Menstruation and the menopausal transition

Measurement of changes to the menstrual cycle: A transdisciplinary systematic review evaluating measure quality and utility for clinical trials

Despite the importance of menstruation and the menstrual cycle to health, human rights, and sociocultural and economic wellbeing, the study of menstrual health suffers from a lack of funding, and research remains fractured across many disciplines. We sought to systematically review validated approaches to measure four aspects of changes to the menstrual cycle-bleeding, blood, pain, and perceptions-caused by any source and used within any field. We then evaluated the measure quality and utility for clinical trials of the identified instruments. We searched MEDLINE, Embase, and four instrument databases and included peer-reviewed articles published between 2006 and 2023 that reported on the development or validation of instruments assessing menstrual changes using quantitative or mixed-methods methodology. From a total of 8,490 articles, 8,316 were excluded, yielding 174 articles reporting on 94 instruments. Almost half of articles were from the United States or United Kingdom and over half of instruments were only in English, Spanish, French, or Portuguese. Most instruments measured bleeding parameters, uterine pain, or perceptions, but few assessed characteristics of blood. Nearly 60% of instruments were developed for populations with menstrual or gynecologic disorders or symptoms. Most instruments had fair or good measure quality or clinical trial utility; however, most instruments lacked evidence on responsiveness, question sensitivity and/or transferability, and only three instruments had good scores of both quality and utility. Although we took a novel, transdisciplinary approach, our systematic review found important gaps in the literature and instrument landscape, pointing towards a need to examine the menstrual cycle in a more comprehensive, inclusive, and standardized way. Our findings can inform the development of new or modified instruments, which-if used across the many fields that study menstrual health and within clinical trials-can contribute to a more systemic and holistic understanding of menstruation and the menstrual cycle.

Perimenopausal women's voices: How does their period at the end of reproductive life affect wellbeing?

OBJECTIVE

To explore perimenopausal women's feelings towards their periods, the impact on their wellbeing and how we can support them.

STUDY DESIGN

Participants were recruited for focus groups through social media advertisements. In 6 online focus groups, 31 perimenopausal women aged 40-55 living in the UK were asked 5 questions relating to periods and perimenopause, support and education.

MAIN OUTCOME MEASURES

Content analysis.

RESULTS

When asked How do you feel about having a period? The participants often related back to the stress of menarche and said their period negatively impacted their wellbeing their whole lives. During perimenopause, their periods had become unpredictable, heavy, and a debilitating disruption to their lives. The women desired support at work through policy, and from family and friends. They believed that educating girls and boys during school was the best place to start, but that education through work and community groups was also needed. They felt healthcare professionals should have mandatory training regarding women's health issues and menopause.

CONCLUSION

The study highlights the impact of menstrual experiences on the wellbeing of perimenopausal women, emphasising the need for improved menstrual education from an early age. Comprehensive menstrual education in schools involving both genders to enable informed decision-making and improved training for healthcare professionals are recommended. Support networks for perimenopausal women will promote better quality of life for women as they go through their perimenopause journey.

Prevalence of and risk factors for self-reported menstrual changes following COVID-19 vaccination: a Danish cohort study

STUDY QUESTION

Are there some characteristics that render individuals more susceptible to report menstrual changes following the Coronavirus disease 2019 (COVID-19) vaccination?

SUMMARY ANSWER

We found that 30% of menstruating women reported menstrual changes following COVID-19 vaccination and several potential risk factors including stress, vaccine concerns, severe COVID-19 infection, and immediate vaccine symptoms were associated with these reports.

WHAT IS KNOWN ALREADY

Studies suggest that COVID-19 vaccination might temporarily prolong menstrual cycle length by less than 1 day. Specific characteristics may trigger menstrual changes in temporal relation to the vaccination simply by chance or render women more vigilant to potential menstrual changes after being vaccinated. However, research investigating potential risk factors for reporting menstrual changes following COVID-19 vaccination is limited.

STUDY DESIGN, SIZE, DURATION

A population-based Danish cohort study. Data were collected from May 2021 to December 2021 as a part of the BiCoVac Cohort with the aim of examining non-specific effects following COVID-19 vaccination. The main study population included 13 648 menstruating women aged 16-65 years who completed all surveys, received their first dose of a COVID-19 vaccine during the data collection period, and completed questions related to their menstrual cycle.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Potential risk factors included 14 biological, physical, or psychological measures. Information on most potential risk factors was self-reported and collected before the participants' first COVID-19 vaccination. Information about any menstrual change following COVID-19 vaccination was self-reported at the end of the data collection period. Logistic regression analyses were used to estimate crude and adjusted odds ratios (ORs) with 95% CIs for the association between each potential risk factor and reporting menstrual changes following COVID-19 vaccination.

MAIN RESULTS AND THE ROLE OF CHANCE

Any menstrual change following COVID-19 vaccination was reported by 30% of menstruating women. Most of the potential risk factors were associated with reports of menstrual changes following COVID-19 vaccination. In particular, higher odds were found among women who reported ≥5 immediate vaccine symptoms; OR 1.67 [1.50-1.86], had had a prior severe COVID-19 infection; OR 2.17 [1.40-3.35], had a high-stress level at baseline; OR 1.67 [1.32-2.10], or were concerned about COVID-19 vaccines prior to vaccination; OR 1.92 [1.50-2.45]. Lower odds were found among women with regular menstrual cycles using hormonal contraception; OR 0.71 [0.65-0.78].

