Estimation of the distribution of age at natural menopause from prevalence data

Molecular differences between younger versus older ER-positive and HER2-negative breast cancers

The RxPONDER and TAILORx trials demonstrated benefit from adjuvant chemotherapy in patients age ≤ 50 with node-positive breast cancer and Recurrence Score (RS) 0-26, and in node-negative disease with RS 16-25, respectively, but no benefit in older women with the same clinical features. We analyzed transcriptomic and genomic data of ER+/HER2- breast cancers with in silico RS < 26 from TCGA (n = 530), two microarray cohorts (A: n = 865; B: n = 609), the METABRIC (n = 867), and the SCAN-B (n = 1636) datasets. There was no difference in proliferation-related gene expression between age groups. Older patients had higher mutation burden and more frequent ESR1 copy number gain, but lower frequency of GATA3 mutations. Younger patients had higher rate of ESR1 copy number loss. In all datasets, younger patients had significantly lower mRNA expression of ESR1 and ER-associated genes, and higher expression of immune-related genes. The ER- and immune-related gene signatures showed negative correlation and defined three subpopulations in younger women: immune-high/ER-low, immune-intermediate/ER-intermediate, and immune-low/ER-intermediate. We hypothesize that in immune-high cancers, the cytotoxic effect of chemotherapy may drive the benefit, whereas in immune-low/ER-intermediate cancers chemotherapy induced ovarian suppression may play important role.

Hormone therapy for uterine and endometrial development in women with premature ovarian insufficiency

BACKGROUND

Premature ovarian insufficiency (POI) is a clinical syndrome resulting from loss of ovarian function before the age of 40. It is a state of hypergonadotropic hypogonadism, characterised by amenorrhoea or oligomenorrhoea, with low ovarian sex hormones (oestrogen deficiency) and elevated pituitary gonadotrophins. POI with primary amenorrhoea may occur as a result of chromosomal and genetic abnormalities, such as Turner syndrome, Fragile X, or autosomal gene defects; secondary amenorrhoea may be iatrogenic after the surgical removal of the ovaries, radiotherapy, or chemotherapy. Other causes include autoimmune diseases, viral infections, and environmental factors; in most cases, POI is idiopathic. Appropriate replacement of sex hormones in women with POI may facilitate the achievement of near normal uterine development. However, the optimal effective hormone therapy (HT) regimen to maximise the reproductive potential for women with POI remains unclear.

OBJECTIVES

To investigate the effectiveness and safety of different hormonal regimens on uterine and endometrial development in women with POI.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, and two trials registers in September 2021. We also checked references of included studies, and contacted study authors to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) investigating the effect of various hormonal preparations on the uterine development of women diagnosed with POI.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. The primary review outcome was uterine volume; secondary outcomes were endometrial thickness, endometrial histology, uterine perfusion, reproductive outcomes, and any reported adverse events.

MAIN RESULTS

We included three studies (52 participants analysed in total) investigating the role of various hormonal preparations in three different contexts, which deemed meta-analysis unfeasible. We found very low-certainty evidence; the main limitation was very serious imprecision due to small sample size. Conjugated oral oestrogens versus transdermal 17ß-oestradiol We are uncertain of the effect of conjugated oral oestrogens compared to transdermal 17ß-oestradiol (mean difference (MD) -18.2 (mL), 95% confidence interval (CI) -23.18 to -13.22; 1 RCT, N = 12; very low-certainty evidence) on uterine volume, measured after 12 months of treatment. The study reported no other relevant outcomes (including adverse events). Low versus high 17ß-oestradiol dose We are uncertain of the effect of a lower dose of 17ß-oestradiol compared to a higher dose of 17ß-oestradiol on uterine volume after three or five years of treatment, or adverse events (1 RCT, N = 20; very low-certainty evidence). The study reported no other relevant outcomes. Oral versus vaginal administration of oestradiol and dydrogesterone We are uncertain of the effect of an oral or vaginal administration route on uterine volume and endometrial thickness after 14 or 21 days of administration (1 RCT, N = 20; very low-certainty evidence). The study reported no other relevant outcomes (including adverse events).

AUTHORS' CONCLUSIONS

No clear conclusions can be drawn in this systematic review, due to the very low-certainty of the evidence. There is a need for pragmatic, well designed, randomised controlled trials, with adequate power to detect differences between various HT regimens on uterine growth, endometrial development, and pregnancy outcomes following the transfer of donated gametes or embryos in women diagnosed with POI.

Investigation and treatment of premature ovarian insufficiency: A multi-disciplinary review of practice

OBJECTIVES

To assess compliance with the European Society for Human Reproduction and Embryology (ESHRE) guidelines on the investigation and management of women with premature ovarian insufficiency at the Leeds Teaching Hospitals NHS Trust (LTHT) and to determine whether this varies depending on the clinical setting in which the women present.

STUDY DESIGN

A retrospective review of all females diagnosed with premature ovarian insufficiency between 1 July 2016 and 30 June 2017, presenting to one of the following clinics: reproductive medicine, specialist menopause, general gynaecology, oncology long-term follow-up, general endocrinology or paediatric endocrinology.

MAIN OUTCOME MEASURES

Proportion of patients who had the necessary investigations performed and relevant treatment options discussed.

RESULTS

103 women were included in the study. Overall, 40.6% had a karyotype. Screening for the Fragile-X pre-mutation, thyroid peroxidase and 21-hydroxylase antibodies occurred in 7.4%, 11.1% and 13.6% of women, respectively. Only 35.9% had their bone mineral density measured. There was significant variation in the performance of a karyotype (p < 0.001) and thyroid peroxidase antibodies (p < 0.01) between the different clinical settings. Overall, lifestyle advice was offered to 30.1%. Estrogen replacement, contraception, fertility options and bone protection were discussed with 76.0%, 38.4%, 59.0% and 75.0%, respectively. Psychological support was offered to 25.2%. There was significant variation for all apart from contraception.

