Symptom clusters during the late reproductive stage through the early postmenopause: observations from the Seattle Midlife Women's Health Study

An empowerment model for managing menopause

Menopause eventually happens to all people with typically functioning ovaries, and almost one billion women worldwide are postmenopausal. Although the biology of typical menopause is ubiquitous, the experience varies substantially. Factors contributing to the experience include not only individual factors, such as the nature and severity of symptoms, but also psychological, social, and contextual considerations, many of which are modifiable. In this first paper in the Lancet Series on menopause, we argue for a new approach that goes beyond the treatment of specific symptoms, to encompass a broad model to support women transitioning this life stage, using the model of empowerment. WHO defines empowerment as an active process of gaining knowledge, confidence, and self-determination to self-manage health and make informed decisions about care. Rather than focusing on menopause as an endocrine deficiency, we propose an empowerment model that recognises factors modifying the experience, in which the patient is an expert in their own condition and the health-care worker supports the patient to become an equal and active partner in managing their own care.

Investigating the Prevalence of Menopausal Symptoms and Medico-Social Dimensions of Menopause in Rural Puducherry, India: A Cross-Sectional Analytical Study

Introduction Globally, the health of women has been of great concern for healthcare providers for the past many years. However, the concern is limited to maternal and adolescent health and the life course approach is lagging. Thus, a need was felt to study the changes after menopause and its influential factors by determining the prevalence of menopausal symptoms and medico-socio-cultural dimensions of menopause among perimenopausal and early postmenopausal women. Methodology A cross-sectional analytical study was conducted from February 2014 to April 2015 in a rural area of Puducherry among 148 women in perimenopausal and early postmenopausal stages by complete enumeration using a pre-tested semi-structured questionnaire. Prevalence was expressed as frequency with percentage and the chi-square test was used to find the association among the study variables. Results The prevalence of menopausal symptoms was in 143 (96.6%) women. Backache (62.3%) was found to have a higher prevalence. Physical symptoms (93.2%) were most prevalent. Of the women, 95% were affected by mild symptoms. Regarding medical and social dimensions of menopausal symptoms, socioeconomic status to vasomotor, age of menarche to physical, marital status, and abortion status to sexual symptoms were significant. A positive correlation was seen among the four menopausal symptom domains, except for vasomotor to sexual symptoms. Conclusion Increased prevalence of menopausal symptoms is seen among menopausal women who are unaware of seeking medical advice. Additional emphasis should be placed on implementing programmes that will critically help to sensitize and intensify the awareness of menopause among women in India.

Developing a Menopausal Transition Health Promotion Intervention With Indigenous, Integrative, and Biomedical Health Education: A Community-Based Approach With Urban American Indian/Alaska Native Women

Background

Few studies have examined the menopausal transition in American Indian and Alaska Native (AI/AN) women; these reports indicate they are the most likely group to report bothersome vasomotor symptoms (VMS). Evidence demonstrates VMS may be a biomarker for chronic diseases. Thus, evidence-based interventions to improve VMS and other symptoms and health-screening rates for urban midlife AI/AN women are needed.

Objective

The objectives of this community-based project were to form a Community Advisory Board (CAB) with whom to: 1) conduct CAB meetings (similar to a focus group) with midlife AI/AN women to understand their lived health care experiences and needs during the menopausal transition; and 2) obtain guidance in creating a tailored intervention.

Methods

Eligible participants indicated they were registered members of American Indian Tribes, self-identified as a woman, aged 35 or older, and were recruited through the Urban Indian Center of Salt Lake and community outreach. Three CAB meetings were conducted via Zoom. A qualitative-descriptive approach was used for analysis, with the aim of staying close to the data to understand AI/AN women's experiences and needs. Transcripts were iteratively coded using content/thematic analysis.

Results

Four themes emerged: 1) lack of and desire for information about the menopause transition; 2) barriers to accessing care; 3) matriarchal priorities impacting personal health outcomes; and 4) preferences for Indigenous and integrative medicine as first-line interventions, followed by conventional medicine.

Conclusions

Among this sample of urban AI/AN women, there was a great need for and interest in information about menopause, both for themselves and for their daughters and family. Integrative and Indigenous approaches were preferred. Proposed next steps include developing and pilot-testing a nurse-delivered health-education intervention with Indigenous, integrative, and conventional medical content.

Identifying Variables Associated with Menopause-Related Shame and Stigma: Results from a National Survey Study

Background: Despite the significance of menopause as a natural biological milestone experienced by approximately half the population, few studies have evaluated factors associated with menopause-related shame and stigma. Given previous research indicating increased shame and stigma are associated with negative outcomes that directly impact health (e.g., reduced access to health care), it is critical to identify variables associated with menopause-related shame and stigma. Materials and Methods: As part of a larger, national survey, 214 perimenopausal (n = 111) and postmenopausal (n = 103) individuals completed self-report questionnaires assessing demographics and menopause-related symptoms, shame, and stigma. Regression analyses examined variables associated with shame and stigma. Results: Over a third of respondents reported feeling shame related to their menopause-related symptoms (37.4%), while the majority of respondents reported feeling stigma associated with symptoms (82.7%). In addition, most respondents endorsed talking about their symptoms with friends, family, partners, or doctors (80.8%), and felt that their peers might experience the same symptoms (93.9%). Regression analyses identified several significant predictor variables; in particular, more severe psychosocial and urogenital symptoms, higher education level, and younger age were significantly associated with greater odds of reporting shame and stigma. Conclusions: Overall, findings suggest that even though menopausal individuals report feeling their symptoms are similar to their peers, shame and stigma are significantly associated with these symptoms, which may be impacted by symptom severity and socioeconomic factors. Results suggest that younger individuals (i.e., those just entering perimenopause) with more education may be more likely to feel shame and stigma, which could inform interventional strategies and improve clinical outcomes.

Latent Profile Analysis for Classification of Psychosomatic Symptoms in Perimenopausal Women

BACKGROUND

Over 80% of perimenopausal women experience various physical and neuropsychiatric symptoms due to changes in hormones. However, accurate evaluation and treatment of menopausal symptoms are lacking due to limited evidence regarding customized treatment for each symptom type.

OBJECTIVE

This study aimed to identify and cluster psychosomatic symptoms in Korean perimenopausal women and to investigate the characteristics of each cluster type.

METHODS

This Web-based survey assessed 1060 Korean perimenopausal women recruited from nationally representative panels available from a commercial research company. Menopausal symptoms were evaluated using the Menopause Rating Scale, Patient Health Questionnaire-15, Patient Health Questionnaire-9, Insomnia Severity Index, Subjective Memory Complaints Questionnaire, and Overactive Bladder Symptom Score. Data were analyzed using latent profile analysis and multinomial logistic regression.

RESULTS

Latent profile analysis identified 4 latent classes: "all unimpaired (class 1)," "impaired sexual function, while others are unimpaired (class 2)," "unimpaired sexual function, while others are impaired (class 3)," and "all impaired (class 4)." Classes 3 and 4 were significantly more likely to have a family history of perimenopausal syndrome and a history of other mental disorders, postpartum depression, and postpartum psychosis than classes 1 and 2.

