Age at menopause and mortality in Taiwan: A cohort analysis

Age at natural menopause and its associated characteristics among Brazilian women: cross-sectional results from ELSI-Brazil

OBJECTIVES

This study aimed to determine the median age at natural menopause and analyze lifestyle, anthropometric, and dietary characteristics associated with the age at natural menopause among Brazilian women.

METHODS

This cross-sectional study involved 2,731 women 50 years and over, drawn from the baseline of the Brazilian Longitudinal Study of Aging (ELSI-Brazil, 2015/16). Nonparametric Kaplan-Meier cumulative survivorship estimates were used to assess the median timing of natural menopause. Cox proportional hazards regression models were employed to estimate the associations between age at natural menopause and exposure variables.

RESULTS

The overall median age at natural menopause was 50 years. In the adjusted Cox model, current smoking (hazard ratio [HR], 1.11; 95% CI, 1.01-1.23) and underweight (HR, 1.34; 95% CI, 1.12-1.61) were associated with earlier natural menopause. Conversely, performing recommended levels of physical activity in the last week (HR, 0.88; 95% CI, 0.80-0.97), being overweight (HR 0.86; 95% CI, 0.74-0.99), and adhering to two or three healthy eating markers (HR, 0.80; 95% CI, 0.66-0.97; HR, 0.76; 95% CI, 0.61-0.94, respectively) were associated with later age at natural menopause. Binge drinking and waist circumference were not associated with age at natural menopause.

CONCLUSIONS

Lifestyle, anthropometric, and dietary characteristics are significant factors that affect the age at natural menopause. Our findings can contribute to public policies targeted at Brazilian women's health.

The association between acute myocardial infarction and subsequent diagnosis of breast cancer: a nationwide, population-based cohort study

Coronary artery disease (CAD) such as acute myocardial infarction (MI) share several common risk factors with cancers, and each disease may influence the prognosis of the other. Recently, acute MI was demonstrated to accelerate the outgrowth of preexisting breast cancer cells but the risk of breast cancer after MI remains unclear. This study aimed to investigate the association between acute MI and a subsequent diagnosis of breast cancer. Female patients with and without a history of acute MI were identified from nationwide databases in Taiwan. Patients with a diagnosis of cancer, MI or CAD prior to the study period were excluded. After reducing confounding through inverse probability of treatment weighting, we compared the incidence of newly diagnosed breast cancer between patients with a history of acute MI and those without. As a result, a total of 66,445 female patients were obtained, including 15,263 patients with a history of acute MI and 51,182 patients without. The incidences of breast cancer during follow-up were 1.93 (95% confidence interval [CI] 1.78-2.09) and 1.80 (95% CI 1.67-1.93) per 1,000 person-years for patients with and without a history of acute MI, respectively. The hazard ratio (HR) was 1.05 (95% CI 0.78-1.41, P = 0.756). In subgroup analysis, breast cancer risk was significantly associated with acute MI in patients using antidiabetic drugs (HR 1.27; 95% CI 1.02-1.58) and in low to moderate urbanization levels (HR 1.28; 95% CI 1.06-1.53). In conclusion, the risk of newly diagnosed breast cancer was not increased in patients with acute MI when compared to general population without MI or CAD.

Association between antihyperlipidemic agents and the risk of chronic periodontitis in patients with hyperlipidemia: A population-based retrospective cohort study in Taiwan

BACKGROUND

The lipid-lowering and anti-inflammatory effects of statins and fibrates may ameliorate periodontitis. Patients with hyperlipidemia tend to have a worse periodontal status. This study assessed the association between the use of statins/fibrates and the incidence of chronic periodontitis in patients with hyperlipidemia in Taiwan.

METHODS

This retrospective cohort study enrolled patients newly diagnosed with hyperlipidemia between 2001 and 2012 from the 2000 Longitudinal Generation Tracking Database and followed them for 5 years. The study population was divided into four groups: statin monotherapy, fibrate monotherapy, combination therapy (both statins and fibrates), and control (neither statins nor fibrates). Each patient in the treatment group was matched at a ratio of 1:1 with a control. Chronic periodontitis risk was compared in the three study arms by using a Cox proportional hazard model.

RESULTS

Chronic periodontitis risk was reduced by 25.7% in the combination therapy group compared with the control group (adjusted hazard ratio [aHR], 0.743; 95% confidence interval (CI), 0.678-0.815). Low dose (<360 cumulative defined daily dose [cDDD]) and shorter duration (<2 years) of statin monotherapy seem to be associated with an increased risk of chronic periodontitis; high dose (≥720 cDDD/≥1080 cDDD) and longer duration (≥3 years) of statin/fibrate monotherapy may be correlated with a lower risk of periodontitis. Hydrophobic statin users had a lower chronic periodontitis risk than hydrophilic statin users.

CONCLUSION

Chronic periodontitis risk was lower in patients with hyperlipidemia on combination treatment with statins and fibrates, and the risk decreased when patients used statins or fibrates for >3 years.

Age at natural menopause and its determinants in female population of Kharameh cohort study: Comparison of regression, conditional tree and forests

BACKGROUND

Natural menopause is defined as the permanent cessation of menstruation that occurs after 12 consecutive months of amenorrhea without any obvious pathological or physiological cause. The age of this phenomenon has been reported to be associated with several health outcomes.

OBJECTIVES

This study aimed to estimate the Age at Natural Menopause (ANM) and to identify reproductive and demographic factors affecting ANM.

METHODS

This cross-sectional, population-based study was conducted on 2517 post-menopausal women aged 40-70 years participating in the first phase of the PERSIAN cohort study of Kharameh, Iran, during 2014-2017. To more accurately detect the determinants of ANM, we applied multiple linear regression beside some machine learning algorithms including conditional tree, conditional forest, and random forest. Then, the fitness of these methods was compared using Mean Squared Error (MSE) and Pearson correlation coefficient.

RESULTS

The mean±SD of ANM was 48.95±6.13. Both applied forests provided more accurate results and identified more predictors. However, according to the final comparison, the conditional forest was the most accurate method which recognized that more pregnancies, longer breastfeeding, Fars ethnicity, and urbanization have the greatest impact on later ANM.