CONCLUSION

The investigation and treatment of women with premature ovarian insufficiency at the LTHT is not consistent with the ESHRE guidelines and requires improvement. Furthermore, there is significant variation in management depending on the department to which the patient initially presents.

Associations between sex and incident chronic kidney disease in a prospective diabetic cohort

Aim

Women with diabetes have a higher prevalence of chronic kidney disease (CKD) risk factors compared with men, but whether they are at higher risk for incident CKD remains uncertain.

Methods

This was a prospective, observational cohort study of 1464 patients with diabetes and normal renal function, recruited from primary care clinics at a vertically integrated healthcare system in Seattle, WA, USA. The primary predictor was sex. Incident CKD was defined by an estimated glomerular filtration rate (eGFR) <60 mL/min per 1.73 m² by Chronic Kidney Disease‐Epidemiology equations or sex‐specific microalbuminuria (urine albumin/creatinine ratio ≥25 mg/g for women or ≥17 mg/g for men).

Results

Of the 1464 patients (52.0% women), CKD incidence rates were 154.0 and 144.3 cases per 1000 patient‐years for women and men, respectively. In the competing risks regression, women had an increased risk of incident CKD (sub‐hazard ratio 1.37, 95% confidence interval (CI) 1.17, 1.60) compared with men after adjustment for demographics, baseline eGFR and duration of diabetes, which persisted after additional adjustment for CKD risk factors, depressive symptoms and diabetes self‐care (sub‐hazard ratio 1.35, 95% CI 1.15, 1.59). Sex differences in incident CKD were consistent across age groups and appeared to be driven by differences in the development of low eGFR rather than microalbuminuria.

Conclusion

Women with diabetes had a higher risk of incident CKD compared with men, which could not be entirely explained by differences in biologic CKD risk factors, depression or diabetes self‐care. Additional work is needed determine if these sex differences contribute to worse outcomes in women with diabetes.

The authors have evaluated associations between sex and chronic kidney disease (CKD) incidence in a primary care population with diabetes using Chronic Kidney Disease‐Epidemiology equations for estimating glomerular filtration rate (GFR) and sex‐specific definitions of microalbuminuria. They found that women had an increased risk of incident CKD compared with men. They also found that this difference in incident CKD was primarily driven by differences in incident eGFR < 60 mL/min per 1.73 m².

Inadequate management for secondary fracture prevention in patients with distal radius fracture by trauma surgeons

We evaluated the secondary fracture prevention in 1445 patients with distal radius fracture by trauma surgeons. The rate of patients with distal radius fracture who underwent bone mineral density (BMD) examination was low, suggesting that appropriate treatment for osteoporosis by trauma surgeons is not performed at present.

INTRODUCTION

To clarify the status of osteoporosis interventions after distal radial fractures by trauma surgeons who play the main role in treatment for these fractures, we performed a survey involving multiple institutions in Japan.

METHODS

We asked 155 board members of the Japanese Society for Fracture Repair for their cooperation and performed a survey in 48 institutions with which members who gave cooperation were affiliated. The subjects consisted of consecutive patients with distal radial fractures occurring between January and December 2012. The presence or absence of a diagnosis of osteoporosis and bone mineral density examination after fracture was investigated.

RESULTS

A total of 1445 patients with distal radial fractures were evaluated in this study. BMD examination for diagnosis and treatment for osteoporosis after fracture was performed respectively in 126 (8.7 %) and 193 (13.4 %) of 1445 patients. Treatment for osteoporosis was performed in 93 (73.8 %) of 126 patients who underwent BMD examination after fracture and 100 (8.2 %) of 1219 who did not undergo BMD examination. Of the 126 patients who underwent BMD examination after fracture, 89 showed a BMD <80 % of the young adult mean as a criterion for the initiation of drug treatment for osteoporosis in Japan and 77 (86.5 %) of the 89 patients were treated with drugs.

CONCLUSIONS

The rate of patients with distal radial fractures who underwent BMD examination was low, suggesting that appropriate treatment for osteoporosis by trauma surgeons is not performed at present.

Trends in ages at key reproductive transitions in the United States, 1951-2010

BACKGROUND

Key sexual and reproductive health milestones typically mark changing life stages with different fertility intentions and family planning needs. Knowing the typical ages at such events contributes to our understanding of changes in family formation and transition to adulthood and helps inform needs for reproductive health services.

METHODS

We used data from the 1982-2010 National Surveys of Family Growth and the 1995 National Survey of Adolescent Males and event history methods to examine trends over time for women and men in the median ages at several reproductive and demographic events.

FINDINGS

Women's reports indicate that age at menarche has changed little since 1951. Women's and men's median ages at first sex declined through the 1978 birth cohort, but increased slightly since then, to 17.8 years for women and 18.1 for men. The interval from first sex to first contraceptive use has narrowed, although Hispanic women have a longer interval. Age at first union (defined as the earlier of first marriage or first cohabiting relationship) has remained relatively stable, but the time between median age at first sex and median age at first birth has increased to 9.2 years for women and 11.4 for men. For some women and men born in the late 1970s, median age at first birth was earlier than median age at first marriage for the first time in at least the past several decades.

CONCLUSION

The large majority of the reproductive years are spent sexually active. Thus, women have a lengthy period during which they require effective methods. In particular, the period between first sex and first childbearing has lengthened, but long-acting method use, although increasing, has not kept up with this shift. Moving the contraceptive method mix toward underutilized but highly effective contraceptive methods has the potential to reduce the unintended pregnancy rate.

