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Kingsberg SA, Schulze-Rath R, Mulligan C, Moeller C, Caetano C, Bitzer J. Global view of vasomotor symptoms and sleep disturbance in menopause: a systematic review. Climacteric 2023; 26:537-549. [PMID: 37751852 DOI: 10.1080/13697137.2023.2256658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/03/2023] [Indexed: 09/28/2023]
Abstract
Studies have shown racial/ethnic differences in the prevalence of vasomotor symptoms (VMS), sleep disturbance and VMS treatment in menopause. To assess the reproducibility of these differences, we systematically reviewed observational studies, published in 2000-2021, reporting the prevalence/incidence of VMS, sleep disturbance or treatment use in menopausal women stratified by race/ethnicity. We screened 3799 records from PubMed and Embase and included 27 papers (19 studies). No incidence data were found. Prevalence data varied widely, but some common patterns emerged. In all five studies comparing VMS between Black women and White, Hispanic and/or East Asian women, the prevalence was highest in Black women and lowest in East Asian women. The prevalence of sleep disturbance overall was compared among Black, White and East Asian women in two study populations, and was highest in White women in both papers. Sleep disturbance was more common than VMS in East Asian women. In all four studies comparing hormone therapy use between White women and Black and/or East Asian women, treatment use was more common in White women. These results highlight the need for individualized counseling and treatment, outreach to under-served minorities, and standardized definitions and outcome measures for VMS and sleep disturbance for future studies.
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Affiliation(s)
- S A Kingsberg
- Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - R Schulze-Rath
- Medical Affairs & Pharmacovigilance, Pharmaceuticals, Bayer AG, Berlin, Germany
| | - C Mulligan
- Evidence Synthesis, Beacon Medical Communications, Brighton, UK
| | - C Moeller
- Medical Affairs & Pharmacovigilance, Pharmaceuticals, Bayer AG, Berlin, Germany
| | - C Caetano
- Pharmaceuticals, Medical Affairs Women's Healthcare, Bayer AG, Basel, Switzerland
| | - J Bitzer
- Department of Obstetrics and Gynecology, University Hospital, University of Basel, Basel, Switzerland
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Richard-Davis G, Singer A, King DD, Mattle L. Understanding Attitudes, Beliefs, and Behaviors Surrounding Menopause Transition: Results from Three Surveys. Patient Relat Outcome Meas 2022; 13:273-286. [PMID: 36540377 PMCID: PMC9760047 DOI: 10.2147/prom.s375144] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 11/22/2022] [Indexed: 03/26/2024] Open
Abstract
PURPOSE To understand women's perspectives, attitudes, and beliefs surrounding menopause transition and increase understanding of digital technology use for symptom management. PATIENTS AND METHODS Information was obtained using three studies of women aged 40-65 years experiencing menopause transition symptoms. The HealthyWomen online cross-sectional survey was designed to reflect an inclusive sociodemographic sample representative of the US population. BECOME was a blinded, ethnographic, qualitative research study of women's menopause transition experiences and comprised facilitator-led online asynchronous discussions, online homework entries, and audio-only teleconferences. The NODE.Health online, two-part, cross-sectional patient survey was designed to capture patient and healthcare provider (HCP) sentiment about the use of digital health technologies to address gaps in perimenopausal symptom knowledge and management. RESULTS The HealthyWomen survey included 1045 participants, 37 were included in BECOME, and 100 completed the NODE.Health survey. Hot flashes, night sweats, and sleep problems were the most frequently experienced symptoms in the HealthyWomen survey, and over half of participants experiencing symptoms felt the need to seek relief. Whether menopause was considered a medical problem or natural process differed by self-identified race, culture, and ethnicity, as did the likelihood of consulting a HCP over symptoms. Participants preferred to discuss menopause transition with HCPs who did not rush them, were good listeners, and had expertise in the area. Most technology experience was with health websites, but nearly half were unsatisfied with online resources describing menopause-related symptoms. Convenience, ease of use, and accessibility were the most common reasons for pursuing digital health technology. CONCLUSION Factors such as cultural beliefs, values and attitudes towards menopause determine personal experiences. More open discussions with friends, family, and HCPs may raise awareness and reduce barriers to seeking help. To provide optimal care throughout the menopause transition, HCPs should consider patients' psychosocial and cultural backgrounds, and personal and subjective perspectives.
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Affiliation(s)
- Gloria Richard-Davis
- Department of Obstetrics and Gynecology, University of Arkansas Medical Center, Little Rock, AR, USA
| | - Andrea Singer
- Medicine and Obstetrics and Gynecology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Deanna D King
- Medical Affairs US, Astellas Pharma, Northbrook, IL, USA
| | - Lisa Mattle
- Behavioral Science Consortium, Astellas Pharma, Northbrook, IL, USA
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Carpenter JS, Sheng Y, Pike C, Elomba CD, Alwine JS, Chen CX, Tisdale JE. Correlates of palpitations during menopause: A scoping review. WOMEN'S HEALTH 2022; 18:17455057221112267. [PMID: 35833667 PMCID: PMC9289918 DOI: 10.1177/17455057221112267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective: Palpitations during peri- and post-menopause are common. It is unclear what
variables are related to palpitations in peri- and post-menopausal women.
