Direct and Indirect Costs of Women Diagnosed With Menopause Symptoms

Unilateral Oophorectomy and Age at Natural Menopause: A Longitudinal Community-Based Cohort Study

OBJECTIVE

To determine the association between unilateral oophorectomy (UO) and age at natural menopause.

DESIGN

Secondary analysis of survey data from Alberta's Tomorrow Project (2000-2022).

SETTING

Prospective cohort study in Alberta, Canada.

POPULATION

23 630 women; 548 experienced UO and 23 082 did not experience UO.

METHODS

Flexible parametric survival analysis was used to analyse age at natural menopause, and logistic regression was used to analyse early menopause and premature ovarian insufficiency by UO status, controlling for birth year, parity, age at menarche, past infertility, hormonal contraceptive use and smoking.

MAIN OUTCOME MEASURES

Age at natural menopause occurred by a final menstrual period without medical cause and sub-classified as early menopause (< 45 years) and premature ovarian insufficiency (< 40 years).

RESULTS

Compared to no UO, any UO was associated with elevated risk of earlier age at natural menopause, which was strongest in early midlife (adjusted HR at age 40 1.71, 95% CI 1.31-2.19) and diminished over time. Compared to age 55 years at UO, risks of earlier age at natural menopause were largest and uniform in magnitude when UO occurred between approximately ages 20-40 years (adjusted HR for UO at age 30 2.32, 1.46-3.54) and then diminished as age at UO approached the average age at natural menopause. Any UO was associated with higher odds of early menopause (adjusted OR 1.90, 1.30-2.79) and premature ovarian insufficiency (adjusted OR 3.75, 1.72-8.16).

CONCLUSIONS

Unilateral oophorectomy is associated with earlier age at natural menopause, particularly when performed before 40 years of age.

Navigating menopause at work: a preliminary study about challenges and support systems

OBJECTIVE

Women's increasing workforce participation necessitates understanding unique life phases like menopause for enhanced workplace inclusivity. This research investigates the challenges and needs of peri-menopausal women in work settings, using the Job Demands-Resources model as a foundation.

METHODS

A cross-sectional survey was administered to 351 working women aged 40 to 65 years in the United States. Hierarchical multiple regression models were employed to assess the relationship between the severity of menopausal symptoms, emotional exhaustion, work engagement, and turnover intentions.

RESULTS

Most of the respondents reported moderate (38.46%) to severe (35.9%) menopausal symptoms. Notably, 54% of the women were caregivers for children or adults. About 77.7% of participants reported work-related challenges due to menopause, with a perceived reduction in productivity (56.8%) being the most common issue. The severity of menopausal symptoms was found to significantly predict more emotional exhaustion ( P < 0.001), less work engagement ( P < 0.001), and greater turnover intentions ( P = 0.03). Concerns about being perceived as less capable in the workplace due to menopausal symptoms were reported by 51.2% of respondents. A striking gap exists between the workplace measures desired by women, such as formal menopause policies and managerial training (65.4%-68%), and their actual implementation (2%-6.3%).

CONCLUSIONS

This study reveals an exigent need for increased awareness and structural changes to support working women going through menopause. The findings have far-reaching implications for not just promoting gender equity and well-being but are also pivotal for maintaining a diversified, engaged, and effective workforce.

"But at a certain point, the lights literally went out": A qualitative study exploring midlife women's experiences of health, wellbeing, and functioning in relation to paid work

BACKGROUND

In the Netherlands, the fact that midlife women constitute a considerable segment of the working population is relatively new. Generally paid work contributes to midlife women's wellbeing, but they also report health challenges, such as work-related fatigue and the menopause.

OBJECTIVE

The objective of this study is to understand how midlife women themselves perceive their health, wellbeing, and functioning in relation to paid work.

METHODS

In this exploratory qualitative study, 28 women participated in five ethnically homogeneous focus group discussions (FGDs). De FGDs were recorded, transcribed verbatim, and thematically analyzed using MAXQDA.

RESULTS

We identified exhaustion as central to our analysis. During midlife, exhaustion seems to occur once a certain limit has been reached, both physically and mentally, with women feeling to have reached the end of their rope. Besides obvious physiological challenges, we identified two major themes in which we discuss challenges both in paid work and private life: (1) work environment and working conditions, and (2) burdens in private life. Participants took various measures to manage and try to reduce exhaustion, including finding a new job or negotiating different job tasks, and reducing work hours.

CONCLUSION

This study indicates that the extent to which women experience exhaustion is associated with challenges in both paid work and private life. The underlying processes do not seem to reflect individual problems, but reflect a complex set of factors at the structural level. Nevertheless, women take several individual measures to reduce their exhaustion, including reducing their participation in paid work.

Impact of menopausal symptoms on work and careers: a cross-sectional study

BACKGROUND

Women over 50 years are one of the fastest-growing employment groups. Menopausal symptoms can adversely impact quality of life, work performance and attendance; however, few studies look at the impact of individual menopausal symptoms on work and career development.

AIMS

To measure the prevalence of menopausal symptoms in employees in a healthcare setting, to assess the impact of individual symptoms on work, attendance and career development and to explore perceptions about workplace supports.

METHODS

In this cross-sectional study of Irish hospital workers, menopausal employees were asked about the frequency of 10 menopausal symptoms and the extent to which each symptom impacted them at work. Impacts on performance, attendance and career development were assessed, along with the benefits of workplace support.

RESULTS

Responses from 407 women showed that the most common menopausal symptoms affecting employees greater than 50% of the time while at work were fatigue (54%), difficulty sleeping (47%), poor concentration (44%) and poor memory (40%). Work performance was impacted for 65% of respondents and 18% had taken sick leave. There was a significant association between symptom severity at work and reduced work performance, career development decisions and attendance. Manager awareness about menopause (29%) and flexible working times (29%) were selected as the most important workplace supports.

CONCLUSIONS

Female employees are negatively impacted by menopausal symptoms while at work, particularly by psychological and neurocognitive symptoms which were associated with reduced work performance, attendance and career decisions. Manager awareness and flexible schedules were considered the most beneficial workplace supports.

Development and verification of the Menopause Emotional Symptom Questionnaire

OBJECTIVE

A detailed, well-validated scale for measuring emotional symptoms in menopausal women is lacking. We aimed to develop the Menopause Emotional Symptom Questionnaire (MESQ) and to confirm its reliability and validity among Koreans.