LIMITATIONS, REASONS FOR CAUTION

We were unable to address the causal effect of COVID-19 vaccination on the reported menstrual changes, as information about menstrual changes was not available among non-vaccinated women.

WIDER IMPLICATIONS OF THE FINDINGS

The study identified several potential risk factors for reporting menstrual changes following COVID-19 vaccination. Further studies are needed to establish causal associations and the clinical impact of self-reported menstrual changes.

STUDY FUNDING/COMPETING INTEREST(S)

The BiCoVac data collection was funded by TrygFonden (id-number: 153678). No competing interests are declared.

TRIAL REGISTRATION NUMBER

N/A.

Menarche, Menstruation, Menopause and Mental Health (4M): a consortium facilitating interdisciplinary research at the intersection of menstrual and mental health

Menstrual and mental health form a close relationship that is under-appreciated in scientific research, clinical practice and social policy. This association is extremely complex, involving interactions between biology, psychology and social, political and structural influences on health and wellbeing. Research in these areas has traditionally been siloed: focusing on menstrual or mental health in isolation, or the interrelation from a limited one-dimensional perspective. We recognised the need for a more holistic and comprehensive approach that considers the complex interweaving nature of menstrual and mental health. In 2021, we established the Menarche, Menstruation, Menopause and Mental Health (4M) consortium as a tool to address this gap and to facilitate interdisciplinary research. This paper provides a comprehensive source of information about 4M for researchers and stakeholders who may be interested in joining or working with the consortium.

Associations between menopause and body image: A systematic review

BACKGROUND

The menopausal transition involves multiple biological and psychosocial challenges that may render middle-aged women vulnerable to body image concerns.

OBJECTIVE

The aim of this study was to summarize evidence on the associations between menopause and body image perception in healthy middle-aged women.

DESIGN

This study is a systematic review of observational studies.

DATA SOURCES AND METHODS

Menopause-related exposure measures included menopausal stages, menopausal symptoms, and reproductive hormone levels during the menopausal transition. Studies investigating body image as an outcome, including through a positive (e.g. body self-esteem) or negative (e.g. body dissatisfaction) lens, were considered eligible. Articles published before March 2023 were identified through MEDLINE, PsycINFO, and Embase and underwent double screening, extraction, and quality assessment by two independent investigators. Characteristics and results were summarized using narrative synthesis.

RESULTS

A total of 820 non-duplicate records were identified, with 18 observational studies deemed eligible for inclusion after full-text screening. All studies investigating menopausal symptoms and body image (n = 6) found some significant association between them, with a higher frequency, intensity, or number of symptoms being associated with greater body image concern. Differences in body image perception between menopausal stages were inconsistent across studies (n = 12), while evidence of potential associations between reproductive hormones and body image was minimal (n = 2). Findings should be interpreted with caution as 17 of the included studies used a cross-sectional design, and not all studies adjusted their analyses for relevant confounders.

CONCLUSION

Overall, menopausal symptoms showed relatively consistent associations with a more negative body image perception. Additional research is required to understand the potential role of menopausal stages and reproductive hormone levels in the body image perception of middle-aged women and to confirm the direction of reported associations.

REGISTRATION

PROSPERO-CRD42021241637.

Breast Cancer-Epidemiology, Classification, Pathogenesis and Treatment (Review of Literature)

Breast cancer is the most-commonly diagnosed malignant tumor in women in the world, as well as the first cause of death from malignant tumors. The incidence of breast cancer is constantly increasing in all regions of the world. For this reason, despite the progress in its detection and treatment, which translates into improved mortality rates, it seems necessary to look for new therapeutic methods, and predictive and prognostic factors. Treatment strategies vary depending on the molecular subtype. Breast cancer treatment is multidisciplinary; it includes approaches to locoregional therapy (surgery and radiation therapy) and systemic therapy. Systemic therapies include hormone therapy for hormone-positive disease, chemotherapy, anti-HER2 therapy for HER2-positive disease, and quite recently, immunotherapy. Triple negative breast cancer is responsible for more than 15-20% of all breast cancers. It is of particular research interest as it presents a therapeutic challenge, mainly due to its low response to treatment and its highly invasive nature. Future therapeutic concepts for breast cancer aim to individualize therapy and de-escalate and escalate treatment based on cancer biology and early response to therapy. The article presents a review of the literature on breast carcinoma-a disease affecting women in the world.

Do vasomotor and genitourinary symptoms of menopause vary between sedente and migrant groups? A study on the Oraon tribal populations of Eastern India

OBJECTIVES

Human reproductive characteristics are embedded within local ecological contexts. A shift in the local ecology is likely to offer challenges in reproductive outcome. We aimed to investigate sedente-migrant variation in experiencing vasomotor and genitourinary symptoms at perimenopausal and postmenopausal stages and its concomitants.

METHODS

Four hundred Oraon tribal populations living in Eastern India (sedente [100 each from perimenopausal and postmenopausal groups] and migrants [100 each from perimenopausal and postmenopausal groups]) were studied. Data on vasomotor and genitourinary symptoms, socio-demographic and reproductive history, body compositions, lifestyle variables, and energy intake were compared between sedente and migrant independently for perimenopausal and postmenopausal groups. Principal component analysis (PCA) was used to identify the principal components (PCs) of menopausal symptoms. A two level multilevel linear regression was applied independently for perimenopausal and postmenopausal groups to identify the concomitants of menopausal symptoms and estimate sedente-migrant variance.