The purpose of this scoping review was to summarize potential correlates of
palpitations in women transitioning through menopause. Methods: The review followed the Preferred Reporting Items for Systematic reviews and
Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Authors included
English-language, full-length, peer-reviewed, cross-sectional research
articles on palpitations in menopausal women published through December 18,
2021, from PubMed, Cumulative Index to Nursing and Allied Health Literature
(CINAHL), and PsycINFO searches. Following de-duplication, screening of
titles and abstracts, and review of full-texts, independent reviewers
extracted data on variables studied in relationship to palpitations from 84
articles and resolved discrepancies. Authors extracted data on (1)
demographic, clinical, biomarker, and symptom/quality of life variables and
(2) data analysis method (bivariate, multivariate). Authors classified each
variable as a likely, unlikely, or unclear correlate of palpitations. Results: Articles were diverse in region of origin, sample sizes, and variables
assessed in relationship to palpitations. Evidence for any one variable was
sparse. Likely correlates of palpitations included race/ethnicity, lower
physical activity, worse vasomotor symptoms (VMSs), worse sleep, and worse
quality of life. Unlikely correlates included age, employment, education,
marital status, socioeconomic status, comorbidities, body mass index, and
sexual difficulties. Unclear correlates due to equivocal evidence were
menopausal status, smoking, and depression. Unclear correlates due to
insufficient evidence (less than three articles) included all of the
assessed biomarkers, anxiety, and stress. Conclusion: Likely correlates were identified including race/ethnicity, physical
activity, VMS, sleep, and quality of life. However, additional research is
needed to better understand potential correlates of palpitations.
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Affiliation(s)
| | - Ying Sheng
- Indiana University School of Nursing, Indianapolis, IN, USA
| | - Caitlin Pike
- University Library, Indiana University–Purdue University Indianapolis, Indianapolis, IN, USA
| | | | | | - Chen X Chen
- Indiana University School of Nursing, Indianapolis, IN, USA
| | - James E Tisdale
- Purdue University College of Pharmacy, West Lafayette, IN, USA
- Indiana University School of Medicine, Indianapolis, IN, USA
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Sheng Y, Carpenter JS, Elomba CD, Alwine JS, Yue M, Pike CA, Chen CX, Tisdale JE. Review of menopausal palpitations measures. Womens Midlife Health 2021; 7:5. [PMID: 34059122 PMCID: PMC8167994 DOI: 10.1186/s40695-021-00063-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/11/2021] [Indexed: 12/22/2022] Open
Abstract
Palpitations are reported commonly by women around the time of menopause as skipped, missed, irregular, and/or exaggerated heartbeats or heart pounding. However, much less is known about palpitations than other menopausal symptoms such as vasomotor symptoms. The objective of this review was to integrate evidence on menopausal palpitations measures. Keyword searching was done in PubMed, CINAHL, and PsycINFO for English-language, descriptive articles containing data on menopause and palpitations and meeting other pre-specified inclusion criteria. Of 670 articles, 110 met inclusion criteria and were included in the review. Results showed that 11 different measures were used across articles, with variability within and between measures. Inconsistencies in the wording of measurement items, recall periods, and response options were observed even when standardized measures were used. Most measures were limited to assessing symptom presence and severity. Findings suggest that efforts should be undertaken to (1) standardize conceptual and operational definitions of menopausal palpitations and (2) develop a patient-friendly, conceptually clear, psychometrically sound measure of menopausal palpitations.
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Affiliation(s)
- Ying Sheng
- School of Nursing, Indiana University, Indianapolis, IN, 46202, USA
| | - Janet S Carpenter
- School of Nursing, Indiana University, Indianapolis, IN, 46202, USA.
| | - Charles D Elomba
- School of Nursing, Indiana University, Indianapolis, IN, 46202, USA
| | | | - Min Yue
- College of Pharmacy, Purdue University, West Lafayette, IN, 47907, USA
| | - Caitlin A Pike
- University Library, Indiana University, Indianapolis, IN, 46202, USA
| | - Chen X Chen
- School of Nursing, Indiana University, Indianapolis, IN, 46202, USA
| | - James E Tisdale
- College of Pharmacy, Purdue University, West Lafayette, IN, 47907, USA.,School of Medicine, Indiana University, Indianapolis, IN, 46202, USA
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Association between anxiety and severe quality-of-life impairment in postmenopausal women: analysis of a multicenter Latin American cross-sectional study. Menopause 2017; 24:645-652. [DOI: 10.1097/gme.0000000000000813] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Prevalence and severity of menopause symptoms and associated factors across menopause status in Korean women. Menopause 2016; 22:1108-16. [PMID: 25783469 DOI: 10.1097/gme.0000000000000438] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The present study investigated the prevalence and severity of menopause symptoms experienced by Korean women aged 44 to 56 years and their associated factors. METHODS A cross-sectional study was performed on 2,201 women aged 44 to 56 years in health checkup centers between November 2012 and March 2013. The 29-item Menopause-Specific Quality of Life Questionnaire was used to assess vasomotor, psychosocial, physical, and sexual symptoms related to menopause. The guidelines for the classification of reproductive aging stages proposed at the Stages of Reproductive Aging Workshop were used. Multivariable linear regression analyses were performed to identify factors associated with severity of menopause symptoms. RESULTS Among participants, 42.6% were premenopausal, 36.7% were perimenopausal, and 20.7% were postmenopausal. Although physical symptoms were the most severe menopause symptoms experienced by premenopausal and perimenopausal women, postmenopausal women reported sexual symptoms as the most bothersome. The mean scores for each domain increased from the premenopausal period through the postmenopausal period (P for trend < 0.001). The regression model revealed that age (for vasomotor and sexual symptoms) and obesity (for vasomotor and physical symptoms) were significantly associated with severity of menopause symptoms (P < 0.05). Physically active women had fewer severe physical symptoms related to menopause than inactive women. CONCLUSIONS Postmenopausal women experience the most severe symptoms. Obesity and physical activity are the main modifiable factors associated with symptom severity. Further studies are needed to examine the effects of physical activity promotion and weight control interventions on preventing menopause symptoms in Korean women.
