Factors associated with resilience or vulnerability to hot flushes and night sweats during the menopausal transition

Menstruation and menopause in autistic adults: Periods of importance?

LAY ABSTRACT

Autism spectrum conditions were once seen as a predominantly male condition, but this has caused research to have little focus on women. Therefore, little is known about menstruation and menopause in autism spectrum conditions. Some smaller studies indicate that autistic individuals might suffer from increased difficulties surrounding these events. This study aimed to investigate whether autistic women experience more frequent premenstrual dysphoric disorder, causing extreme physical, emotional, and functional impairment. In a partly overlapping sample, we also examined whether women with autism spectrum condition experience increased complaints surrounding menopause. We did not find an increased prevalence of premenstrual dysphoric disorder in autism spectrum conditions (14.3%) compared with non-autistic women (9.5%). Those with autism spectrum conditions did experience increased menopausal complaints. These menopausal complaints were associated with higher levels of depression and autistic traits. In non-autistic women, menopausal complaints were associated with increased inattention, hyperactivity/impulsivity (i.e. attention deficit hyperactivity disorder traits), and depression. With this work, we show the important role that major reproductive milestones can have in an autistic woman's life.

Treating menopause - MHT and beyond

Every woman who lives past midlife will experience menopause, which, by definition, is complete cessation of ovarian function. This process might occur spontaneously (natural menopause) or be iatrogenic (secondary menopause), and can be further classified as 'early' if it occurs before the age of 45 years and 'premature' if it occurs before the age of 40 years. Globally, the mean age of natural menopause is 48.8 years, with remarkably little geographic variation. A woman's age at menopause influences health outcomes in later life. Early menopause is associated with a reduced risk of breast cancer, but increased risks of premature osteoporosis, cardiovascular disease and premature death. The cardinal symptoms of menopause, and adverse health sequelae, are due to loss of ovarian oestrogen production. Consequently, menopausal hormone therapy (MHT) that includes oestrogen or an oestrogenic compound ameliorates menopausal symptoms, while preventing menopause-associated bone loss and cardiometabolic changes. Importantly, comprehensive care of postmenopausal women involves lifestyle optimization (attention to nutrition and physical activity, reducing alcohol consumption and not smoking) and treating other established chronic disease risk factors. This Review offers a commentary specifically on the contemporary use of MHT and novel pharmaceutical alternatives to manage menopausal symptoms.

Subjective well-being's alterations as risk factors for major depressive disorder during the perimenopause onset: an analytical cross-sectional study amongst Mexican women residing in Guadalajara, Jalisco

BACKGROUND

Subjective well-being (SWB) can be defined as a self-report evaluation that reflects the satisfaction, and emotional level, over several social and personal indicators. Alterations in these indicators could become risk factors (RF) for major depressive disorder (MDD), but this association has not been studied at women's life stages such as the perimenopause onset, despite its increasing prevalence for depressive symptomatology. Therefore, the aim of this study was to identify if SWB's alterations determine RF for MDD during the perimenopause.

METHODS

An analytical cross-sectional study was realized in 252 Mexican women with perimenopause's age range (48 ± 1.7) and menopausal symptomatology, treated on Medical Units belonging to Jalisco's 13th Health-Region. We applied the INEGI's Basic Self-Reported Wellbeing Survey (BIARE) that measured 30 SWB's indicators. To identify MDD's presence, the Beck's Depression Inventory-II (BDI-II) was applied. The sample was studied with associative analysis, along with logistic regression models, to determine adjusted odds ratio (aOR) and corresponding 95% confidence interval (95% CI).

RESULTS

Trough the BDI-II we identified 40.5% women with MDD. When compared with the undepressed group we found lower scores in all the SWB's indicators, along with significant associations for depressive symptomatology. However, the logistic regression allowed us to identify significant RF when the women specifically reported personal life-dissatisfaction (aOR 9.6, 95% CI 1.90-17.68), emotional imbalances between happiness/sadness (aOR 7.1, 95% CI 1.49-13.57) and concentration/boredom (aOR 6.7, 95% CI 1.43-13.48); free-time dissatisfaction (aOR 5.5, 95% CI 1.17-5.70), public security unconformity (aOR 5.4, 95% CI 2.20-11.3), and sense of purposelessness (aOR 4.2, 95% CI 1.07-19.41).