RESULTS

Bivariate analysis showed significant (p ≤ .05) sedente-migrant differences in socio-demographic, reproductive, body composition, energy intake, and lifestyle variables and in some of the vasomotor and genitourinary symptoms. In multilevel analyses, random effect did not show significant heterogeneity between sedente and migrant groups in experiencing menopausal symptoms; however, fixed effect showed that region from which participants were recruited (Gram Panchayat [GP]) and individual level characteristics were concomitants (p ≤ .05) for menopausal symptoms, irrespective of menopausal status.

CONCLUSION

Variability at GP levels and individual level characteristics of sedente and migrant groups predominantly determined menopausal symptoms of the study populations, but not the migration status.

A practical clinical guide to counselling on and managing contraception, pre-conception planning, and menopause for women living with HIV

BACKGROUND

Women represent one quarter of the population living with HIV in Canada and are an increasingly important sector of the HIV community. While some women's health issues such as cervical cancer screening and management are well addressed in HIV management guidelines, others are not. These include sexual and reproductive health factors such as contraception, pre-conception planning, and menopause. Existing literature has shown that while women living with HIV in Canada receive good HIV care based on HIV care cascade indicators, their women's health and sexual and reproductive health care needs are not being met.

METHODS

In this article, we present a clinical guide for clinicians providing care for women living with HIV on three key women's health topics that are under-discussed during HIV care visits: (1) contraception, (2) pre-conception planning, and (3) menopause.

RESULTS

We have summarized the most pertinent clinical factors on each topic to support straightforward counselling and present important considerations in the context of HIV-related diseases and treatment. Finally, when relevant, we have provided practical stepwise approaches for addressing each of these women's health care topics when seeing a patient during a visit.

CONCLUSIONS

It is important that HIV specialists stay well-versed in the complex clinical interactions between HIV treatment and management of women's health issues.

Management of pre-, peri-, and post-menopausal abnormal uterine bleeding: When to perform endometrial sampling?

Abnormal uterine bleeding (AUB) is defined as abnormal volume, duration, or frequency of menstrual period and is a common symptom in women of all ages (premenopausal, perimenopausal, and postmenopausal). The acronym PALM-COEIN, introduced by the International Federation of Gynecology and Obstetrics (FIGO), facilitates the evaluation and differential diagnosis of AUB, mostly in premenopausal women with AUB. Endometrial evaluation (including ultrasound or hysteroscopic imaging and tissue sampling) for subtle pathology is proposed in patients who are at high risk for endometrial cancer and in patients at low risk who present with AUB and who present poor correspondence in medical treatment. Many new diagnostic modalities are available in clinicians in order to help the assessment of women presenting with abnormalities in their menstrual pattern. The present study reviews the optimal management of women presenting with AUB, taking into consideration the actual need for invasive management in these women, who of them require it, and who can be diagnosed without histological verification. The importance of endometrial tissue sampling in women who present with AUB as well as the best timing for a clinician to conduct a biopsy are two axons analyzed below, according to the latest worldwide guidelines and major publications about this subject.

Premature menopause among women in India: Evidence from National Family Health Survey-IV

AIM

Women who experience premature menopause either due to biological or induced reasons have a longer duration of exposure to severe symptoms and adverse health consequences when compared to those who undergo menopause at later age. Despite the fact that premature menopause has a profound effect on the health of women, there has been limited study on this issue. Therefore, this study attempted to determine the prevalence and factors associated with premature menopause among 302 557 women aged 25-39 years in India.

METHODS

This study utilized secondary data from the fourth round of the National Family Health Survey-IV (NFHS-4), conducted during 2015-2016 in India. Descriptive statistics and multinomial logistic regression were used for statistical analyses of the data.

RESULTS

The results revealed that the prevalence of premature menopause in this sample of Indian women was 3.7%, out of which 2.1% of women had experienced natural premature menopause, whereas 1.7% had surgical premature menopause. The prevalence of premature menopause was highest in the southern region of India. Factors like age, education, wealth index, place of residence, smoking status, children ever born, age at first birth, use of hormonal contraception, sterilization, and body mass index were found to be associated with premature menopause in India.

CONCLUSION

A sizeable proportion of women in India are attaining menopause prematurely. Furthermore, the percentage and likelihood of experiencing premature menopause are relatively high among rural women, women with higher parity, early age at childbearing, and women who smoke.

Endometrial thickness on the day of the LH surge: an effective predictor of pregnancy outcomes after modified natural cycle-frozen blastocyst transfer

STUDY QUESTION

Can the endometrial thickness (EMT) on the day of the LH surge predict pregnancy outcomes after single vitrified-warmed blastocyst transfers (SVBTs) in modified natural cycles?

SUMMARY ANSWER

Decreased EMT on the day of the LH surge is associated with older female age and a shortened proliferation phase and may be associated with low live birth and high chemical pregnancy rates.

WHAT IS KNOWN ALREADY

The relation between EMT on the day of embryo transfer (ET) and pregnancy outcomes remains controversial; although numerous studies reported an association between decreased EMT on the day of ET and a reduced likelihood of pregnancy, recent studies demonstrated that the EMT on the day of ET had limited independent prognostic value for pregnancy outcomes after IVF. The relation between EMT on the day of the LH surge and pregnancy outcomes after SVBT in modified natural cycles is currently unknown.