METHODS

Eighteen primary items based on previous research results were selected using exploratory factor analysis and confirmatory factor analysis (CFA). New data, including answers to the novel MESQ, Menopause Rating Scale, Kupperman Index, Beck Depression Inventory-II, and Beck Anxiety Inventory, were collected from 200 perimenopausal women and 100 young men through a research company. Exploratory factor analysis and CFA were performed again to determine whether the MESQ accurately measures emotional symptoms in perimenopausal women. Receiver operating characteristic curve and k-means cluster analyses were used to identify the most appropriate cutoff value.

RESULTS

The MESQ showed high internal consistency (Cronbach α = 0.926), and the CFA revealed that the factor structure comprised two subscales: nine items for mood/anxiety symptoms and four items for sleep symptoms. A high correlation between the total MESQ score and total scores of the existing scales was confirmed, indicating high convergence validity. Comparison of the mean MESQ scores between men and women showed significant sex difference, indicating secure known-group validity. The cutoff point of the total MESQ score between the high-risk and low-risk groups was 26.

CONCLUSIONS

The novel MESQ has high validity and reliability, and this study confirmed that the MESQ is a valid tool for screening for and measuring emotional symptoms in menopausal women in Korea.

Cost-Effectiveness Analysis of MammaPrint® to Guide the Use of Endocrine Therapy in Patients with Early-Stage Breast Cancer

BACKGROUND

Gene expression profiling tests can predict the risk of disease recurrence and select patients who are expected to benefit from therapy, while allowing other patients to forgo therapy. For breast cancers, these tests were initially designed to tailor chemotherapy decisions, but recent evidence suggests that they may also guide the use of endocrine therapy. This study evaluated the cost effectiveness of a prognostic test, MammaPrint^®, to guide the use of adjuvant endocrine therapy in patients eligible according to Dutch treatment guidelines.

METHODS

We constructed a Markov decision model to calculate the lifetime costs (in 2020 Euros) and effects (survival and quality-adjusted life-years) of MammaPrint^® testing versus usual care (endocrine therapy for all patients) in a simulated cohort of patients. The population of interest includes patients for whom MammaPrint^® testing is currently not indicated, but for whom it may be possible to safely omit endocrine therapy. We applied both a health care perspective and a societal perspective and discounted costs (4%) and effects (1.5%). Model inputs were obtained from published research (including randomized controlled trials), nationwide cancer registry data, cohort data and publicly available data sources. Scenario and sensitivity analyses were conducted to explore the impact of uncertainty around input parameters. Additionally, threshold analyses were performed to identify under which circumstances MammaPrint^® testing would be cost effective.

RESULTS

Adjuvant endocrine therapy guided by MammaPrint^® resulted in fewer side effects, more (quality-adjusted) life-years (0.10 and 0.07 incremental QALYS and LYs, respectively) and higher costs (€18,323 incremental costs) compared with the usual care strategy in which all patients receive endocrine therapy. While costs for hospital visits, medication costs and productivity costs were somewhat higher in the usual care strategy, these did not outweigh costs of testing in the MammaPrint^® strategy. The incremental cost-effectiveness ratio was €185,644 per QALY gained from a healthcare perspective and €180,617 from a societal perspective. Sensitivity and scenario analyses showed that the conclusions remained the same under changed input parameters and assumptions. Our results show that MammaPrint^® can become a cost-effective strategy when either the price of the test is reduced (> 50%), or the proportion of patients for which treatment is altered (i.e. those with ultra-low risk) increases to > 26%.

CONCLUSION

Standard MammaPrint^® testing to guide the use of endocrine therapy in our simulated patient population appears not to be a cost-effective strategy compared with usual care. The cost effectiveness of the test can be improved by reducing the price or preselecting a population more likely to benefit from the test.

Emergency Gynecologic Considerations in the Older Woman

As women mature through menopause, they will experience normal physiologic changes that can contribute to emergency complaints specific to this patient population. Reviewing the expected physiologic changes of menopause and correlating these normal processes to the development of specific pathologic conditions offers a framework for emergency physicians and practitioners to use when evaluating older women for breast, genitourinary, and gynecologic symptoms.

Impact of Menopause Symptoms on Women in the Workplace

OBJECTIVE

To evaluate the impact of menopause symptoms on work outcomes and to assess the estimated economic impact.

PATIENTS AND METHODS

Women aged 45 to 60 years receiving primary care at 1 of the 4 Mayo Clinic sites were invited to participate in a survey study (Hormones and ExpeRiences of Aging) from March 1 through June 30, 2021. A total of 32,469 surveys were sent, with 5219 responses (16.1% response rate). Of the 5219 respondents, 4440 (85.1%) reported current employment information and were included in the study. The primary outcome was self-reported adverse work outcomes related to menopause symptoms assessed by the Menopause Rating Scale (MRS).

RESULTS

The mean age of the 4440 participants was 53.9±4.5 years, with the majority being White (4127 [93.0%]), married (3398 [76.5%]), and educated (2632 [59.3%] college graduate or higher); the mean total MRS score was 12.1, signifying moderate menopause symptom burden. Overall, 597 women (13.4%) reported at least one adverse work outcome due to menopause symptoms; 480 women (10.8%) reported missing work in the preceding 12 months (median, 3 days missed). The odds of reporting an adverse work outcome increased with increasing menopause symptom severity; women in the highest quartile of total MRS scores were 15.6 (95% CI, 10.7 to 22.7; P<.001) times more likely to have an adverse work outcome vs those in the first quartile. Based on workdays missed due to menopause symptoms, we estimate an annual loss of $1.8 billion in the United States.

CONCLUSION

This large cross-sectional study identified a major negative impact of menopause symptoms on work outcomes and the need to improve medical treatment for these women and make the workplace environment more supportive. Additional studies are needed to confirm these findings in larger and more diverse groups of women.

Effects of concurrent exercise on health-related quality of life in middle-aged women

OBJECTIVE

This study aimed to evaluate the influence of a 16-week concurrent exercise program on health-related quality of life in middle-aged women.

METHODS

A total of 150 middle-aged women from the FLAMENCO project (age range 45-60 years) were randomized into a counseling (n = 75) or an exercise (n = 75) group. The exercise group followed a 16-week (3 days/week, 60 min/session) concurrent exercise program (aerobic + resistance training). The counseling group attended conferences on a healthy lifestyle. Participants' health-related quality of life was assessed with the EuroQol plus, a visual analog scale and the 36-item Short Form Health Survey (SF-36), where greater values indicate a better health-related quality of life.