CONCLUSIONS

This study found a wide range of reproductive and demographic factors affecting ANM. Considering our findings in decision-making can reduce the complications related to this phenomenon and, consequently, improve the quality of life of post-menopausal women.

Age at natural or surgical menopause, all-cause mortality, and lifespan among postmenopausal women in the United States

OBJECTIVE

This study investigated the association of age at natural menopause with or without undergoing hysterectomy and/or bilateral oophorectomy after menopause and age at surgical menopause with all-cause mortality and lifespan in postmenopausal women.

METHODS

The data stemmed from the National Health and Nutrition Examination Survey (NHANES) (1999-2018) and NHANES III (1988-1994), including 14,161 postmenopausal women over 40. Cox proportional hazard models were used to estimate unadjusted and adjusted hazard ratios (HRs) (95% confidence intervals [CIs]). We also used Cox proportional hazard models with penalized splines to depict the association between continuous age at menopause and all-cause mortality and nonparametric regression with smoothing splines to illustrate the association between age at menopause and lifespan in deceased participants.

RESULTS

The adjusted HRs (95% CIs) for age at natural menopause of <40, 40 to 44, and 55+ years in women without undergoing hysterectomy or bilateral oophorectomy after menopause were 1.48 (1.15-1.91), 1.16 (1.00-1.35), and 0.91 (0.77-1.07) compared with age at natural menopause of 45 to 54, respectively. The respective HRs (95% CIs) for age at surgical menopause were 1.39 (1.11-1.75), 1.09 (0.86-1.38), and 0.83 (0.53-1.32). However, no significant association was found between age at natural menopause and all-cause mortality among women undergoing hysterectomy and/or bilateral oophorectomy after menopause. When treated as continuous variables, age at natural menopause without undergoing hysterectomy or bilateral oophorectomy after menopause presented inverse and nonlinear associations with all-cause mortality, whereas age at surgical menopause was linearly inversely associated with all-cause mortality. The association between age at menopause and lifespan was linearly positive regardless of menopausal type.

CONCLUSION

Young age at menopause was associated with increased risks of all-cause mortality. The later menopause age was related to a longer lifespan.

Identifying the Risk Factors for Orbital Complications in Isolated Sphenoid Rhinosinusitis

Background and Objectives: Isolated sphenoid rhinosinusitis may have devastating consequences such as orbital complications due to its anatomical contiguity with vital structures. This study aimed to identify patients with isolated sphenoid inflammatory diseases at high risk for developing orbital complications and requiring aggressive management through investigation of the clinical and computed tomography (CT) characteristics of patients with isolated sphenoid rhinosinusitis. Materials and Methods: The medical records of patients who underwent endoscopic sinus surgery between 2005 and 2022 were retrospectively reviewed. Patients with isolated sphenoid rhinosinusitis were identified based on a manual review of the clinical and histopathological findings. Participants' clinical and CT features were reviewed. Results: Among the 118 patients with isolated sphenoid rhinosinusitis, 15 (12.7%) developed orbital complications, including diplopia, extraocular motility limitation, ptosis, and visual impairment. Headaches and facial pain occurred significantly more frequently in patients with orbital complications than in those without orbital complications (p < 0.001). Patients with diabetes mellitus or malignant neoplasms were more likely to develop orbital complications than those without these comorbidities (p < 0.05). Bony dehiscence on CT images was significantly more common in patients with orbital complications than in those without. In the regression analysis, diabetes mellitus (OR, 4.62), malignant neoplasm (OR, 4.32), and bony dehiscence (OR, 4.87) were significant predictors of orbital complications (p < 0.05). Conclusions: Headaches and facial pain are the most common symptoms of isolated sphenoid rhinosinusitis. Orbital complications of isolated sphenoid rhinosinusitis are more common in patients with comorbidities such as diabetes mellitus or malignancy or in those with bony dehiscence on CT images.

Sociodemographic characteristics associated with indications for surgical menopause in women: a retrospective study

OBJECTIVE

The aim of this study was to evaluate the surgical menopause indications and sociodemographic characteristics of women.

METHODS

In this retrospective study, we analyzed the sociodemographic characteristics of women with indications for surgical menopause in 2010-2020. The R Version 4.1.1 (2021-08-10) software and logistic regression analysis were used to evaluate the data.

RESULTS

A total of 704 women's data were obtained in this study. Surgical menopause indications were found to stem from bleeding (46.0%), cancer (28.3%), cancer risk (18.9%), and other causes (6.8%). Surgical menopause indications originating from cancer were increased by 0.08 times (95%CI 0.01-0.68) due to smoking, 0.45 times (95%CI 0.23-0.88) due to regular drug use, and 0.36 times (95%CI 0.19-0.69) due to the presence of chronic disease (p<0.05).

CONCLUSION

More than half of the women with surgical menopause indications were between 41 and 46 years of age. Additionally, 54.9% of the women had a chronic disease. Therefore, it is recommended to plan preventive health services for morbidity and mortality risks that may develop due to surgical menopause.

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.

Application of SHAP for Explainable Machine Learning on Age-Based Subgrouping Mammography Questionnaire Data for Positive Mammography Prediction and Risk Factor Identification

Mammography is considered the gold standard for breast cancer screening. Multiple risk factors that affect breast cancer development have been identified; however, there is an ongoing debate regarding the significance of these factors. Machine learning (ML) models and Shapley Additive Explanation (SHAP) methodology can rank risk factors and provide explanatory model results. This study used ML algorithms with SHAP to analyze the risk factors between two different age groups and evaluate the impact of each factor in predicting positive mammography. The ML model was built using data from the risk factor questionnaires of women participating in a breast cancer screening program from 2017 to 2021. Three ML models, least absolute shrinkage and selection operator (lasso) logistic regression, extreme gradient boosting (XGBoost), and random forest (RF), were applied. RF generated the best performance. The SHAP values were then applied to the RF model for further analysis. The model identified age at menarche, education level, parity, breast self-examination, and BMI as the top five significant risk factors affecting mammography outcomes. The differences between age groups ranked by reproductive lifespan and BMI were higher in the younger and older age groups, respectively. The use of SHAP frameworks allows us to understand the relationships between risk factors and generate individualized risk factor rankings. This study provides avenues for further research and individualized medicine.