CONCLUSIONS

Psychosomatic symptoms appear during perimenopause along with depression, somatic symptoms, insomnia, impaired memory, and overactive bladder symptoms. Individuals with these symptoms are more likely to have a history of postpartum depression, psychosis, and other psychiatric disorders. Therefore, sexual dysfunction must be independently treated. Further studies are needed to develop and verify individualized treatments according to symptom class.

Symptom experience during the late reproductive stage versus the menopausal transition in the Spanish-language Women Living Better survey

OBJECTIVES

The aim of this study was to characterize and compare the symptoms women self-report during the late reproductive stage and the menopausal transition.

METHODS

This cross-sectional analysis used data from the Spanish-language Women Living Better survey. Women aged 35 to 55 years completed an 82-item online survey to assess menstrual cycle patterns, changes, and 61 symptoms sometimes associated with menopause. Women's menstrual patterns were classified as late reproductive stage or menopausal transition using the Stages of Reproductive Aging Workshop. Demographic and health-related data were collected, including age, country of residence, race/ethnicity, education, parity, smoking, and alcohol use. Descriptive statistics characterized reported symptoms, and logistic regression models examined associations between reproductive stage and symptoms.

RESULTS

Of 853 respondents, 358 women were included in the sample analyzed. Participants were on average 40 ± 4.1 years old, 46% reported difficulty paying for basics, 34% lived in Spain, and 20% lived in Mexico. A similar proportion of women in the late reproductive stage and menopausal transition reported 8 of 18 symptom groups. Women in the late reproductive stage had a lower age-adjusted odds of musculoskeletal pain (odds ratio, 0.35; 95% CI, 0.19-0.66) and lower odds of decreased interest in sex (odds ratio, 0.49; 95% CI, 0.25-0.92). Both groups of women reported a similar interference with personal relationships.

CONCLUSIONS

Late-reproductive-stage women experience multiple symptoms often associated with menopause. A better understanding of symptoms experienced among Spanish-speaking women may lead to more personalized health care and facilitate anticipatory guidance about menopause. Future cross-cultural studies focusing on symptoms during the late reproductive stage are necessary.

Nocturnal Hot Flashes, but Not Serum Hormone Concentrations, as a Predictor of Insomnia in Menopausal Women: Results from the Midlife Women's Health Study

Background: Sleep disruptions are among the most common symptoms experienced during menopause and can be associated with depression, hot flashes, and fluctuating hormones. However, few studies have examined how such risk factors influence sleep in midlife women in a network-based approach that will establish the complex relationship between variables. Materials and Methods: We used a Bayesian network (BN) to examine the relationship between multiple factors known to influence sleep and depression in midlife women, including hormone concentrations, hot flashes, and menopause status among participants of the longitudinal Midlife Women's Health Study. In year 1, 762 women (45-54 years of age) answered questions regarding the frequency of insomnia, hot flashes, and depression; 389 of the same women answered similar questions at year 4. We measured serum hormones and calculated free estradiol index, free testosterone index, and ratios of estradiol:progesterone, and estradiol:testosterone. For our model, we calculated the change in frequency of insomnia, depression, and covariates (body mass index, menopause status, hot flashes at night, and present quality of life) from year 1 to 4. Results: Using a BN, we found that self-reported hot flashes at night, and no other factors, were direct predictors of self-reported insomnia in year 1. Surprisingly, we did not identify an association between hormone concentrations and self-reported insomnia. Frequency of insomnia in year 4 was only predicted by frequency of insomnia in year 1, whereas frequency of depression in year 4 was predicted by year 4 insomnia and frequency of depression in year 1. No other factors were direct predictors of insomnia or depression in our model. Conclusions: Therefore, hot flashes at night, previous insomnia, and depression are stronger predictors of how women will self-report frequency of sleep disruptions and treatment may reduce menopausal sleep complaints.

The Prevalence and Patterns of Menopausal Symptoms in Women Living with HIV

Increasing numbers of women with HIV are experiencing menopause. We use data from a large, representative sample of women with HIV to describe the prevalence and clustering of menopausal symptoms amongst pre-, peri- and post-menopausal women using hierarchical agglomerative cluster analysis. Of the 709 women included, 21.6%, 44.9% and 33.6% were pre-, peri- and post-menopausal, respectively. Joint pain (66.4%) was the most commonly reported symptom, followed by hot flashes (63.0%), exhaustion (61.6%) and sleep problems (61.4%). All symptoms were reported more commonly by peri- and post-menopausal women compared to pre-menopausal women. Psychological symptoms and sleep problems clustered together at all menopausal stages. Somatic and urogenital symptom clusters emerged more distinctly at peri- and post-menopause. We recommend regular and proactive assessment of menopausal symptoms in midlife women with HIV, with an awareness of how particular patterns of symptoms may evolve over the menopausal transition.

Hormone therapy in the postmenopausal years: considering benefits and risks in clinical practice

BACKGROUND

Menopausal symptoms can be very distressing and considerably affect a woman's personal and social life. It is becoming more and more evident that leaving bothersome symptoms untreated in midlife may lead to altered quality of life, reduced work productivity and, possibly, overall impaired health. Hormone therapy (HT) for the relief of menopausal symptoms has been the object of much controversy over the past two decades. At the beginning of the century, a shadow was cast on the use of HT owing to the concern for cardiovascular and cerebrovascular risks, and breast cancer, arising following publication of a large randomized placebo-controlled trial. Findings of a subanalysis of the trial data and extended follow-up studies, along with other more modern clinical trials and observational studies, have provided new evidence on the effects of HT.

OBJECTIVE AND RATIONALE

The goal of the following paper is to appraise the most significant clinical literature on the effects of hormones in postmenopausal women, and to report the benefits and risks of HT for the relief of menopausal symptoms.

SEARCH METHODS

A Pubmed search of clinical trials was performed using the following terms: estrogens, progestogens, bazedoxifene, tibolone, selective estrogen receptor modulators, tissue-selective estrogen complex, androgens, and menopause.

OUTCOMES

HT is an effective treatment for bothersome menopausal vasomotor symptoms, genitourinary syndrome, and prevention of osteoporotic fractures. Women should be made aware that there is a small increased risk of stroke that tends to persist over the years as well as breast cancer risk with long-term estrogen-progestin use. However, healthy women who begin HT soon after menopause will probably earn more benefit than harm from the treatment. HT can improve bothersome symptoms, all the while conferring offset benefits such as cardiovascular risk reduction, an increase in bone mineral density and a reduction in bone fracture risk. Moreover, a decrease in colorectal cancer risk is obtainable in women treated with estrogen-progestin therapy, and an overall but nonsignificant reduction in mortality has been observed in women treated with conjugated equine estrogens alone or combined with estrogen-progestin therapy. Where possible, transdermal routes of HT administration should be preferred as they have the least impact on coagulation. With combined treatment, natural progesterone should be favored as it is devoid of the antiapoptotic properties of other progestogens on breast cells. When beginning HT, low doses should be used and increased gradually until effective control of symptoms is achieved. Unless contraindications develop, patients may choose to continue HT as long as the benefits outweigh the risks. Regular reassessment of the woman's health status is mandatory. Women with premature menopause who begin HT before 50 years of age seem to have the most significant advantage in terms of longevity.

WIDER IMPLICATIONS

In women with bothersome menopausal symptoms, HT should be considered one of the mainstays of treatment. Clinical practitioners should tailor HT based on patient history, physical characteristics, and current health status so that benefits outweigh the risks.

