear association between DDS scores and incident depressive symptoms was found (P nonlinear < 0.05) regardless of whether the variables were adjusted. Besides, age, menarche age, physical activity, sleep duration, longer sedentary behavior and other lifestyle factors were influencing factors of depressive symptoms (P < 0.05).

CONCLUSIONS

The present study identified bidirectional associations between dietary diversity and depressive symptoms, and the associations were found to have a non-linear pattern. Adherence to dietary diversity and a healthy lifestyle could be effective non-pharmacological preventive measures to reduce the incidence of depressive symptoms.

The relationship between timing of onset of menarche and depressive symptoms from adolescence to adulthood

AIMS

Girls who experience an earlier onset of menarche than their peers are at increased risk of depressive symptoms in mid-adolescence, but it is unclear if this association persists into adulthood. This study examines whether longitudinal patterns of depressive symptoms from adolescence to adulthood vary according to timing of menarche.

METHODS

About 4,864 female participants in the UK Avon Longitudinal Study of Parents and Children provided data on age at onset of menarche (assessed in repeated questionnaires from 8 to 17 years) and depressive symptoms across nine time points (13 to 26 years) using the Short Mood and Feelings Questionnaire. We compared patterns of depressive symptoms in girls with 'early' (<11.5 years), 'normative' (11.5 to 13.5 years) and 'late' (≥13.5 years) menarche using a linear spline multilevel growth curve model adjusted for indicators of socioeconomic position, father absence and body mass index.

RESULTS

Early, compared with normative, menarche was associated with higher levels of depressive symptoms at age 14 (imputed adjusted estimated difference = 0.94, 95% confidence interval [CI] = 0.44, 1.45), but the association attenuated at 24 years (0.24 [-0.72, 1.19]). Late menarche, compared with normative, was associated with a lower level of depressive symptoms at age 14 (-0.69 [-1.10, -0.29]), but this association also attenuated at 24 years (-0.15 [-0.92, 0.62]).

CONCLUSIONS

This study did not find a persistent effect of early menarche, compared to normative, on depressive symptoms. However, our findings are consistent with the level of depressive symptoms increasing at the onset of menarche irrespective of timing. The late onset girls 'catch up' with their peers who experience menarche earlier in terms of depressive symptoms. Future studies should continue to assess the impact of timing of menarche further into adulthood.