STUDY DESIGN, SIZE, DURATION

In total, 808 SVBTs in modified natural cycles, performed from November 2018 to October 2019, were analysed in this retrospective cohort study. Associations of EMT on the days of the LH surge with SVBT and clinical and ongoing pregnancy rates were statistically evaluated. Clinical and ongoing pregnancy rates were defined as the ultrasonographic observation of a gestational sac 3 weeks after SVBTs and the observation of a foetal heartbeat 5 weeks after SVBTs, respectively. Similarly, factors potentially associated with the EMT on day of the LH surge, such as patient and cycle characteristics, were investigated.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study includes IVF/ICSI patients aged 24–47 years, who underwent their first SVBT in the study period. After monitoring follicular development and serum hormone levels, ovulation was triggered via a nasal spray containing a GnRH agonist. After ovulation was confirmed, SVBTs were performed on Day 5. The EMT was evaluated by transvaginal ultrasonography on the day of the LH surge and immediately before the SVBT procedure.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the original 901 patients, 93 who were outliers for FSH or proliferative phase duration data were excluded from the analysis. Patients were classified according to quartiles of EMT on day of the LH surge, as follows: EMT < 8.1 mm, 8.1 mm ≤ EMT < 9.1 mm, 9.1 mm ≤ EMT < 10.6 mm and EMT ≥ 10.6 mm. Decreased EMT on day of the LH surge was associated with lower live birth (P = 0.0016) and higher chemical pregnancy (P = 0.0011) rates. Similarly, patients were classified according to quartiles of EMT on day of the SVBT, as follows: EMT < 9.1 mm, 9.1 mm ≤ EMT < 10.1 mm, 10.1 mm ≤ EMT < 12.1 mm and EMT ≥ 12.1 mm. A decreased EMT on the day of SVBT was associated with a lower live birth rate (P = 0.0095) but not chemical pregnancy rate (P = 0.1640). Additionally, multivariate logistic regression analysis revealed a significant correlation between EMT on day of the LH surge and ongoing pregnancy; however, no correlation was observed between EMT on the day of SVBT and ongoing pregnancy (adjusted odds ratio 0.952; 95% CI, 0.850–1.066; P = 0.3981). A decreased EMT on day of the LH surge was significantly associated with greater female age (P = 0.0003) and a shortened follicular/proliferation phase (P < 0.0001).

LIMITATIONS, REASONS FOR CAUTION

The data used in this study were obtained from a single-centre cohort; therefore, multi-centre studies are required to ascertain the generalisability of these findings to other clinics with different protocols and/or patient demographics.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first report demonstrating a significant correlation between EMT on day of the LH surge and pregnancy outcomes after frozen blastocyst transfer in modified natural cycles. Our results suggest that EMT on day of the LH surge may be an effective predictor of the live birth rate.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by resources from the Kato Ladies Clinic. The authors have no conflicts of interest to declare.

A multi-component, community-engaged intervention to reduce cardiovascular disease risk in perimenopausal Latinas: pilot study protocol

BACKGROUND

Cardiovascular disease (CVD) risk increases substantially during perimenopause. Latinas have a significantly worse CVD risk factor profile than non-Hispanic White women, potentially due to multiple sociocultural and environmental factors. To date, interdisciplinary interventions have not focused on improving nutrition, physical activity, stress management, and biologic CVD risk in perimenopausal Latinas. The purpose of this study is to examine the feasibility and initial efficacy of a multi-component intervention to reduce CVD risk in perimenopausal Latinas.

METHODS

This is a two-group, repeated measures experimental study. Eighty perimenopausal Latinas (age 40-55 years) from two community groups will be randomized: one group will complete the intervention; the other will be a wait-list control. The intervention consists of 12-weekly sessions (education, physical activity, stress management, coping skills training), followed by 3 months of continued support, and 6 months of skill maintenance on their own. The primary outcomes include arterial stiffness, blood pressure, lipids, and blood glucose. Secondary outcomes are health behaviors (nutrition, physical activity, sleep, coping strategies), self-efficacy, and other biological factors related to CVD risk (adiposity, C-reactive protein, hair cortisol, vasomotor symptoms). We will assess changes in outcomes from Time 1 (baseline) to Time 2 (6 months) and Time 3 (12 months) using general linear mixed models to test the hypotheses. We will also evaluate the feasibility of the intervention by assessing enrollment and retention rates, barriers, and facilitators to enrollment, intervention fidelity, the suitability of study procedures, and participant satisfaction with the intervention and study protocol. We hypothesize the intervention group will decrease biologic CVD risk and improve health behaviors and self-efficacy significantly more than the wait-list control.

DISCUSSION

Results from this study will contribute to knowledge on the feasibility of behavioral interventions, including stress management and coping skills training, which could reduce CVD burden among perimenopausal Latinas. Because Hispanic/Latinos are the largest ethnic minority in the United States (US), progress regarding CVD risk among perimenopausal Latinas may lead to significant improvement in the overall CVD burden in the US.

TRIAL REGISTRATION

Prospectively registered, NCT04313751 (03/19/2020), Protocol version 1.0.

The evolutionary ecology of age at natural menopause: implications for public health

Evolutionary perspectives on menopause have focused on explaining why early reproductive cessation in females has emerged and why it is rare throughout the animal kingdom, but less attention has been given to exploring patterns of diversity in age at natural menopause. In this paper, we aim to generate new hypotheses for understanding human patterns of diversity in this trait, defined as age at final menstrual period. To do so, we develop a multilevel, interdisciplinary framework, combining proximate, physiological understandings of ovarian ageing with ultimate, evolutionary perspectives on ageing. We begin by reviewing known patterns of diversity in age at natural menopause in humans, and highlight issues in how menopause is currently defined and measured. Second, we consider together ultimate explanations of menopause timing and proximate understandings of ovarian ageing. We find that ovarian ageing is highly constrained by ageing of the follicle - the somatic structure containing the oocyte - suggesting that menopause timing might be best understood as a by-product of ageing rather than a facultative adaptation. Third, we investigate whether the determinants of somatic senescence also underpin menopause timing. We show that diversity in age at menopause can be, at least partly, explained by the genetic, ecological and life-history determinants of somatic ageing. The public health implications of rethinking menopause as the by-product rather than the catalyst of biological ageing are discussed.