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Barati M, Ahmadpanah M, Shirahmadi S, Bashirian S, Parsa P, Holsboer-Trachsler E, Brand S, Haghighi M. Differential Impact of Sociodemographic Variables on the Quality of Life of Menopausal Iranian Women. ACTA ACUST UNITED AC 2016. [DOI: 10.17795/ajnpp-39026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Constantine GD, Graham S, Clerinx C, Bernick BA, Krassan M, Mirkin S, Currie H. Behaviours and attitudes influencing treatment decisions for menopausal symptoms in five European countries. Post Reprod Health 2016; 22:112-22. [PMID: 26895640 PMCID: PMC5019289 DOI: 10.1177/2053369116632439] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Objective To assess women’s behaviours and attitudes regarding the treatment of menopausal symptoms in five European countries. Study design Women aged ≥45 years in France, Germany, Italy, Spain, and the United Kingdom participated in an internet survey. Completers were those who reported menopausal symptoms and had treated their symptoms. Women were equally stratified by age (45–54 years, 55–64 years, ≥65 years). Main outcome measures Behaviours, attitudes, and experiences regarding treatment of menopausal symptoms. Results Of 3890 peri- to postmenopausal women screened, 67% experienced symptoms and 54% sought either medical input or some treatment concerning their symptoms. Hot flushes, the most common symptom, decreased with age but remained prevalent after age 64. Roughly 75% of women who sought relief consulted a physician, mostly a gynaecologist or a general practitioner (GP) as in the United Kingdom. The decision to seek treatment was influenced by age, number, and severity of symptoms. Approximately 79% visiting a physician received prescription therapy. Of the women who received non-hormone therapy (HT) treatment instead of HT: patients refused HT (20–44%), physicians did not discuss HT (32–46%), or advised against HT (24–43%). Women in the United Kingdom were most familiar with and favorable to HT. Interest in a new HT (34–50%) was higher than use (19–28%). Conclusions Menopausal symptoms are common, persistent, and bothersome, but many fail to seek treatment. Sources and types of treatment vary among age groups and countries. Education regarding women’s attitudes toward treatment should be provided to those physicians who treat menopausal symptoms in each country.
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Affiliation(s)
| | | | | | | | | | | | - Heather Currie
- Department of Obstetrics and Gynecology, Dumfries & Galloway Royal Infirmary, Dumfries, UK
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Longitudinal analysis of associations between women's consultations with complementary and alternative medicine practitioners/use of self-prescribed complementary and alternative medicine and menopause-related symptoms, 2007-2010. Menopause 2016; 23:74-80. [DOI: 10.1097/gme.0000000000000479] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Peng W, Sibbritt DW, Hickman L, Adams J. Association between use of self-prescribed complementary and alternative medicine and menopause-related symptoms: a cross-sectional study. Complement Ther Med 2015; 23:666-73. [PMID: 26365446 DOI: 10.1016/j.ctim.2015.07.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 06/05/2015] [Accepted: 07/10/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To examine the association between self-prescribed complementary and alternative medicine use and menopause-related symptoms, stratified by menopausal status. METHODS Data were obtained from a cross-sectional survey of a nationally representative sample of 10,011 menopausal women from the Australian Longitudinal Study on Women's Health, conducted in 2010. Multivariable logistic regression models were applied to identify if the use of selected self-prescribed complementary and alternative medicine was significantly associated with a range of menopause-related symptoms. RESULTS Vitamins/minerals were more likely to be used by natural menopausal women experiencing anxiety (adjusted OR=1.20) and/or stiff/painful joints (adjusted OR=1.16). Yoga/meditation was more likely to be used by women with hysterectomy (adjusted OR=1.76) or natural menopausal women (adjusted OR=1.38) experiencing anxiety. Herbal medicines were more likely to be used by natural menopausal women experiencing anxiety (adjusted OR=1.22), tiredness (adjusted OR=1.20), and/or stiff/painful joints (adjusted OR=1.17), and by women with oophorectomy experiencing tiredness (adjusted OR=1.45). Aromatherapy oils were more likely to be used by natural menopausal women experiencing night sweats (adjusted OR=1.25) and by women with hysterectomy experiencing anxiety (adjusted OR=2.02). Chinese medicines were more likely to be used by women with oophorectomy experiencing stiff/painful joints (adjusted OR=4.06) and/or palpitations (adjusted OR=3.06). CONCLUSIONS Our study will help improve the patient-provider communication regarding complementary and alternative medicine use for menopause, and we conclude that menopausal status should be taken into account by providers for menopause care. The women's experience and motivations of such use warrant further research.
