Age at Menarche and Risk of Cardiovascular Disease Outcomes: Findings From the National Heart Lung and Blood Institute-Sponsored Women's Ischemia Syndrome Evaluation

Age at Menarche Is Associated With Leg-Length Components Among the Adolescent Girls in West Bengal, India

BACKGROUND

The relationship between early age at menarche (AAM) and body height (HT), including its different segments has not been extensively studied among non Western populations. Lengths of the lower (distal) part of the leg, such as knee HT (KH) and tibial length (TbL), are considered to be sensitive indicators of living conditions during early growth and development. Life history theory predicts that within a survival challenge the growth of vital parts of the body shall be prioritized over less essential parts. The present study hypothesized that earlier age at menarche would be associated with shorter tibial length in resource constrained settings.

AIM

To investigate the potential associations of menarcheal age with HT, KH, TbL, and other linear components of HT among the Bengalee schoolgirls aged 10-13 years.

METHODS

Among the 208 girls aged 10-13 years, menarcheal status and age at menarche were determined by status quo and retrospective methods, respectively. Lower leg length was represented by two measures, KH and the supracutaneous measure of TbL. The differences in HT, sitting HT (SH), total leg length (LL), thigh length (TL), KH, and TbL, between pre-menarcheal-(PMG) and post-menarcheal girls (POMG), as well as between earlier menarcheal-(EMG) and later menarcheal girls (LMG), were assessed by student t-test and analysis of covariance.

RESULTS

The POMG were heavier, taller and had higher adiposity than their PMG peers, without showing any significant age-difference. HT, knee HT, TbL, and TbL to HT ratio showed significant differences between the EMG and LMG. The EMG showed lower values for all of those measures and the strongest difference was observed for TbL. However, there were no significant differences in SH and SHR between EMG and LMG.

CONCLUSIONS

The study indicated a possible effect of early AAM on growth of distal body parts in a resource poor socioeconomic condition. Further studies on the relationship between growth and AAM among different populations living in different socio-ecological conditions could be worth conducting.

Age at menarche and risk of premature coronary artery disease: results from Iran premature coronary disease (IPAD) study

BACKGROUND

Premature coronary artery diseases (PCAD) is a major health concern. Finding the potential risk factors for this health issue is crucial for early detection and prevention. This study aimed to evaluate the relation between age at menarche and PCAD presence and severity.

METHODS

This study was performed in the framework of the Iran premature coronary disease (IPAD). IPAD is a multiethnic case-control study conducted from 2020. PCAD was defined as at least 75% obstruction in more than one coronary artery or above 50% in the left main artery in man and women under the age of 60 years and 70 years, respectively. Age at menarche is evaluate using self-reporting questionnaire. We categorized age at menarche into three groups: early (8-11 years), average (12-13 years), and late (14-17 years).

RESULTS

A total number of 1035 women participated in this study. No significant association was observed between every year increase in age at menarche and the PCAD risk after fully adjustment with odds ratio (OR) 95% confidence interval (95% CI) OR = 0.98, 95% CI 0.91-1.05, P = 0.65 Besides, no significant association was seen between number of obstructed vessels and age at menarche (OR = 1.01; 95% CI 0.94-1.08, P = 0.76). Following the subgroup analysis based on ethnicity, it was observed that only individuals of Gilak ethnicity showed a significant association between a 1-year increase in age at menarche and the risk of PCAD (OR = 0.68, 95% CI 0.49-0.95, P = 0.026).

CONCLUSION

This study suggested that age at menarche may not be connected to PCAD risk and number of obstructed vessels. However, ethnicity may have roles in terms of the relationship between age at menarche and PCAD. More longitudinal studies are needed to evaluate this relationship.

TRIAL REGISTRATION NUMBER

IR.MUI.REC.1396.2.055.

Age at Menarche and Coronary Artery Disease Risk: Divergent Associations with Different Sources of Variation

Background

In women, both earlier and later age at menarche (AAM) are associated with increased risk of coronary artery disease (CAD). This study sought to determine if the relationship of AAM with CAD and CAD risk factors differs for different underlying sources of variation in AAM - specifically, variation attributable to common genetic variants as represented by a polygenic score (PGS) vs. variation in AAM adjusted for the PGS.

Methods

Primary analyses were conducted on data from 201,037 women in the UK Biobank and validation studies on data from 23,268 women in the Women's Genome Health Study (WGHS). For each individual, a PGS for AAM was calculated, then two variables were estimated from linear regression models: the genetically predicted AAM (the estimated AAM for each woman solely due to the effects of common genetic variants) and the PGS-adjusted AAM (estimated AAM for each woman solely due to factors other than the PGS). Logistic regression and linear splines were then used to study the relationships of these variables with CAD and CAD risk factors.

Results

Genetically predicted AAM demonstrated a linear relationship with CAD and linear or roughly linear relationships with CAD risk factors. In contrast, PGS-adjusted AAM demonstrated a U-shaped relationship with CAD and with hemoglobin A1c, triglycerides, HDL-C, and waist-hip ratio. Validation studies using WGHS data produced similar results.

Conclusions

These results suggest that later AAM itself does not cause increased risk of CAD; rather, upstream sources of variation other than common genetic variants can cause both later AAM and increased risk of CAD. Dysglycemia, dyslipidemia, and central adiposity are candidate mediators of the association of later AAM with increased risk of CAD.

Reproductive factors predict risks of cardiovascular disease and premature death in postmenopausal women with type 2 diabetes: The Fukuoka Diabetes Registry

AIMS

Reproductive factors (reproductive period, age at menarche, and age at menopause) are associated with a risk of cardiovascular disease (CVD) and death in individuals without focusing on comorbid diabetes. However, it remains unclear whether this association also applies to individuals with diabetes. This study investigated the relationship between reproductive factors and the risk of CVD and death in postmenopausal Japanese women with type 2 diabetes.

METHODS

1,592 postmenopausal women with type 2 diabetes without pre-existing CVD were subclassified based on reproductive period (age at menopause minus age at menarche). The primary outcome was a composite of CVD incidence and all-cause death.