Increased long-term recreational physical activity is associated with older age at natural menopause among heavy smokers: the California Teachers Study

OBJECTIVE

Although physical activity modulates the hypothalamic-pituitary-ovarian axis, the few studies that have investigated whether physical activity is associated with age at natural menopause have yielded mixed results. We set out to determine whether physical activity is associated with the timing of natural menopause in a large cohort of California women overall and by smoking history.

METHODS

We investigated the association between long-term physical activity (h/wk/y) and age at natural menopause among 97,945 women in the California Teachers Study. Multivariable Cox proportional hazards regression methods were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). The impact of cigarette smoking (never smoker, former light smoker, former heavy smoker, current light smoker, and current heavy smoker) as an effect modifier was evaluated.

RESULTS

In a multivariable model adjusted for body mass index at age 18 years, age at menarche, race/ethnicity, and age at first full-term pregnancy, increased physical activity was statistically significantly associated with older age at natural menopause (P(trend) = 0.005). Higher body mass index at age 18 years (P(trend) = 0.0003) and older age at menarche (P(trend) = 0.0003) were also associated with older age at natural menopause. Hispanic ethnicity (vs non-Hispanic whites; HR, 1.17; 95% CI, 1.09-1.26), current smokers (vs never smokers; HR, 1.68; 95% CI, 1.60-1.75 for current light smokers; HR, 1.38; 95% CI, 1.33-1.44 for current heavy smokers), and older age at first full-term pregnancy (HR(≥29, 2+ full-term pregnancies) vs HR(<29, 2+ full-term pregnancies), 1.10; 95% CI, 1.06-1.14) were associated with earlier age at natural menopause. Upon stratification by smoking history, increased physical activity was statistically significantly associated with older age at natural menopause among heavy smokers only (HR(highest quartile) vs HR(lowest quartile), 0.88; 95% CI, 0.81-0.97; P(trend) = 0.02 for former heavy smokers; HR(highest quartile) vs HR(lowest quartile), 0.89; 95% CI, 0.80-0.99; P(trend) = 0.04 for current heavy smokers).

CONCLUSIONS

Age at natural menopause is a complex trait; the determinants of age at natural menopause, including physical activity, may differ by smoking status.

The timing of the age at which natural menopause occurs

The timing of natural menopause is a clinically important indicator of longevity and risk of morbidity and mortality. Demographic, menstrual, reproductive, familial, genetic, and lifestyle factors seem to be important in this timing. Smoking, lower parity and poor socioeconomic status are associated with earlier menopause. However, a number of relationships have been inconsistent; others remain largely unexplored. Much remains to be learned about factors that affect follicular atresia and the onset and duration of perimenopause and the timing of the natural menopause. Knowledge about these relationships offers women and their health care providers enhanced understanding and choices to deal with menopause.

Relation of sex and estrogen therapy to serum fibroblast growth factor 23, serum phosphorus, and urine phosphorus: the Heart and Soul Study

BACKGROUND

Menopause is associated with urine phosphorus retention, which is mitigated by estrogen therapy. Fibroblast growth factor 23 (FGF-23) is a hormone originating from bone that regulates urine phosphorus excretion. Whether sex or estrogen therapy is associated with different FGF-23 levels is unknown.

STUDY DESIGN & SETTING

Cross-sectional study of ambulatory individuals with prevalent cardiovascular disease.

PREDICTORS

Sex and, in women, use or nonuse of estrogen.

OUTCOMES

Serum phosphorus, tubular maximum reabsorption of phosphorus indexed to glomerular filtration rate (TMP/GFR), and plasma FGF-23 concentrations.

RESULTS

For 987 participants, mean age was 67 ± 11 years, 182 (18%) were women, and 46 (25%) were using estrogen. Mean estimated GFR was 71 ± 23 (SD) mL/min/1.73 m(2). Compared with women who were not using estrogen, both women on estrogen therapy and men had significantly lower serum phosphorus concentrations, lower TMP/GFR values (indicating higher urine phosphorus excretion), and lower FGF-23 concentrations with adjustment for age, demographics, and kidney function (P < 0.001 for each). Mean FGF-23 levels were 68.7 (95% CI, 59.7-79.0) relative units (RU)/mL in non-estrogen-using women, 43.8 (95% CI, 41.2-46.5) RU/mL in men, and 45.1 (95% CI, 35.2-57.4) RU/mL in women using estrogen in adjusted analysis (P < 0.001).

LIMITATIONS

Most participants were men. Estrogen therapy was not randomly assigned.

CONCLUSIONS

Older women who are not using estrogen have higher FGF-23 levels than either men or women using estrogen. In the context of prior literature, these data suggest that postmenopausal phosphorus retention may stimulate higher FGF-23 concentrations after menopause.

Nonparametric inference for competing risks current status data with continuous, discrete or grouped observation times

New methods and theory have recently been developed to nonparametrically estimate cumulative incidence functions for competing risks survival data subject to current status censoring. In particular, the limiting distribution of the nonparametric maximum likelihood estimator and a simplified naive estimator have been established under certain smoothness conditions. In this paper, we establish the large-sample behaviour of these estimators in two additional models, namely when the observation time distribution has discrete support and when the observation times are grouped. These asymptotic results are applied to the construction of confidence intervals in the three different models. The methods are illustrated on two datasets regarding the cumulative incidence of different types of menopause from a cross-sectional sample of women in the United States and subtype-specific HIV infection from a sero-prevalence study in injecting drug users in Thailand.

Association of serum phosphorus with left ventricular mass in men and women with stable cardiovascular disease: data from the Heart and Soul Study

BACKGROUND

Higher serum phosphorus levels are associated with cardiovascular disease (CVD) events in the general population, an association that may be stronger in men. Estradiol has phosphaturic properties. Whether higher serum phosphorus levels are associated with left ventricular (LV) mass in persons without end-stage renal disease and whether the association is modified by sex is unknown.