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Affiliation(s)
- Wenbo Peng
- Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, University of Technology Sydney, Sydney 2007, NSW, Australia
| | - David W Sibbritt
- Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, University of Technology Sydney, Sydney 2007, NSW, Australia
| | - Louise Hickman
- Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, University of Technology Sydney, Sydney 2007, NSW, Australia
| | - Jon Adams
- Australian Research Centre in Complementary and Integrative Medicine (ARCCIM), Faculty of Health, University of Technology Sydney, Sydney 2007, NSW, Australia.
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Examining the relationship between subjective sleep disturbance and menopause: a systematic review and meta-analysis. Menopause 2015; 21:1301-18. [PMID: 24800878 DOI: 10.1097/gme.0000000000000240] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to conduct a systematic review and meta-analysis of the relationship between menopausal stages and sleep disturbance reported using subjective methods. Secondary aims included examining the influence of culture/ethnicity on the relationship between menopausal stages and sleep disturbance. METHODS Multiple electronic databases were searched from the first available year to November 2013, and a manual search of the reference lists of review articles identified was also conducted. Twenty-four studies with a total of 63,542 midlife women were identified, coded, and analyzed. RESULTS The crude and adjusted odds of experiencing sleep disturbance were small but statistically significant for perimenopausal and postmenopausal women, using premenopause as the reference group. The ethnicity of the samples influenced effect sizes; Asian and white women both experienced an increased rate of sleep disturbance at the perimenopausal and postmenopausal stages compared with the premenopausal stage, whereas Hispanic women experienced no change in sleep disturbance across the menopausal transition. CONCLUSIONS The prevalence of sleep disturbance is higher in perimenopausal, postmenopausal, and surgical menopausal women than in premenopausal women. There is an independent relationship between menopausal stages and sleep disturbance beyond the effects of aging and other confounders, although the magnitude of the relationship is small. Culture, ethnicity, or both might affect the levels of sleep disturbance at various menopausal stages.
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Crowe BM, Van Puymbroeck M, Linder SM, Mcguire FA, Watt PJ. The Effects of Yoga Participation on Women's Quality of Life and Symptom Management During the Menopausal Transition: A Pilot Study. Health Care Women Int 2015; 36:1124-42. [DOI: 10.1080/07399332.2015.1066789] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Pimenta F, Maroco J, Ramos C, Leal I. Menopausal symptoms: is spirituality associated with the severity of symptoms? JOURNAL OF RELIGION AND HEALTH 2014; 53:1013-1024. [PMID: 23471772 DOI: 10.1007/s10943-013-9696-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The aim of this study was to explore whether spirituality was associated with menopausal symptoms. Menopausal symptoms, spirituality, health and menopausal status, and socio-demographic variables were assessed in a community sample of 710 peri- and postmenopausal women. A structural model was explored using structural equation modeling. The results evidence spirituality as a significant contributor regarding the severity of most menopausal symptoms. Among others, spirituality had a significant weight in depressive mood (β = -.414; p < .001), anxiety (β = -.308; p < .001), cognitive impairment (β = -.287; p < .001), aches/pain (β = -.148; p < .001), vasomotor (β = -.125; p = .005) and sexual symptoms (β = -.211; p < .001). Some socio-demographic variables, as well as perceived health, also predicted the menopausal symptoms' severity. Therefore, spirituality can have a positive impact on the menopausal symptoms' reporting.
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Affiliation(s)
- Filipa Pimenta
- Psychology and Health Research Unit, ISPA - Instituto Universitário, Rua Jardim do Tabaco, 34, 1149-041, Lisbon, Portugal,
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Singh A, Pradhan SK. Menopausal symptoms of postmenopausal women in a rural community of Delhi, India: A cross-sectional study. J Midlife Health 2014; 5:62-7. [PMID: 24970983 PMCID: PMC4071646 DOI: 10.4103/0976-7800.133989] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: There is very little data on the consequence of menopause on women in South East Asia region, especially from rural India. Importance is always given to reproductive health from menarche to menopause. Menopausal health demands priority in Indian scenario due to rising population of postmenopausal women. Objectives: The aim was to determine the mean age at attaining menopause and the prevalence of various self-reported menopausal symptoms complained by postmenopausal women (40-54 years). Furthermore, to determine the prevalence of anxiety and depression among postmenopausal women. Materials and Methods: A cross-sectional study was conducted in a rural area of New Delhi among 252 postmenopausal women from October 2011 to March 2013. A pretested, self-designed, semi structured, interview based, oral questionnaire was used. The Statistical Package for Social Sciences software Version 21.0 (SPSS) was used for analyses. Results: The mean age at attaining menopause was 46.24 (Standard Deviation = 3.38) years. Only 4 (1.6%) postmenopausal women had premature menopause. A total of 225 (89.3%) postmenopausal women experienced at least one or more menopausal symptom(s). The most common complaints of postmenopausal women were sleep disturbances (62.7%), muscle or joint pain (59.1%), hot flushes (46.4%) and night sweats (45.6%). A total of 32.1% (n=81) postmenopausal women suffered from depression and 21.0% (n=53) postmenopausal women suffered from anxiety. Conclusion: It is necessary to critically introspect health needs of postmenopausal women and specific components can be incorporated in the national health programs.