Identifying the different subtypes in menopausal symptoms among middle-aged women in China: a latent class analysis

OBJECTIVE

Many studies have focused on the severity and prevalence of menopausal symptoms among middle-aged women, which are limited by heterogeneity and diversity of subtypes. Subtyping facilitates the adaptation to prevention and clinical intervention strategies that target women. To determine the existence of significant subgroups of women with similar menopausal symptoms, a person-centered approach was used to identify potential profiles of women during the menopausal transition. In addition, we aimed to examine the association between latent subtypes and individual factors.

METHODS

This cross-sectional study included 797 middle-aged women, aged 40 to 60 years, who were recruited from Shandong Province, China, between December 2017 and August 2018. We identified the subtypes in menopausal symptoms by performing a latent class analysis according to the self-reported Menopause Rating Scale and evaluated the robustness of our identified subtypes using a sensitivity analysis. Multinomial logistic regression was performed to explore the association between emergent latent subtypes and sociodemographic, clinical, and psychosocial characteristics.

RESULTS

The mean age of participants was 49.83 ± 5.05 years. (1) Four potential classes were identified in middle-aged women: "severe symptoms" (14.9%), "dominant sleep-emotion symptoms" (31.4%), "physical/mental exhaustion symptoms" (32.5%), and "no symptoms" (21.2%). The four classes were also verified using a sensitivity analysis according to age and menopause status subgroups, which revealed the robust subtypes of menopausal symptoms. (2) The odds ratio of neuroticism, chronic diseases, and gynecological diseases were significantly higher for the "severe symptoms," "dominant sleep-emotion symptoms," and "physical/mental exhaustion symptoms" classes, compared to the "no symptoms" class, while the odds ratio of mindfulness and social support were lower.

CONCLUSIONS

A person-centered approach for middle-aged women could address the unmet need to understand the heterogeneity of menopausal symptoms. Subtyping facilitates the identification of the potential causes of menopausal symptoms and the development of personalized interventions.

Symptom experience during the late reproductive stage and the menopausal transition: observations from the Women Living Better survey

OBJECTIVE

The aim of this study was to examine the occurrence of a variety of symptoms, their frequency, bother, burden, and interference in the lives of women in the late reproductive stage (LRS) and compare their experiences to that of women in the menopausal transition (MT) stage.

METHODS

Women ages 35 to 55 years responded to an 82-question online survey offered by Women Living Better. Participants reported current menstrual patterns, recent changes and symptom frequency, bother, and interference. Women's cycles were classified as LRS or MT using Stages of Reproductive Aging Workshop +10 criteria.

RESULTS

Of 2,406 respondents, 946 met criteria for LRS and 583 for MT. Participants included 30% from outside the United States, 31% from diverse racial/ethnic groups, and 18% reported having difficulty paying for basics. A similar proportion of women in the LRS and MT+ groups reported each of the symptoms: there was a less than 10% difference for 54 of the 61 symptoms. Of mean bother ratings for all symptoms, only hot flashes differed significantly between the LRS and MT groups. LRS women experienced similar levels of symptom-related interference with personal relationships and daily living to those in the MT stage but did not anticipate these symptoms occurring until they were 50 years old.

CONCLUSIONS

Women in the LRS experience symptoms strikingly similar to those often associated with the MT. Women do not expect these changes until the age of 50 years or later and are surprised by such symptoms before cycle irregularity. Research about the epidemiology and management of LRS symptoms, anticipatory guidance for women, and education for clinicians who care for them warrant increased attention.

Transitioning to the menopausal transition: a scoping review of research on the late reproductive stage in reproductive aging

IMPORTANCE AND OBJECTIVE

In 2001 Staging Reproductive Aging Workshop conferees described the late reproductive stage (LRS) of reproductive aging as preceding the onset of the menopausal transition, yet there has been little attention to this aspect of reproductive aging. The aim of this scoping review was to examine scientific publications characterizing the LRS to map what is known about this stage with particular focus on reproductive endocrine patterns, menstrual cycle changes, and symptoms.

METHODS

The initial search strategy included PubMed and CINAHL searches for the phrase LRS and "human." Given a low yield of research articles, a second stage used "late reproductive age" (LRA) as a search term. These strategies yielded 9 and 26 research articles, respectively. Publications meeting inclusion criteria (data-based research studies, focus on LRS or LRA and hormonal patterns, menstrual characteristics, and symptoms) published in English were reviewed by coinvestigators. Excluded studies were related to specific diseases, such as cardiovascular disease, and treatment studies. Data were summarized using qualitative methods. To ensure adequate coverage of published research we expanded our review to a third phase in which we identified longitudinal studies of the menopausal transition.

DISCUSSION AND CONCLUSIONS

Studies of the LRS focused on: symptoms (anxiety and mood symptoms, bladder symptoms, urinary incontinence, urinary frequency, and nocturia) and associated factors, such as endocrine levels and gene polymorphisms; symptom clusters women experienced during the LRS; cognitive function testing results; changing patterns of physiology such as cytokines and chemokines, lipids, hormone patterns/levels; and association of lifestyle factors such as smoking with hormone levels and symptoms. The LRA search yielded a preponderance of studies of reproductive hormones (such as anti-Mullerian hormone) and menstrual cycle patterns. Remaining studies focused on symptoms, gene variants, health-related behaviors and approaches to classifying menstrual cycles. Longitudinal studies revealed reports of symptoms as well as attempts to classify the progression from the reproductive years to the menopausal transition. Study of the LRS has not been systematic and the limited number and scope of completed studies have yet to contribute a clear and complete picture of the LRS. In some, LRS provided a comparison stage against which to evaluate menopausal transition hormonal and cycle patterns and symptoms. Harmonizing the results of studies of the LRS and LRA is essential to understand more completely women's experiences of the LRS and to allow clinicians to provide better support for women during this time. The LRS also represents an ideal inflection point to promote lifestyle choices that could alter the trajectories of chronic diseases that arise in the fifth, sixth, and seventh decades of women's lives.

#Menopause on Instagram: a mixed-methods study

OBJECTIVE

The aims of this study were to: (1) characterize the menopause transition (MT) on social media and (2) determine if concordance or discordance exists when comparing MT-focused social media posts and biomedical research literature.

METHODS

We analyzed 440 sequential Instagram posts with the hashtag #menopause over 2 weeks from January to February 2019. Posts were composed of 299 unique accounts, resulting in an average of 1.7 posts per account (standard deviation [SD] 1; range 1-9; median 1 and interquartile range [IQR] 1-2). Each account had an average of 2,616 followers (SD 11,271; range 3-129,000; median 421.5 and IQR 177-1,101). Content and thematic analyses were completed for posts, images, and videos to identify codes related to the MT. The top 15 codes were then searched along with the key term "menopause" in PubMed to ascertain the level of concordance between Instagram content and peer-reviewed literature on the MT.

RESULTS

We identified 69 codes in our corpus of Instagram content, resulting in 9 categories: physical health, mental health, complementary and integrative health, advertising, social, advice, self-care, nature, and self-expression (kappa 0.95-1.00). The most prevalent codes were related to weight loss/fitness (20.5%) and hormones (18.4%). The majority of frequent codes identified in Instagram posts were infrequently listed in biomedical literature related to menopause. However, there were two codes, Weight loss/Fitness and Hot flashes, that were frequently discussed in Instagram posts and the biomedical literature.