STUDY DESIGN

Cross-sectional observational study.

SETTING & PARTICIPANTS

978 outpatients with stable CVD.

PREDICTOR

The primary predictor variable was serum phosphorus level. Sex was evaluated as an effect modifier.

OUTCOME & MEASUREMENTS

LV mass using transthoracic echocardiography.

RESULTS

The association of serum phosphorus level with LV mass differed by sex (interaction P=0.04). In models adjusted for age, race, kidney function, smoking, diabetes, blood pressure, cholesterol level, C-reactive protein level, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use, each 1-mg/dL higher serum phosphorus level was associated with 4.52-g/m2 greater LV mass (95% CI, 1.04-8.01; P=0.01) in men. Conversely, in women, no statistically significant association was found between serum phosphorus level and LV mass.

LIMITATIONS

Older adult population with stable CVD; 19% were women.

CONCLUSIONS

In outpatients with stable CVD, higher serum phosphorus levels are associated with greater LV mass in men, but not women. Whether sex hormones may account for these differences requires future study.

The normal menopause transition

This paper presents analyses from perhaps the largest and most comprehensive prospective cohort study of mid-aged women--the Massachusetts Women's Health Study (MWHS)--with numbers sufficient to provide, for the first time, stable estimates of parameters in the normal menopause transition. The three questions addressed in this analysis are (i) what are the natural menopause transitions and when do they occur, (ii) what factors affect these transitions and (iii) what signs and/or symptoms accompany these transitions? The data were obtained primarily from 5 years of follow-up of 2570 women in Massachusetts who were aged 45-55 years as of January 1, 1982. An initial baseline cross-sectional survey (T0) yielded a total of 8050 completed responses with an overall response rate of 77%. From this cross-sectional sample a cohort of approximately 2570 women was identified, consisting of women who had menstruated in the preceding 3 months and who had not undergone removal of the uterus and/or ovaries. Prospective study of the cohort consisted of six telephone contacts (T1-T6) at 9-month intervals with excellent retention of the respondents. A subset of the full cohort was defined that consisted of women who were premenopausal (rather than perimenopausal) at baseline (T0) (n = 1178). Confirming prior reports, the age at natural menopause occurred at 51.3 years with a highly significant median difference (1.8 years) between current smokers and non-smokers. The new analyses reported here on median age at inception of perimenopause (47.5 years) and factors affecting it are consistent with findings for age at last menstrual period, particularly the overwhelming effect of smoking. Smokers tend to have not only an earlier but also a shorter perimenopause. The length of the perimenopausal transition (estimated at nearly 4 years) has not been previously reported. Moreover, the highest rate of physician consultations is observed among those with longer perimenopause transitions. The relationship between menopause transitions and symptom reporting appears to be transitory, with reported rates showing an increase in the perimenopause and a compensatory decrease in the postmenopause. The implications of combined hormone replacement therapy for future research on menopause in industrial societies is discussed in relation to these findings.

Differences in health characteristics between native Japanese and Japanese-Americans

Health characteristics were compared among 1193 Japanese in Hiroshima, and 2306 Japanese-Americans in Hawaii. Japanese women experienced later menarche, earlier menopause, and a shorter interval between menarche and menopause than Japanese-Americans. Japanese men and women were shorter and lighter and the men bad lower body mass index than Japanese-Americans. Differences between populations were also found for the prevalence of artificial menopause, number of live births, lactation period, smoking, and alcohol consumption. Within one or both populations, significant trends with birth year were found for age at menarche, age at menopause, interval between menarche and menopause, lactation period, height, weight, and body mass index, suggesting the existence of cohort effects. Some of these trends may also reflect age-related changes. Environmental factors likely contribute to the differences in physique and reproductive factors, which may explain differences in frequency of osteoporosis, cardiovascular diseases, and cancer between the two populations.

Gender and the use of neuroleptics in schizophrenia

INTRODUCTION

The oestrogen hypothesis proposes that the lower need for neuroleptic drugs in female schizophrenia patients is caused by the antidopaminergic effect of oestrogens, and that when oestrogen production decreases at menopause, the need for neuroleptic drugs increases in female schizophrenia patients.

SUBJECTS AND METHOD

The oestrogen hypothesis was tested in a sample of 4338 schizophrenia patients (DSM III R), who were discharged from hospital and followed up for 3 years. Prescribed daily doses of neuroleptics (DDN) were recorded and converted to chlorpromazine equivalents.

RESULTS

Males had higher DDN than females. When the age at first admission (AFA) was controlled, DDNs were higher in males than in females in all age groups. In addition to AFA, DDNs were associated with duration of illness (DUI), education, smoking and clinical status as well as with concurrently prescribed antidepressants, anti-manics, sedatives and hypnotics, but these factors did not explain the gender differences in DDN.

CONCLUSIONS

The results did not support the original oestrogen hypothesis. It is proposed that testosterone secretion may explain why male schizophrenia patients are prescribed higher DDNs than female patients. Ageing processes in the central nervous system (CNS) may explain why DDNs decrease after middle age in both genders.

The frequency distribution of age at natural menopause among Saudi Arabian women

OBJECTIVE

Hormonal changes at the menopause are associated with the onset of a number of medical conditions. The distribution of age-at-menopause (AAM) within a given population can, therefore, indicate how the disease prevalence changes with age. The objective of this study was to estimate the distribution of AAM among Saudi Arabian women, in order to predict local trends in the prevalence of osteoporosis.

METHODS

Patient age, AAM, medical history and associated information for 858 Saudi Arabian women were extracted from a Dual Energy Absorptiometry database at King Faisal Specialist Hospital and Research Centre, resulting in an AAM distribution for 391 postmenopausal women with natural menopause. This was preprocessed using a Fast Fourier Transform 0.15 cycles/year low-pass filter, eliminating last-digit-preference errors and high frequency noise, and facilitating quantitative comparison with other published results.