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Affiliation(s)
- Akanksha Singh
- Department of Community Medicine, Vardhman Mahavir Medical College, Safdarjung Hosital, New Delhi, India
| | - Shishir Kumar Pradhan
- Department of Community Medicine, Vardhman Mahavir Medical College, Safdarjung Hosital, New Delhi, India
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Ojeda E, Blümel JE, Vallejo MS, Lavín P. Climacteric symptoms in Quechua and Mestizo women from the Andean region of Cusco, Peru: Effects of altitude and ethnicity. Maturitas 2014; 77:356-60. [DOI: 10.1016/j.maturitas.2014.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/24/2014] [Accepted: 01/27/2014] [Indexed: 11/15/2022]
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Batool SF, Saggu Y, Ghani M. Perception of Menopausal Symptoms among Educated versus Non Educated Women by Using Menopausal Rating Scale (MRS). ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ojn.2014.48063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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da Silva AR, d'Andretta Tanaka AC. Factors associated with menopausal symptom severity in middle-aged Brazilian women from the Brazilian Western Amazon. Maturitas 2013; 76:64-9. [PMID: 23810489 DOI: 10.1016/j.maturitas.2013.05.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 05/21/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine the frequency and severity of menopausal symptoms and associated factors in middle-aged Brazilian women. METHODS A cross-sectional study was carried out involving 1415 women aged 35-65 years attended at the Outpatient unit of the Clinicas Hospital of Rio Branco, Acre state, Brazil. The Menopause Rating Scale (MRS) was used to assess the severity of menopause symptoms. The Stata 10 statistical package was used for all data analysis whereas Pearson's x(2) nonparametric association test was used for bivariate analysis, adopting a level of statistical significance of 5%. On the multivariate analysis, independent variables positively associated with the dependent model were retained in the final model (p<0.005). RESULTS Overall, 54.1% of participants were premenopausal, 10.1% perimenopausal, and 35.8% postmenopausal. Irritability was the most frequent symptom (78.3%), followed by joint and muscular discomfort (74.8%), and anxiety (72.7%). Mean total MRS score was 15.6+8.8 (median 15). After adjusting for confounding factors, the logistic regression analysis found low educational level (OR:1.53; [95% CI:1.21-1.95]; p<0.001); self-perceived poor/very poor health (OR:4.48; [95% CI: 3.53-5.69]; p<0.001), and menopausal transition phase (OR:1.73; [95% CI:1.18-2.53]; p=0.005) to be statistically significantly associated with more severe menopausal symptoms. CONCLUSION Among Brazilian women, atypical symptoms of the menopause were the most frequently reported. Severe menopausal symptoms were more likely in women with low educational level, self-perceived poor health and at the menopausal transition phase.
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Affiliation(s)
- Andréa Ramos da Silva
- Centre for Health Sciences and Sport, Federal University of Acre, Rio Branco, AC, Brazil.
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Blümel JE, Chedraui P, Baron G, Belzares E, Bencosme A, Calle A, Danckers L, Espinoza MT, Flores D, Gomez G, Hernandez-Bueno JA, Izaguirre H, Leon-Leon P, Lima S, Mezones-Holguin E, Monterrosa A, Mostajo D, Navarro D, Ojeda E, Onatra W, Royer M, Soto E, Tserotas K, Vallejo MS. Menopause could be involved in the pathogenesis of muscle and joint aches in mid-aged women. Maturitas 2013; 75:94-100. [DOI: 10.1016/j.maturitas.2013.02.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 02/19/2013] [Accepted: 02/22/2013] [Indexed: 01/01/2023]
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Abstract
BACKGROUND AND OBJECTIVES Research on menopause in Arab women is limited. The aim of our study was to assess the commonly experienced symptoms of menopause and their severity among Saudi women. DESIGN AND SETTING A cross-sectional study conducted at King Khalid University Hospital (KKUH) in Riyadh, Saudi Arabia. PATIENTS AND METHODS Four hundred and ninety healthy women aged 40-55 years and either attending KKUH themselves or accompanying their relatives in outpatient clinics participated in the study. The Menopause Rating Scale (MRS) was used to assess menopausal symptoms and severity. RESULTS The mean (SD) age of the women in menopause was 47.9 (6.03) years. The most frequent symptoms were muscle and joint problems occurring in 411 women (83.9%), physical and mental exhaustion in 393 (80.2%), heart discomfort in 358 (73.1%), sleeping disorders in 349 (71.2%), hot flashes in 348 (71.0%), and irritability in 348 (71.0%); in addition, 179 (36.5%) of these women experienced severe psychological distress. Perimenopausal women had higher total and subscales scorings for somatic symptoms than did premenopausal and postmenopausal women (P=.008). CONCLUSION The number of Saudi women reporting hot flashes and night sweats was comparable to the number of Western women. In addition, somatic symptoms were more prevalent among perimenopausal than among premenopausal women.
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Affiliation(s)
- AlJoharah M AlQuaiz
- Princess Nora Bent Abdullah Chair for Women's Health Research, King Saud University, Riyadh, Saudi Arabia.