RESULTS

The risk of the outcome decreased with a longer reproductive period. Compared with a reproductive period of ≤ 29 years, the multivariable-adjusted hazard ratios (95 % CI) were 0.80 (0.39-1.66), 0.73 (0.37-1.43), and 0.43 (0.19-0.99) for reproductive periods of 30-34, 35-39, and ≥ 40 years, respectively (p for trend = 0.046). Earlier age at menarche and later age at menopause were also associated with a decreased risk of the outcome.

CONCLUSIONS

Evaluating reproductive factors may help predict the risks of CVD and death in postmenopausal women with type 2 diabetes.

Sex-Specific Cardiovascular Risk Factors and Treatment in Females With T2DM and CVD: Developments and Knowledge Gaps

PURPOSE

There are large disparities in the impact of diabetes on cardiovascular disease (CVD) risk and outcomes by sex and gender. Achieving health equity requires understanding risks and medication efficacy in female patients, especially now, as novel pharmacologic treatments are transforming the diabetes and CVD treatment landscape. This review examines 2 bodies of research that can inform sex differences in CVD in patients with diabetes: female-specific risk factors for CVD and sex-related limitations of clinical trial research in evaluating novel diabetes and CVD treatments.

METHODS

Two literature searches were performed using Ovid Medline(R) All. The first retrieved manuscripts covering sex and gender differences related to CVD risk and therapies and diabetes. The second focused on randomized controlled trial data on sex/gender differences and GLP-1/SGLT-2/DPP-4 drugs.

RESULTS

Female-specific risk factors for CVD include early menarche, premature or early menopause, irregular cycles and polycystic ovary syndrome; pregnancy; adverse pregnancy outcomes; history of breast cancer; and autoimmune diseases. Clinical trials of novel pharmacological treatments for diabetes and CVD have undersampled female populations, and clinical characteristics of male and female participants have differed significantly. Thus, evidence to evaluate potential sex differences in treatment efficacy and side effects has been lacking.

CONCLUSION

To improve health of female patients with diabetes, sex-specific cardiovascular risk factors should be taken into account in screening and treatment decisions. Further, studies of cardiovascular and diabetes medications must ensure adequate representation by sex and report participant characteristics and outcomes by sex.

Reproductive Risk Factor Patterns in Caribbean Women With Breast Cancer Across 4 Generations

Importance

Breast cancer (BC) is commonly diagnosed among Caribbean women. Shifts in reproductive patterns modify the incidence of BC diagnosis and age at BC diagnosis in population-based studies; however, reproductive patterns in Caribbean women remain understudied.

Objective

To describe the temporal trends in reproductive patterns and age at BC diagnosis in Caribbean-born women.

Design, Setting, and Participants

A cross-sectional observational study-the Caribbean Women's Cancer Study-was conducted, with data on reproductive patterns known to affect BC risk collected in The Bahamas, Barbados, Cayman Islands, Dominica, Haiti, Jamaica, and Trinidad and Tobago. Participants were recruited prospectively. The sample included women born in Caribbean countries and diagnosed with invasive BC and/or ovarian cancer from June 1, 2010, to June 30, 2018, and was divided into 4 birth cohorts (born before 1950, 1950-1959, 1960-1969, and in or after 1970). Data were analyzed between August 1, 2023, and July 31, 2024.

Exposures

Receipt of a BC diagnosis and birth in a Caribbean country.

Main Outcomes and Measures

Change in reproductive patterns between birth cohorts, including age at BC diagnosis, family history of cancer, age at first pregnancy, number of pregnancies, number of full-term pregnancies, number of siblings, age at menarche and menopause, estrogen receptor status, and germline pathogenic/likely pathogenic variants.

Results

Of 1015 participants diagnosed with BC and ovarian cancer, 995 women (mean [SD] age, 46.6 [10.8] years; 605 [81.8%] Afro-Caribbean, 98 [13.2%] East Indian, 22 [3.0%] White, and 12 [1.6%] >1 race) received a diagnosis of invasive BC. Comparison from older to younger birth cohorts (presented in the order of born before 1950, 1950-1959, 1960-1969 and in or after 1970) showed an increased proportion of women experiencing menarche at age 12 years or younger (33.0% vs 47.3% vs 45.5% vs 57.9%; P < .001), women with no pregnancies (6.8% vs 6.8% vs 10.5% vs 22.8%; P < .001), and nulliparous women (8.6% vs 9.2% vs 13.9% vs 27.6%; P < .001). Younger age at BC diagnosis was observed in women experiencing menarche at age 12 years or younger (mean [SD], 45.0 [10.5] years) vs 15 years or older (mean [SD], 49.1 [11.2] years) and in nulliparous women (mean [SD], 42.1 [11.2] years) vs 3 or more full-term pregnancies (mean [SD], 49.9 [10.6] years; P < .001). For every year of first pregnancy delay, women had a 4% increased chance of being diagnosed with estrogen receptor-positive tumors (odds ratio, 1.04; 95% CI, 1.01-1.08; P = .02).

Conclusions and Relevance

In this cross-sectional study, between each 10-year birth cohort, women diagnosed with BC had a lower age at menarche, number of pregnancies, and number of full-term pregnancies. These findings suggest that interventions targeting other BC risk factors need to be implemented.

Early puberty: a review on its role as a risk factor for metabolic and mental disorders

Accumulating evidence indicates that there is a trend of early puberty onset in humans. The early timing of puberty has raised concerns due to its association with significant negative health outcomes. However, overall impact and potential risk of early puberty remain uncertain. In this study, we conducted a comprehensive review of existing epidemiological studies to gain insights into the long-term adverse health effects associated with early puberty. Our objective was to provide a consolidated summary of these outcomes at a population level by considering studies that encompass various indicators of puberty. In all, early puberty has been identified as a potential risk factor for various metabolic diseases, such as obesity, diabetes, cardiovascular diseases (CVD). Children who experience early puberty are more likely to have a higher body mass index (BMI) during adulthood, increasing their risk of obesity. Early puberty also has been found to be an independent risk factor for diabetes mellitus, including gestational diabetes mellitus (GDM) and type 2 diabetes mellitus (T2DM), as earlier onset of menarche in girls and voice breaking in boys is associated with a higher prevalence of T2DM. Furthermore, evidence suggests that early puberty may contribute to an elevated risk of CVD, including conditions like coronary heart disease (CHD), stroke, angina, and hypertension. In addition, adolescents who experience early puberty, particularly girls, are more likely to suffer from mental problems, such as behavioral dysfunction and depression. Notably, early puberty has a more significant impact on girls than boys. Further research should consider the underlying mechanisms and potential preventive measures.