RESULTS

The visual analog scale increased by 9.0% in the exercise group, whereas it only increased by 3.5% in the counseling group (p = 0.040). The SF-36 physical function, physical role, bodily pain, vitality and emotional role increased by 5.5%, 11.3%, 10.8%, 9.6% and 8.9%, respectively, in the exercise group, whereas these only increased by 0.6%, decreased by 0.7% and increased by 1.4%, 3.8% and 0.6% in the counseling group (all p < 0.05).

CONCLUSIONS

Our results suggest that a 16-week concurrent exercise program adapted for midlife women improved their health-related quality of life.

CLINICALTRIALS.GOV IDENTIFIER

NCT02358109. Date of registration: 05/02/2015.

Women's Health and Working Life: A Scoping Review

Women's health matters for participation in working life. The objective of this study was to explore female physiology in a work-life context and to investigate possible associations between women's health, sickness absence and work ability. A scoping review was conducted to develop a systematic overview of the current research and to identify knowledge gaps. The search strategy was developed through a population, concept and context (PCC) model, and three areas of women's health were identified for investigation in the context of work. A total of 5798 articles were screened by title and abstract and 274 articles were screened by full text; 130 articles were included in the review. The material included research from 19 countries; the majority of the studies used quantitative methods. The results showed an impact on the occupational setting and an association between sickness absence, work ability and all three areas of women's health, but a holistic and overall perspective on female biology in the work context is missing. This review calls for more knowledge on health and work and possible gender differences in this regard. Women's health and working life involve a complex connection that has the potential to develop new knowledge.

Impact of Menopausal Symptoms on Work: Findings from Women in the Health and Employment after Fifty (HEAF) Study

Women make up a growing proportion of the workforce and therefore many women experience menopause while in paid employment. We explored the prevalence of menopausal symptoms, the relationship between symptoms and coping with work and the risk factors associated with struggling at work during the menopause. The Health and Employment After Fifty (HEAF) community-based cohort of people aged 50-64 years was incepted 2013-2014 to study health and work. In 2019, female participants were asked to complete a questionnaire about their menopausal symptoms, and effect of those symptoms on their ability to cope at work. 409 women were eligible for inclusion. The commonest symptoms were vasomotor (91.7%); trouble sleeping (68.2%); psychological (63.6%) and urinary (49.1%). The prevalence of reporting symptoms was similar no matter which type of occupation women were performing at the time. Around one-third of women reported moderate/severe difficulties coping at work because of menopausal symptoms. Risk factors for difficulties coping at work included: financial deprivation, poorer self-rated health, depression, and adverse psychosocial occupational factors but not physical demands. More awareness is needed amongst employers in all sectors but women with financial difficulties and those with jobs in which they feel insecure, unappreciated, or dissatisfied are at greatest risk.

Menopause and work: A narrative literature review about menopause, work and health

BACKGROUND:

Menopause is part of working women’s lives. In Western countries, labour market patterns are changing rapidly: women’s labour participation has increased, the percentage of full-time working women is rising, and retirement age is increasing.

OBJECTIVE:

This narrative literature study aims to provide an insight in the state of the art in the literature about the relationship between menopause, work and health and to identify knowledge gaps as input for further research.

METHODS:

The search was conducted in PubMed, CINAHL, MEDLINE and ScienceDirect. The final set includes 36 academic articles, 27 additional articles related to the topic and 6 additional sources.

RESULTS:

Research on menopause, work and health is scarce. Results are grouped thematically as follows: Menopause and (1) a lack of recognising; (2) sickness absence and costs; (3) work ability; (4) job characteristics; (5) psychosocial and cultural factors; (6) health; (7) mental health, and (8) coping and interventions. Work ability of women with severe menopausal complaints may be negatively affected.

CONCLUSIONS:

Due to taboo, menopause remains unrecognised and unaddressed within an organisational context. New theoretical and methodological approaches towards research on menopause, work and health are required in order to match the variety of the work contexts world-wide.

Treat more than heat-New therapeutic implications of Cimicifuga racemosa through AMPK-dependent metabolic effects

BACKGROUND

Cimicifuga racemosa extracts (CRE) have obtained a "well-established use status" in the treatment of postmenopausal (i.e., climacteric) complaints, which predominantly include vasomotor symptoms such as hot flushes and sweating, as well as nervousness, irritability, and metabolic changes. Although characteristic postmenopausal complaints are known for a very long time and the beneficial effects of CRE on climacteric symptoms are well accepted, both the pathophysiology of postmenopausal symptoms and the mechanism of action of CREs are not yet fully understood. In particular, current hypotheses suggest that changes in the α-adrenergic and serotonergic signaling pathways secondary to estrogen depletion are responsible for the development of hot flushes.

PURPOSE

Some of the symptoms associated with menopause cannot be explained by these hypotheses. Therefore, we attempted to extend our classic understanding of menopause by integrating of partly age-related metabolic impairments.

METHODS

A comprehensive literature survey was performed using the PubMed database for articles published through September 2021. The following search terms were used: (cimicifuga OR AMPK) AND (hot flush* OR hot flash* OR menopaus* OR osteoporos* OR cancer OR antioxida* OR cardiovasc*). No limits were set with respect to language, and the references cited in the articles retrieved were used to identify additional publications.

RESULTS

We found that menopause is a manifestation of the general aging process, with specific metabolic changes that aggravate menopausal symptoms, which are accelerated by estrogen depletion and associated neurotransmitter dysregulation. Cimicifuga extracts with their metabolic effects mitigate climacteric symptoms but may also modulate the aging process itself. Central to these effects are effects of CRE on the metabolic key regulator, the AMP-activated protein kinase (AMPK).

CONCLUSIONS

As an extension of this effect dimension, other off-label indications may appear attractive in the sense of repurposing of this herbal treatment.