Positive associations between menstrual lifespan, geriatric depression and healthy longevity in Chinese oldest-old and centenarian women

OBJECTIVE

Menstrual lifespan (ML) is an important biological characteristic for women. Rare evidence has established the associations between menopause age (MI), geriatric depression and healthy longevity. This study aimed to address these associations in Chinese oldest-old and centenarian women, and explore their related factors in order to provide strategy support for healthy aging.

METHODS

The China Hainan Centenarian Cohort Study provides a population-based sample in Hainan, China. A total of 723 women including 318 centenarian women and 405 oldest-old women aged 80-99 years were included in this study. Data on demographic information were collected using a structured questionnaire. Physical examination and blood samples were obtained following standard procedure. Geriatric Depression Scale (GDS-15) was used to evaluate depressive symptoms for all participants.

RESULTS

The proportions of participants with depression and longevity were 19.78 % (143 older adults) and 43.98 % (318 older adults), respectively. After adjusting for a wide range of other covariates in multiple logistic regression analyses, ML was positively and significantly associated with depression and longevity [Exp(β) 1.076 and 1.121; P < 0.05 for all]. In multiple linear regression analyses, there were significantly positive associations of ML with GDS-15 (β = 0.061) and age (β = 0.238, p < 0.05 for all) after adjusting for all covariates.

CONCLUSIONS

This study provides epidemiological evidence that menstrual lifespan has positive associations with geriatric depression and healthy longevity in Chinese oldest-old and centenarian women. Future researches should focus on the effects of intervening MI on psychological health and successful longevity.

Age Specific Risks of Uterine Cancer in Type 2 Diabetes and Associated Comorbidities in Taiwan

Introduction: The global incidence of uterine cancer has increased substantially in recent decades. We evaluated if the trend of increasing prevalence of diabetes mellitus (DM) and obesity are attributed to the development of uterine cancer. Methods: Using data derived from the National Health Insurance database and Taiwan Cancer Registry, multivariate Cox proportional hazards regression models were adapted to analyze the risk factors of uterine cancer with potential confounding variables. Results: There were a total of 5,104,242 women aged 30−70 years enrolled in the study and 147,772 of them were diagnosed with DM during 2005−2007. In a total of 11 years of follow-up, 14,398 subjects were diagnosed with uterine cancer. An elevated risk of uterine cancer was observed in women with DM of all ages (HR 1.66, 95% CI 1.53−1.81, p < 0.0001). The effect of DM was highest at age 30−39 years (RR 3.05, 95% CI 2.35−3.96, p < 0.0001). In the group of <50 years old, DM patients had at least a twofold higher risk of developing uterine cancer (HR 2.39, 95% CI 2.09−2.74, p < 0.0001). Subjects among all ages diagnosed with polycystic ovary syndrome (PCOS) (HR 2.91, 95% CI 2.47−3.42, p < 0.0001), obesity (HR 2.13, 95% CI 1.88−2.41, p < 0.0001), and those undergoing hormone replacement therapy (HRT) (HR 1.60, 95% CI 1.33−1.93, p < 0.0001) were also positively associated with uterine cancer. Positive associations of hyperlipidemia (HR 1.33, 95% CI 1.22−1.46, p < 0.0001) and statin use (HR 1.27, 95% CI 1.12−1.44, p = 0.0002) on uterine cancer were only observed in subjects <50 years. On the contrary, hyperlipidemia was negatively associated with uterine cancer in subjects ≥50 years (HR 0.91, 95% CI: 0.84−0.98, p = 0.0122). Conclusions: DM is in general the most important risk factor for uterine cancer, especially in premenopausal women. Obesity, PCOS, HPL, statin use, and HRT were also associated with uterine cancer in subjects younger than 50 years. Premenopausal women with DM and respective comorbidities should be aware of the development of uterine cancer.

The interplay between diabetes mellitus and menopause: clinical implications

The menopausal transition is an impactful period in women's lives, when the risk of cardiovascular disease is accelerated. Similarly, diabetes mellitus profoundly impacts cardiovascular risk. However, the interplay between menopause and diabetes mellitus has not been adequately studied. The menopausal transition is accompanied by metabolic changes that predispose to diabetes mellitus, particularly type 2 diabetes mellitus (T2DM), as menopause results in increased risk of upper body adipose tissue accumulation and increased incidence of insulin resistance. Equally, diabetes mellitus can affect ovarian ageing, potentially causing women with type 1 diabetes mellitus and early-onset T2DM to experience menopause earlier than women without diabetes mellitus. Earlier age at menopause has been associated with a higher risk of T2DM later in life. Menopausal hormone therapy can reduce the risk of T2DM and improve glycaemic control in women with pre-existing diabetes mellitus; however, there is not enough evidence to support the administration of menopausal hormone therapy for diabetes mellitus prevention or control. This Review critically appraises studies published within the past few years on the interaction between diabetes mellitus and menopause and addresses all clinically relevant issues, such as the effect of menopause on the development of T2DM, and the management of both menopause and diabetes mellitus.

Menopause, hysterectomy, menopausal hormone therapy and cause-specific mortality: cohort study of UK Biobank participants

STUDY QUESTION

What is the association between menopausal hormone therapy (MHT) and cause-specific mortality?

SUMMARY ANSWER

Self-reported MHT use following early natural menopause, surgical menopause or premenopausal hysterectomy is associated with a lower risk of breast cancer mortality and is not consistently associated with the risk of mortality from cardiovascular disease or other causes.

WHAT IS KNOWN ALREADY

Evidence from the Women's Health Initiative randomized controlled trials showed that the use of estrogen alone is not associated with the risk of cardiovascular mortality and is associated with a lower risk of breast cancer mortality, but evidence from the Million Women Study showed that use of estrogen alone is associated with a higher risk of breast cancer mortality.

STUDY DESIGN, SIZE, DURATION

Cohort study (the UK Biobank), 178 379 women, recruited in 2006-2010.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Postmenopausal women who had reported age at menopause (natural or surgical) or hysterectomy, and information on MHT and cause-specific mortality. Age at natural menopause, age at surgical menopause, age at hysterectomy and MHT were exposures of interest. Natural menopause was defined as spontaneous cessation of menstruation for 12 months with no previous hysterectomy or oophorectomy. Surgical menopause was defined as the removal of both ovaries prior to natural menopause. Hysterectomy was defined as removal of the uterus before natural menopause without bilateral oophorectomy. The study outcome was cause-specific mortality.