Slow electroencephalographic oscillations and behavioral measures as predictors of high executive processing in early postmenopausal females: A discriminant analysis approach

Decline in cognitive function is frequent in early postmenopause. There are postmenopausal females who show high performance while others display low performance in executive function, modulated by the prefrontal cortex. These differences have led to confusing and inconclusive results, which have not been explained entirely by the decline in estrogens, which affect the prefrontal cortex functions. An analysis of brain function and the application of a discriminant analysis can help to clarify the deficits in executive function shown by some postmenopausal females. The objective was to examine electroencephalographic recording during the performance of an executive function test in early postmenopausal females, ten with a high level of performance and ten with a low level of performance. Absolute power of delta, theta, alpha1, alpha2, beta1 and beta2 and the numbers of completed categories, trials, perseverative errors and overall errors were submitted to stepwise discriminant analysis to identify predictor variables. Four predictors emerged as significant of group membership based on cognitive performance, with the high-performance group characterized by more completed categories, more delta power, less theta power and more alpha1 power. These findings suggest that postmenopausal females classified in the high-performance group displayed appropriate temporary activation in slow oscillations during executive processing.

Describing the status of reproductive ageing simply and precisely: A reproductive ageing score based on three questions and validated with hormone levels

OBJECTIVE

Most women live to experience menopause and will spend 4-8 years transitioning from fertile age to full menstrual stop. Biologically, reproductive ageing is a continuous process, but by convention, it is defined categorically as pre-, peri- and postmenopause; categories that are sometimes supported by measurements of sex hormones in blood samples. We aimed to develop and validate a new tool, a reproductive ageing score (RAS), that could give a simple and yet precise description of the status of reproductive ageing, without hormone measurements, to be used by health professionals and researchers.

METHODS

Questionnaire data on age, menstrual regularity and menstrual frequency was provided by the large multicentre population-based RHINE cohort. A continuous reproductive ageing score was developed from these variables, using techniques of fuzzy mathematics, to generate a decimal number ranging from 0.00 (nonmenopausal) to 1.00 (postmenopausal). The RAS was then validated with sex hormone measurements (follicle stimulating hormone and 17β-estradiol) and interview-data provided by the large population-based ECRHS cohort, using receiver-operating characteristics (ROC).

RESULTS

The RAS, developed from questionnaire data of the RHINE cohort, defined with high precision and accuracy the menopausal status as confirmed by interview and hormone data in the ECRHS cohort. The area under the ROC curve was 0.91 (95% Confidence interval (CI): 0.90-0.93) to distinguish nonmenopausal women from peri- and postmenopausal women, and 0.85 (95% CI: 0.83-0.88) to distinguish postmenopausal women from nonmenopausal and perimenopausal women.

CONCLUSIONS

The RAS provides a useful and valid tool for describing the status of reproductive ageing accurately, on a continuous scale from 0.00 to 1.00, based on simple questions and without requiring blood sampling. The score allows for a more precise differentiation than the conventional categorisation in pre-, peri- and postmenopause. This is useful for epidemiological research and clinical trials.

The menopause transition and women's health at midlife: a progress report from the Study of Women's Health Across the Nation (SWAN)

OBJECTIVE

Our initial understanding of the menopause transition (MT) has been framed by clinical samples of women seeking treatment rather than by population-based studies. The Study of Women's Health Across the Nation (SWAN) initiated in 1996 with an overall goal to define the MT, to characterize its biological and psychosocial antecedents and sequelae in an ethnically and racially diverse sample of midlife women.

METHODS

This review summarizes the central findings of SWAN to date that can inform women and their healthcare providers about the impact of the MT and midlife aging on overall health and well-being.

RESULTS

SWAN characterized changes in reproductive axis and menstrual cycle patterns that informed the development of the reproductive aging staging system Staging of Reproductive Aging Workshop+10; MT-related symptoms and mental health (vasomotor symptoms, sleep complaints, psychological symptoms, cognitive performance, and urogenital and sexual health); and physiological systems and functions (cardiovascular and cardiometabolic health, bone health, physical function performance) that are influenced by the MT. SWAN demonstrated substantial interrelations among these changes and significant racial/ethnic differences in the rate and magnitude of change in multiple health indictors in midlife women. The findings point to midlife as a critical stage for adopting healthy behavior and preventive strategies.

CONCLUSIONS

Over the past 23 years, SWAN has advanced our understanding of the impact of the MT and midlife aging on health and well-being in women. SWAN will be instrumental to determine whether MT-related changes during midlife are related to unfavorable health and well-being in early old age.