The consequences of early menopause and menopause symptoms for labour market participation

Using a difference-in-difference estimator we identify the causal impact of early menopause and menopause symptoms on the time women spend in employment through to their mid-50s. We find the onset of early natural menopause (before age 45) reduces months spent in employment by 9 percentage points once women enter their 50s compared with women who do not experience early menopause. Early menopause is not associated with a difference in full-time employment rates. The number of menopause symptoms women face at age 50 is associated with lower employment rates: each additional symptom lowers employment rates and full-time employment rates by around half a percentage point. But not all symptoms have the same effects. Vasomotor symptoms tend not to be associated with lower employment rates, whereas the employment of women who suffer psychological problems due to menopause is adversely affected. Every additional psychological problem associated with menopause reduces employment and full-time employment rates by 1-2 percentage points, rising to 2-4 percentage points when those symptoms are reported as particularly bothersome.

Menopause and Sustainable Career Outcomes: A Science Mapping Approach

This paper provides a systematic review of the phenomenon of menopause at the workplace from a sustainable career perspective, by highlighting its major themes along with the evolution and tendencies observed in this field. A conceptual science mapping analysis based on co-word bibliographic networks was developed, using the SciMAT tool. From 1992 to 2020, 185 documents were retrieved from the Web of Science. In the first analyzed time span (1992-2002), postmenopausal women, health, and risk factors appeared to be the motor themes (well-developed and important for the structure of the discipline under focus), and disorder was an emerging or disappearing theme in the phenomenon under research. In the second studied period (2003-2013), risk and health were motor themes, menopausal symptoms was a basic or transversal theme (important for the discipline but not well-developed), coronary heart disease was a specialized theme (well-developed but less important for the structure of the research field), and postmenopausal women was an emerging or disappearing theme (both weakly developed and marginal to the field). In the third studied period (2014-2020), menopause, breast cancer, and menopausal symptoms were motor themes, Anxiety was a specialized theme and risk and body mass index were emerging or disappearing themes. Sustainability of women's careers in the second half of life is of increasing importance given the increasing equal representation of men and women in working organizations, and the impact of the changing nature of work in the 21st century on older workers.

Effects of a Combination of Foeniculum vulgare, Melissa officinalis Extract, and Nigella saliva Powder on Healthy Menopausal Women with Sexual Dysfunction: A Randomized Clinical Trial

Background: Menopause is a critical period with frequent sexual disorders. Objectives: The current study assessed the therapeutic effect of a combination of the aerial part of Melissa officinalis, fennel fruit extract, and Nigella sativa seed powder on the sexual dysfunction of postmenopausal women. Methods: This randomized clinical trial was performed on 48 menopausal women from April 2015 to October 2017. The participants included the menopausal women referring to the clinic of Gorgan health centers aged between 41 and 54 years with natural menopause (amenorrhea for at least 12 months) and discomfort in sexual activity. They were randomized into two treatment groups. Group 1 (n = 27) received 1000 mg capsules (Melissa officinalis, fennel extract, and Nigella sativa powder), and group 2 (n = 21) received a placebo (1000 mg starch capsules (in an eight-week course of treatment (one capsule per day for each group). The variables in the female sexual function index (FSFI) questionnaire were compared in the two groups before and after the intervention. Results: The results showed that the mean scores of sexual dysfunction in the domains of arousal, lubrication, orgasm, satisfaction, and pain were not significantly different between the two groups (P > 0.05). Conclusions: Despite many studies on the effectiveness of Melissa, Foenculum, and Nigella, this study showed that a combination of Foeniculum vulgare, Melissa officinalis extract, and Nigella sativa seed powder does not improve the sexual function of postmenopausal women with sexual dysfunction, and it might be the synergism effect of this combination.

17β-estradiol/progesterone in a single, oral, softgel capsule (TX-001HR) significantly increased the number of vasomotor symptom-free days in the REPLENISH trial

Objective:

To examine responder rates and vasomotor symptom-free days with oral 17β-estradiol/progesterone (E2/P4; TX-001HR) versus placebo in the REPLENISH trial.

Methods:

REPLENISH (NCT01942668) was a phase 3, randomized, double-blind, placebo-controlled, multicenter trial, evaluating single, oral, softgel E2/P4 capsules in postmenopausal women (40-65 y) with a uterus and vasomotor symptoms (VMS). Women with moderate to severe hot flushes (≥7/d or ≥50/wk) were randomized (VMS substudy) to daily E2/P4 (mg/mg) of 1/100, 0.5/100, 0.5/50, 0.25/50, or placebo. Proportions of women with ≥50% or ≥75% reductions in moderate to severe VMS (responders), and those with no severe VMS as well as the weekly number of days without moderate to severe VMS with TX-001HR versus placebo were determined. Mixed model repeated measures was used to analyze data and Fisher exact test was employed to compare E2/P4 versus placebo.

Results:

Seven hundred twenty-six women were eligible for the VMS efficacy analysis (E2/P4 1/100 [n = 141], 0.5/100 [n = 149], 0.5/50 [n = 147], 0.25/50 [n = 154], or placebo [n = 135]). Significantly more women treated with all E2/P4 doses versus placebo were ≥50% responders and ≥75% responders at weeks 4 and 12 (P < 0.05) and also had significantly more days per week without moderate to severe VMS at week 12 (1.9-3.0 d for E2/P4 versus 1.3 d for placebo; P < 0.05). The proportion of women without severe hot flushes at week 12 was 43% to 56% for all E2/P4 doses versus 26% for placebo (P ≤ 0.01).

Conclusions:

Women treated with E2/P4 had a greater response to treatment with more VMS-free days than with placebo. The E2/P4 1/100 dose (Bijuva [E2 and P4] capsules) represents an oral treatment option for postmenopausal women with moderate to severe VMS and a uterus.

A critical appraisal of vasomotor symptom assessment tools used in clinical trials evaluating hormone therapy compared to placebo

OBJECTIVE

Vasomotor symptoms (VMS) have been consistently reported as the leading predictor of health-related quality of life (HRQOL) among menopausal women, and the strongest indication for treatment. The North American Menopause Society endorses the use of oral estrogen for the treatment of VMS based on a Cochrane meta-analysis. The Cochrane review concludes that oral hormone therapy reduces the frequency and severity of VMS. The objective of this review is to critically appraise the outcome measures used in these clinical trials to evaluate whether there is adequate evidence that oral hormone therapy improves HRQOL.

METHODS

Each trial in the 2004 Cochrane review of oral hormone therapy for the management of VMS was evaluated with respect to study design, outcome measures, and method of analysis.