MAIN RESULTS AND THE ROLE OF CHANCE

Among the 178 379 women included, 136 790 had natural menopause, 17 569 had surgical menopause and 24 020 had hysterectomy alone. Compared with women with natural menopause at the age of 50-52 years, women with natural menopause before 40 years (hazard ratio (HR): 2.38, 95% CI: 1.64, 3.45) or hysterectomy before 40 years (HR: 1.60, 95% CI: 1.23, 2.07) had a higher risk of cardiovascular mortality but not cancer mortality. MHT use was associated with a lower risk of breast cancer mortality following surgical menopause before 45 years (HR: 0.17, 95% CI: 0.08, 0.36), at 45-49 years (HR: 0.15, 95% CI: 0.07, 0.35) or at ≥50 years (HR: 0.28, 95% CI: 0.13, 0.63), and the association between MHT use and the risk of breast cancer mortality did not differ by MHT use duration (<6 or 6-20 years). MHT use was also associated with a lower risk of breast cancer mortality following natural menopause before 45 years (HR: 0.59, 95% CI: 0.36, 0.95) or hysterectomy before 45 years (HR: 0.49, 95% CI: 0.32, 0.74).

LIMITATIONS, REASONS FOR CAUTION

Self-reported data on age at natural menopause, age at surgical menopause, age at hysterectomy and MHT.

WIDER IMPLICATIONS OF THE FINDINGS

The current international guidelines recommend women with early menopause to use MHT until the average age at menopause. Our findings support this recommendation.

STUDY FUNDING/COMPETING INTEREST(S)

This project is funded by the Australian National Health and Medical Research Council (NHMRC) (grant numbers APP1027196 and APP1153420). G.D.M. is supported by NHMRC Principal Research Fellowship (APP1121844), and M.H. is supported by an NHMRC Investigator Grant (APP1193838). There are no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Association of Dietary Pattern with Cardiovascular Risk Factors among Postmenopausal Women in Taiwan: A Cross-Sectional Study from 2001 to 2015

Unhealthy diet and inappropriate lifestyle contribute to an imbalance in cardiometabolic profiles among postmenopausal women. This research aimed to analyze the association between dietary pattern and changes in cardiovascular risk factors among postmenopausal Taiwanese women using binary logistic regression. This cross-sectional study involved 5689 postmenopausal Taiwanese women aged 45 years and above, and the data were obtained from Mei Jau Health Management Institution database between 2001 and 2015. The cardiovascular risk dietary pattern characterized by high intakes of processed food, rice/flour products, organ meat, and sauce was derived by reduced rank regression. Participants in the highest quartile of the cardiovascular risk dietary pattern were more likely to have high levels of systolic blood pressure (OR = 1.29, 95% CI 1.08-1.53), diastolic blood pressure (OR = 1.28, 95% CI 1.01-1.62), atherogenic index of plasma (OR = 1.26, 95% CI 1.06-1.49), triglycerides (OR = 1.38, 95% CI 1.17-1.62), and fasting blood glucose (Q3: OR = 1.45, 95% CI 1.07-1.97). However, this dietary pattern was not correlated with total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and C-reactive protein. Therefore, adherence to the cardiovascular risk dietary pattern increases the risk of having higher levels of blood pressure, triglycerides, fasting blood glucose in postmenopausal Taiwanese women.

Comprehensive Clinicopathologic Analysis for Mismatch Repair Protein Expression in Unselected Endometrial Carcinoma Patients With an Emphasis on the Role of MLH1 Deficiency

Screening for mismatch repair (MMR) deficiency in unselected patients with endometrial carcinoma (EC) and the clinicopathologic descriptions of ECs with MMR deficiency have been well demonstrated in Western populations, but studies on Asian populations are relatively scarce. In this study, we described the clinicopathologic features of ECs according to MMR status in unselected Taiwanese patients. We also conducted subgroup analysis of MMR-deficient (dMMR) cases according to the presence or absence of MLH1. Patients diagnosed with ECs between January 2017 and February 2020 at our institution were included. Immunohistochemistry analysis of MLH1, PMS2, MSH2, and MSH6 proteins on endometrial primary tumors and clinicopathologic variables were assessed retrospectively. A total of 231 EC patients were enrolled, of whom 50 (21.6%) had dMMR tumors. Of these 50 cases, 39 had tumors that lacked MLH1 expression and 11 were positive for MLH1. The overall dMMR group was significantly related to older age, parity, and high histologic grade compared with the MMR-proficient (pMMR) group. ECs with MLH1 deficiency were obviously associated with several poor pathologic features, including high histologic grade, lymph node metastasis, and lymphovascular space invasion. Moreover, we first reported that parity and the late age at menopause are strongly correlated with MLH1-related dMMR EC group compared with pMMR group. In conclusion, triaging EC patients into pMMR, MLH1-related dMMR and non-MLH1-related dMMR groups by immunohistochemistry analysis may help clinicians to predict disease behavior and guide further management. The strong association between parity and MLH1-related dMMR ECs warrants further investigation on the underlying mechanism.

The Effects of Whole-Body Vibration Exercise Combined With an Isocaloric High-Fructose Diet on Osteoporosis and Immunomodulation in Ovariectomized Mice

Background

Osteoporosis and immune-associated disorders are highly prevalent among menopausal women, and diet control and exercise exert beneficial effects on physiological modulation in this population. A controlled diet with a low fat content and a balanced caloric intake improves menopausal health, but the health effects of excessive fructose consumption on menopausal women are yet to be confirmed. In addition, whole-body vibration (WBV), a safe passive-training method, has been shown to have multiple beneficial effects on metabolism regulation, obesity, and bone health.

Methods

The ovariectomized (OVX) C57BL/6J model was used to verify the effects of WBV combined with a high-fructose diet (HFrD) for 16 weeks on physiological modulation and immune responses. The mice were randomly allocated to sham, OVX, OVX+HFrD, and OVX+HFrD+WBV groups, which were administered with the indicated ovariectomy, dietary and WBV training treatments. We conducted growth, dietary intake, glucose homeostasis, body composition, immunity, inflammation, histopathology, and osteoporotic assessments (primary outcomes).