CONCLUSIONS

The examination of #menopause on Instagram provides novel insights for researchers and clinicians. Our findings provide a better understanding of the experiences and support needs of individuals experiencing menopause. Furthermore, codes related to menopause have low prominence in the biomedical literature, suggesting key topics that could be explored in the future.

Insomnia and menopause: a narrative review on mechanisms and treatments

The menopausal transition is associated with an increased frequency of sleep disturbances. Insomnia represents one of the most reported symptoms by menopausal women. According to its pathogenetic model (3-P Model), different predisposing factors (i.e. a persistent condition of past insomnia and aging per se) increase the risk of insomnia during menopause. Moreover, multiple precipitating and perpetuating factors should favor its occurrence across menopause, including hormonal changes, menopausal transition stage symptoms (i.e. hot flashes, night sweats), mood disorders, poor health and pain, other sleep disorders and circadian modifications. Thus, insomnia management implies a careful evaluation of the psychological and somatic symptoms of the individual menopausal woman by a multidisciplinary team. Therapeutic strategies encompass different drugs but also behavioral interventions. Indeed, cognitive behavioral therapy represents the first-line treatment of insomnia in the general population, regardless of the presence of mood disorders and/or vasomotor symptoms (VMS). Different antidepressants seem to improve sleep disturbances. However, when VMS are present, menopausal hormone therapy should be considered in the treatment of related insomnia taking into account the risk-benefit profile. Finally, given its good tolerability, safety, and efficacy on multiple sleep and daytime parameters, prolonged-released melatonin should represent a first-line drug in women aged ≥ 55 years.

Vasomotor Symptoms Across the Menopause Transition: Differences Among Women

Vasomotor symptoms (VMS) are the primary menopausal symptoms, occurring in up 80% of women and peaking around the final menstrual period. The average duration is 10 years, longer in women with an earlier onset. Compared with non-Hispanic white women, black and Hispanic women are more likely and Asian women are less likely to report VMS. Risk factors include greater body composition (in the early stage of menopausal transition), smoking, anxiety, depression, sensitivity to symptoms, premenstrual syndrome, lower education, and medical treatments, such as hysterectomy, oophorectomy, and breast cancer-related therapies. VMS patterns over time and within higher-risk subgroups are heterogeneous across women.

Polymorphisms in Estrogen Synthesis Genes and Symptom Clusters During the Menopausal Transition and Early Postmenopause: Observations From the Seattle Midlife Women's Health Study

During the menopausal transition and early postmenopause, participants in the Seattle Midlife Women's Health Study (SMWHS) experienced one of the three symptom severity clusters identified through latent class analysis: severe hot flashes with moderate sleep, mood, cognitive, and pain symptoms (high-severity hot flash); low-severity hot flashes with moderate levels of all other symptom groups (moderate severity); and low levels of all symptom groups (low severity). In an effort to determine whether gene polymorphisms were associated with these symptom severity classes, we tested associations between gene polymorphisms in the estrogen synthesis pathways (cytochrome P450 19 [CYP 19] and 17 beta hydroxysteroid dehydrogenase [ 17HSDB1]) and the three symptom severity clusters. SMWHS participants ( N = 137) recorded symptoms monthly in diaries and provided buccal smears for genotyping. Multilevel latent class analysis with multinomial regression was used to determine associations between gene polymorphisms and symptom severity clusters. Only the 17HSDB1 polymorphisms ( rs615942 and rs592389) were associated significantly with the high-severity hot flash cluster versus the low-severity symptom cluster. None of the polymorphisms was associated with the moderate-severity cluster versus the low-severity symptom cluster. Findings of associations of the 17HSDB1 polymorphisms with the high-severity hot flash symptom cluster are consistent with those of an association between 17HSDB1 polymorphisms and hot flashes in the Study of Women and Health Across the Nation population and our previous findings of associations between these polymorphisms with greater estrone levels.

Validity, cut-points, and minimally important differences for two hot flash-related daily interference scales

OBJECTIVES

To conduct psychometric analyses to condense the Hot Flash-Related Daily Interference Scale (HFRDIS) into a shorter form termed the Hot Flash Interference (HFI) scale; evaluate cut-points for both scales; and establish minimally important differences (MIDs) for both scales.

METHODS

We analyzed baseline and postrandomization patient-reported data pooled across three randomized trials aimed at reducing vasomotor symptoms (VMS) in 899 midlife women. Trials were conducted across five MsFLASH clinical sites between July 2009 and October 2012. We eliminated HFRDIS items based on experts' content validity ratings and confirmatory factor analysis, and evaluated cut-points and established MIDs by mapping HFRDIS and HFI to other measures.

RESULTS

The three-item HFI (interference with sleep, mood, and concentration) demonstrated strong internal consistency (alphas of 0.830 and 0.856), showed good fit to the unidimensional "hot flash interference factor," and strong convergent validity with HFRDIS scores, diary VMS, and menopausal quality of life. For both scales, cut-points of mild (0-3.9), moderate (4-6.9), and severe (7-10) interference were associated with increasing diary VMS ratings, sleep, and anxiety. The average MID was 1.66 for the HFRDIS and 2.34 for the HFI.

CONCLUSIONS

The HFI is a brief assessment of VMS interference and will be useful in busy clinics to standardize VMS assessment or in research studies where response burden may be an issue. The scale cut-points and MIDs should prove useful in targeting those most in need of treatment, monitoring treatment response, and interpreting existing and future research findings.

It is not just menopause: symptom clustering in the Study of Women's Health Across the Nation

Background

Patterns of symptom clustering in midlife women may suggest common underlying mechanisms or may identify women at risk of adverse health outcomes or, conversely, likely to experience healthy aging. This paper assesses symptom clustering in the Study of Women’s Health Across the Nation (SWAN) longitudinally by stage of reproductive aging and estimates the probability of women experiencing specific symptom clusters. We also evaluate factors that influence the likelihood of specific symptom clusters and assess whether symptom clustering is associated with women’s self-reported health status.

Methods

This analysis includes 3289 participants in the multiethnic SWAN cohort who provided information on 58 symptoms reflecting a broad range of physical, psychological and menopausal symptoms at baseline and 7 follow-up visits over 16 years. We conducted latent transition analyses to assess symptom clustering and to model symptomatology across the menopausal transition (pre, early peri-, late peri- and post-menopausal). Joint multinomial logistic regression models were used to identify demographic characteristics associated with premenopausal latent class membership. A partial proportional odds regression model was used to assess the association between latent class membership and self-reported health status.

Results

We identified six latent classes that ranged from highly symptomatic (LC1) across most measured symptoms, to moderately symptomatic across most measured symptoms (LC2), to moderately symptomatic for a subset of symptoms (vasomotor symptoms, pain, fatigue, sleep disturbances and physical health symptoms) (LC3 and LC5) with one class (LC3) including interference in life activities because of physical health symptoms, to numerous milder symptoms, dominated by fatigue and psychological symptoms (LC4), to relatively asymptomatic (LC6). In pre-menopause, 10% of women were classified in LC1, 16% in LC2, 14% in LC3 and LC4, 26% in LC5, and 20% in LC6. Intensity of vasomotor and urogenital symptoms as well as sexual desire) differed minimally by latent class. Classification into the two most symptomatic classes was strongly associated with financial strain, White race/ethnicity, obesity and smoking status. Over time, women were most likely to remain within the same latent class as they transitioned through menopause stages (range 39–76%), although some women worsened or improved. The probability of moving between classes did not differ substantially by menopausal stage. Women in the highly symptomatic classes more frequently rated their health as fair to poor compared to women in the least symptomatic class.