RESULTS

Twenty-four randomized, double-blind, placebo-controlled clinical trials were appraised. Six trials were excluded from the Cochrane meta-analysis due to inadequate reporting of outcome measures. Of the remaining trials, 15 trials assessed only symptom frequency and/or severity. One trial used a subscale of the General Health Questionnaire. Two trials used the Greene Climacteric Scale, a validated outcome measure in menopausal women, to directly assess the impact of hormone therapy on HRQOL. Both studies showed an improvement in HRQOL in the hormone-treated group, although the sample size was small (n = 118) and the effect was modest.

CONCLUSION

Although oral hormone therapy improves VMS scores, there is a paucity of evidence on whether it improves HRQOL in menopausal women. Future studies using validated, patient-reported outcome measures that directly assess HRQOL are needed.

Healthcare Utilization and Prevalence of Symptoms in Women with Menopause: A Real-World Analysis

Objective

Self-reported studies estimated that as many as 50-75% of women experience symptoms during menopause; however, limited real-world clinical data are available to support this observation. The electronic databases of Maccabi Healthcare Services were used to describe the prevalence of menopause symptoms in Israel and to characterize patients with regard to socioeconomic status, comorbidities and use of healthcare services.

Methods

Females aged 45-54 years diagnosed with menopausal symptoms (N=17,046, cumulative incidence of 8% during the study period) were identified from the Maccabi Healthcare Services electronic database and matched to female members without menopause symptoms, one-to-one on birth year and enumeration area.

Results

Symptomatic peri- and post-menopausal women, and particularly those under 52 years, were more likely to have a higher prevalence of comorbid conditions such as depression, anxiety, osteoporosis and insomnia in the year following index. Correspondingly, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors and hypnotic drug use were significantly higher in symptomatic women as was healthcare utilization including hospitalization (OR=1.10; 95% CI=1.00-1.20), primary care visits (1.90; 1.73-2.08), gynecologist visits (24.84; 22.36-27.59) and hysterectomy procedures (2.26; 1.63-3.14).

Conclusion

Medically documented menopausal symptoms are associated with increased burden of disease (particularly among women diagnosed with menopausal symptoms prior to age 52 years), healthcare utilization and greater likelihood of undergoing hysterectomy within one year of diagnosis. This burden is expected to rise further as awareness and social acceptance of peri- and post-menopausal symptoms increase.

Oral 17β-estradiol/progesterone (TX-001HR) and quality of life in postmenopausal women with vasomotor symptoms

Objective:

The aim of the study was to describe the effects of TX-001HR (17β-estradiol [E2] and natural progesterone [P4] in a single oral capsule) on menopause-specific quality of life in women with moderate to severe vasomotor symptoms (VMS).

Methods:

The REPLENISH study (NCT01942668) was a phase 3, randomized, double-blind, placebo-controlled, multicenter trial which evaluated four E2/P4 doses in postmenopausal women with VMS and a uterus. Women with moderate to severe hot flushes (≥7/d or ≥50/wk) were included in a VMS substudy. Participants self-administered the Menopause-Specific Quality of Life (MENQOL) questionnaire. Baseline changes in MENQOL overall and domains were determined as well as correlations between changes in MENQOL scores and VMS frequency or severity.

Results:

In the VMS substudy, women treated with E2/P4 had significantly greater improvements from baseline in their MENQOL overall score at week 12, and months 6 and 12, compared with placebo (all, P < 0.05, except the lowest E2/P4 dose at months 6 and 12). Improvements from baseline for the MENQOL vasomotor domain score were significantly greater with TX-001HR doses versus placebo at all time points (all, P < 0.01). Changes in MENQOL vasomotor scores moderately correlated with changes in VMS frequency (r = 0.56, P < 0.0001) and severity (r = 0.55, P < 0.0001).

Conclusion:

In the REPLENISH trial, women with moderate to severe VMS treated with most E2/P4 doses reported significant improvements in quality of life from baseline to 12 weeks compared with placebo, which were maintained up to 12 months. TX-001HR, if approved, may provide the first oral hormone therapy formulation in a single capsule containing E2 and P4 for the treatment of VMS in postmenopausal women with a uterus.

Relationship between vasomotor symptom improvements and quality of life and sleep outcomes in menopausal women treated with oral, combined 17β-estradiol/progesterone

Objective:

To characterize the impact of TX-001HR on the relationship between vasomotor symptom (VMS) improvement and quality of life and sleep.

Methods:

REPLENISH (NCT01942668) was a phase 3, randomized, double-blind, placebo-controlled, multicenter trial, which evaluated four daily doses of 17β-estradiol and progesterone (E2/P4) combined in a single, oral, softgel capsule in postmenopausal women (40-65 years) with a uterus and moderate to severe VMS (≥7/day or ≥50/week). In post hoc analyses, growth models were used to examine relationships between linear changes in VMS frequency and severity over 12 weeks and changes from baseline in the Menopause-Specific Quality of Life (MENQOL; total score and VMS domain) and the Medical Outcomes Study-Sleep (total score, sleep problems indices I and II) questionnaire outcomes at 12 weeks with treatment compared with placebo.

Results:

Outcomes with all four E2/P4 doses were combined (n = 591) and compared with placebo (n = 135). In all 5 growth models, the effects of TX-001HR on MENQOL total score and vasomotor domain were significantly associated with changes in VMS frequency and severity observed over 12 weeks (all, P < 0.001). Treatment-mediated effects on MENQOL via VMS frequency and severity models were significant. Similar results were found with Medical Outcomes Study-Sleep total score and sleep problems indices.

Conclusions:

TX-001HR improvements in quality of life and sleep outcomes are associated with and may be mediated through improvements in VMS frequency and severity.

The relationship between menopausal symptoms and burnout. A cross-sectional study among nurses

Background

Despite the growing presence of menopausal women in workplaces, studies aimed at exploring the link between menopausal symptoms and job well-being are scarce. In the interest of addressing this gap, the present study aimed to explore whether menopausal symptoms might contribute to increased levels of burnout and whether this relationship can be moderated by social or personal resources.

Method

The study design was cross-sectional and non-randomized. Ninety-four menopausal nurses completed a self-report questionnaire including scales aimed at measuring menopausal symptoms, burnout, social (i.e., support from superiors and colleagues) and personal (i.e., self-efficacy, resilience, and optimism) resources. Moderated regression analyses were performed to test study hypotheses.