Results

Our results showed that the isocaloric HFrD in OVX mice negated estrogen-deficiency–associated obesity, but that risk factors such as total cholesterol, glucose intolerance, osteoporosis, and liver steatosis still contributed to the development of metabolic diseases. Immune homeostasis in the OVX mice was also negatively affected by the HFrD diet, via the comprehensive stimulation of T cell activation, causing inflammation. The WBV intervention combined with the HFrD model significantly ameliorated weight gain, glucose intolerance, total cholesterol, and inflammatory cytokines (interferon gamma [IFN-γ], interleukin [IL]-17, and IL-4) in the OVX mice, although osteoporosis and liver steatosis were not affected compared to the negative control group. These findings indicate that an isocaloric high-fructose diet alone may not result in menopausal obesity, but that some deleterious physiological impacts still exist.

Conclusion

The WBV method may modulate the physiological impacts of menopause and the HFrD diet, and should be considered as an alternative exercise prescription for people with poor compliance or who are unable or unwilling to use traditional methods to improve their health. In future studies, using the WBV method as a preventive or therapeutic strategy, combined with nutritional interventions, medication, and other exercise prescriptions, may prove beneficial for maintaining health in menopausal women.

Association of Thiazide Use in Patients with Hypertension with Overall Fracture Risk: A Population-Based Cohort Study

Thiazide diuretics have long been widely used as antihypertensive agents. In addition to reducing blood pressure, thiazides also control calcium homeostasis and increase bone density. We hypothesized that the use of thiazides in patients with hypertension would reduce overall fracture risk. We used the Taiwan National Health Insurance Research Database to find patients with a hypertension diagnosis who accepted antihypertensive treatment from 2000 to 2017. The patients were further classified into thiazide users and nonthiazide users. Multivariable Cox regression analysis and Kaplan-Meier survival analysis were performed to estimate the adjusted hazard ratios (aHRs) and cumulative probability of fractures. After 1:1 propensity score matching by sex, age, urbanization level of place of residence, income, comorbidities, and medications, there were 18,483 paired thiazide users and non-users, respectively. The incidence densities of fractures (per 1000 person-months) were 1.82 (95% CI: 1.76-1.89) and 1.99 (95% CI: 1.92-2.06) in the thiazide and nonthiazide groups, respectively. The results indicated a lower hazard ratio for fractures in thiazide users (aHR = 0.93, 95% CI: 0.88-0.98). Kaplan-Meier survival analysis revealed a significantly lower cumulative incidence of fractures in the thiazide group (log-rank test; p = 0.0012). In conclusion, our results reveal that thiazide use can reduce fracture risk. When antihypertensive agents are being considered, thiazide may be a better choice if the patient is at heightened risk of fracture.

Combined Low Plant and High Animal Dietary Pattern Is Associated with a Lower Risk of Anemia among Dyslipidemic Adult Women in Taiwan: A Retrospective Study from 2001 to 2015

Anemia and dyslipidemia often occurs in premenopausal women. This study investigated the association between dietary patterns and anemia among dyslipidemic women in Taiwan. This study recruited 22,631 dyslipidemic women aged 20–45 years between 2001 and 2015. The dietary assessment was collected by a validated food frequency questionnaire. The biochemical data including blood lipids, red blood cells, hemoglobin, hematocrit, and C-reactive protein (CRP) were retrieved from the database. Women with a combined high plant diet (HP) and low animal diet (LA) were associated with a lower prevalence of obesity (11.7%), central obesity (16.0%), high total cholesterol (16.4%), and high low-density lipoprotein cholesterol (11.9%), and had lower hemoglobin (12.9 ± 1.4 g/dL), hematocrit (38.8 ± 3.6%), and CRP levels (20.6 ± 31.4 nmol/L). The low plant diet (LP) + high animal diet (HA) pattern was negatively associated with moderate to severe anemia (OR: 0.76, 95% CI: 0.64–0.92, p = 0.004) compared to the low plant diet (LP) + low animal diet (LA) pattern. However, the HP + LA pattern was positively correlated with moderate to severe anemia (OR: 1.22, 95% CI: 1.04–1.43, p = 0.015). In conclusion, a low plant and high animal diet plays a role in preventing anemia development among dyslipidemic women.

Differential prognoses among male and female patients with hepatocellular carcinoma

BACKGROUND

The incidence of hepatocellular carcinoma (HCC) is significantly higher in men than women. Nonetheless, the impact of sex disparities on HCC outcomes remains unclear. We aimed to compare the clinical manifestations and prognoses between male and female patients with HCC.

METHODS

This retrospective study enrolled 5337 consecutive patients (3976 men, 1361 women) who were diagnosed with HCC from 2007 to 2020. The prognostic factors were identified by the Cox proportional hazards model.

RESULTS

Male patients were younger upon HCC diagnosis (median age 64 vs 69 years; p < 0.001) with more favorable hepatic functional reserves (39.0% vs 35.1% albumin-bilirubin grade 1; p = 0.025) but had greater tumor burdens than the female patients. Furthermore, fewer male patients underwent curative therapies for HCC compared with the female patients (49.0% vs 57.0%; p < 0.001). After a median follow-up of 20.1 months (interquartile range, 5.8-47.3 months), 3133 patients died. The cumulative 5-year overall survival rates were 37.1% and 41.9% for male and female patients, respectively (p < 0.001). From the multivariate analysis, male sex was not an independent factor predictive of poor overall survival in all patients and in the subgroup analysis stratified by treatment modalities. When stratified by age, the female sex was an independent factor associated with lower mortality in younger (≤50 years) patients but not in older patients with HCC.

CONCLUSION

Sex was not an independent predictor of the outcome of patients with HCC, especially for those aged more than 50 years.