Prevalence, Wellbeing, and Symptoms of Dysmenorrhea among University Nursing Students in Greece

Dysmenorrhea (pain during menstruation) is one of the most common medical conditions among women of reproductive age. Dysmenorrhea has been studied around the world but not yet in Greece. The aim of the present study was to investigate the prevalence, characteristics, and impact of dysmenorrhea on the wellbeing (exercising, and social and academic functioning) among nursing students in Greece. A cross-sectional study of 637 nursing students was conducted by administering a questionnaire at a university in Athens. The prevalence of dysmenorrhea was 89.2% and the rate of severe intensity was 52.5%. Factors that were associated with severe dysmenorrhea were family history (p = 0.02), early menarche (p = 0.05) and menstruation duration (p = 0.05). Women with moderate and severe pain reported using pain relievers (non-steroidal anti-inflammatory drugs (NSAIDs), paracetamol etc., p < 0.0005). Finally, activities affected by severe pain were class attendance (p = 0.01), personal studying (p < 0.0005), exercising (p < 0.0005), and socializing (p < 0.0005). Exam attendance (p = 0.27) and clinical placement attendance (p = 0.48) were not affected by severe dysmenorrhea. Dysmenorrhea has a high prevalence among nursing students and seems to affect important aspects of wellbeing and academic performance when the pain intensity is severe. The present findings lay the foundation for further investigation of dysmenorrhea both in the Greek population and cross-culturally.

Exercise Improves Insulin Sensitivity in the Absence of Changes in Cytokines

PURPOSE

The benefits of aerobic exercise training on insulin sensitivity in subjects with metabolic syndrome (MetS) are, at least in part, associated with changes in cytokines. Recent studies identified novel cytokines (e.g., fractalkine, omentin, and osteopontin) that are strongly involved in glucose homeostasis and therefore potentially contribute in the exercise-induced changes in insulin sensitivity. Therefore, we aim to examine changes in skeletal muscle RNA expression and plasma levels of novel cytokines after exercise training and correlate these changes to the exercise-induced changes in insulin sensitivity.

METHODS

Women with metabolic syndrome (MetS, n = 11) and healthy women (n = 10) participated in a 6-month aerobic exercise training intervention (three times a week, 45 min per session at 65%-85% of individual heart rate reserve). Before and after training, we examined insulin sensitivity (M value during hyperinsulinemic euglycemic clamp) and circulating blood levels of cytokines (venous blood sample; leptin, adiponectin, omentin, fraktalkin, and osteopontin). The skeletal muscle RNA expression of these cytokines (muscle biopsy) was examined in two subgroups (MetS, n = 6; healthy women, n = 6).

RESULTS

At baseline, plasma levels of omentin (85.8 ± 26.2 ng·mL) and adiponectin (5.0 ± 1.7 μg·mL) levels were significantly higher in controls compared with MetS (51.1 ± 27.1; 3.6 ± 1.1 respectively), and leptin levels were lower in controls (18.7 ± 11.5 vs 53.0 ± 23.5 ng·mL). M value was significantly higher in controls (8.1 ± 1.9 mg·kg·min) than in MetS (4.0 ± 1.7). Exercise training significantly improved M values in both groups (P < 0.01). Exercise training did not alter plasma and skeletal muscle RNA expression levels of cytokines, but no correlation was observed between changes in cytokine level/RNA expression and M values (P > 0.05).

CONCLUSION

Although exercise training successfully improves insulin sensitivity in MetS and healthy women, we found no change in plasma and mRNA expression levels of novel cytokines.

Age-Based Reproductive Healthcare Stereotype Threat (HCST) as a Stressor Affecting Prenatal Mental Health in Pregnant Women of Advanced Maternal Age: Measurement, Process, Outcomes, and Interactions with Ethnicity/Race, SES, and Other Social Identities

PURPOSE OF REVIEW

Reproductive health, and pregnancy more specifically, is the first critical link between generations. Beginning with this first critical link, pregnancy acts as a domino, affecting the expression of genes and determining the lifespan mental and physical health and reproductive potential of offspring and, likely, of subsequent generations. Given the powerful intergenerational domino that is pregnancy, the development of innovative models to enhance reproductive health and outcomes is an invaluable public health investment.

RECENT FINDINGS

While U.S. pregnancy and birth outcomes have improved dramatically since the 1960s- including substantial progress within the past 15 years, largely catalyzed by the Healthy People initiative-group-based disparities remain. What's more, social change and medical advancements have led to an evolving window of female reproductive age. Despite becoming more common, being an older expectant mother remains a stigmatized social identity. The concept of healthcare stereotype threat (HCST) is introduced in relation to reproductive health. Stereotype threat is a situational predicament in which an individual who possesses a stigmatized social identity fears confirming negative group-based stereotypes. HCST is a healthcare-specific form of stereotype threat, arising out of stereotypes that are salient in healthcare settings. It is hypothesized that the experience of age-based reproductive HCST is an overlooked stressor affecting prenatal mental and physical health among women of advanced maternal age.

SUMMARY

The hypothesized process of age-based reproductive HCST is described; outcomes and consequences are discussed; interactions with ethnicity/race, SES, and other aspects of social identity are considered; and strategies for prevention and intervention are explored, including active and passive shifts in three areas: (1) internally, in both providers and patients; (2) in the external environment, or the physical healthcare setting itself; and (3) within interpersonal interactions that occur within healthcare settings, particularly between physicians and patients. Implications for gynecological, infertility, and obstetric care and improving the reproductive outcomes of older women are discussed.

The prevalence of sexual activity, and sexual dysfunction and behaviours in postmenopausal woman in Poland

Introduction

Despite the aging of the population, there is limited data available about sexual life and behaviours among of postmenopausal and late postmenopausal women. Aim of the study was to assess the prevalence of sexual dysfunction, behaviours, and preferences in the Polish population in 2015.

Material and methods

This observational survey study involved 538 women, of whom 220 were over 50 years old. The main focus was on the differences and changes between older age groups, mainly 50-59 years and over 60 years.