Age at Menarche and Its Association With Adult-Onset Metabolic Syndrome and Related Disorders in Women: A Cross-Sectional Study of a Nationally Representative Sample Over 10 Years

The prevalence of metabolic syndrome (MetS) as well as related social costs and efforts is increasing. The purpose of this study was to investigate the association between age at menarche and the risk of MetS, obesity, diabetes, and cardiovascular disease (CVD) in women over 30 years, using data from the Korean National Health and Nutrition Examination Survey (2010-2020). The analysis of 30 916 participants showed that early menarche (before 11 years) significantly increased the risk of obesity, diabetes, and MetS compared with the median age of 14 years. Late menarche (after 17 years) was also linked to MetS and related disorders. The relationship between age at menarche (at <10 years and >19 years) and the risk of MetS and related disorders exhibited a reversed J-shaped (し) pattern characterized by a pronounced increased risk among those who experience early menarche, whereas the increased risk associated with late menarche was less consistent. These results will help to decrease the risk of MetS and related disorders by enabling early intervention in early and late menarche age groups.

Indications of younger age at menarche in Greek adolescents but with no relation to body mass index

PURPOSE

This study aimed to present recent trends in the pubertal timing of a Greek female sample.

METHODS

Data were collected retrospectively from medical records of healthy females aged 6-18 years who attended a tertiary Adolescent Friendly Health Center over a 5-year period (2016-2020) and included gestational age, birth anthropometrics, and age of thelarche and/or pubarche and/or menarche, along with corresponding anthropometric, hormonal, and biochemical measurements.

RESULTS

Data from 298 girls' medical records were included in the analysis. Median age at menarche, thelarche, and pubarche was 12, 9, and 9 years, respectively. The mean interval between pubertal onset and menarche was 1.99 years. The mean body mass index (BMI) at menarche and thelarche was 20.99 kg/m2 and 18.90 kg/m2, respectively. The mean weight at menarche was 49.6 kg, whereas the mean height difference between thelarche and menarche was 19.17 cm. Among participants, 6.3% had premature menarche, while 24.0% had premature thelarche. Birth weight was moderately correlated with BMI at thelarche/pubarche (rs=0.334, p = 0.005). Birth weight and BMI at thelarche/pubarche were not predictive of premature menarche or premature thelarche. Median (interquartile range, IQR) levels at menarche vs. thelarche were significantly higher for insulin-like growth factor-1 [358.00 (140.50) vs. 176.00 (55.00) ng/ml], follicle stimulation hormone [5.65 (3.14) vs. 3.10 (4.23) mIU/ml], testosterone [25.50 (31.00) vs. 13.00 (21.00) ng/dl], dehydroepiandrosterone sulfate [117.00 (112.50) vs. 46.40 (51.90) µg/dl], and insulin [17.40 (15.05) vs. 8.47 (4.97) µIU/ml].

CONCLUSION

The timing of pubertal stages in the Greek female sample studied followed the recent international downward trends. Younger age at menarche was not related to BMI.

Reproductive factors and risk of cardiovascular outcomes in women with ST-elevation myocardial infarction

BACKGROUND

There are many sex-specific factors affecting myocardial infarction (MI) outcomes in males and females. This study aimed to evaluate the relationship between reproductive factors and cardiovascular outcomes in women after ST-elevation MI.

METHOD

This retrospective cohort study was initiated in 2016-2017 at Chamran Hospital, Isfahan, Iran. One hundred eighty women with a diagnosis of ST-elevation MI were followed up for 3 years, and any occurrence of cardiovascular events (CVs) was recorded. All information regarding reproductive factors was recorded via questionnaire. This information was compared between women with cardiovascular events and women without adverse events using a sample t test, chi-square test, and multiple backward logistic regression analysis. SPSS version 24 was used to conduct all analyses.

RESULT

Sixty-four women with a mean age of 65.81 ± 13.14 years experienced CV events, and 116 women with a mean age of 65.51 ± 10.88 years did not experience CV events. A history of ischemic heart disease and diabetes mellitus were more prevalent in women with CV events (P = 0.024 and P = 0.019). After adjusting for ischemic heart disease and diabetes mellitus, oral contraceptive pill (OCP) usage was more prevalent in women with CV events than in women without CV events (60.9% vs. 40.4%, P = 0.008). There was a greater chance of CV events in women with OCP usage (OR = 3.546, P = 0.038) and a lower chance of CV events in women with greater age at menarche (OR = 0.630, P = 0.009) and longer breastfeeding duration (OR = 0.798, P = 0.041) according to multiple backward logistic regression models.

CONCLUSION

Based on this study, OCP consumption is a risk factor, while older age at menarche and longer duration of breastfeeding are protective factors for cardiovascular outcomes in women after STEMI.

Incorporating Cardiovascular Risk Assessment into Adolescent Reproductive Health and Primary Care Visits

STUDY OBJECTIVE

This study aimed to evaluate the usability and feasibility of incorporating a cardiovascular risk assessment tool into adolescent reproductive health and primary care visits.

DESIGN, SETTING, AND PARTICIPANTS

We recruited 60 young women ages 13-21 years to complete the HerHeart web-tool in 2 adolescent clinics in Atlanta, GA.

MAIN OUTCOME MEASURES

Participants rated the tool's usability via the Website Analysis and Measurement Inventory (WAMMI, range 0-95) and their perceived 10-year and lifetime risk of cardiovascular disease (CVD) on a visual analog scale (range 0-10). Participants' perceived risk, blood pressure, and body mass index were measured at baseline and 3 months after enrollment. Health care providers (HCP, n = 5) completed the WAMMI to determine the usability and feasibility of incorporating the HerHeart tool into clinical practice.