Association of weight, smoking, and alcohol consumption with age at natural menopause

In South Korea, rapid economic growth and modernization have led to changes in lifestyle factors that may affect age at natural menopause. Data from 4,793 women aged ≥55 years, who had a natural menopause, were analyzed from the Korea National Health and Nutrition Examination Survey (2013-2017). Multinomial logistic regression was used to examine the association between lifestyle factors and age at natural menopause after adjusting for birth cohort (Model 1) and sociodemographic and reproductive factors (Model 2). Overall, 3.1% of women experienced premature menopause (<40 years), 7.6% early menopause (40-44 years), and 12.8% late menopause (≥55 years). Women born in the 1940s or earlier among the birth cohorts had the highest prevalence of premature (70.0%), early (58.5%), and late (43.1%) menopause. In Model 2, current smoking (odds ratio = 3.99 and 95% confidence interval = 1.35-11.81) was associated with premature menopause. Low (<18.5 kg/m²) and high (≥25 kg/m²) body mass index were associated with early (odds ratio = 2.30 and 95% confidence interval = 1.01-5.22) and late (odds ratio = 1.38 and 95% confidence interval = 1.10-1.72) menopause respectively. Conversely, there was no association between age at natural menopause and alcohol consumption. The results suggest that healthy lifestyle factors, such as not smoking and proper weight maintenance, are significant factors affecting age at natural menopause. Our findings may help develop health policies and provide targeted care to improve women's health after midlife.

Early Menopause May Associate With a Higher Risk of CKD and All-Cause Mortality in Postmenopausal Women: An Analysis of NHANES, 1999–2014

Background

Chronic kidney disease (CKD) in women is often accompanied by hormone disorders such as sex hormones, and most women with CKD are in the post-menopausal age group. Due to the close relationship between menopause and sex hormones, we aimed to explore the association between early menopause and CKD in post-menopausal women, and the influence of early menopause on longevity in the CKD population.

Methods

Information regarding 4,945 post-menopausal women was extracted from the database of the National Health and Nutrition Examination Survey (NHANES) 1999–2014, and then divided into 4 groups according to the type of menopause (natural or surgical) and early menopause (menopause at age <45) or not. The association between early menopause and CKD prevalence was examined using multivariable logistic regression, while we used multivariable Cox proportional hazards models to investigate the possible relationship between early menopause and all-cause mortality in CKD and non-CKD populations. The differences in the levels of sex hormones between women with and without CKD were also explored.

Results

Compared with women with natural menopause at age ≥45, women experiencing early natural menopause had a higher risk of CKD [OR = 1.26 (1.01–1.56)]. Similarly, as compared to women with surgical menopause at age ≥ 45, women in the early surgical menopause group were more likely to have CKD [OR = 1.38 (1.05–1.81)]. In addition, early surgical menopause was associated with higher mortality in the non-CKD group [HR = 1.62 (1.06–2.49)], but not in the CKD group. Women with CKD had a higher level of luteinizing hormone and follicle-stimulating hormone, combined with a lower level of testosterone and estradiol than the non-CKD women.

Conclusion

Both early natural and surgical menopause were associated with a higher risk of CKD. Early surgical menopause was a hazard factor for survival in the non-CKD group, but not in the CKD group. Further research is required to understand the mechanisms.

Changes in Bone Mineral Density and Trabecular Bone Score over Time between Vegetarian and Non-Vegetarian Middle-Aged and Older Women: A Three-Year Retrospective Medical Record Review

The effect of a vegetarian diet on bone health remains controversial. This retrospective medical record review compared changes in bone mineral density (BMD) and trabecular bone score (TBS) between vegetarian and non-vegetarian middle-aged and older women who underwent two general health examinations (T1 and T2) that were approximately three years apart. Generalized estimating equations were used to compare the change in lumbar spine and bilateral hip BMD and TBS over time. At T1, the mean age of the patients was 56.6 years (standard deviation 9.7 years) and the mean interval between T1 and T2 was 2.7 years. For women aged 40–55 years, compared with non-vegetarians, vegetarians were significantly associated with a larger reduction in lumbar spine BMD (p < 0.001) and left hip femoral neck BMD (p = 0.015) over the three-year interval. On the contrary, changes in BMD were not significant at any site in women aged ≥ 56 years. Moreover, the changes in BMD and TBS over the three-year interval did not significantly differ between vegetarian and non-vegetarian women aged 65–90 years. In conclusion, for women aged 40–55 years, vegetarian diets reduced bone quantity, as measured by BMD, but not bone quality, as measured by TBS.

Differences in clinical and imaging presentation of maxillary sinus fungus ball with and without intralesional hyperdensity

Maxillary sinus fungal balls (MSFBs) mostly occur in older individuals and demonstrate female predominance. Early diagnosis is important to avoid treatment delays. Intralesional hyperdensity (IH) indicates the presence of heavy metal deposition within fungal hyphae and has been the most specific characteristic of MSFB on computed tomography (CT). For those without IH on CT, the diagnosis of MSFB remains challenging. This study aimed to characterize clinical presentation of MSFB with and without IH and to study factors contributing to MSFB with no IH formation. We retrospectively identified 588 patients with MSFB. The clinical characteristics and CT findings were reviewed. Patients with unilateral MSFB had a mean age of 57.4 years and demonstrated female predominance (64.63%). The female-to-male ratio was highest at 51–60 years (2.02) and rose to 2.60 in MSFB with IH only. Compared to those with IH, MSFB without IH was significantly more common in males (OR = 2.49), in those with diabetes mellitus (DM) (OR = 1.87), adjacent maxillary odontogenic pathology (OR = 1.75). Complete opacification on CT was less common in MSFB without IH (OR = 0.60). Patients with MSFB without IH were more likely to have DM, no female predominance, adjacent maxillary odontogenic pathology, and partial opacification of the sinus, compared to those with IH. These may be helpful in better understanding of the formation of MSFBs without IH, early identification of them and prevention of post-operative recurrence.

Do peripartum and postmenopausal women with primary liver cancer have a worse prognosis? A nationwide cohort in Taiwan

BACKGROUND

While primary liver cancer (PLC) is one of the most common cancers around the world, few large-scale population-based studies have been reported that evaluated the clinical survival outcomes among peripartum and postmenopausal women with PLC.

AIM

To investigate whether peripartum and postmenopausal women with PLC have lower overall survival rates compared with women who were not peripartum and postmenopausal.

METHODS

The Taiwan National Health Insurance claims data from 2000 to 2012 was used for this propensity-score-matched study. A cohort of 40 peripartum women with PLC and a reference cohort of 160 women without peripartum were enrolled. In the women with PLC with/without menopause study, a study cohort of 10752 menopausal females with PLC and a comparison cohort of 2688 women without menopause were enrolled.