Results

For 80.9% of the women above 50 years old, sex played at least a moderately important role in life. Sex was definitely important and very important for 40.45% of them. Most women over 50 years old (65.5%) were sexually active. Regardless of age, the respondents were more likely to have sexual intercourse several times a month. Less than half of the women over 50 years old (42.7%) realised their sexual fantasies. Women in the group of 50-59 years old statistically less often than younger women declared that the frequency of intercourse they had was too small. There was a statistical tendency showing that women up to 49 years old declared more sexual problems than older women. Women over 50 years old reported fewer problems in comparison to younger women, e.g. less often they claimed that sex is not pleasurable (p = 0.064).

Conclusions

The prevalence of sexual activity declines with age, yet a substantial number of woman engage in vaginal intercourse, oral sex, and masturbation even past the seventh decade of life.

Analysis of urinary human chorionic gonadotrophin concentrations in normal and failing pregnancies using longitudinal, Cox proportional hazards and two-stage modelling

Background

Human chorionic gonadotrophin is a marker of early pregnancy. This study sought to determine the possibility of being able to distinguish between healthy and failing pregnancies by utilizing patient-associated risk factors and daily urinary human chorionic gonadotrophin concentrations.

Methods

Data were from a study that collected daily early morning urine samples from women trying to conceive (n = 1505); 250 of whom became pregnant. Data from 129 women who became pregnant (including 44 miscarriages) were included in these analyses. A longitudinal model was used to profile human chorionic gonadotrophin, a Cox proportional hazards model to assess demographic/menstrual history data on the time to failed pregnancy, and a two-stage model to combine these two models.

Results

The profile for log human chorionic gonadotrophin concentrations in women suffering miscarriage differs to that of viable pregnancies; rate of human chorionic gonadotrophin rise is slower in those suffering a biochemical loss (loss before six weeks, recognized by a rise and fall of human chorionic gonadotrophin) and tends to plateau at a lower log human chorionic gonadotrophin in women suffering an early miscarriage (loss six weeks or later), compared with viable pregnancies. Maternal age, longest cycle length and time from luteinizing hormone surge to human chorionic gonadotrophin reaching 25 mIU/mL were found to be significantly associated with miscarriage risk. The two-stage model found that for an increase of one day in the time from luteinizing hormone surge to human chorionic gonadotrophin reaching 25 mIU/mL, there is a 30% increase in miscarriage risk (hazard ratio: 1.30; 95% confidence interval: 1.04, 1.62).

Conclusion

Rise of human chorionic gonadotrophin in early pregnancy could be useful to predict pregnancy viability. Daily tracking of urinary human chorionic gonadotrophin may enable early identification of some pregnancies at risk of miscarriage.

Menopause and Parkinson's disease. Interaction between estrogens and brain renin-angiotensin system in dopaminergic degeneration

The neuroprotective effects of menopausal hormonal therapy in Parkinson's disease (PD) have not yet been clarified, and it is controversial whether there is a critical period for neuroprotection. Studies in animal models and clinical and epidemiological studies indicate that estrogens induce dopaminergic neuroprotection. Recent studies suggest that inhibition of the brain renin-angiotensin system (RAS) mediates the effects of estrogens in PD models. In the substantia nigra, ovariectomy induces a decrease in levels of estrogen receptor-α (ER-α) and increases angiotensin activity, NADPH-oxidase activity and expression of neuroinflammatory markers, which are regulated by estrogen replacement therapy. There is a critical period for the neuroprotective effect of estrogen replacement therapy, and local ER-α and RAS play a major role. Astrocytes play a major role in ER-α-induced regulation of local RAS, but neurons and microglia are also involved. Interestingly, treatment with angiotensin receptor antagonists after the critical period induced neuroprotection.

Influence of race/ethnicity, body mass index, and proximity of menopause on menstrual cycle patterns in the menopausal transition: the Study of Women's Health Across the Nation

OBJECTIVE

Few studies have evaluated factors that influence menstrual cycle length (MCL) during the menopausal transition (MT), a life stage during which very long cycles become more likely to occur. The objective of this article was to assess how body mass index and race/ethnicity--factors associated with MCL in young women--influence MCL during the MT.

METHODS

Study of Women's Health Across the Nation menstrual calendar substudy data of African-American, white, Chinese, and Japanese women were available for three sites (southeastern Michigan, Los Angeles, and northern California). Self-recorded monthly menstrual calendars with end-of-the-month questions on hormone therapy use and smoking were collected from 1996 to 2006. Height and weight were measured at annual study visits. We used quantile regression to model MCL at the 25th, 50th, 75th, and 90th percentiles with bootstrap sampling to construct 95% CIs. Models evaluated MCL with time indexed to the start of the MT (n = 963) and to the final menstrual period (n = 431).

RESULTS

During the MT, increases in MCL occurred mostly at the right tail of the distribution, reflecting a lengthening of long menstrual cycles, not of the median MCL. After adjustment for smoking, education, physical activity, and time, Chinese and Japanese women had 1 day to 6 days longer MCLs compared with white women. Obese women had 1 day to 5 days longer MCLs compared with nonobese women.

CONCLUSIONS

As occurs in younger women, menstrual characteristics during the MT are influenced by race/ethnicity and obesity. The long menstrual cycles characteristic of the MT are longer in obese women and in Chinese and Japanese women.