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Quality of life in a large cohort of mid-aged Colombian women assessed using the Cervantes Scale. Menopause 2012; 19:924-30. [DOI: 10.1097/gme.0b013e318247908d] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Blümel JE, Chedraui P, Baron G, Belzares E, Bencosme A, Calle A, Danckers L, Espinoza MT, Flores D, Gomez G, Hernandez-Bueno JA, Izaguirre H, Leon-Leon P, Lima S, Mezones-Holguin E, Monterrosa A, Mostajo D, Navarro D, Ojeda E, Onatra W, Royer M, Soto E, Tserotas K, Vallejo MS. Menopausal symptoms appear before the menopause and persist 5 years beyond: a detailed analysis of a multinational study. Climacteric 2012; 15:542-51. [DOI: 10.3109/13697137.2012.658462] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kim MH. Menopausal Symptoms according to Sasang Constitution and Menopausal Status among Perimenopause Women. KOREAN JOURNAL OF WOMEN HEALTH NURSING 2012; 18:28-37. [PMID: 37697525 DOI: 10.4069/kjwhn.2012.18.1.28] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023] Open
Abstract
PURPOSE The purpose of this study was to address the difference menopausal symptoms according to sasang constitution and menopausal status among perimenopausal women. METHODS Data for this cross-sectional study was collected by administering questionnaires that elicited general information. The menopause rating scale (MRS) and Questionnaire for the Sasang Constitution Classification II (QSCC II) was given to 284 perimenopausal women who met the eligibility criteria and agreed to participate in the study. RESULTS The study subjects were composed of 27.5% so-yangin, 24.6% so-eumin, 18.7% tae-eumin, and 29.6% undefined category. The total MRS and all subscales were significantly higher for postmenopausal women in comparison to premenopausal women. Especially, so-eumin and tae-eumin displayed significantly higher scores in urogenital symptoms. The MRS score in postmenopausal women who belonged to the group of tae-eumin and so-eumin was significantly higher than those for premenopausal women. However, so-yangin displayed higher scores in psychological and urogenital symptoms than tae-eumin for premenopausal women. So-eumin presented significantly higher scores in urogenital symptoms in comparison to the undefined category for postmenopausal women. CONCLUSION These findings suggest that sasang constitution could be an important factor in understanding the woman's menopausal symptoms and identify the best treatment.
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Ojeda E, Monterrosa A, Blümel JE, Escobar-López J, Chedraui P. Severe menopausal symptoms in mid-aged Latin American women can be related to their indigenous ethnic component. Climacteric 2011; 14:157-63. [DOI: 10.3109/13697130903576297] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Green R, Polotsky AJ, Wildman RP, McGinn AP, Lin J, Derby C, Johnston J, Ram KT, Crandall CJ, Thurston R, Gold E, Weiss G, Santoro N. Menopausal symptoms within a Hispanic cohort: SWAN, the Study of Women's Health Across the Nation. Climacteric 2010; 13:376-84. [PMID: 20136411 DOI: 10.3109/13697130903528272] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Since the designation of people as Hispanic involves the amalgamation of a number of different cultures and languages, we sought to test the hypothesis that menopausal symptoms would differ among Hispanic women, based upon country of origin and degree of acculturation. METHODS A total of 419 women, aged 42-52 years at baseline, were categorized as: Central American (CA, n = 29) or South American (SA, n = 106), Puerto Rican (PR, n = 56), Dominican (D, n = 42), Cuban (Cu, n = 44) and non-Hispanic Caucasian (n = 142). We assessed vasomotor symptoms, vaginal dryness and trouble in sleeping. Hispanics and non-Hispanic Caucasians were compared using the chi(2) test, t test or non-parametric alternatives; ANOVA or Kruskal-Wallis testing examined differences among the five Hispanic sub-groups. Multivariable regression models used PR women as the reference group. RESULTS Hispanic women were overall less educated, less acculturated (p < 0.001 for both) than non-Hispanic Caucasians and more of them reported vasomotor symptoms (34.1-72.4% vs. 38.3% among non-Hispanic Caucasians; p = 0.0293) and vaginal dryness (17.9-58.6% vs. 21.1% among non-Hispanic Caucasians, p = 0.0287). Among Hispanics, more CA women reported vasomotor symptoms than D, Cu, SA, or PR women (72.4% vs. 45.2%, 34.1%, 50.9%, and 51.8%, respectively). More CA (58.6%) and D women (38.1%) reported vaginal dryness than PR (17.9%), Cu (25.0%) and SA (31.4%) women. More PR and D women reported trouble in sleeping (66.1 and 64.3%, respectively) compared to CA (51.7%), Cu (36.4%), and SA (45.3%) women. CONCLUSION Symptoms associated with menopause among Hispanic women differed by country of origin but not acculturation. Central American women appear to be at greatest risk for both vasomotor symptoms and vaginal dryness.