RESULTS

Adolescent participants and HCPs rated the tool's usability highly on the WAMMI with a median of 79 (interquartile range [IQR] 65, 84) and 76 (IQR 71, 84). At the baseline visit, participants' median perceived 10-year risk of a heart attack was 1 (IQR 0, 3), and perceived lifetime risk was 2 (IQR 0, 4). Immediately after engaging with the tool, participants' median perceived 10-year risk was 2 (IQR 1, 4.3), and perceived lifetime risk was 3 (IQR 1.8, 6). Thirty-one participants chose to set a behavior change goal, and 12 participants returned for follow-up. Clinical metrics were similar at the baseline and follow-up visits.

CONCLUSION

HerHeart is acceptable to young women and demonstrates potential for changing risk perception and improving health habits to reduce risk of CVD. Future research should focus on improving retention in studies to promote cardiovascular health within reproductive health clinics.

Body Mass Index and Hypertension as Mediators of the Association Between Age at Menarche and Subclinical Atherosclerosis: A Sex-Specific Mendelian Randomization Analysis

BACKGROUND

Early age at menarche (AAM) has been associated with a higher risk of carotid artery intima-media thickness (cIMT), an indicator of subclinical vascular disease, albeit the mechanisms underlying this association remain elusive. A better understanding of the relationship between AAM, modifiable cardiometabolic risk factors, and subclinical atherosclerosis may contribute to improved primary prevention and cardiovascular disease treatment. We aimed to investigate the putative causal role of AAM on cIMT, and to identify and quantify the potentially mediatory effects of cardiometabolic risk factors underlying this relationship.

METHODS AND RESULTS

We conducted linkage disequilibrium score regression analyses between our exposure of interest, AAM, our outcome of interest, cIMT and potential mediators of the AAM-cIMT association to gauge cross-trait genetic overlap. We considered as mediators the modifiable anthropometric risk factors body mass index (BMI), systolic blood pressure (SBP), lipid traits (total cholesterol, triglycerides, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol), and glycemic traits (fasting glucose). We then leveraged the paradigm of Mendelian randomization to infer causality between AAM and cIMT, and to identify whether cardiometabolic risk factors served as potential mediators of this effect. Our analyses showed that genetically predicted AAM was inversely associated with cIMT, BMI, SBP, and triglycerides, and positively associated with high-density lipoprotein, low-density lipoprotein, and total cholesterol. We showed that the effect of genetically predicted AAM on cIMT may be partially mediated through BMI (20.1% [95% CI, 1.4% to 38.9%]) and SBP (13.5% [95% CI, 0.5%-26.6%]). Our cluster-specific Mendelian randomization revealed heterogeneous causal effect estimates of age at menarche on BMI and SBP.

CONCLUSIONS

We highlight supporting evidence for a potential causal association between earlier AAM and cIMT, and almost one third of the effect of AAM on cIMT may be mediated by BMI and SBP. Early intervention aimed at lowering BMI and hypertension may be beneficial in reducing the risk of developing subclinical atherosclerosis due to earlier age at menarche.

Early Menarche as a Protective Factor Against Cardiovascular Events: A Systematic Review and Meta-analysis

BACKGROUND

Women are often neglected in cardiovascular health prevention. Age at menarche (AAM) has been linked to cardiovascular (CVD) disease in women and is potentially identified as one of the significant CVD risk factor. However, there is still limited comprehensive evidence addressing this issue. This systematic review and meta-analysis aimed to investigate how early menarche affects the outcome of all-cause mortality, CVD mortality, total cardiovascular disease event, stroke (ischemic, hemorrhagic, and total stroke), and coronary heart disease (CHD).

METHOD

The Cochrane Library, MEDLINE, Embase, ScienceDirect, and Google Scholar databases were searched from March 2013 to March 2023 for cohorts investigating the effect of early onset of menarche on CVD events with a minimum follow-up period of 5 years. Studies that observed specific population and/or included women with a history of CVD at baseline were excluded. The Newcastle-Ottawa scale was used for risk of bias assessment for each cohort included. The data were presented as dichotomous measure using risk ratios. I2 statistics were utilized to evaluate the heterogeneity of presented data.

RESULTS

Thirteen cohorts included 18 626 799 female patients with ages ranging from 43 to 62.6 years. These reported 6 estimates each for CHD (5 483 298 patients) and all-cause mortality (1 595 878 patients), 5 estimates each for total stroke (2 941 321 patients) and CVD mortality (1 706 742 patients), 4 estimates each for total CVD events (3 988 311 patients) and ischemic stroke (2 434 580 patients), and 1 estimate for hemorrhagic stroke (66 104 patients). Our study found that events of CHD were significantly lower in early menarche (RR 0.57; 95% CI 0.41-0.78; P <.00001), as well as total stroke (RR 0.51; 95% CI 0.35-0.73; P =.0003), CVD mortality (RR 0.47; 95% CI 0.22-0.98; P =.04), total CVD events (RR 0.44; 95% CI 0.25-0.76; P =.003), ischemic stroke (RR 0.31; 95% CI 0.15-0.61; P <.0008), and hemorrhagic stroke (RR 0.12; 95% CI 0.07-0.20; P <.00001); and insignificantly higher in all-cause mortality (RR 0.90, 95% CI 0.76-1.06, P =.20).

CONCLUSION

In our study, cardiovascular events are lower in women with early menarche; hence, the later age of menarche is a potential risk factor to be considered when assessing CVD risk in a patient. However, our sample characteristics were heterogenous, and we did not consider other female hormonal factors that might potentially contribute to the CVD outcomes observed; thus, further studies are needed to clarify.

Maternal exposure to polycyclic aromatic hydrocarbons during pregnancy and timing of pubertal onset in a longitudinal mother-child cohort in rural Bangladesh

BACKGROUND

In experimental studies, several polycyclic aromatic hydrocarbons (PAHs) have shown endocrine disrupting properties, but very few epidemiological studies have examined their impact on pubertal development and results have been heterogenous.