RESULTS

Mean AAM was 48.94 years (S.E. 0.290 years) with a median of 50 years (25th/75th percentiles: 45 and 53 years, respectively). The AAM distribution was described by a quadruple-Gaussian curve with a major peak at almost 51 years and minor peaks at approximately 36, 44 and 59 years. Although both the central peaks were similar to that observed in other populations (UK, USA and Finland), the early menopause peak at 36 years was larger. The peak over 55 years may be unique to the Kingdom of Saudi Arabia. It may reflect local cultural and childbearing practices.

CONCLUSIONS

Although the median menopause age and general shape of the AAM distribution in Saudi Arabia appear similar to that observed in the West, the parameters governing the distribution are different, and there is evidence that it may have a unique fourth peak.

[From pathological diagnosis to ovulation induction. The case of ovarian insufficiency]

The incidence of premature ovarian failure (POF) is around 1 to 3%. This pathology occurs in young women, who often wish to become pregnant. Theoretically, two mechanisms could be involved: initial follicle depletion and follicle dysfunction. However, in some cases, mixed mechanisms are involved. Initially, PFO was considered irreversible. In fact, signs of intermittent ovarian function in normal karyotypically women have been described, but predicting the probability of spontaneous remission in a specific woman is impossible. Therefore, various treatments for ovulation induction have been proposed to these patients. Most of the pregnancies occur after hormone replacement therapy. The action of this treatment is unclear and the cause-and-effect relation has not been proven by prospective, randomized studies. The benefit of suppressing endogen gonadotropins by GnRH agonists is not proven either. Estrogen supplementation and high-dose gonadotropin ovarian stimulation protocols have been proposed. Even so, this therapy cannot be recommended because of the lack of controlled studies. Finally, numerous case reports have described the return of ovarian function after using immunosuppressive therapies. The lack of particular criteria for the diagnosis of autoimmune mechanisms have lead to treat heterogeneous groups of patients. No randomized controlled studies with immunologic monitorage have been performed that could establish the success of this therapy. Therefore, in order to find effective treatments, basic pathophysiologic mechanisms must be better understood. For those women who want to become pregnant, the lack of prospective, randomized studies cannot lead to formal conclusions. Depending on the patients' age and history, it appears reasonable to attempt a corrective therapy based on defined etiology, before entering in a donor oocyte program.

Treatment of osteoporosis: are physicians missing an opportunity?

BACKGROUND

Medical treatment of women with established osteoporosis may decrease the incidence of future fractures. Postmenopausal women who have sustained a distal radial fracture have decreased bone-mineral density and nearly twice the risk of a future hip fracture. The purpose of this study was to evaluate the adequacy of diagnosis and treatment of osteoporosis in postmenopausal women following an acute fracture of the distal part of the radius.

METHODS

A retrospective cohort study was performed with use of a claims database that includes more than three million patients, from thirty states, enrolled in multiple health plans. All women, fifty-five years of age or older, who sustained a distal radial fracture between July 1, 1994, and June 30, 1997, were identified in the database. Only patients with at least six months of continuous and complete medical and pharmaceutical health-care coverage from the date of the fracture were enrolled, to ensure that all health-care claims would be captured in the database. This cohort of patients was then evaluated to determine the proportion who had undergone either a diagnostic bone-density scan or treatment with any recommended medication for established osteoporosis (estrogen, a bisphosphonate, or calcitonin) within six months following the fracture.

RESULTS

A search of the database identified 1,162 women, fifty-five years of age or older, who had a distal radial fracture. Of these 1,162 patients, thirty-three (2.8 percent) underwent a bone-density scan and 266 (22.9 percent) were treated with at least one of the medications approved for treatment of established osteoporosis. Twenty women had both a bone-density scan and drug treatment. Therefore, only 279 (24.0 percent) of the 1,162 women who sustained a distal radial fracture underwent either diagnostic evaluation or treatment of osteoporosis. There was a significant decrease in the rate of treatment of osteoporosis with increasing patient age at the time of the fracture (p < 0.0001).

CONCLUSIONS

Current physician practice may be inadequate for the diagnosis and treatment of osteoporosis in postmenopausal women who have sustained a distal radial fracture.

Effect of exclusion: Rates of hysterectomy and comparisons of age at natural menopause

The objectives of this study were to identify factors related to history of hysterectomy; to evaluate whether or not subgroups with different rates of hysterectomy also report significantly different mean ages at natural menopause; and to consider how variation in rates of hysterectomy may affect intrapopulation and cross-population comparisons of median ages at natural menopause. Data were drawn from a community sample in upstate New York. It is demonstrated that hysterectomy rates are not random with respect to variables that are also related to age at natural menopause. For example, women reporting high levels of education reported lower rates of hysterectomy and earlier mean ages at menopause. In addition, median ages at menopause and rates of hysterectomy were examined by correlation and regression analysis across a selection of industrialized countries. Avenues for further study are suggested. Am. J. Hum. Biol. 11:687-693, 1999. Copyright 1999 Wiley-Liss, Inc.

The age and symptomatology of natural menopause among United Arab Emirates women

OBJECTIVES

To determine the median age of natural menopause in United Arab Emirates women, the factors affecting that age and the prevalence of climacteric symptoms amongst those women.

METHODS

A population-based survey was conducted on a community sample of United Arab Emirates women who had had natural menopause defined as cessation of menstruation for at least 6 months at the end of reproductive years. A total of 742 women aged 40 years and above were recruited from both urban and rural areas of the country using the multi-stage stratified cluster sampling technique. Data were collected using a structured questionnaire and face to face interviews and included a number of familial, reproductive and life-style variables.