Conclusion

Clear patterns of symptom clustering were present early in midlife, tended to be stable over time, and were strongly associated with self-perceived health. Notably, vasomotor symptoms tended to cluster with sleep disturbances and fatigue, were present in each of the moderate to highly symptomatic classes, but were not a defining characteristic of the symptom clusters. Clustering of midlife women by symptoms may suggest common underlying mechanisms amenable to interventions. Given that one-quarter of midlife women were highly or moderately symptomatic across all domains in the pre-menopause, addressing symptom burden in early midlife is likely critical to ameliorating risk in the most vulnerable populations.

Electronic supplementary material

The online version of this article (doi:10.1186/s40695-017-0021-y) contains supplementary material, which is available to authorized users.

Prevalence and predictors of severe menopause symptoms among HIV-positive and -negative Nigerian women

We compared the prevalence of menopause symptoms between women living with HIV to their HIV-negative peers and determined predictors of severe menopause symptoms in Jos, Nigeria. This descriptive cross-sectional study included 714 women aged 40-80 years. We compared prevalence and severity of menopause symptoms using the menopause rating scale (MRS). Logistic regression analysis was used to determine the predictors of severe symptoms. Six-hundred and seven (85.0%) were HIV-positive, with a mean duration of infection of 5.6 ± 2.7 years. The mean age of the cohort was 46 ± 5 years. The most prevalent menopause symptoms were hot flushes (67.2%), joint and muscle discomfort (66.2%), physical/mental exhaustion (65.3%), heart discomfort (60.4%), and anxiety (56.4%). The median MRS score was higher for HIV-positive compared to HIV-negative women (p = 0.01). Factors associated with severe menopause symptoms included HIV-positive status (aOR: 3.01, 95% CI: 1.20-7.54) and history of cigarette smoking (aOR: 4.18, 95% CI: 1.31-13.26). Being married (aOR: 0.49, 95% CI: 0.32-0.77), premenopausal (aOR: 0.60, 95% CI: 0.39-0.94), and self-reporting good quality of life (aOR: 0.62. 95% CI: 0.39-0.98) were protective against severe menopause symptoms. We found HIV infection, cigarette smoking, quality of life, and stage of the menopause transition to be associated with severe menopause symptoms. As HIV-positive populations are aging, additional attention should be given to the reproductive health of these women.

The Seattle Midlife Women's Health Study: a longitudinal prospective study of women during the menopausal transition and early postmenopause

Background

The need for longitudinal, population-based studies to illuminate women’s experiences of symptoms during the menopausal transition motivated the development of the Seattle Midlife Women’s Health Study.

Methods

Longitudinal, population-based study of symptoms women experienced between the Late Reproductive stage of reproductive aging and the early postmenopause. Data collection began in 1990 with 508 women ages 35–55 and continued to 2013. Entry criteria included age, at least one period in past 12 months, uterus intact and at least 1 ovary. Women were studied up to 5 years postmenopause. Data collection included yearly health questionnaires, health diaries, urinary hormonal assays, menstrual calendars and buccal cell smears.

Results

Contributions of the study included development of a method for staging the menopausal transition; development of bleeding criteria to differentiate bleeding episodes from intermenstrual bleeding from menstrual calendars; identification of hormonal changes associated with menopausal transition stages; assessment of the effects of menopausal transition factors, aging, stress-related factors, health factors, social factors on symptoms, particularly hot flashes, depressed mood, pain, cognitive, sexual desire, and sleep disruption symptoms, and urinary incontinence symptoms; identification of naturally occurring clusters of symptoms women experienced during the menopausal transition and early postmenopause; and assessment of gene polymorphisms associated with events such as onset of the early and late menopausal transition stages and symptoms.

Conclusions

Over the course of the longitudinal Seattle Midlife Women's Health Study, investigators contributed to understanding of symptoms women experience during the menopausal transition and early postmenopause as well as methods of staging reproductive aging.

Electronic supplementary material

The online version of this article (doi:10.1186/s40695-016-0019-x) contains supplementary material, which is available to authorized users.

Symptom clusters among MsFLASH clinical trial participants

OBJECTIVE

Our objective was to identify symptom clusters using standardized measures completed by participants in the Menopausal Strategies: Finding Lasting Answers to Symptoms and Health clinical trial at baseline, including hot flash interference, and sleep, depressive, anxiety, and pain symptoms.

METHODS

Data from all women randomized to interventions and controls from Menopausal Strategies: Finding Lasting Answers to Symptoms and Health studies 1, 2, and 3 (N = 899) were included; 797 with complete data were used in the analyses. Scores from standardized measures obtained at baseline included the following: Hot Flash-Related Daily Interference Scale, Insomnia Severity Index, Pittsburgh Sleep Quality Index, Patient Health Questionnaire-9 measure of depressed mood, Generalized Anxiety Disorder, and Brief Pain Inventory PEG scores (pain intensity [P], interference with enjoyment of life [E], and interference with daily activity [G]). Latent class analysis was used to identify symptom clusters using standardized scale scores and their established cut points.

RESULTS

We identified five classes using the Bayesian Information Criterion and the Akaike Information Criterion. Women in classes 1 and 2 had high hot flash interference levels relative to the others, and class 1 (10.5% of total) included severe hot flash interference, severe sleep symptoms, and moderately severe pain symptoms (hot flash, sleep, pain). In class 2 (14.1%), severe hot flash interference was paired with the severe sleep symptoms, and moderate to severe depressed and anxious mood symptoms and pain (hot flash, sleep, mood, pain). In class 3 (39.6%), women reported moderately severe sleep symptoms with moderate hot flash interference, and low severity mood and pain symptoms (hot flash, sleep). Those in class 4 (7.0%) reported moderate hot flash interference with severe levels of anxiety and depressed mood symptoms, but low levels of other symptoms (hot flash, mood). Women in class 5 (28.7%) reported the lowest levels of all the five symptoms (low severity symptoms).

CONCLUSIONS

Women meeting hot flash frequency criteria for inclusion in clinical trials exhibited multiple co-occurring symptoms that clustered into identifiable groups according to symptom interference and severity. Variability of symptom profiles between the classes was evident, indicating that the classes were composed of differing symptom types and not simply differing severity levels. These symptom clusters may be useful phenotypes for differentiating treatment effects or evaluating associations with biomarkers or genes.

Midlife women's symptom cluster heuristics: evaluation of an iPad application for data collection

OBJECTIVE

This study aims to elicit midlife women's heuristics about symptom clusters they were experiencing, as identified by the Computerized Symptom Capture Tool for Menopause (C-SCAT M).