Results

Whereas menopausal symptoms were associated significantly with emotional exhaustion, no social or personal resources were found to moderate this relationship. Regarding depersonalization, our study indicated that it was affected by menopausal symptoms only among nurses who reported low social support (from superiors and colleagues), optimism, and resilience.

Conclusion

The present study highlights the importance of organizations that employ a growing number of menopausal women to seek solutions at the individual and social levels that help these women deal with their menopausal transition while working.

Improvement in sleep outcomes with a 17β-estradiol-progesterone oral capsule (TX-001HR) for postmenopausal women

Objective:

The aim of the study was to evaluate the effects of TX-001HR, a single-capsule 17β-estradiol–progesterone on sleep parameters in postmenopausal women with vasomotor symptoms (VMS) using the Medical Outcomes Study (MOS)-Sleep scale questionnaire in the REPLENISH trial.

Methods:

In the REPLENISH trial (NCT01942668), women were randomized to one of four doses of TX-001HR or placebo, and the 12-item MOS-Sleep questionnaire (secondary endpoint) was self-administered at baseline, week 12, and months 6 and 12. Changes from baseline in the MOS-Sleep total score and 7 subscale scores were analyzed for treatment groups versus placebo at all time points. Somnolence was also collected as an adverse event.

Results:

Women (mean age 55 y) were randomized to TX-001HR (estradiol/ progesterone [E2/P4] [mg/mg]) doses: 1/100 (n = 415), 0.5/100 (n = 424), 0.5/50 (n = 421), 0.25/50 (n = 424), or placebo (n = 151). TX-001HR significantly improved MOS-Sleep total score, Sleep Problems Index II subscale, and sleep disturbance subscale versus placebo at all time points, except with 0.25 mg E2/50 mg P4 at week 12. Differences in LS mean changes between TX-001HR and placebo for MOS-Sleep total scores ranged from −6.5 to −7.6 at 12 months (all; P ≤ 0.001). All doses of TX-001HR significantly improved the Sleep Problems Index I subscale at all time points. The sleep somnolence subscale significantly improved from baseline with 0.5 mg E2/100 mg P4 and 0.5 mg E2/50 mg P4 at month 12. The incidence of somnolence as a treatment-emergent adverse event ranged from 0.2% to 1.2% versus 0% with placebo.

Conclusion:

TX-001HR significantly improved MOS-Sleep parameters from baseline to week 12, which was sustained for up to 12 months, and was associated with a very low incidence of somnolence.

Body Composition Changes Following a Concurrent Exercise Intervention in Perimenopausal Women: The FLAMENCO Project Randomized Controlled Trial

We assessed the effects of a 16-week primary-care-based exercise program on body composition in perimenopausal women. The women (n = 150) were randomized into control (n = 75) or exercise (n = 75) groups. Exercise was provided in a 16-week (60 min/session, 3 days/week) concurrent program. Body composition was measured using dual-energy X-ray absorptiometry. These are secondary analyses of the FLAMENCO Project (Clinical Trials Reference NCT02358109). In the intention-to-treat analyses, the control group showed no changes in body mass index (BMI) between post- and pre-test, whereas the exercise group showed a 0.75 kg/m² decrease in BMI (95% CI: −1.29 to −0.22; p = 0.006). Gynoid and android fat mass in control group decreased by 98.3 g and 46.1 g after the 16 weeks, whereas they decreased by 213 g and 139 g in the exercise group, respectively (95% CI: −209 to −3.86; p = 0.042 and 95% CI: −164 to −26.9; p = 0.007, respectively). The control group decreased their pelvis bone mineral content by 2.85 g in the post-test compared with the pre-test, whereas the exercise group increased it by 1.13 g (95% CI: 0.93 to 7.81; p = 0.013). Per-protocol analyses showed similar results. These analyses suggest that the exercise intervention decreased fat depositions and BMI. Exercise might improve bone mineral content in specific areas such as the pelvis.

Ospemifene versus local estrogen: adherence and costs in postmenopausal dyspareunia

Aim: Objective was to compare adherence and persistence, as well as direct healthcare costs and utilization, of ospemifene to available local estrogen therapies (LETs). Patients & methods: This retrospective database study used integrated medical and pharmacy claims data from the IQVIA Real-World Data Adjudicated Claims - US Database. Results: Ospemifene patients had significantly greater adherence and persistence compared with the other nonring LETs. Ospemifene had the lowest mean outpatient costs of any of the LET cohorts, including the estradiol vaginal ring. Total all-cause healthcare costs were also significantly less for ospemifene patients compared with all other LETs.

Metabolic and cardiovascular effects of TX-001HR in menopausal women with vasomotor symptoms

Objective: This study aimed to evaluate the effects of TX-001HR (17β-estradiol [E2] and progesterone [P4] in a single oral capsule) on cardiometabolic markers and outcomes. Methods: Four E2/P4 doses (1 mg/100 mg, 0.5 mg/100 mg, 0.5 mg/50 mg, 0.25 mg/50 mg) were compared with placebo in menopausal women with vasomotor symptoms (VMS) and a uterus in the phase 3 REPLENISH (ClinicalTrials.gov, NCT01942668) trial. Changes in lipid and coagulation parameters and blood glucose from baseline at 6, 9, and 12 months as well as cardiovascular events are summarized. Results: A total of 1835 participants took ≥1 capsule of daily E2/P4; 1684 received E2/P4 and 151 received placebo. No clinically significant changes in lipid parameters, coagulation factors, or glucose were observed between treatment groups. Minimal increases of potential clinical importance were observed in total cholesterol, triglycerides, and glucose at month 12 with E2/P4 (1-4%, 6-11%, and 1%, respectively) and placebo (3%, 7%, and 2%, respectively). One episode of deep venous thrombosis and three cases of cardiovascular disease were observed, similar to expected rates of these events in the general population. Conclusions: In the REPLENISH trial, postmenopausal women with VMS treated with E2/P4 had no clinically meaningful effects on lipids, glucose, or coagulation parameters compared with placebo.

Self-help cognitive behavior therapy for working women with problematic hot flushes and night sweats (MENOS@Work): a multicenter randomized controlled trial

OBJECTIVE

The aim of the study was to examine the efficacy of an unguided, self-help cognitive behavior therapy (SH-CBT) booklet on hot flush and night sweat (HFNS) problem rating, delivered in a work setting.