RESULTS

The median age of the menopause in the United Arab Emirates is 48 years (mean = 47.3 +/- 3.29, range 40-59). This is significantly lower than the median age reported from the West (50.3 years). The subject median age of the menopause was significantly related to that of the mother (P < 0.001), older sister (P < 0.001), parity (P < 0.0001) and the previous use of oral contraceptive pills for more than 1 year (P < 0.001). Hot flushes were the commonest feature of the menopause occurring in 45% of women.

CONCLUSION

The age of natural menopause in United Arab Emirates women, as in other developing countries, is less than in Western women and may be influenced by genetic factors, parity and previous use of oral contraceptives. Climacteric symptomatology, however, is similar in the different patient groups.

Cardiovascular stress response and coronary artery disease: evidence of an adverse postmenopausal effect in women

OBJECTIVES

To test the hypothesis that postmenopausal women demonstrate greater vascular instability, measured by enhanced cardiovascular stress responses during mental stress, compared with men and premenopausal women.

BACKGROUND

Recent data suggest that estrogen plays a role in regulating vascular tone. The possible consequences of estrogen deficiency during menopause on systemic vascular reactivity is largely unexplored.

METHODS

One hundred subjects (84 men and 16 women) underwent mental stress testing with radionuclide ventriculo graphy. Study subjects included 19 normal volunteers, 23 control subjects with chest pain syndromes or hypertension but without coronary artery disease, and 58 coronary artery disease subjects. The subjects performed a series of three mental stress tasks, during which hemodynamic data and radionuclide ventriculograms were obtained.

RESULTS

Overall, women demonstrated greater hemodynamic responses during mental stress measured by changes in heart rate, systolic and diastolic blood pressure, and double product compared with those of men (all p < 0.05). Women with coronary artery disease demonstrated greater heart rate, diastolic blood pressure, and double product stress responses than their male counterparts (all p < 0.05). Women of postmenopausal age demonstrated significantly greater systolic blood pressure reactivity than men or premenopausal women (p < 0.05).

CONCLUSIONS

Women of postmenopausal age have greater cardiovascular responses to stress than men or premenopausal women. These findings suggest an additional mechanism by which estrogen deficiency conveys a poor prognosis in female patients with coronary artery disease.

The menopause transition

New paradigms for the study of menopause will increase our understanding of whether symptoms, syndromes, and chronic diseases are associated with menopause. Rather than considering menopause as a discrete event, it has become clear that the menopause transition takes place over many years. Although this realization is central to our understanding of menopause, it is difficult to measure the temporal pattern of changes in hormones and their relation to concurrent or subsequent health-related events. The model of hormonal changes at the time of the transition has been expanded to include not only declines in estrogen but changes in a broader range of hormones, including the potential role of androgens. New models are attempting to account for the pattern and frequency of changes in hormone levels. Another level of complexity is contributed by the expansion of the menopause model to include comorbid medical and psychiatric conditions, environmental influences, and behaviors as covariates that influence the expression of menopause-related events. Although this more complicated paradigm makes the conduct of menopause research more challenging, it is also likely to elucidate previously confusing data, as the proper understanding of potentially complex exposures, effect modifiers, and confounders is more likely to provide clearer answers to critical research questions.

Premature ovarian failure and ovarian autoimmunity

Premature ovarian failure (POF) is defined as a syndrome characterized by menopause before the age of 40 yr. The patients suffer from anovulation and hypoestrogenism. Approximately 1% of women will experience menopause before the age of 40 yr. POF is a heterogeneous disorder with a multicausal pathogenesis involving chromosomal, genetic, enzymatic, infectious, and iatrogenic causes. There remains, however, a group of POF patients without a known etiology, the so-called "idiopathic" form. An autoimmune etiology is hypothesized for the POF cases with a concomitant Addison's disease and/or oöphoritis. It is concluded in this review that POF in association with adrenal autoimmunity and/or Addison's disease (2-10% of the idiopathic POF patients) is indeed an autoimmune disease. The following evidence warrants this view: 1) The presence of autoantibodies to steroid-producing cells in these patients; 2) The characterization of shared autoantigens between adrenal and ovarian steroid-producing cells; 3) The histological picture of the ovaries of such cases (lymphoplasmacellular infiltrate around steroid-producing cells); 4) The existence of various autoimmune animal models for this syndrome, which underlines the autoimmune nature of the disease. There is some circumstantial evidence for an autoimmune pathogenesis in idiopathic POF patients in the absence of adrenal autoimmunity or Addison's disease. Arguments in support of this are: 1) The presence of cellular immune abnormalities in this POF patient group reminiscent of endocrine autoimmune diseases such as IDDM, Graves' disease, and Addison's disease; 2) The more than normal association with IDDM and myasthenia gravis. Data on the presence of various ovarian autoantibodies and anti-receptor antibodies in these patients are, however, inconclusive and need further evaluation. A strong argument against an autoimmune pathogenesis of POF in these patients is the nearly absent histological confirmation (the presence of an oöphoritis) in these cases (< 3%). However, in animal models using ZP immunization, similar follicular depletion and fibrosis (as in the POF women) can be detected. Accepting the concept that POF is a heterogenous disorder in which some of the idiopathic forms are based on an abnormal self-recognition by the immune system will lead to new approaches in the treatment of infertility of these patients. There are already a few reports on a successful ovulation-inducing treatment of selected POF patients (those with other autoimmune phenomena) with immunomodulating therapies, such as high dosages of corticosteroids (288-292).

Unraveling bleeding problems in midlife women

Menopause often is accompanied by abnormal uterine bleeding-mostly due to anovulation and correctable with hormone therapy. However, all patients should be fully evaluated for gynecologic and nongynecologic causes of bleeding.