METHODS

Women aged 40 to 60 years who were experiencing symptoms that they associated with menopause were recruited through flyers posted on campus and in clinics. Women completed the C-SCAT M application (app), using an iPad, by identifying and drawing symptom clusters they experienced during the last 24 hours, indicating relationships among symptoms, prioritizing the clusters and symptoms within them, making causal attributions, and identifying exacerbating and ameliorating factors. They were asked to prioritize the clusters and a symptom within each cluster. While women were completing the app, they were asked to "think aloud" about their experience using the app. Data generated from the C-SCAT M app were transmitted securely to an Amazon Web Services account and saved as screen images and Excel files to preserve both graphical images and text elicited from the app. Qualitative data were saved in verbatim phrases. Conventional content analysis was used to analyze qualitative data.

RESULTS

Thirty women completed the app. Most women (77%) stated that the final diagrams were very/extremely accurate in depicting their symptoms and their connections. Women reported between 1 and 22 symptoms (median, 11). Hot flashes, waking up during the night, night sweats, and early morning awakening were the most commonly reported symptoms. Women rated hot flashes as their most bothersome symptom, followed by waking up during the night and fatigue. They reported more than 300 different bivariate relationships between their symptoms and more than 150 unique causal paths. They believed that hot flashes caused several symptoms, especially sleep disruption, and most could describe the time order of their symptoms. Women reported clusters consisting of 2 to 18 symptoms. Women also named each cluster based on their response to their symptoms ("really annoying"), time of occurrence ("night problem"), and symptoms included in the cluster ("hot flash"). They attributed their clusters to menopause, life demands, and other symptoms, among other causes. Management strategies that women used included over-the-counter preparations, sleep, rest, and other lifestyle changes. Some women requested for a copy of their final symptom cluster diagram to discuss with their healthcare providers.

CONCLUSIONS

Use of the C-SCAT M affords women an opportunity to depict their symptoms and clusters and the relationships between them and to provide narrative data about their heuristics. Women's unsolicited comments about using the cluster diagram to facilitate conversations (about their symptoms) with their healthcare providers suggest the potential value of modifying the C-SCAT M and evaluating its use in a healthcare setting.

Incremental direct and indirect costs of untreated vasomotor symptoms

OBJECTIVE

Most women with moderate to severe vasomotor symptoms (VMS) are untreated. This retrospective matched-cohort study aims to evaluate the healthcare resource utilization, work loss, and cost burden associated with untreated VMS.

METHODS

Health insurance claims (1999-2011) were used to match (1:1) women with untreated VMS with control women using propensity score. Healthcare resource utilization, work productivity loss (disability + medically related absenteeism), and associated costs were compared between cohorts.

RESULTS

During the 12-month follow-up, women with untreated VMS (n = 252,273; mean age, 56 y) had significantly higher healthcare resource utilization than women in the control cohort: 82% higher for all-cause outpatient visits (95% CI, 81-83; P < 0.001) and 121% higher (95% CI, 118-124; P < 0.001) for VMS-related outpatient visits. Mean direct costs per patient per year were significantly higher for VMS women (direct cost difference, US$1,346; 95% CI, 1,249-1,449; P < 0.001). VMS women had 57% (95% CI, 51-63; P < 0.001) more indirect work productivity loss days than controls, corresponding to an incremental indirect cost per patient per year associated with untreated VMS of US$770 (95% CI, 726-816; P < 0.001).

CONCLUSIONS

This study shows that untreated VMS are associated with significantly higher frequency of outpatient visits and incremental direct and indirect costs.

MsFLASH participants' priorities for alleviating menopausal symptoms

OBJECTIVE

To describe self-reported menopausal symptom priorities and their association with demographics and other symptoms among participants in an intervention trial for vasomotor symptoms (VMS).

METHODS

Cross-sectional study embedded in the MsFLASH 02 trial, a three-by-two factorial design of yoga vs. exercise vs. usual activity and omega-3-fatty acid vs. placebo. At baseline, women (n = 354) completed hot flush diaries, a card sort task to prioritize symptoms they would most like to alleviate, and standardized questionnaires.

RESULTS

The most common symptom priorities were: VMS (n = 322), sleep (n = 191), concentration (n = 140), and fatigue (n = 116). In multivariate models, women who chose VMS as their top priority symptom (n = 210) reported significantly greater VMS severity (p = 0.004) and never smoking (p = 0.012), and women who chose sleep as their top priority symptom (n = 100) were more educated (p ≤ 0.001) and had worse sleep quality (p < 0.001). ROC curves identified sleep scale scores that were highly predictive of ranking sleep as a top priority symptom.

CONCLUSIONS

Among women entering an intervention trial for VMS and with relatively low prevalence of depression and anxiety, VMS was the priority symptom for treatment. A card sort may be a valid tool for quickly assessing symptom priorities in clinical practice and research.

Feasibility of an iPad application for studying menopause-related symptom clusters and women's heuristics

PURPOSE

To evaluate feasibility, including usability and utility, of the Computerized Symptom Capture Tool for Menopause (C-SCAT-M), a symptom heuristics application (app) for the iPad, with midlife women.

METHODS

Thirty midlife women aged 40-60 and experiencing symptoms they associated with menopause were recruited through flyers posted on a university campus, primary care and women's health clinics. The C-SCAT-M guided participants to identify symptoms they experienced, draw temporal and causal relationships between symptoms and identify symptom clusters. Women were encouraged to think aloud as they encountered questions or problems and their comments were audio recorded. After completing the C-SCAT-M, they completed a 22-item acceptability survey and a demographic survey. Data were downloaded from catalyst website and analyzed using SPSS.

RESULTS

Women completed the C-SCAT-M with minimal difficulty, with most indicating that using the app was very/extremely easy and most (57%) preferred using the iPad app to paper. Most women stated that the final diagrams were very/extremely accurate depictions of their symptom clusters and relationships (77%).

CONCLUSION

The C-SCAT-M demonstrated initial feasibility, including usability and utility, for collecting data about symptom clusters experienced by midlife women.

Perimenopause as a neurological transition state

Perimenopause is a midlife transition state experienced by women that occurs in the context of a fully functioning neurological system and results in reproductive senescence. Although primarily viewed as a reproductive transition, the symptoms of perimenopause are largely neurological in nature. Neurological symptoms that emerge during perimenopause are indicative of disruption in multiple estrogen-regulated systems (including thermoregulation, sleep, circadian rhythms and sensory processing) and affect multiple domains of cognitive function. Estrogen is a master regulator that functions through a network of estrogen receptors to ensure that the brain effectively responds at rapid, intermediate and long timescales to regulate energy metabolism in the brain via coordinated signalling and transcriptional pathways. The estrogen receptor network becomes uncoupled from the bioenergetic system during the perimenopausal transition and, as a corollary, a hypometabolic state associated with neurological dysfunction can develop. For some women, this hypometabolic state might increase the risk of developing neurodegenerative diseases later in life. The perimenopausal transition might also represent a window of opportunity to prevent age-related neurological diseases. This Review considers the importance of neurological symptoms in perimenopause in the context of their relationship to the network of estrogen receptors that control metabolism in the brain.

Symptoms of depressed mood, disturbed sleep, and sexual problems in midlife women: cross-sectional data from the Study of Women's Health Across the Nation

BACKGROUND

Women report many nonvasomotor symptoms across the menopausal transition, including sleep disturbances, depressed mood, and sexual problems. The co-occurrence of these three symptoms may represent a specific menopausal symptom triad. We sought to evaluate the interrelatedness of disturbed sleep, depressed mood, and sexual problems in the Study of Women's Health Across the Nation (SWAN) and determine the characteristics of women exhibiting this symptom triad.