METHODS

Women aged 45 to 60 years, having 10 or more problematic HFNS a week, were recruited to a multicenter randomized controlled trial, via the occupational health/human resources departments of eight organizations. Participants were 1:1 randomized to SH-CBT or no treatment waitlist control (NTWC). The primary outcome was HFNS problem rating; secondary outcomes included HFNS frequency, work and social adjustment, sleep, mood, beliefs and behaviors, and work-related variables (absence, performance, turnover intention, and work impairment due to presenteeism). Intention-to-treat analysis was used, and between-group differences estimated using linear mixed models.

RESULTS

A total of 124 women were randomly allocated to SH-CBT (n = 60) and NTWC (n = 64). 104 (84%) were assessed for primary outcome at 6 weeks and 102 (82%) at 20 weeks. SH-CBT significantly reduced HFNS problem rating at 6 weeks (SH-CBT vs NTWC adjusted mean difference, -1.49; 95% CI, -2.11 to -0.86; P < 0.001) and at 20 weeks (-1.09; 95% CI, -1.87 to -0.31; P < 0.01). SH-CBT also significantly reduced HFNS frequency, improved work and social adjustment; sleep, menopause beliefs, HFNS beliefs/behaviors at 6 and 20 weeks; improved wellbeing and somatic symptoms and reduced work impairment due to menopause-related presenteeism at 20 weeks, compared with the NTWC. There was no difference between groups in other work-related outcomes.

CONCLUSIONS

A brief, unguided SH-CBT booklet is a potentially effective management option for working women experiencing problematic HFNS.

Cost-effectiveness of a primary care-based exercise intervention in perimenopausal women. The FLAMENCO Project

OBJECTIVE

Adequate physical activity levels and a healthy lifestyle may prevent all kinds of non-communicable diseases, promote well-being and reduce health-care costs among perimenopausal women. This study assessed an exercise programme for perimenopausal women.

METHOD

A total of 150 women (aged 45-64 years) not engaged in regular physical activity were randomly assigned to either a 16 week exercise intervention or to the control group. The study was conducted from the perspective of the National Health System. Health outcomes were quality-adjusted life years (QALYs), measured by the EuroQol-5D-5L questionnaire. The total direct costs of the programme were the costs of visits to primary care, specialty care, emergency, medicines, instructor cost and infrastructure cost. The results were expressed as the incremental cost-effectiveness ratio. Sensitivity analysis was undertaken to test the robustness of the analysis.

RESULTS

Mean QALYs over 16 weeks were.228 in the control group and.230 in the intervention group (mean difference: .002; 95% confidence interval [95%CI]: -0.005 to 0.009). Improvements from baseline were greater in the intervention group in all dimensions of the EuroQol-5D-5L but not statistically significant. The total costs at the end of the intervention were 160.38 € in the control group and 167.80 € in the intervention group (mean difference: 7.42 €; 95%CI: -47 to 62). The exercise programme had an incremental cost-effectiveness ratio of 4,686 €/QALY.

CONCLUSIONS

The programme could be considered cost-effective, although the overall difference in health benefits and costs was very modest. Longer term follow-up is needed.

Sleep and Sleep Disorders in the Menopausal Transition

The menopausal transition is associated with an increase in insomnia symptoms, especially difficulty staying asleep, which negatively impacts quality of life. Vasomotor symptoms are a key component of sleep disruption. Findings from polysomnographic studies are less consistent in showing disrupted sleep in menopausal transition independent of aging; further prospective studies are needed. Hormone therapy alleviates subjective sleep disturbances, particularly if vasomotor symptoms are present. However, because of contraindications, other options should be considered. Further work is needed to develop preventive and treatment strategies for alleviating sleep disturbances to ensure better health, quality of life, and productivity in midlife women.

Women veterans and menopause: Knowledge and preferences

The increasing number and older age of women Veterans receiving care at Veterans Health Administration (VHA) requires health-care providers to adjust to their changing patient population. We explored women Veterans' self-reported knowledge of menopause, current/preferred sources of menopausal health information, and perceptions/barriers regarding treatment of menopausal symptoms. Three focus groups were conducted at two South Florida VHA facilities in 2014, which included 30 women Veterans (aged 45-60 years) who visited VHA primary care clinics at least once in the past year. Participants reported using various sources to obtain general and menopausal health information, particularly family, friends, and the internet. Some women also had discussions with their health-care providers, but believed not all VHA providers were knowledgeable about menopause. Most preferred older female providers, thinking they were better informed about menopausal issues. Women favored complementary/alternative therapies and were against using hormone therapy (HT) for symptom relief, although they felt they were insufficiently informed about HT. Menopausal-age women are the fastest growing group at VHA. To provide better care and enhance their experiences, the VHA must educate all primary care providers about menopausal care and strive to address women Veterans' menopausal concerns and preferences.

The impact of menopause on work ability in women with severe menopausal symptoms

OBJECTIVE

To measure the impact of menopause on work ability in women with severe menopausal symptoms.

STUDY DESIGN

This cross-sectional study compared the work ability of a sample of otherwise healthy employed Dutch women (n=205) with that of a sample of first-time attendees of a menopause clinic (n=60); both groups were aged 44-60 years. Self-reported questionnaire data assessing work ability (Work Ability Index; WAI) and menopausal symptoms (Greene Climacteric Scale; GCS) were used.

MAIN OUTCOME MEASURES

Logistic regression analyses were used to examine whether women with severe menopausal symptoms were more likely to have low work ability (defined as a score <37.0 points on the WAI) than were women in the reference group, after adjustment for individual and lifestyle factors.

RESULTS

Symptomatic women had significantly higher total GCS scores (mean 26.7 vs 14.2, t=10.8, P<0.001) and significantly lower WAI scores (median 32.0 vs 40.0, U=2380, P<0.001) than the reference group. They were 8.4 times more likely to report low work ability than their healthy counterparts: 76.7% versus 30.2% (OR 8.4, 95% CI 4.1-17.2).

CONCLUSIONS

Over three-quarters of symptomatic menopausal women report serious problems in dealing with the physical and mental demands of their work (recorded here as low work ability); hence these women might be at risk of prolonged sickness absence from work.

Treatment of pain at sexual activity (dyspareunia) with intravaginal dehydroepiandrosterone (prasterone)

OBJECTIVE

This study aims to confirm the local effects of intravaginal prasterone on moderate to severe dyspareunia, a symptom of vulvovaginal atrophy (VVA) associated with menopause.