RESULTS

Patients with peripartum PLC had a non-significant risk of death compared with the non-peripartum cohort [adjusted hazard ratios (aHR) = 1.40, 95% confidence intervals (CI): 0.89-2.20, P = 0.149]. The survival rate at different follow-up durations between peripartum PLC patients and those in the non-peripartum cohort showed a non-significant difference. Patients who were diagnosed with PLC younger than 50 years old (without menopause) had a significant lower risk of death compared with patients diagnosed with PLC at or older than 50 years (postmenopausal) (aHR = 0.64, 95%CI: 0.61-0.68, P < 0.001). The survival rate of women < 50 years with PLC was significantly higher than older women with PLC when followed for 0.5 (72.44% vs 64.16%), 1 (60.57% vs 51.66%), 3 (42.92% vs 31.28%), and 5 year(s) (37.02% vs 21.83%), respectively (P < 0.001).

CONCLUSION

Peripartum females with PLC have no difference in survival rates compared with those patients without peripartum. Menopausal females with PLC have worse survival rates compared with those patients without menopause.

Age-Specific Normative Values of Lumbar Spine Trabecular Bone Score (TBS) in Taiwanese Men and Women

Trabecular bone score (TBS) is a novel method for assessing trabecular microarchitecture. Normative values of TBS are available for various populations of the world but are not yet available for Taiwanese adults. Therefore, the purpose of this study was to estimate age-specific, normative TBS curves for Taiwanese men and women. Medical records of general health examinations from a regional hospital in Southern Taiwan were reviewed. Individuals aged 30–90 years with data on lumbar spine bone mineral density (BMD) were included. TBS was retrospectively calculated from dual-energy X-ray absorptiometry scans using TBS iNsight software. Of the 12,028 patients included, 4533 (37.7%) were male and the mean age was 55.8 years. The mean TBS was 1.392 (standard deviation (SD) 0.089) for men and 1.344 (SD 0.107) for women. In women, TBS declined at a rate of 0.0004/year among those aged 30.0–45.9 years, 0.0106/year among those 46.0–60.7 years, and 0.0028/year among those 60.8–90.0 years. In men, TBS declined at a constant rate of 0.0023/year over the entire age range. In conclusion, age-adjusted, normative curves of TBS for Taiwanese men and women are presented, which could be used to facilitate the use of TBS in assessing bone status in clinical practice.

Risk of chronic spontaneous urticaria in reproductive-aged women with abnormal uterine bleeding: A population-based cohort study

Women with abnormal uterine bleeding (AUB) have been reported to develop chronic spontaneous urticaria (CSU). Nevertheless, whether or not AUB women have an increased risk of CSU has not been examined in large-scale epidemiologic studies. This study aimed to investigate the risk of CSU among reproductive-aged women with AUB. A total of 79 595 patients and 79 107 propensity-score matched controls were recruited from Taiwan's National Health Insurance Research Database to conduct a nationwide cohort study. The Cox proportional-hazard regression model was applied to examine the adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for CSU in relation to AUB. We found that women with AUB had a higher risk for CSU (aHR = 1.83; 95% CI, 1.76-1.90) than women without AUB. Subgroup analyses revealed that AUB with an abnormal bleeding frequency (aHR = 1.70; 95% CI, 1.60-1.79), irregular bleeding (aHR = 1.80; 95% CI, 1.71-1.89), and intermenstrual bleeding (aHR = 1.65; 95% CI, 1.49-1.83) were associated with an increased risk of CSU compared with those without abnormalities. The Kaplan-Meier analysis revealed that the cumulative incidence of developing CSU was consistently higher in the AUB cohort than in the non-AUB cohort during the entire follow-up period (log-rank test, p < 0.001). In conclusion, reproductive-aged women with AUB were found to have a higher risk of developing CSU. This study emphasizes the importance of enquiring CSU patients about menstrual problems in clinical practice. Further consultation with obstetrician-gynecologists may be beneficial.

A retrospective study on sex difference in patients with urolithiasis: who is more vulnerable to chronic kidney disease?

Background

Urolithiasis is considered a vital public health issue with a substantial burden on kidney function. Additionally, only few reports focused on the gender difference in patients with urolithiasis. Therefore, this study aimed to compare the clinical characteristics of sex difference and their potential risk for chronic kidney disease (CKD) in patients with urolithiasis.

Methods

Patients diagnosed with stone disease from 2013 to 2018 were retrospectively reviewed and divided into two groups by gender. Clinical demographic characteristics, stone location, stone composition, urine chemistries, and renal function were investigated. Univariate and multivariate analyses were used to assess the relationship and potential risk of CKD between sex groups.

Results

A total of 1802 patients were included: 1312 from men and 490 from women. Female patients had a higher rate of hypertension, diabetes, and dyslipidemia. Male patients predominantly had calcium-containing stones, especially calcium oxalate stone, uric acid stone, and struvite stone. Carbonate apatite stone was more frequently found in women. Complex surgeries such as percutaneous nephrolithotomy (PCNL) and ureteroscopic lithotripsy (URSL) were more frequently performed in women than that in men. Multivariate analysis confirmed that age > 60 years (odds ratios [ORs] = 6.36; 95% confidence interval [CI], 3.8–10.8), female sex (ORs = 5.31; 95% CI 3.3–8.4), uric acid stone (ORs = 3.55; 95% CI 2.0–6.4), hypertension (OR = 7.20; 95% CI 3.8–13.7), and diabetes (OR = 7.06; 95% CI 3.1–16.2) were independent predictors of poor prognoses in CKD.

Conclusions

The female gender is significantly associated with a higher prevalence of CKD among patients with urolithiasis. Therefore, women with stone disease may need close renal function monitoring during follow-up.

Hemoglobin A1c Levels Associated with Age and Gender in Taiwanese Adults without Prior Diagnosis with Diabetes

Several studies have reported that Hemoglobin A1c (HbA1c) levels increase with age for people without diabetes. However, HbA1c levels associated with age and gender have not been well investigated for Taiwanese adults. The objective of this study was to investigate the sex-specific association between HbA1c levels and age for Taiwanese adults without diabetes. The data were collected from the Taiwan Biobank database with inclusive criteria being participants without diabetes. The association between HbA1c values and age was conducted by linear regression analysis, HbA1c values between sexes were compared by two-sample t-test, and HbA1c levels among age groups were compared using one-way ANOVA. The results showed that HbA1c levels were positively correlated with age, and the levels for males were significantly higher than for females among all participants. However, there was no significantly positive correlation between HbA1c levels and age in males for age group of 50–70 years. The levels of males were significantly higher than females for age groups of 30–39 and 40–49 years. There were significant differences in HbA1c levels among age groups for all participants, males, and females except for the two age groups of 50–59 and 60–70 years in males. Age and gender were important factors affecting HbA1c levels. Our results suggested that the HbA1c cut-point levels for the diagnosis of diabetes should vary by age and gender.