OBJECTIVE

To explore if maternal PAH exposure during pregnancy was associated with the offspring's timing of pubertal onset.

METHODS

We studied 582 mother-daughter dyads originating from a population-based cohort in a rural setting in Bangladesh. Maternal urinary samples, collected in early pregnancy (on average, gestational week 8), were analyzed for monohydroxylated metabolites of phenanthrene (1-OH-Phe, Σ2-,3-OH-Phe, and 4-OH-Phe), fluorene (Σ2-,3-OH-Flu), and pyrene (1-OH-Pyr) using liquid chromatography with tandem mass spectrometry (LC-MS/MS). The girls were interviewed on two separate occasions concerning date of menarche, as well as breast and pubic hair development according to Tanner. Associations were assessed using Kaplan-Meier analysis and multivariable-adjusted Cox proportional hazards regression or ordered logistic regression.

RESULTS

In early pregnancy, the mothers' median urinary concentrations of Σ1-,2-,3-,4-OH-Phe, Σ2-,3-OH-Flu, and 1-OH-Pyr were 3.25 ng/mL, 2.0 ng/mL, and 2.3 ng/mL respectively. At the second follow-up, 78 % of the girls had reached menarche, and the median age of menarche was 12.7 ± 0.81 years. Girls whose mothers belonged to the second and third quintiles of ΣOH-Phe metabolites had a higher rate of menarche, indicating a younger menarcheal age (HR 1.39; 95 % CI 1.04, 1.86, and HR 1.41; 95 % CI 1.05, 1.88, respectively), than girls of mothers in the lowest quintile. This trend was not observed in relation to either breast or pubic hair development. None of the other maternal urinary PAH metabolites or the sum of all thereof in early pregnancy were associated with age at menarche or pubertal stage.

CONCLUSIONS

Indications of non-monotonic associations of prenatal phenanthrene exposure with the daughters' age of menarche were found, warranting further investigation.

Earlier Menarche in Greek Girls Born by Caesarean Section: A Case-Control Study

Objectives: The purpose of this study was to report on the menarcheal age in girls of Greek origin and assess its potential associations with their demographic and perinatal data, as well as their maternal menarcheal age. Methods: In this case-control study, adolescent girls were recruited between September 2021 and September 2022 from two Pediatric Endocrinology Units, Aristotle University of Thessaloniki, Greece. Eligible participants included Greek girls up to the age of 18 years, with menarche and the absence of chronic disease or chronic medication use. Participants were divided into two groups, the early menarche group and the control group (menarche before or after 11 years of age, respectively). Data included participants' maternal menarcheal age, their chronological age, place of residence, anthropometric data (at recruitment) and perinatal data (birth order, gestational age, type of delivery, birth weight/length). Results: A total of 100 girls aged 7-17 years (mean age ± SD 12.51 ± 2.59 years) were included in this study. The mean ± SD menarcheal age of the total sample was 11.47 ± 1.55 years (median 11.20 years; range 7.50-16.25 years); 43% had early menarche (median menarcheal age 10.50 years; range 7.50-10.91 years), and 57% had menarche after age 11 (median menarcheal age 12.08 years; range 11.00-16.25 years). The caesarean section rate was significantly (p < 0.001) higher in girls with early menarche (83.7%) than controls, whereas other variables did not differ significantly between groups. Conclusions: This Greek sample demonstrated a relatively young age at menarche with a significant proportion of girls with early menarche; in the latter group, the rate of caesarian sections was significantly higher than controls.

Menarche and Time to Cycle Regularity Among Individuals Born Between 1950 and 2005 in the US

Importance

Early menarche is associated with adverse health outcomes. Trends toward earlier menarche have been observed in the US, but data remain limited on differences by sociodemographic factors and body mass index (BMI). Time from menarche to cycle regularity is another understudied early-life characteristic with health implications.

Objectives

To evaluate the temporal trends and disparities in menarche and time to regularity and explore early-life BMI as a mediator.

Design, Setting, and Participants

This ongoing cohort study enrolled participants from an ongoing mobile application-based US cohort from November 14, 2019, to March 20, 2023.

Exposures

Birth year (categorized as 1950-1969, 1970-1979, 1980-1989, 1990-1999, and 2000-2005).

Main Outcomes and Measures

Main outcomes were age at menarche and time to regularity, which were self-recalled at enrollment. In addition, early (aged <11 years), very early (aged <9 years), and late (aged ≥16 years) age at menarche was assessed.

Results

Among the 71 341 female individuals who were analyzed (mean [SD] age at menarche, 12.2 [1.6] years; 2228 [3.1%] Asian, 3665 [5.1%] non-Hispanic Black, 4918 [6.9%] Hispanic, 49 518 [69.4%] non-Hispanic White, and 8461 [11.9%] other or multiple races or ethnicities), 5223 were born in 1950 to 1969, 12 226 in 1970 to 1979, 22 086 in 1980 to 1989, 23 894 in 1990 to 1999, and 7912 in 2000 to 2005. The mean (SD) age at menarche decreased from 12.5 (1.6) years in 1950 to 1969 to 11.9 (1.5) years in 2000 to 2005. The number of individuals experiencing early menarche increased from 449 (8.6%) to 1223 (15.5%), the number of individuals experiencing very early menarche increased from 31 (0.6%) to 110 (1.4%), and the number of individuals experiencing late menarche decreased from 286 (5.5%) to 137 (1.7%). For 61 932 participants with reported time to regularity, the number reaching regularity within 2 years decreased from 3463 (76.3%) to 4075 (56.0%), and the number not yet in regular cycles increased from 153 (3.4%) to 1375 (18.9%). The magnitude of the trend toward earlier menarche was greater among participants who self-identified as Asian, non-Hispanic Black, or other or multiple races (vs non-Hispanic White) (P = .003 for interaction) and among participants self-rated with low (vs high) socioeconomic status (P < .001 for interaction). Within a subset of 9865 participants with data on BMI at menarche, exploratory mediation analysis estimated that 46% (95% CI, 35%-61%) of the temporal trend in age at menarche was explained by BMI.