CONCLUSION

The main objective of the study was to determine if SWB's alterations are RF for depressive symptomatology, finding that social indicators with low scores are associated with MDD by means of aOR -Which were higher when compared to international research studies. Considering this, we suggest that more studies should be implemented, in order to understand and correctly attend the women's social conditions during their perimenopause transition.

Nutritional Risk Factors Associated with Vasomotor Symptoms in Women Aged 40-65 Years

Vasomotor symptoms (VMS) are the most common symptoms among menopausal women; these include hot flashes and night sweats, and palpitations often occur along with hot flashes. Some studies in Mexico reported that around 50% of women presented with VMS mainly in the menopausal transition. It has been proven that VMS are not only triggered by an estrogen deficiency, but also by nutritional risk factors. Evidence of an association between nutritional risk factors and VMS is limited in Mexican women. The aim of this study is to identify nutritional risk factors associated with VMS in women aged 40−65 years. This is a comparative cross-sectional study, undertaken in a retrospective way. A sample group (n = 406 women) was divided into four stages according to STRAW+10 (Stages of Reproductive Aging Workshop): late reproductive, menopausal transition, early postmenopause, and late postmenopause. Hot flashes were present mainly in the early postmenopause stage (38.1%, p ≤ 0.001). Two or more VMS were reported in 23.2% of women in the menopausal transition stage and 29.3% in the early postmenopause stage (p < 0.001). The presence of VMS was associated with different nutritional risk factors (weight, fasting glucose levels, cardiorespiratory fitness, and tobacco use) in women living in the northeast of Mexico.

Resilience and psychosocial factors linked to symptom experience during the menopause transition for women living with HIV

OBJECTIVE

Women living with HIV (WLWH) are commonly symptomatic during perimenopause and menopause (≥1 y without menstruation), however, little is known of risks for symptoms and their timing. We analyzed these unwanted experiences to inform care.

METHODS

WLWH (≥40 y) in the Canadian HIV Women's Sexual and Reproductive Health Cohort Study rated midlife experiences for seven symptoms and a symptom composite (from 0 to 21). Timing was categorized into four phases: i) perimenopause (flow in the last year), ii) 1-2 years from final menstrual period (FMP), iii) 2-5 years post-FMP; and iv) >5 years post-FMP. Resilience (standardized out of 100) was assessed based on Wagnild's Resilience Scale. Univariable/multivariable mixed effects linear regression assessed correlates of symptom intensity by composite score.

RESULTS

Among 457 peri-/menopausal women mean age 54.7 (±6.6) over two time points (703 observations), 88% experienced ≥1 mild symptom; 75% were of moderate and 55% severe intensity. The most frequently reported symptoms were joint/muscle stiffness (67%), depressed mood (67%), and hot flashes (57%). After adjusting for reproductive phase, we found that women with greater resilience had fewer/lower intensity symptoms (symptom score 1.37 [2.30 to 0.44] lower; P = 0.004); those with depressive symptoms and recreational drug use (respectively) had more/higher intensity symptoms (scores 1.71 [0.61 to 2.82] [P = 0.002]; 2.89 [2.09 to 3.77] [P<0.001] higher). Symptoms were most intense in perimenopause and declined with increasing menopausal years (P = 0.03).

CONCLUSIONS

WLWH experiences a high burden of midlife symptoms, decreased by resilience and most intense during perimenopause. Unwanted experiences were linked to psychosocial and behavioral factors. These data encourage HIV providers to adopt a bio-psychosocial approach to midlife management.

Neuroendocrine Changes during Menopausal Transition

Menopause is the permanent cessation of menstrual cycles following the loss of ovarian follicular activity. Quality of life of postmenopausal woman is the result of a series of psychobiological transformations, that see in the reduction of sex hormones and steroids the etiopathogenetic determinant moment. Symptoms of menopause range from somatic side such as metabolic changes, increased cardiovascular disease, irregular vaginal bleeding, urogenital symptoms, vaginal dryness, osteoporosis and risk of bones fractures to changes of central nervous system as vasomotor symptoms, sleep disruption, mood changes, migraine, sexual dysfunctions. It is fundamental to know the mechanisms underlying changes in the central nervous system during menopause, related to hypoestrogenism, to be able to create appropriate target therapy for patients, improving their quality of life. In fact, the central nervous system is now one of the major targets of sex steroids that cannot be achieved disregard when dealing with the problem of choice of a particular type of MHT.