Meta-analysis: Early Age at Natural Menopause and Risk for All-Cause and Cardiovascular Mortality

Aims

The aim of this meta-analysis was to comprehensively evaluate the association of early age at natural menopause with the risk for all-cause and cardiovascular mortality.

Methods

Literature retrieval was done on August 4, 2020. Article selection and data extraction were completed independently and in duplicate. Early age at natural menopause was grouped into premature menopause (<40 years), early menopause (40-44 years), and relatively early menopause (45-49 years). Effect-size estimates are summarized as hazard ratio (HR) or relative risk (RR) with 95% confidence interval (CI).

Results

Sixteen articles involving 321,233 women were meta-analyzed. Overall analyses revealed a statistically significant association of early age at natural menopause with all-cause mortality risk (HR_adjusted = 1.08, 95% CI: 1.03 to 1.14, P = 0.002; RR_adjusted = 1.05, 95% CI 1.01 to 1.08, P = 0.005), but not with cardiovascular mortality risk. In dose-response analyses, the association with all-cause mortality was significant for premature menopause with (HR_adjusted = 1.10; 95% CI: 1.01 to 1.21; P = 0.034) and without (RR_adjusted = 1.34; 95% CI: 1.08 to 1.66; P = 0.007) considering follow-up intervals. As for cardiovascular mortality, marginal significance was noted for premature menopause after considering follow-up intervals (HR = 1.09; 95% CI: 1.00-1.19; P = 0.045). Subgroup analyses indicated that gender, country, and follow-up periods were possible causes of heterogeneity. There was an overall low probability of publication bias.

Conclusions

Our findings indicate that premature menopause is a promising independent risk factor for both all-cause and cardiovascular mortality.

Age at menopause in India: A systematic review

BACKGROUND AND AIMS

Menopause is a physiological process in nature and hence, variations in the age of menopause are not expected. Hence, the study was conducted with an objective to calculate the reliable estimates of age at menopause for India, and understand the differentials in women's age at menopause throughout the country.

METHODS

A total of 202 studies of age at menopause, covering the period 2009-2020, were accessed from PubMed database and Google. Of these only ten studies met the selection criteria for this paper, which is that the data for these studies must be collected from house-to-house surveys.

RESULTS

The average age at menopause in India, with minimal publication bias, is 46.6 years (95% CI: 44.83, 48.44). In one study slightly above 1.96 Standard Deviation, was observed, as ascertained by Funnel Plot and Egger's test. The mean age ranged from a minimum of 44.69 years (95% CI: 35.01, 54.37) to a maximum of 48.95 (95% CI: 42.29, 55.61) years. Furthermore, the age at menopause did not exhibit any significant variation by age at menarche, although the association was positive.

CONCLUSIONS

The age at menopause showed positive association with age at menarche. In India, during the period 2009-2020, it was 46.6 years, which significantly lower than the age in some developed countries. The differences may be methodological since no information was found regarding the distribution of age at menopause in the studies that were considered for meta-analysis.

Correlation between Sleep Quality and Frailty Status among Middle-Aged and Older Taiwanese People: A Community-Based, Cross-Sectional Study

Poor sleep quality and frailty are common problems among aged people. However, the association between sleep quality and frailty in middle-aged and older people is seldom discussed in Asia, especially in Taiwan. This study investigated this association hopefully to provide pertinent knowledge for the prevention of frailty. We conducted a cross-sectional study and enrolled 828 subjects, 237 male and 591 female, aged 50–85 years old, from a community in Northern Taiwan. Poor sleep quality was defined as the Chinese version of the Pittsburgh Sleep Quality Index (CPSQI) > 5. Prefrailty and frailty were defined as fulfillment of one or two and three, respectively, of five phenotypic criteria: exhaustion, weakness, slowness, weight loss, and low physical activity. Our univariate analysis showed that the incidence of prefrailty/frailty in the group of poor sleep quality was higher than that in the group of CPSQI ≤ 5 (p < 0.001). Further multiple logistic regression analysis revealed that poor sleep quality was an independent factor for prefrailty and frailty status (odds ratio = 1.95, 95% confidence interval = 1.38–2.77), after adjustment for confounding factors. We concluded that poor sleep quality is independently associated with prefrailty and frailty status in our study population.

Association between Anemia and Stroke in Females: A Nationwide, Population-Based Cohort Study in Taiwan

Optimal stroke prevention strategies for women should take into account specific sex-related stroke risk factors. Anemia is a common medical condition in females, particularly in women of reproductive age. This study investigated whether anemia is an independent risk factor for stroke in females in a population-based cohort study. We investigated newly diagnosed anemic female patients with no history of central nervous system disease, psychiatric disorders, traumatic brain injury, major operations or hemorrhagic diseases identified from the Taiwan National Health Insurance Research Database. Non-anemic matched controls (1:1) were selected based on a propensity score estimated using a logistic regression model that included demographic characteristics and comorbidities. A competing risk analysis was applied to estimate the stroke risk in anemic patients compared to that of their matched controls. In our study, the adjusted sub-distribution hazard ratios (aSHRs) of overall, hemorrhagic and ischemic stroke in anemic female patients aged <50 years were 1.35 (95% confidence interval (CI): 1.19-1.52, p < 0.001), 1.31 (95% CI, 1.09-1.56, p < 0.003), and 1.35 (95% CI, 1.15-1.58, p < 0.001), respectively, compared to non-anemic female controls. However, a positive association between anemia and stroke was not found for those aged ≥50 years. Similar results were observed when the follow-up age was limited to 50 years to reduce the potential effects of menopause on stroke. In conclusion, the present population-based cohort study found that anemia is a potential risk factor for overall, hemorrhagic and ischemic stroke in females of reproductive age.