METHODS

SWAN is a multisite, multiethnic observational cohort study of the menopausal transition in the United States. Sleep disturbance, sexual problems, and depressed mood were determined based on self-report. Women who reported all three symptoms simultaneously were compared to those who did not. Logistic regression models estimated the association of demographic, psychosocial, and clinical characteristics with the symptom triad.

RESULTS

Study participants (n=1716) were 49.8 years old on average and primarily in very good or excellent health. Sixteen and a half percent had depressed mood, 36.6% had a sleep problem, and 42.2% had any sexual problem. Five percent of women (n=90) experienced all three symptoms. Women with the symptom triad compared with those without had lower household incomes, less education, were surgically postmenopausal or late perimenopausal, rated their general health as fair or poor, and had more stressful life events and lower social support.

CONCLUSIONS

The symptom triad of sleep disturbance, depressed mood, and sexual problems occurred in only 5% of women, and occurred most often among women with lower socioeconomic status, greater psychosocial distress, and who were surgically menopausal or in the late perimenopause.

Subgrouping of Japanese middle-aged women attending a menopause clinic using physical and psychological symptom profiles: a cross-sectional study

BACKGROUND

Women in the menopausal transition and the postmenopausal period are affected with vasomotor symptoms, urogenital atrophy, sexual dysfunction, somatic symptoms, cognitive difficulty, sleep disturbance, and psychological problems. It is important to gain a better understanding of the complexity and diversity of climacteric disturbance in order to optimize treatments for individual patients. The aim of this study was to identify subgroups of Japanese perimenopausal and postmenopausal women attending a menopause clinic based on their physical and psychological symptom profiles.

METHODS

We administered the Menopausal Health-Related Quality of Life questionnaire to 491 Japanese women aged 40-64 years who had enrolled in the Systematic Health and Nutrition Education Program at the Menopause Clinic of the Tokyo Medical and Dental University Hospital between 2005 and 2012. We performed a principal component analysis followed by a hierarchical cluster analysis of the responses to 9 physical and 12 psychological items on the questionnaire.

RESULTS

The first analysis extracted 3 principal components that defined the variance of physical and psychological symptom profiles: depression, somatic, and vasomotor/sleep. A subsequent cluster analysis was performed based on the 3 principal components to generate 4 clusters, CL8 (N = 162; 33.0%), CL6 (N = 111; 22.6%), CL5 (N = 102; 20.8%), and CL4 (N = 116; 23.6%). CL8 included women who only had mild-to-moderate musculoskeletal pains and tiredness. All women in CL6, CL5, and CL4 described their musculoskeletal pains and tiredness as moderate to severe. The women in CL5 also had moderate-to-severe vasomotor symptoms, while the women in CL4 also suffered from moderate-to-severe psychological symptoms, such as depression, anxiety, and insomnia.

CONCLUSIONS

Distinct subgroups of Japanese perimenopausal and postmenopausal women were identified based on their symptom profiles. Menopausal symptoms were shown to accumulate in this population in the order of musculoskeletal pains and tiredness, vasomotor symptoms, and psychological symptoms.

Sleep regulation and sex hormones exposure in men and women across adulthood

This review aims to discuss how endogenous and exogenous testosterone exposures in men and estrogens/progesterone exposures in women interact with sleep regulation. In young men, testosterone secretion peaks during sleep and is linked to sleep architecture. Animal and human studies support the notion that sleep loss suppresses testosterone secretion. Testosterone levels decline slowly throughout the aging process, but relatively few studies investigate its impact on age-related sleep modifications. Results suggest that poorer sleep quality is associated with lower testosterone concentrations and that sleep loss may have a more prominent effect on testosterone levels in older individuals. In women, sex steroid levels are characterized by a marked monthly cycle and reproductive milestones such as pregnancy and menopause. Animal models indicate that estrogens and progesterone influence sleep. Most studies do not show any clear effects of the menstrual cycle on sleep, but sample sizes are too low, and research designs often inhibit definitive conclusions. The effects of hormonal contraceptives on sleep are currently unknown. Pregnancy and the postpartum period are associated with increased sleep disturbances, but their relation to the hormonal milieu still needs to be determined. Finally, studies suggest that menopausal transition and the hormonal changes associated with it are linked to lower subjective sleep quality, but results concerning objective sleep measures are less conclusive. More research is necessary to unravel the effects of vasomotor symptoms on sleep. Hormone therapy seems to induce positive effects on sleep, but key concerns are still unresolved, including the long-term effects and efficacy of different hormonal regimens.

Effects of herbal preparations on symptom clusters during the menopausal transition

AIMS

To determine the effects of herbal therapies on hot flushes and at least one other symptom including, sleep, mood, cognition, and pain that women experience during the menopausal transition and early postmenopause.

METHODS

An extensive search of PubMed/Medline, CINAHL Plus, PsycInfo, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Web of Science, EMBASE, AMED, and Alt-Health Watch for randomized, controlled trials reported in English between January 2004 and July was conducted by an experienced reference librarian. There were 1193 abstracts identified but only 58 trials examined effectiveness of therapies for hot flushes and at least one additional co-occurring symptom.

RESULTS

Seventeen studies used herbal preparation including seven studies of black cohosh, two studies of black cohosh mixed with other herbals, and eight studies of other herbals. Of these, one study of black cohosh, two studies of black cohosh mixed with other herbals, and four other herbal studies had significant effects on hot flushes and at least one additional co-occurring symptom. The adverse events of herbal therapies were various, ranging from mild to moderate and women were generally tolerant of the preparations.

CONCLUSIONS

Black cohosh mixed with other herbals, Rheum rhaponticum, and French maritime pine bark had significant effects on hot flushes and at least one other symptom. These herbal therapies may be a promising alternative treatment to hormonal treatment. Future studies should classify women based on their menopausal stages, report each symptom separately, have adequate sample size, focus on multiple co-occurring symptoms, and target symptom management of menopausal symptoms.

Endocrine biomarkers and symptom clusters during the menopausal transition and early postmenopause: observations from the Seattle Midlife Women's Health Study

OBJECTIVE

During the menopausal transition and early postmenopause, participants in the Seattle Midlife Women's Health Study were likely to belong to one of three symptom severity classes: severe hot flashes with moderate sleep, mood, cognitive, and pain symptoms (high-severity hot flash); moderate levels of all but hot flashes (moderate severity); and low levels of all (low severity). We tested models of the differential effects of hypothalamic-pituitary-ovarian (HPO) axis, hypothalamic-pituitary-adrenal (HPA) axis, and autonomic nervous system (ANS) biomarkers on the three symptom severity classes.

METHODS

The Seattle Midlife Women's Health Study participants recorded symptoms monthly in diaries and provided overnight urine samples several times per year that were analyzed for estrone, follicle-stimulating hormone (FSH), cortisol, testosterone, epinephrine, and norepinephrine. Multilevel latent class analysis with multinomial regression was used to determine the effects of HPO axis, HPA axis, and ANS biomarkers on symptom severity class membership.