The normal menopause transition: an overview

OBJECTIVES

This review emphasizes results from population based studies in order to provide a reliable knowledge base and define major knowledge gaps for future research.

METHODS

The review systematically addresses the following aspects of menopause research: definition of menopause and menopause transitions; age at natural menopause and at inception of perimenopause; factors affecting timing and length of menopause transitions; concurrent hormone, menstrual and vascular changes. Under each substantive heading, available reports of original research are reviewed, assessed for reliability and summarized with respect to their contribution to the knowledge base.

RESULTS

From this review, the following reliable information can be summarized: median age at natural menopause in Caucasian women occurs between 50 and 51-55 years of age, is not affected by timing of surgical menopause and is affected by cigarette smoking, with current smokers having an earlier menopause by 1.5-2.0 years. No other factors appear to have an independent effect on age at menopause. There is no evidence of any secular trend in age at menopause. Evidence is accumulating that most physiological change associated with menopause either occurs or begins before the final menstrual period.

CONCLUSIONS

We lack reliable information on the following: estimates of age at menopause from non-industrialized countries and diverse ethnic groups; information on perimenopause; differing perceptions of menopause, cross culturally; multi-disciplinary prospective data that can link various processes into coherent patterns.

Is menopause withering away?

Menopause (cessation of menstruation) and the period surrounding it (climacterium) are often defined retrospectively by asking a woman the date of her last menstrual period (LMP). Based on a survey of 2000 women aged 45-64 in 1989 in Finland, this study examines (1) the relation between these definitions and women's own definition of their climacteric status and of the cessation of menstruation and (2) the effect of menopausal and postmenopausal hormone therapy and hysterectomy on the definition of menopause and climacterium. Agreement of the woman's own definition of her climacteric status and interval since LMP was 25% among current hormone users, 41% among hysterectomised women and 64% among those who were neither currently using hormones nor had been hysterectomised. Current hormone users defined the climacteric phase as longer than their LMP suggested. Current hormone use and hysterectomy had little effect on reported final cessation of menstrual periods. It is concluded that hysterectomy and hormone therapy shape women's thinking about the end of reproductive life, blur the concepts of menopause and postmenopause and confuse the measurement of age at menopause.

Influence of the menopausal age on the severity of osteoporosis in women with vertebral fractures

To assess the effect of age at the onset of menopause over the skeleton we have determined the age and cause of menopause and bone mineral density (BMD), by dual and single photon absorptiometry of the lumbar spine, the proximal femur and the radius shaft on 1050 osteoporotic women (suffering with at least one atraumatic vertebral fracture). The mean +/- 1 S.D. menopausal age was 47.1 +/- 7.6 years. The onset of menopause occurred prior to age 45 in 22% (premature), after age 52 in 9% (late), and between 45 and 52 years of age in 69% (normal menopausal age). When the osteoporotic women were categorized into three groups according to the age of menopause, those osteoporotic with premature menopause had a significantly greater frequency of hip fractures, a significantly lower age, weight and BMD over the spine, proximal femur and radius shaft compared with those of normal menopausal age. In turn, patients with late menopause had a significantly increased weight and BMD over the spine. These findings indicate that among patients with vertebral osteoporosis those women with premature menopause had a more severe bone loss and a significantly greater frequency of hip fractures.

Postmenopausal hormone replacement therapy--clinical implications

The menopause is defined as cessation of menstruation, ending the fertile period. The hormonal changes are a decrease in progesterone level, followed by a marked decrease in estrogen production. Symptoms associated with these hormonal changes may advocate for hormonal replacement therapy. This review is based on the English-language literature on the effect of estrogen therapy and estrogen plus progestin therapy on postmenopausal women. The advantages of hormone replacement therapy are regulation of dysfunctional uterine bleeding, relief of hot flushes, and prevention of atrophic changes in the urogenital tract. Women at risk of osteoporosis will benefit from hormone replacement therapy. The treatment should start as soon after menopause as possible and it is possible that it should be maintained for life. The treatment may be supplemented with extra calcium intake, vitamin D, and maybe calcitonin. Physical activity should be promoted, and cigarette smoking reduced if possible. Women at risk of cardiovascular disease will also benefit from hormone replacement therapy. There is overwhelming evidence that hormone therapy will protect against both coronary heart disease and stroke, and there is no increased risk of venous thrombosis or hypertension. A disadvantage of hormone replacement therapy is an increased risk of forming gall-bladder stones and undergoing cholecystectomy. Unopposed estrogen therapy gives a higher incidence of endometrial cancer in women with an intact uterus, but the contribution of progestins for about 10 days every month excludes this risk. Breast cancer in relation to estrogen-progestogen therapy has been given much concern, and the problem is still not fully solved. If there is a risk, it is small, and only after prolonged use of estrogen (15-20 years). The decision whether or not to use hormone replacement therapy should, of course, be taken by the individual woman in question, but her decision should be based on the available scientific information. It is the opinion of the authors that the advantages of hormone replacement therapy far exceed the disadvantages. We suggest that every woman showing any signs of hormone deprivation should be treated with hormone replacement therapy. This includes women with subjective or objective vaso-motor symptoms, genito-urinary symptoms, women at risk of osteoporosis (fast bone losers), and women at risk of cardiovascular diseases.