Menoprogen, a TCM Herbal Formula for Menopause, Increases Endogenous E2 in an Aged Rat Model of Menopause by Reducing Ovarian Granulosa Cell Apoptosis

The effect of Menoprogen (MPG) on ovarian granulosa cell (GC) apoptosis was investigated in vitro and in vivo in an aged rat model of menopause. Intragastric administration of Menoprogen or estradiol valerate to 14-month-old senile female rats for eight weeks increased plasma E₂ levels, as well as the weight of both ovarian and uterine tissues. Flow cytometric (FCM) analysis of isolated GCs from MPG-treated aged rats showed reductions in the G₀/G₁ ratio and apoptotic peaks. Isolated GCs also exhibited an increase in cell size and the number of cytoplastic organelles and intracellular gap junctions, the reappearance of secretory granules, and a lack of apoptotic bodies as determined by TEM. Results from a TdT-mediated dUTP nick end-labeling (TUNEL) assay revealed a reduction in TUNEL-positive GCs after MPG treatment. Immunohistochemical analysis showed a downregulation of proapoptotic Bax proteins and an upregulation of antiapoptotic Bcl-2 proteins. The addition of MPG-medicated serum to the media of cultured GCs also reduced cadmium chloride-induced apoptosis and downregulated caspase-3 protein expression. This work demonstrates that Menoprogen inhibits GC apoptosis in aged female rats and thereby increases E₂ production. This represents a novel mechanism of action for this herbal medicine in the treatment of menopausal symptoms.

Migraine in menopausal women: a systematic review

Evidence suggests that migraine activity is influenced by hormonal factors, and particularly by estrogen levels, but relatively few studies have investigated the prevalence and characteristics of migraine according to the menopausal status. Overall, population-based studies have shown an improvement of migraine after menopause, with a possible increase in perimenopause. On the contrary, the studies performed on patients referring to headache centers have shown no improvement or even worsening of migraine. Menopause etiology may play a role in migraine evolution during the menopausal period, with migraine improvement more likely occurring after spontaneous rather than after surgical menopause. Postmenopausal hormone replacement therapy has been found to be associated with migraine worsening in observational population-based studies. The effects of several therapeutic regimens on migraine has also been investigated, leading to nonconclusive results. To date, no specific preventive measures are recommended for menopausal women with migraine. There is a need for further research in order to clarify the relationship between migraine and hormonal changes in women, and to quantify the real burden of migraine after the menopause. Hormonal manipulation for the treatment of refractory postmenopausal migraine is still a matter of debate.

Postmenopausal hormone therapy and cognition

This article is part of a Special Issue "Estradiol and cognition". Prior to the publication of findings from the Women's Health Initiative (WHI) in 2002, estrogen-containing hormone therapy (HT) was used to prevent age-related disease, especially cardiovascular disease, and to treat menopausal symptoms such as hot flushes and sleep disruptions. Some observational studies of HT in midlife and aging women suggested that HT might also benefit cognitive function, but randomized clinical trials have produced mixed findings in terms of health and cognitive outcomes. This review focuses on hormone effects on cognition and risk for dementia in naturally menopausal women as well as surgically induced menopause, and highlights findings from the large-scale WHI Memory Study (WHIMS) which, contrary to expectation, showed increased dementia risk and poorer cognitive outcomes in older postmenopausal women randomized to HT versus placebo. We consider the 'critical window hypothesis', which suggests that a window of opportunity may exist shortly after menopause during which estrogen treatments are most effective. In addition, we highlight emerging evidence that potential adverse effects of HT on cognition are most pronounced in women who have other health risks, such as lower global cognition or diabetes. Lastly, we point towards implications for future research and clinical treatments.

Management of endometrial modifications in perimenopausal women

Perimenopause has a variable length and time of onset and is characterized by its variability in hormonal levels. The histological changes in the perimenopausal endometrium may be represented by nonproliferative or proliferative benign or malignant lesions. A commonly encountered manifestation of endometrium lesions during menopausal transition is the abnormal uterine bleeding (AUB). The clinical management of AUB must follow a standardized classification system for optimal results. The medical and surgical treatment must be adapted according to age, risk factors, symptoms, and cycle irregularities. Use of alternative therapies and proper diet may result in improved long-term outcomes.

Assessing the utility of methods for menopausal transition classification in a population-based cohort: the CARDIA Study

OBJECTIVES

Perimenopause significantly impacts women's health, but is under-researched due to challenges in assessing perimenopause status. Using CARDIA data, we compared the validity of six approaches for classifying perimenopause status in order to better understand the performance of classification techniques which can be applied to general cohort data. Specifically, we examined the validity of a self-reported question concerning changes in menstrual cycle length and two full prediction models using all available data concerning menstrual cycles as potential indicators of perimenopause. The validity of these three novel methods of perimenopause classification were compared to three previously established classification methods.

METHODS

For each method, women were classified as pre- or peri-menopausal at Year 15 of follow-up (ages 32-46). Year 15 perimenopause status was then used to predict Year 20 post-menopausal status (yes/no) to estimate measures of validity and area under the curve.

RESULTS

The validity of the methods varied greatly, with four having an area under the curve greater than 0.8.

CONCLUSIONS

When designing studies, researchers should collect the data required to construct a prediction model for classifying perimenopause status that includes age, smoking status, vasomotor symptoms, and cycle irregularities as predictors. The inclusion of additional data regarding menstrual cycles can be used to construct a full prediction model which may offer improved validity. Valid classification methods that use readily available data are needed to improve the scientific accuracy of research regarding perimenopause, promote research on this topic, and inform clinical practices.