METHODS

In a prospective, randomized, double-blind, placebo-controlled phase III clinical trial, we examined the effects of daily intravaginal prasterone (6.5 mg) on four co-primary objectives, namely, percentage of vaginal parabasal cells, percentage of vaginal superficial cells, vaginal pH, and moderate to severe dyspareunia identified by women as the most bothersome VVA symptom.

RESULTS

After daily intravaginal prasterone administration for 12 weeks, the percentage of parabasal cells decreased by 45.8% compared with placebo (P < 0.0001), the percentage of superficial cells increased by 4.7% over placebo (P < 0.0001), and vaginal pH decreased by 0.83 pH units compared with placebo (P < 0.0001). The severity of most bothersome dyspareunia decreased by 46% over placebo (P = 0.013) at 12 weeks, whereas moderate to severe vaginal dryness decreased by 0.43 severity score units (or 42%) compared with placebo (P = 0.013). On gynecologic evaluation, a 14.4% to 21.1% improvement in vaginal secretions, epithelial integrity, epithelial surface thickness, and color over placebo (P = 0.0002 to P < 0.0001) was observed. Serum steroids, in agreement with the physiology of intracrinology and menopause, remained well within reference postmenopausal concentrations. All endometrial biopsies at 12 weeks have shown atrophy.

CONCLUSIONS

Daily intravaginal prasterone (0.50%; 6.5 mg) treatment has clinically and statistically significant beneficial effects on the four co-primary objectives of VVA, according to US Food and Drug Administration guidelines. No significant drug-related adverse effect in line with the strictly local action of treatment has been reported, thus providing a high benefit-to-risk ratio for intravaginal prasterone.

Menopause in the workplace: What employers should be doing

Large numbers of women transition through menopause whilst in paid employment. Symptoms associated with menopause may cause difficulties for working women, especially if untreated, yet employers are practically silent on this potentially costly issue. This review summarises existing research on the underexplored topic of menopause in the workplace, and synthesises recommendations for employers. Longstanding scholarly interest in the relationship between employment status and symptom reporting typically (but not consistently) shows that women in paid employment (and in specific occupations) report fewer and less severe symptoms than those who are unemployed. Recent studies more systematically focused on the effects of menopausal symptoms on work are typically cross-sectional self-report surveys, with a small number of qualitative studies. Though several papers established that vasomotor (and associated) symptoms have a negative impact on women's productivity, capacity to work and work experience, this is not a uniform finding. Psychological and other somatic symptoms associated with menopause can have a relatively greater negative influence. Physical (e.g., workplace temperature and design) and psychosocial (e.g., work stress, perceptions of control/autonomy) workplace factors have been found to influence the relationship between symptoms and work. Principal recommendations for employers to best support menopausal women as part of a holistic approach to employee health and well-being include risk assessments to make suitable adjustments to the physical and psychosocial work environment, provision of information and support, and training for line managers. Limitations of prior studies, and directions for future research are presented.

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.

The economic impact of symptomatic menopause among low-socioeconomic women in the United States

BACKGROUND

Menopausal symptoms have a significant negative impact on patient's quality of life and increase healthcare costs among women.

METHODS

This retrospective analysis used data from a U.S. national database (01 January 2008-31 December 2010). Patients with a diagnosis of menopause symptoms or a prescription claim for hormone therapy were matched to control patients. Healthcare resource utilization and costs during the 6-month follow-up period were compared. Generalized linear models were used to adjust for differences in baseline and demographic characteristics between the cohorts.

RESULTS

A total of 71,076 patients were included in each cohort. Patients with menopausal symptoms were more likely to have depression and anxiety and incurred significantly higher follow-up healthcare costs ($7237 vs $6739, p < 0.001) and healthcare utilization during the 6-month follow-up period.

CONCLUSION

Patients diagnosed with menopausal symptoms or treated with hormone therapy incurred significantly higher healthcare costs than those without menopausal symptoms or treatment.

All sex steroids are made intracellularly in peripheral tissues by the mechanisms of intracrinology after menopause

Following the arrest of estradiol secretion by the ovaries at menopause, all estrogens and all androgens in postmenopausal women are made locally in peripheral target tissues according to the physiological mechanisms of intracrinology. The locally made sex steroids exert their action and are inactivated intracellularly without biologically significant release of the active sex steroids in the circulation. The level of expression of the steroid-forming and steroid-inactivating enzymes is specific to each cell type in each tissue, thus permitting to each cell/tissue to synthesize a small amount of androgens and/or estrogens in order to meet the local physiological needs without affecting the other tissues of the organism. Achieved after 500 million years of evolution, combination of the arrest of ovarian estrogen secretion, the availability of high circulating levels of DHEA and the expression of the peripheral sex steroid-forming enzymes have permitted the appearance of menopause with a continuing access to intratissular sex steroids for the individual cells/tissues without systemic exposure to circulating estradiol. In fact, one essential condition of menopause is to maintain serum estradiol at biologically inactive (substhreshold) concentrations, thus avoiding stimulation of the endometrium and risk of endometrial cancer. Measurement of the low levels of serum estrogens and androgens in postmenopausal women absolutely requires the use of MS/MS-based technology in order to obtain reliable accurate, specific and precise assays. While the activity of the series of steroidogenic enzymes can vary, the serum levels of DHEA show large individual variations going from barely detectable to practically normal "premenopausal" values, thus explaining the absence of menopausal symptoms in about 25% of women. It should be added that the intracrine system has no feedback elements to adjust the serum levels of DHEA, thus meaning that women with low DHEA activity will not be improved without external supplementation. Exogenous DHEA, however, follows the same intracrine rules as described for endogenous DHEA, thus maintaining serum estrogen levels at substhreshold or biologically inactive concentrations. Such blood concentrations are not different from those observed in normal postmenopausal women having high serum DHEA concentrations. Androgens, on the other hand, are practically all made intracellularly from DHEA by the mechanisms of intracrinology and are always maintained at very low levels in the blood in both pre- and postmenopausal women. Proof of the importance of intracrinology is also provided, among others, by the well-recognized benefits of aromatase inhibitors and antiestrogens used successfully for the treatment of breast cancer in postmenopausal women where all estrogens are made locally. Each medical indication for the use of DHEA, however, requires clinical trials performed according to the FDA guidelines and the best rules of clinical medicine.