The normal menopause transition

This paper presents analyses from perhaps the largest and most comprehensive prospective cohort study of mid-aged women--the Massachusetts Women's Health Study (MWHS)--with numbers sufficient to provide, for the first time, stable estimates of parameters in the normal menopause transition. The three questions addressed in this analysis are (i) what are the natural menopause transitions and when do they occur, (ii) what factors affect these transitions and (iii) what signs and/or symptoms accompany these transitions? The data were obtained primarily from 5 years of follow-up of 2570 women in Massachusetts who were aged 45-55 years as of January 1, 1982. An initial baseline cross-sectional survey (T0) yielded a total of 8050 completed responses with an overall response rate of 77%. From this cross-sectional sample a cohort of approximately 2570 women was identified, consisting of women who had menstruated in the preceding 3 months and who had not undergone removal of the uterus and/or ovaries. Prospective study of the cohort consisted of six telephone contacts (T1-T6) at 9-month intervals with excellent retention of the respondents. A subset of the full cohort was defined that consisted of women who were premenopausal (rather than perimenopausal) at baseline (T0) (n = 1178). Confirming prior reports, the age at natural menopause occurred at 51.3 years with a highly significant median difference (1.8 years) between current smokers and non-smokers. The new analyses reported here on median age at inception of perimenopause (47.5 years) and factors affecting it are consistent with findings for age at last menstrual period, particularly the overwhelming effect of smoking. Smokers tend to have not only an earlier but also a shorter perimenopause. The length of the perimenopausal transition (estimated at nearly 4 years) has not been previously reported. Moreover, the highest rate of physician consultations is observed among those with longer perimenopause transitions. The relationship between menopause transitions and symptom reporting appears to be transitory, with reported rates showing an increase in the perimenopause and a compensatory decrease in the postmenopause. The implications of combined hormone replacement therapy for future research on menopause in industrial societies is discussed in relation to these findings.

A prospective study of factors affecting age at menopause

This paper describes a multivariate analysis of a 3-year prospective study of the covariates of age at menopause among women who were randomly sampled from a general population. This approach avoids three problems that may account for the inconsistent results of prior studies: recall bias in retrospectively collected data, failure to control confounding in data analyses, and self-selection in the target populations. At baseline, the 2014 subjects in this study were 46.5-56.5 years old and still menstruating. Median age at last menstruation estimated from a model of the marginal distribution of age at menopause, was 50.7 years. When covariates were considered singly, age at menopause varied with smoking, education and income but not with marital status, parity, location, height, weight or use of either oral contraceptives or menopausal estrogens. Multivariate analyses showed that education and income were confounded with smoking status. The results indicate that many previously identified sources of variation in age at menopause reflect confounding with smoking and self-selection in target populations, rather than real effects.

Multiple sclerosis: updated risks for relatives

Two important characteristics of multiple sclerosis (MS) are familial clustering and a variable age of onset. There is increasing evidence for a genetically influenced susceptibility in MS. Because of this, patients and their relatives are increasingly asking about the risk for relatives of developing MS. In the MS Clinic in Vancouver, genetic histories are taken routinely for all patients and are updated annually. Patients do not attend the clinic specifically to participate in genetic studies, which could result in over-representation of familial cases. Data were available for 815 MS index cases and 11,345 of their relatives. Age-specific MS risks were calculated for first-, second-, and third-degree relatives of probands and are presented in an easy-reference format. In general, first-degree relatives of probands have a risk that is 30-50 times greater than the 0.1% risk for the general population.

Factors influencing the age at natural menopause

To examine sociodemographic, menstrual, reproductive, and other factors which may influence the age at natural menopause, the authors analyzed data from a large series of women participating in a nationwide breast cancer screening program conducted between 1973 and 1980. Standard life table techniques permitted assessment of factors suspected of varying the time to menstrual cessation among 983 premenopausal women, 1091 surgically menopausal women, and 1423 naturally menopausal women. The median age at natural menopause was 51.1 years. Multivariate analysis indicated that parity, irregularity of menstrual cycles before age 25 or first livebirth, and high socioeconomic status were significantly related to menopausal age. These data provide evidence for the hypothesis that certain environmental and hormonal factors which affect ovulation during reproductive years may ultimately postpone the menopause.

Steroid and gonadotropin levels in women during the peri-menopausal years

We obtained blood samples from 88 women 45-58 yr old who were having cyclic menses every 1-2 mth (37 women, 133 samples) or were amenorrheic for greater than 3 mth (51 women, 310 samples). Samples were obtained at intervals of 3-4 mth and analyzed for estrogens, androgens and gonadotropins using radioimmunoassay techniques. There was a gradual decline in the concentrations of estrone (E1), estradiol (E2), estrone sulfate (E1SO4) and progesterone (P) as the time from the last menses increased. A relatively stable concentration was reached in 12 mth for E1, E2, and E1SO4 and in 2 mth for P. The concentrations of testosterone, dihydrotestosterone, androstenedione, dehydroepiandrosterone and dehydroepiandrosterone sulfate remained relatively constant as the time from the last menses increased. There was no apparent difference in the mean values of any of these hormones for any time interval from the last menses. The concentrations of both luteinizing hormone (LH) and follicle stimulating (FSH) were noted to increase initially but they appeared to become stable after 12 mth for FSH and after only 6 mth for LH. Using only the measurements made on the initial blood samples obtained in all patients, we found significant correlations between FSH concentrations and the concentrations of E1, E2 and E1SO4 for women who were less than 3 mth from a menses as well as those whose last menses had occurred 3 or more mth previously. The correlations were generally not significant for LH in either groups of women.(ABSTRACT TRUNCATED AT 250 WORDS)

'Hormonal' risk factors, 'breast tissue age' and the age-incidence of breast cancer

For most cancer sites there is a linear log-log relationship between incidence and age. This relationship does not hold for breast cancer, and certain 'key' breast cancer risk factors suggest that breast tissue does not 'age' in step with calendar time. A quantitative description of 'breast tissue age' is suggested which brings the age-incidence curve of breast cancer into line with the common log-log cancers and explains quantitatively the known key risk factors. The model also explains the 'anomalous' finding that although early first birth is protective, late first birth carries a higher risk than nulliparity. US breast cancer rates are some four to six times the rates in Japan--the model suggests that the key risk factors, when considered jointly with weight, can explain about 85% of the difference.