Autism research is 'all about the blokes and the kids': Autistic women breaking the silence on menopause

OBJECTIVES

The menopause is a major transition marked by considerable challenges to health and well-being. Its impact on autistic women has been almost largely ignored but is of significant concern, given the poorer physical and mental health, emotion regulation and coping skills, and the common social isolation of this group. We aimed to explore awareness and perception of the menopause; menopausal experiences and their impact across each individual's life; ways that menopause with autism might differ from a non-autistic menopause; and what optimal support might look like.

DESIGN

A qualitative interview study.

METHODS

Comprehensive interviews were conducted with 17 autistic participants (16 of whom identified as cisgender women). Inductive thematic analysis was used, guided by IPA principles and literature.

RESULTS

Four major themes were identified: (1) covering the long journey of our participants to recognizing autism in adulthood; (2) menopausal awareness and perceptions; (3) symptoms and their impact; and (4) ways that a neurodiverse menopause might differ from the norm. Menopausal experiences varied greatly and some participants experienced marked deterioration in daily function and coping skills, mental health, and social engagement. Menopausal awareness was often low, so too was confidence in help from health care professionals.

CONCLUSIONS

These findings implicate the potential for menopause to severely compromise health and well-being of autistic people and indicate an area of underserved support needs.

'When my autism broke': A qualitative study spotlighting autistic voices on menopause

LAY ABSTRACT

Autistic girls are known to struggle with the onset of menstruation, reporting that during their period, sensory sensitivities are heightened, it becomes more difficult to think clearly and control their emotions and they struggle more with everyday life and self-care. Yet surprisingly, nothing is known about how autistic women handle the menopausal transition in midlife. In non-autistic women, the menopause brings many physical changes and challenging symptoms from hot flushes to feeling more anxious and depressed. Because autistic women are already vulnerable to suicide, poor physical and mental health, and because they may already struggle with planning, controlling their emotions and coping with change, the menopause may be an especially challenging time. Yet, not one single study exists on the menopause in autism, so we conducted an online discussion (focus group) with seven autistic women. They confirmed that very little is known about menopause in autistic people, very little support is available and that menopause might be especially difficult for autistic people. Autism-related difficulties (including sensory sensitivity, socializing with others and communicating needs) were reported to worsen during the menopause, often so dramatically that some participants suggested they found it impossible to continue to mask their struggles. Participants also reported having extreme meltdowns, experiencing anxiety and depression, and feeling suicidal. This study highlights how important it is that professionals pay attention to menopause in autism, and discusses future research directions.

The dynamics of stress and fatigue across menopause: attractors, coupling, and resilience

OBJECTIVE

The objective of this study was to evaluate the regulatory dynamics between stress and fatigue experienced by women during the menopausal transition (MT) and early postmenopause (EPM). Fatigue and perceived stress are commonly experienced by women during the MT and EPM. We sought to discover relationships between these symptoms and to employ these symptoms as possible markers for resilience.

METHODS

Participants were drawn from the longitudinal Seattle Midlife Women's Health Study. Eligible women completed questionnaires on 60+ occasions (annual health reports and monthly health diaries) (n = 56 women). The total number of observations across the sample was 4,224. STRAW+10 criteria were used to stage women in either in late reproductive, early or late transition, or EPM stage. Change values were generated for fatigue and stress and analyzed with a multilevel structural equation model; slopes indicate how quickly a person returns to homeostasis after a perturbation. Coupling of stress and fatigue was modeled to evaluate resilience, the notion of maintaining stability during change.