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Affiliation(s)
- R Green
- Department of Obstetrics, Gynecology & Women's Health, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, USA
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Risk factors related to the presence and severity of hot flushes in mid-aged Ecuadorian women. Maturitas 2010; 65:378-82. [DOI: 10.1016/j.maturitas.2009.11.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2009] [Revised: 11/23/2009] [Accepted: 11/25/2009] [Indexed: 11/18/2022]
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Chedraui P, Pérez-López FR, Mendoza M, Leimberg ML, Martinez MA, Vallarino V, Hidalgo L. Assessment of self-esteem in mid-aged women. Maturitas 2010; 66:77-82. [PMID: 20137871 DOI: 10.1016/j.maturitas.2010.01.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 01/12/2010] [Accepted: 01/12/2010] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To assess self-esteem and affecting factors in a middle-aged Ecuadorian female population using the Rosenberg Self-Esteem Scale (RSES). STUDY DESIGN This was a cross-sectional study in which 149 women (40-59 years) were requested to fill out the RSES and a general socio-demographic form containing personal and partner data. RESULTS Mean age of sample was 47.6+/-5.5 years, a 67.8% had less than 12 years of schooling and 33.6% were postmenopausal. At the moment of the survey 2.7% were on hormone therapy, and 2% were taking psychotropic drugs. Mean total RSES score was 26.6+/-3.1 (median 26, range 17-35). A 35.6% and 18.1% of women respectively presented total RSES scores below 26 (median) and 25 (25th percentile) suggesting lower self-esteem. Total scores did not differ when comparing older age, menopausal phases or time since the menopause. Logistic regression analysis determined that women with lower parity and an unhealthy partner were related to lower total RSES scores (below the 25th percentile) suggesting lower self-esteem. CONCLUSIONS In this mid-aged series lower self-esteem was not related to the aging process per se yet to socio-demographic female/male aspects. More research is needed in this regard that incorporates other sociological aspects.
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Affiliation(s)
- Peter Chedraui
- Academic and Research Department, Hospital Gineco-Obstétrico Enrique C. Sotomayor, Facultad de Ciencias Médicas, Universidad Católica de Guayaquil, Guayaquil, Ecuador.
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Lipovac M, Chedraui P, Gruenhut C, Gocan A, Stammler M, Imhof M. Improvement of postmenopausal depressive and anxiety symptoms after treatment with isoflavones derived from red clover extracts. Maturitas 2009; 65:258-61. [PMID: 19948385 DOI: 10.1016/j.maturitas.2009.10.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Revised: 10/28/2009] [Accepted: 10/30/2009] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the effect of isoflavones derived from red clover extracts (MF11RCE) over anxiety and depressive symptoms among postmenopausal women. METHODS One hundred and nine postmenopausal women aged 40 or more were randomly assigned to receive two daily capsules of MF11RCE (80mg red clover isoflavones, Group A) or placebo of equal appearance (Group B) for a 90-day period. After a washout period of 7 days, medication was crossed over and taken for 90 days more. Anxiety and depressive symptoms were measured at baseline, 90 and 187 days with the Hospital Anxiety and Depression Scale (HADS) and Zung's Self Rating Depression Scale (SDS). RESULTS After receiving the MF11RCE compound the total HADS (anxiety and depression subscale scores also) and the total SDS scores decreased significantly. This effect was equivalent to a 76.9% reduction in the total HADS score (76% for anxiety and 78.3% for depression) and an 80.6% reduction in the total SDS score. After placebo, total HADS (anxiety and depression subscale also) and total SDS scores also decreased significantly in comparison to baseline but only equivalent to an average 21.7% decline. CONCLUSION Red clover derived isoflavones (MF11RCE) were effective in reducing depressive and anxiety symptoms among postmenopausal women.
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Affiliation(s)
- Markus Lipovac
- Division of Obstetrics and Gynecology General Teaching Hospital Korneuburg, Austria
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Chedraui P, Pérez-López FR, Morales B, Hidalgo L. Depressive symptoms in climacteric women are related to menopausal symptom intensity and partner factors. Climacteric 2009; 12:395-403. [DOI: 10.1080/13697130902718150] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Severe menopausal symptoms in middle-aged women are associated to female and male factors. Arch Gynecol Obstet 2009; 281:879-85. [DOI: 10.1007/s00404-009-1204-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Accepted: 07/27/2009] [Indexed: 11/27/2022]
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Monterrosa A, Blumel JE, Chedraui P, Gomez B, Valdez C. Quality of life impairment among postmenopausal women varies according to race. Gynecol Endocrinol 2009; 25:491-7. [PMID: 19903056 DOI: 10.1080/09513590902972091] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Few studies have addressed the impact of menopausal symptom severity over quality of life (QoL) in Latin American women with different ethnics. OBJECTIVE To assess menopausal symptom severity and the QoL among postmenopausal Colombian women with three different ethnicities. METHOD Data of healthy naturally occurring postmenopausal Hispanic, indigenous and black women aged 40-59 years who participated in a cross-sectional study filling out the Menopause Rating Scale (MRS) and a general questionnaire was analysed. RESULTS A total of 579 women were included, 153 Hispanic, 295 indigenous and 131 Afro-descendent. Hispanic women had an average age of 55.3 +/- 3.3 years. Indigenous and black women were less educated than the Hispanic ones (2.2 +/- 1.8 and 4.6 +/- 4.4 vs. 6.4 +/- 3.5 years, p < 0.0001). Hispanic women displayed lower total MRS scores (better QoL) when compared to indigenous and black women. Urogenital scoring was worse among indigenous women compared to Hispanic and black women. Black women presented higher MRS psychological and somatic scorings than Hispanic and indigenous women. After adjusting for confounding factors, indigenous and black women continued to display a higher risk for impaired QoL, total MRS score > 16 (OR: 3.11, 95% CI: 1.30-7.44 and OR: 5.29, 95% CI: 2.52-11.10, respectively), which was significantly higher among indigenous women due to urogenital symptoms (OR: 102.75, 95% CI: 38.33-275.47) and black women due to psychological (OR: 6.58, 95% CI: 3.27-13.27) and somatic symptoms (OR: 3.88, 95% CI: 1.83-8.22). CONCLUSION In this postmenopausal Colombian series, menopausal symptoms in indigenous (urogenital) and black (somatic/psychological) women were more severe (impaired QoL) when compared to Hispanic ones.