Conclusions and Relevance

In this cohort study of 71 341 individuals in the US, as birth year increased, mean age at menarche decreased and time to regularity increased. The trends were stronger among racial and ethnic minority groups and individuals of low self-rated socioeconomic status. These trends may contribute to the increase in adverse health outcomes and disparities in the US.

Systolic blood pressure as a critical mediator in the association between adult height and 25-year risk of stroke

BACKGROUND

Adult height is associated with the risk of stroke. However, the underlying mechanism remains unclear. We explored the mediating role of metabolic factors in the association between adult height and stroke incidence.

METHODS

We used data from 3306 community-dwelling participants with complete information on adult height, metabolic factors, and 25-year cardiovascular outcomes. Participants were classified into three adult height groups based on sex-specific height quartiles: short (Q1), average (Q2-Q3), and tall (Q4). The primary endpoint was the occurrence of cardiovascular disease, including coronary artery disease and stroke.

RESULTS

Taller adult height was associated with a lower risk of stroke. Compared with the short group the risk of stroke reduced with taller height with a hazard ratio (HR) of 0.68 in the average group (95% confidence interval [CI]: 0.50-0.93), and 0.45 in the tall group (95% CI: 0.31-0.65). Low systolic blood pressure was considered as a protective mediator in the effect of adult height on the risk of stroke in the average (HR: 0.86; 95% CI: 0.82-0.93) and the tall group (HR: 0.85; 95% CI: 0.78-0.91). Systolic blood pressure significantly contributed to height-related stroke risk (proportion mediated: 0.41; 95% CI: 0.19-1.56).

CONCLUSIONS

This study found an inverse association between adult height and stroke risk, which is partly driven by lower systolic blood pressure. These findings highlight the importance of systolic blood pressure management as a potential preventive strategy against stroke.

Association of blood metal exposure with age at menarche in Korean women: KNHANES (2008-2017)

Humans are exposed to metals in their daily lives and this metal exposure is responsible for various adverse health effects. Delayed pubertal development has been suggested as an adverse outcome of metal exposure; however, evidence in nationally representative populations, especially in Asia, is limited. We evaluated the association of blood cadmium (Cd), lead (Pb), and mercury (Hg) levels with the age at menarche in Korean females whose blood heavy metals were measured as part of the Korean National Health and Nutrition Examination Survey (KNHANES) 2008-2017. Among the females 16 years of age or older, all measured heavy metals in blood, i.e., Cd, Pb, and Hg, were positively associated with age at menarche. These associations remained significant in a model adjusted for age, survey year, income, education, body mass index, smoking history, and menopausal status as covariates (β: 0.10, 95% confidence interval (CI): 0.03-0.18 for Cd; β: 0.17, 95%CI: 0.06-0.27 for Pb; β: 0.12, 95%CI: 0.05-0.19 for Hg). When the population was separated by age group at the time of the survey, the significance between heavy metal levels and age at menarche became inconsistent, but the general trends were similar. Among those in their 20s and 40s, blood Cd showed a significant association, while Pb was significant among those in their 40s and 50s. A similar trend was observed in the sensitivity analysis in the girls aged 10-15 years at the time of the survey. Blood Cd levels were associated with decreased odds of precocious menarche (OR: 0.57, 95%CI: 0.31-1.03). Delayed menarche is a risk factor for cardiovascular and chronic kidney diseases in later life; hence, public health implication of heavy metal exposure warrants a public health attention.

Update on sex specific risk factors in cardiovascular disease

Cardiovascular disease (CVD) is the leading cause of death worldwide and accounts for roughly 1 in 5 deaths in the United States. Women in particular face significant disparities in their cardiovascular care when compared to men, both in the diagnosis and treatment of CVD. Sex differences exist in the prevalence and effect of cardiovascular risk factors. For example, women with history of traditional cardiovascular risk factors including hypertension, tobacco use, and diabetes carry a higher risk of major cardiovascular events and mortality when compared to men. These discrepancies in terms of the relative risk of CVD when traditional risk factors are present appear to explain some, but not all, of the observed differences among men and women. Sex-specific cardiovascular disease research-from identification, risk stratification, and treatment-has received increasing recognition in recent years, highlighting the current underestimated association between CVD and a woman's obstetric and reproductive history. In this comprehensive review, sex-specific risk factors unique to women including adverse pregnancy outcomes (APO), such as hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus, preterm delivery, and newborn size for gestational age, as well as premature menarche, menopause and vasomotor symptoms, polycystic ovarian syndrome (PCOS), and infertility will be discussed in full detail and their association with CVD risk. Additional entities including spontaneous coronary artery dissection (SCAD), coronary microvascular disease (CMD), systemic autoimmune disorders, and mental and behavioral health will also be discussed in terms of their prevalence among women and their association with CVD. In this comprehensive review, we will also provide clinicians with a guide to address current knowledge gaps including implementation of a sex-specific patient questionnaire to allow for appropriate risk assessment, stratification, and prevention of CVD in women.

Epigenetic age acceleration is associated with speed of pubertal growth but not age of pubertal onset

Using data from a longitudinal cohort of children, we examined whether epigenetic age acceleration (EAA) was associated with pubertal growth and whether these associations were mediated by adiposity. We examined associations between EAA at approximately 10 years of age with pubertal growth metrics, including age at peak height velocity (PHV), PHV, and sex steroid levels and whether these associations were mediated by measures of adiposity including body mass index (BMI) and MRI-assessed visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT). Children (n = 135) with accelerated EAA had higher PHV (β 0.018, p = 0.0008) although the effect size was small. The association between EAA and age at PHV was not significant (β  - 0.0022, p = 0.067). Although EAA was associated with higher BMI (β 0.16, p = 0.0041), VAT (β 0.50, p = 0.037), and SAT (β 3.47, p = 0.0076), BMI and VAT did not mediate associations between EAA and PHV, while SAT explained 8.4% of the association. Boys with higher EAA had lower total testosterone (β  - 12.03, p = 0.0014), but associations between EAA and other sex steroids were not significant, and EAA was not associated with sex steroid levels in girls. We conclude that EAA did not have strong associations with either age at onset of puberty or pubertal growth speed, although associations with growth speed were statistically significant. Studies with larger sample sizes are needed to confirm this pattern of associations.