RESULTS

Eligible women were on average 35 years old (SD = 4.71), well educated, employed, married or partnered, and white. Fit indices suggested the model depicts the relationships of stress and fatigue (χ(9 df) = 7.638, P = 0.57, correction factor = 4.9244; root mean square error of approximation (RMSEA) 90% CI = 0.000 ≤ 0.000 ≤ 0.032; comparative fit index (CFI) = 1.00). A loss in model fit across stages suggests that the four stages differed in their dynamics (χΔ(12 df) = 21.181, P = .048). All stages showed fixed-point attractor dynamics: fatigue became less stable over time; stress generally became more stable over time. Coupling relationships of stress on fatigue show evidence for shifts in regulatory relationships with one another across the MT.

CONCLUSIONS

Results are suggestive of general dysregulation via disruptions to coupling relationships of stress and fatigue across the MT. Findings support a holistic approach to understanding symptoms and supporting women during the MT.

Self-awareness and the evaluation of hot flash severity: observations from the Seattle Midlife Women's Health Study

OBJECTIVE

The purpose of this study was to test the association of two dimensions of self-awareness with hot flash (HF) severity.

METHODS

A subset of women from the Seattle Midlife Women's Health Study (N = 232) provided data for these analyses. Structural equation modeling was used to evaluate two dimensions of self-awareness (Internal States Awareness [ISA] and Self-Reflectiveness [SR]), and secondary factors of perceived stress, anxiety, and attitudes toward menopause as continuous with earlier life, health perceptions, and menopausal stage with respect to HF severity. The measurement and structural models were tested with a maximum likelihood missing values estimator and displayed good model fit.

RESULTS

Women with greater ISA reported greater HF severity (β = 0.17, P < 0.05). In addition, women in later menopausal transition stages reported greater HF severity and those with attitudes of continuity toward menopause reported less severe HFs (β = 0.20, P < 0.01, β = -0.30, P < 0.001, respectively). SR was not related to HF severity. Women with higher levels of SR reported greater perceived stress levels (β = .51, P < 0.001), and those with greater perceived stress reported greater anxiety levels (β = 0.63, P < 0.001) and attitudes of continuity toward menopause as less continuous with earlier life (β = -0.30, P < 0.001).

CONCLUSIONS

ISA (balanced self-awareness) was associated with greater HF severity, suggesting that enhanced balanced self-awareness may promote women's ability to evaluate their symptom experience. A multidimensional construct of self-awareness, perceived stress, anxiety, and attitude toward menopause are all plausible targets for future intervention studies of symptom management.

Expectancy after the first treatment and response to acupuncture for menopausal hot flashes

Background

Evidence on the impact of expectancy on acupuncture treatment response is conflicting.

Objectives

This secondary analysis of a randomized sham-controlled trial on acupuncture for menopausal hot flashes investigated whether treatment expectancy score was associated with hot flash score at end-of-treatment. Secondary analyses investigated whether there were associations between other pre-specified factors and hot flash score.

Study design

Women experiencing moderately-severe hot flashes were randomized to receive 10 sessions of real or sham acupuncture over eight weeks. Hot flash score was collected using a seven-day hot flash diary, and expectancy using the modified Credibility and Expectancy Questionnaire immediately after the first treatment. Linear mixed-effects models with random intercepts were used to identify associations between expectancy score and hot flash score at end-of-treatment. Regression was also used to identify associations between pre-specified factors of interest and hot flash score. Because there was no difference between real and sham acupuncture for the primary outcome of hot flash score, both arms were combined in the analysis.

Results

285 women returned the Credibility and Expectancy Questionnaire, and 283 women completed both expectancy measures. We found no evidence for an association between expectancy and hot flash score at end-of-treatment for individual cases in either acupuncture or sham group. Hot flash scores at end-of-treatment were 8.1 (95%CI, 3.0 to 13.2; P = 0.002) points lower in regular smokers compared to those who had never smoked, equivalent to four fewer moderate hot flashes a day.

Conclusion

In our study of acupuncture for menopausal hot flashes, higher expectancy after the first treatment did not predict better treatment outcomes. Future research may focus on other determinants of outcomes in acupuncture such as therapist attention. The relationship between smoking and hot flashes is poorly understood and needs further exploration.

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.