RESULTS

Having lower estrogen and higher FSH levels was significantly associated with belonging to the high-severity hot flash class versus the low-severity class. Having lower epinephrine and higher norepinephrine levels increased the likelihood of belonging to the high-severity hot flash class versus the low-severity class. Having lower epinephrine levels was significantly associated with belonging to the moderate-severity class versus the low-severity class. Cortisol and testosterone were unrelated to symptom severity class membership.

CONCLUSIONS

The association of HPO axis biomarkers (estrogen and FSH) with the high-severity hot flash class is anticipated based on prior hot flash research, and the associations of HPA axis biomarkers are as expected based on earlier laboratory studies. The association of lower epinephrine levels with the moderate-severity class suggests that these symptoms may be mediated by the ANS.

Effects of isoflavones and amino acid therapies for hot flashes and co-occurring symptoms during the menopausal transition and early postmenopause: a systematic review

AIMS

Review controlled clinical trials of isoflavones and amino acid preparation effects on hot flashes and at least one other symptom including mood, sleep, pain, and cognitive function that women report during the menopausal transition and early postmenopause.

METHODS

An experienced reference librarian searched PubMed/Medline, CINAHL Plus, PsycInfo, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Web of Science, EMBASE, AMED, and Alt-Health Watch for English-language randomized controlled trials between 2004 and July 2011. Seventeen trials of isoflavones and amino acid effects on hot flashes and one additional symptom were identified.

RESULTS

In five trials of soy isoflavone preparations, two (6g soy germ extract and 25 g soy protein in soy nuts) significantly decreased hot flashes, but no other symptoms. In the seven trials of other isoflavones, six significantly reduced hot flashes; in addition, red clover (80 mg) significantly reduced mood symptoms; Rexflavone (350 mg) for women with Kupperman Index>20 significantly reduced sleep symptoms; two trials had significant reductions for pain: isoflavone powder (90 mg) and red clover (80 mg). The only trial in this systematic review that significantly reduced cognitive symptoms was red clover (80 mg). In one trial, red clover isoflavone (80 mg/day) significantly relieved hot flashes, mood, pain, and cognitive symptoms. Amino acids yielded no significant results. Equol supplements of 30 mg/day for non-Equol producing women significantly reduced mood symptoms in one trial. The magnolia bark extract combination significantly reduced hot flashes, mood, and sleep symptoms.

CONCLUSIONS

Isoflavone trials yielded significant reductions on hot flashes and co-occurring symptoms during the menopausal transition and postmenopause, but studies require replication with larger sample sizes and attention to measurement of outcomes.

What midlife women want from gynecologists: a survey of patients in specialty and private practices

BACKGROUND

This study characterized the self-reported reason for a gynecology visit among midlife women in three different practice settings. We hypothesized that women seeking specialty care were more likely to report nonvasomotor symptoms potentially related to the menopausal transition.

METHODS

Participants were 625 women aged 40-60 seen by gynecologists at three sites: an urban, academic, gynecologic menopause practice (Midlife Practice, or MLP) and urban (site A) and suburban (site B) locations of a general, nonacademic obstetrics and gynecology practice. Participants completed a self-report questionnaire asking them to choose and weigh the reason for their visit as "very much," "somewhat," or "not at all" for 15 common gynecologic and menopausal concerns. Demographic questions included age, self-rated health status, race/ethnicity, difficulty of paying for basics, and education. Comparisons between the three groups were made using parametric and nonparametric tests as appropriate. The main outcome measure was the response to the reason for participants' visit compared across the three sites.

RESULTS

Women presenting to the MLP were significantly older and more likely to report vasomotor symptoms (VMS), moodiness, sexual problems, sleep problems, and weight and to learn more about menopause. When "very much" and "somewhat" reasons were combined, nearly 80% of the MLP responses listed sleep problems, 60% listed vaginal dryness or low desire, 34% listed weight gain, and 30.7% listed mood.

CONCLUSIONS

Midlife women seeking care in a menopause gynecology practice had significantly more visits for vasomotor and nonvasomotor concerns than did women seeing general gynecologists. Women sought care for a broad range of concerns that are not typically in gynecologists' scope of practice, including sleep disturbances, moodiness, and weight management.

Effects of mind-body therapies on symptom clusters during the menopausal transition

AIMS

Although most women experience symptom clusters during the menopausal transition and early postmenopause, investigators reporting clinical trial effects for hot flushes often omit co-occurring symptoms. Our aim was to review controlled clinical trials of mind-body therapies for hot flushes and at least one other co-occurring symptom from these groups: sleep, cognitive function, mood, and pain.

METHODS

An experienced reference librarian performed an extensive search of PubMed/Medline, CINAHL Plus, PsycInfo, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Web of Science, EMBASE, AMED, and Alt-Health Watch for randomized controlled trials reported in English between 2004 and July 2011. Of 1193 abstracts identified, 58 trials examining effectiveness of therapies for hot flushes and at least one additional co-occurring symptom of interest were identified.

RESULTS

Eight trials (ten publications) examined relaxation, yoga, or exercise. Physical activity/exercise trials (six) yielded mixed results; only one significantly reduced hot flushes and mood symptoms. Of two relaxation therapy trials, only mindfulness-based stress reduction training reduced sleep and mood symptoms and had within-group treatment effects on hot flushes. Yoga (one trial) significantly reduced hot flushes and improved cognitive symptoms more than exercise, and also had within-group effects on sleep and pain symptoms.

CONCLUSIONS

Studies of mind-body therapies for hot flushes increasingly measure multiple symptom outcomes, but few report treatment effects in ways that allow clinicians to consider symptom clusters when prescribing therapies. Future studies need to measure and report results for individual symptoms or group like symptoms together into subscales rather than use subscales with mixed dimensions. Trials with larger numbers of participants are essential to allow evaluation of these therapies on multiple co-occurring symptoms.

Identifying symptom clusters during the menopausal transition: observations from the Seattle Midlife Women's Health Study

OBJECTIVES

First, to explore the variability in how symptoms clustered together over the late reproductive stage, early and late menopausal transition (MT) stages, and early postmenopause; second, to determine whether the symptom factor structure of the preceding MT stage would predict the symptom factor structure of the MT stage immediately following.

METHODS

The sample consisted of a subset of Seattle Midlife Women's Health Study participants who were in late reproductive or early or late menopausal transition stages or early postmenopause and provided self-reported data on symptoms experienced between 1990 and 2005. Principal components analysis was used to determine how symptoms clustered together across the stages. Variables predicting the symptom factor structure were analyzed by multiple regression.

RESULTS

Principal components analysis with varimax rotation revealed different factor structures for each of the four stages. The three-factor solution in the late reproductive stage explained a total of 54.9% of the variance. The four-factor solutions in the early and late menopausal transition stages and postmenopause explained a total of 56.5%, 59.3%, and 60.7%, respectively.

CONCLUSIONS

This analysis revealed similar factor structures across the four stages in that each stage revealed a mood component, a vasomotor component, and a pain component. However, the symptoms differed somewhat in how they grouped from stage to stage. Regression analysis demonstrated that a relationship exists between the symptom factor structures across stages. Controlling for demographic and lifestyle variables, it was revealed that the symptom clusters at the early and late menopausal transition stages and early postmenopause were best predicted by the symptom factor structure of the previous stage.