The J shaped association of age at menarche and cardiovascular events: systematic review and meta-analysis

This study aimed to evaluate the association between age at menarche and cardiovascular (CV) events through a systematic review and meta-analysis of observational studies. A comprehensive literature search covering studies published from January 1, 2000, to October 31, 2023, was conducted in PubMed, MEDLINE, Embase, and Scopus. Twenty-nine observational studies involving 4,931,160 adult women aged 18 years or older were included. The meta-analysis revealed a J-shaped association between age at menarche and CV events. Individuals with menarche at 12-13 years exhibited the lowest risk, while those with younger (≤ 11 years) or older ages (14-15 years and ≥ 16 years) showed an increased risk. Notably, individuals with age at menarche of 16 years and older had the highest risk of CV events. The pooled odds of CV mortality in age at menarche categories 14-15 years and ≥ 16 years were 37% (OR: 1.37, 95% CI 1.14-1.64, I2: 76.9%) and 64% (OR: 1.64, 95% CI 1.20-2.24, I2: 87%) higher than referent age at menarche 12-13 years. No statistically significant difference was found in CV mortality risk between individuals with age at menarche ≤ 11 years and those with age at menarche 12-13 years. The ORs for coronary heart disease were significantly higher for age at menarche ≥ 16 years (35% increase), while no significant difference was found for age at menarche ≤ 11 years or 14-15 years compared to age at menarche 12-13 years. Regarding stroke, the ORs for age at menarche ≤ 11, 14-15, and ≥ 16 years were significantly higher (7%, 24%, and 94% increase, respectively) compared to age at menarche 12-13 years. Dose-response meta-analysis and one-stage random-effect cubic spline models confirmed the J-shaped risk pattern. Meta-regression indicated that age and BMI were not significant sources of heterogeneity. Sensitivity analyses and the absence of publication bias further supported the robustness of the findings. This study concludes that age at menarche is independently associated with CV events, with a J-shaped pattern. The findings underscore the significance of considering menarche age as an independent risk factor for CV events. Further research is warranted to validate these findings and explore potential underlying mechanisms.

Tailored to a Woman's Heart: Gender Cardio-Oncology Across the Lifespan

PURPOSE OF REVIEW

Females outnumber males among long-term cancer survivors, primarily as a result of the prevalence of breast cancer. Late cardiovascular effects of cancer develop over several decades, which for many women, may overlap with reproductive and lifecycle events. Thus, women require longitudinal cardio-oncology care that anticipates and responds to their evolving cardiovascular risk.

RECENT FINDINGS

Women may experience greater cardiotoxicity from cancer treatments compared to men and a range of treatment-associated hormonal changes that increase cardiometabolic risk. Biological changes at critical life stages, including menarche, pregnancy, and menopause, put female cancer patients and survivors at a unique risk of cardiovascular disease. Women also face distinct psychosocial and physical barriers to accessing cardiovascular care. We describe the need for a lifespan-based approach to cardio-oncology for women. Cardio-oncology care tailored to women should rigorously consider cancer treatment/outcomes and concurrent reproductive/hormonal changes, which collectively shape quality of life and cardiovascular outcomes.

Sex-specific differences in cardiovascular risk factors and implications for cardiovascular disease prevention in women

Cardiovascular disease (CVD) is the leading cause of mortality for women globally. Sex differences exist in the relative risks conferred by traditional CVD risk factors, including diabetes, hypertension, obesity, and smoking. Additionally, there are female-specific risk factors, including age of menarche and menopause, polycystic ovary syndrome, infertility and the use of assisted reproductive technology, spontaneous pregnancy loss, parity, and adverse pregnancy outcomes, as well as female-predominant conditions such as autoimmune diseases, migraines, and depression, that enhance women's cardiovascular risk across the lifespan. Along with measurement of traditional risk factors, these female-specific factors should also be ascertained as a part of cardiovascular risk assessment to allow for a more comprehensive overview of the risk for developing cardiometabolic disorders and CVD. When present, these factors can identify women at elevated cardiovascular risk, who may benefit from more intensive preventive interventions, including lifestyle changes and/or pharmacotherapy such as statins. This review describes sex differences in traditional risk factors and female-specific/female-predominant risk factors for CVD and examines the role of coronary artery calcium scores and certain biomarkers that can help further risk stratify patients and guide preventive recommendations.

Sex Differences in Coronary Artery Disease: Insights From the KoRean wOmen'S chest pain rEgistry (KoROSE)

Interest in sex differences in coronary artery disease (CAD) has been steadily increasing. Concurrently, most of the data on these differences have primarily been Western-oriented. The KoRean wOmen'S chest pain rEgistry (KoROSE), started in 2011, has since published numerous research findings. This review aims to summarize the reported differences between men and women in CAD, integrating data from KoROSE. Cardiovascular risk in postmenopausal women escalates dramatically due to the decrease in estrogen levels, which normally offer cardiovascular protective effects. Lower estrogen levels can lead to abdominal obesity, insulin resistance, increased blood pressure, and endothelial dysfunction in older women. Upon analyzing patients with CAD, women are typically older and exhibit more cardiovascular risk factors than men. Diagnosing CAD in women tends to be delayed due to their symptoms being more atypical than men's. While in-hospital outcome was similar between sexes, bleeding complications after percutaneous coronary intervention occur more frequently in women. The differences in long-term prognosis for CAD patients between men and women are still a subject of ongoing debate. Pregnancy and reproductive factors also play a significant role as risk factors for cardiovascular disease in women. A notable sex disparity exists, with women found to use fewer cardiovascular protective drugs and undergo fewer interventional or surgical procedures than men. Additionally, women participate less frequently than men in clinical research. Through concerted efforts to increase awareness of sex differences and mitigate sex disparity, personalized treatment can be provided. This approach can ultimately improve patient prognosis.