Menopause

Menopause is an inevitable component of ageing and encompasses the loss of ovarian reproductive function, either occurring spontaneously or secondary to other conditions. It is not yet possible to accurately predict the onset of menopause, especially early menopause, to give women improved control of their fertility. The decline in ovarian oestrogen production at menopause can cause physical symptoms that may be debilitating, including hot flushes and night sweats, urogenital atrophy, sexual dysfunction, mood changes, bone loss, and metabolic changes that predispose to cardiovascular disease and diabetes. The individual experience of the menopause transition varies widely. Important influential factors include the age at which menopause occurs, personal health and wellbeing, and each woman's environment and culture. Management options range from lifestyle assessment and intervention through to hormonal and non-hormonal pharmacotherapy, each of which has specific benefits and risks. Decisions about therapy for perimenopausal and postmenopausal women depend on symptomatology, health status, immediate and long-term health risks, personal life expectations, and the availability and cost of therapies. More effective and safe therapies for the management of menopausal symptoms need to be developed, particularly for women who have absolute contraindications to hormone therapy. For an illustrated summary of this Primer, visit: http://go.nature.com/BjvJVX.

Miniature hygrometric hot flush recorder as an objective indicator of hot flushes: a validation study

OBJECTIVE

Hot flushes are a very common symptom of menopause for which many women seek medical help. Accurate assessment of clinical severity and of the impact of treatment is limited by a lack of methods for objective hot flush recording. The aim of the current study is to test the diagnostic value of a miniature hygrometric hot flush recorder (HFR).

METHODS

The HFR was tested in 50 women with severe postmenopausal hot flushes. Results were compared with recordings in 27 asymptomatic postmenopausal women, 12 premenopausal women, and 12 age-matched healthy men. The number of HFR events was compared with the number of diary-reported hot flushes.

RESULTS

Healthy young women and men had a mean (SEM) of 17.3 (1.3) HFR events/day. Asymptomatic postmenopausal women had 13.6 (1.4) HFR events/day, whereas symptomatic postmenopausal women had 21.0 (1.0) HFR events/day (P < 0.001). The number of HFR events in symptomatic women was significantly higher than the number of diary-reported hot flushes (mean [SEM], 13.8 [0.6] hot flushes/d) (P < 0.001). HFR sensitivity to diary-reported hot flushes was 55.1%, with 61.4% specificity.

CONCLUSIONS

The miniature hygrometric HFR has limited sensitivity and specificity. It detects sweating in general but does not differentiate between natural sweating and hot flush-related sweating. However, it may become useful as a tool for improving the data quality of diary-reported hot flushes.

Resilience does matter: evidence from a 10-year cohort record linkage study

OBJECTIVES

To examine 10-year mortality and hospital use among individuals categorised as resilient and vulnerable to the impact of chronic pain.

DESIGN

A cohort record linkage study.

SETTING

Grampian, Scotland.

PARTICIPANTS

5858 individuals from the Grampian Pain Cohort, established in 1996, were linked, by probability matching, with national routinely collected datasets.

MAIN OUTCOME MEASURES

HRs for subsequent 10-year mortality and ORs/incidence rate ratios for subsequent 10-year hospital use, each with adjustment for potential confounding variables.

RESULTS

36.5% of those with high pain intensity reported a low pain-related disability (categorised resilient) and 7.1% of those reporting low pain intensity reported a high pain-related disability (categorised vulnerable). Sex, age, housing, employment and long-term limiting illness were independently associated with being vulnerable or resilient. After adjustment for these variables, individuals in the resilient group were 25% less likely to die within 10 years of the survey compared with non-resilient individuals: HR 0.75, 95% CI 0.62 to 0.91 and vulnerable individuals were 45% more likely to die than non-vulnerable individuals: HR 1.45, 95% CI 1.01 to 2.11. Resilient individuals were less likely to have had an outpatient or day-case visit for anaesthetics: OR 0.46, 95% CI 0.27 to 0.79, but no other clinical specialities. Vulnerable individuals were significantly less likely to have had any outpatient or day-case visit (OR 0.43, 0.25 to 0.75); but more likely to have had a psychiatric visit (OR 1.96, 1.06 to 3.61). No significant differences in likelihood of any inpatient visits were found.

CONCLUSIONS

Resilient individuals have a better 10-year survival than non-resilient individuals indicating that resilience is a phenomenon worth researching. Further research is needed to explore who is likely to become resilient, why and how, as well as to tease out the internal and external factors that influence resilience.