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Affiliation(s)
- Alvaro Monterrosa
- Department of Gynecology and Obstetrics, Facultad de Medicina, Universidad de Cartagena, Cartagena, Colombia
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Green R, Santoro N. Menopausal symptoms and ethnicity: the Study of Women's Health Across the Nation. ACTA ACUST UNITED AC 2009; 5:127-33. [PMID: 19245351 DOI: 10.2217/17455057.5.2.127] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
A number of studies have suggested that ethnic background influences a woman's perception of her symptoms. The Study of Women's Health Across the Nation (SWAN) is a multiethnic, longitudinal, cohort study of US women that includes non-Hispanic Caucasian, African-American, Chinese, Japanese and Hispanic women. The initial strategy for this seven-site study involved community-based recruitment of non-Hispanic Caucasians at each site, plus one minority ethnic group. Since ethnicity varies with many other factors, measures of education, acculturation, social status, psychological wellbeing and financial strain were all taken into account in interpreting symptom onset, frequency and severity of the common menopausal symptoms. Biological and physical measures were also assessed and related to symptoms. Most symptoms varied by ethnicity. Vasomotor symptoms were more prevalent in African-American and Hispanic women and were also more common in women with greater BMI, challenging the widely held belief that obesity is protective against vasomotor symptoms. Vaginal dryness was present in 30-40% of SWAN participants at baseline, and was most prevalent in Hispanic women. Among Hispanic women, symptoms varied by country of origin. Acculturation appears to play a complex role in menopausal symptomatology. We conclude that ethnicity should be taken into account when interpreting menopausal symptom presentation in women.
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Affiliation(s)
- Robin Green
- Albert Einstein College of Medicine, Department of Obstetrics & Gynecology & Women's Health, Bronx, NY 10461, USA.
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Chedraui P, San Miguel G, Avila C. Quality of life impairment during the female menopausal transition is related to personal and partner factors. Gynecol Endocrinol 2009; 25:130-5. [PMID: 19253110 DOI: 10.1080/09513590802617770] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE To assess the female quality of life (QoL) during the menopausal transition and determine factors (personal and partner) related to its impairment. The frequency of menopausal symptoms was also assessed. METHODS In this cross-sectional study, healthy women aged 40-59 years were asked to fill out the Menopause Rating Scale (MRS) and a questionnaire assessing personal and partner demographic data. RESULTS During the study period, a total of 409 women were surveyed. Mean age was 47 +/- 5.3 years (median 46). Mean educational level was 13.2 +/- 4.1 years (median 14), with 28.1% having 12 or less years of schooling; premenopausal (42.1%), perimenopausal (24.4%) and postmenopausal (33.5%). At the time of the survey, 9.8% were receiving hormonal therapy (HT) for the menopause, 1.5% were on psychotropic drugs and 1.2% on alternative treatments for the menopausal. Regarding partner profile, 10.3% had erectile dysfunction, 11.2% had precocious ejaculation and 7.3% had abused alcohol. Mean total MRS score was 9.1 +/- 6.4 (median 9); for the somatic subscale, 4 +/- 2.7; the psychological subscale, 3 +/- 2.8 and the urogenital subscale, 2.1 +/- 2.5. Of the surveyed women, 50.6% presented a total MRS scoring of 9 or more (moderate to severe intensity). The four most frequently found symptoms of those composing the MRS were hot flushes (68.9%), sleeping problems (68.4%), depressive mood (55.2%) and irritability (51.6%). After adjusting for confounding factors, logistic regression analysis determined that female age, menopause and partner precocious ejaculation increased the risk for presenting higher total MRS scores (impaired female QoL) whereas HT use, church assistance and partner faithfulness decreased this risk. CONCLUSIONS A high rate of middle-aged women in this series presented impaired QoL associated to female age and hormonal status and additionally to partner's health and sexual behavior.
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Affiliation(s)
- Peter Chedraui
- Collaborative Group for Research of the Climacteric in Latin America (REDLINC, Ecuador Group 1), Guayaquil, Ecuador.
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Menopause-specific questionnaire assessment in US population-based study shows negative impact on health-related quality of life. Maturitas 2009; 62:153-9. [PMID: 19157732 DOI: 10.1016/j.maturitas.2008.12.006] [Citation(s) in RCA: 210] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2008] [Revised: 12/08/2008] [Accepted: 12/09/2008] [Indexed: 11/27/2022]
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Chedraui P, Blümel JE, Baron G, Belzares E, Bencosme A, Calle A, Danckers L, Espinoza MT, Flores D, Gomez G, Hernandez-Bueno JA, Izaguirre H, Leon-Leon P, Lima S, Mezones-Holguin E, Monterrosa A, Mostajo D, Navarro D, Ojeda E, Onatra W, Royer M, Soto E, Tserotas K. Impaired quality of life among middle aged women: A multicentre Latin American study. Maturitas 2008; 61:323-9. [DOI: 10.1016/j.maturitas.2008.09.026] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Revised: 09/23/2008] [Accepted: 09/24/2008] [Indexed: 10/21/2022]
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