Menstrual Cycle Irregularity in Adolescence Is Associated With Cardiometabolic Health in Early Adulthood

Background Menstrual cycle irregularities are associated with cardiovascular and cardiometabolic disease. We tested associations between age at menarche and cycle irregularity in adolescence and cardiometabolic health in early adulthood in a subsample from the Pittsburgh Girls Study. Methods and Results Data from annual interviews were used to assess age at menarche and cycle irregularity (ie, greater or less than every 27-29 days) at age 15 years. At ages 22 to 25 years, cardiometabolic health was measured in a subsample of the Pittsburgh Girls Study (n=352; 68.2% Black), including blood pressure, waist circumference, and fasting serum insulin, glucose, and lipids. T tests were used for continuous data and odds ratios for dichotomous data to compare differences in cardiometabolic health as a function of onset and regularity of menses. Early menarche (ie, before age 11 years; n=52) was associated with waist circumference (P=0.043). Participants reporting irregular cycles (n=50) in adolescence had significantly higher levels of insulin, glucose, and triglycerides, and higher systolic and diastolic blood pressure (P values range from 0.035 to 0.005) and were more likely to have clinical indicators of cardiometabolic predisease in early adulthood compared with women who reported regular cycles (odds ratios ranged from 1.89 to 2.56). Conclusions Increasing rates and earlier onset of cardiovascular and metabolic disease among women, especially among Black women, highlights the need for identifying early and reliable risk indices. Menstrual cycle irregularity may serve this purpose and help elucidate the role of women's reproductive health in protecting and conferring risk for later cardiovascular and cardiometabolic diseases.

A Woman's Heart: Improving Uptake and Awareness of Cardiovascular Screening for Middle-Aged Populations

Mid-life, the years leading up to and following the menopause transition, in women is accompanied by a change in cardiometabolic risk factors, including increases in body weight, changes in body composition, a more insulin-resistant state, and a shift towards a more atherogenic dyslipidemia pattern. Cardiovascular disease (CVD) risk assessment should be performed continually throughout the lifespan, as risk is not stagnant and can change throughout the life course. However, mid-life is a particularly important time for a woman to be evaluated for CVD risk so that appropriate preventive strategies can be implemented. Along with assessing traditional risk factors, ascertainment of a reproductive history is an integral part of a comprehensive CVD risk assessment to recognize unique female-specific or female-predominant factors that modify a woman's risk. When there is uncertainty about CVD risk and the net benefit of preventive pharmacotherapy interventions (such as statins), measuring a coronary artery calcium score can help further refine risk and guide shared decision-making. Additionally, there should be heightened sensitivity around identifying signs and symptoms of ischemic heart disease in women, as these may present differently than in men. Ischemia from coronary microvascular disease and/or vasospasm may be present even without obstructive coronary artery disease and is associated with a heightened risk for major cardiovascular events and reduced quality of life. Therefore, correctly identifying CVD in women and implementing preventive and treatment therapies is paramount. Unfortunately, women are underrepresented in cardiovascular clinical trials, and more data are needed about how to best incorporate novel and emerging risk factors into CVD risk assessment. This review outlines an approach to CVD screening and risk assessment in women using several methods, focusing on the middle-aged population.

Cardiovascular Disease Risk Factors in Women: The Impact of Race and Ethnicity: A Scientific Statement From the American Heart Association

Cardiovascular disease is the leading cause of death in women, yet differences exist among certain racial and ethnic groups. Aside from traditional risk factors, behavioral and environmental factors and social determinants of health affect cardiovascular health and risk in women. Language barriers, discrimination, acculturation, and health care access disproportionately affect women of underrepresented races and ethnicities. These factors result in a higher prevalence of cardiovascular disease and significant challenges in the diagnosis and treatment of cardiovascular conditions. Culturally sensitive, peer-led community and health care professional education is a necessary step in the prevention of cardiovascular disease. Equitable access to evidence-based cardiovascular preventive health care should be available for all women regardless of race and ethnicity; however, these guidelines are not equally incorporated into clinical practice. This scientific statement reviews the current evidence on racial and ethnic differences in cardiovascular risk factors and current cardiovascular preventive therapies for women in the United States.

Women's Reproductive Milestones and Cardiovascular Disease Risk: A Review of Reports and Opportunities From the CARDIA Study

In 1985 to 1986, the CARDIA (Coronary Artery Risk Development in Young Adults) study enrolled 5115 Black or White participants, including 2788 women, aged 18 to 30 years. Over the following 35 years, the CARDIA study amassed extensive longitudinal data on women's reproductive milestones, spanning menarche to menopause. Although not initially conceived as a study of women's health, >75 CARDIA study publications address relationships between reproductive factors and events with cardiovascular and metabolic risk factors, subclinical and clinical cardiovascular disease, and social determinants of health. The CARDIA study was one of the earliest population-based reports to note Black-White differences in age at menarche and associations with cardiovascular risk factors. Adverse pregnancy outcomes, particularly gestational diabetes and preterm birth, have been assessed along with postpartum behaviors, such as lactation. Existing studies have examined risk factors for adverse pregnancy outcomes and lactation, as well as their relationship to future cardiovascular and metabolic risk factors, diagnoses, and subclinical atherosclerosis. Ancillary studies examining components of polycystic ovary syndrome and ovarian biomarkers, such as anti-Müllerian hormone, have facilitated examination of reproductive health in a population-based cohort of young adult women. As the cohort transitioned through menopause, examination of the importance of premenopausal cardiovascular risk factors along with menopause has improved our understanding of shared mechanisms. The cohort is now aged in the 50s to mid-60s, and women will begin to experience a greater number of cardiovascular events as well as other conditions, such as cognitive impairment. Thus, in the next decade, the CARDIA study will provide a unique resource for understanding how the women's reproductive life course epidemiology informs cardiovascular risk, as well as reproductive and chronological aging.

Female sex-specific considerations to improve rigor and reproducibility in cardiovascular research

Cardiovascular disease is the leading cause of death in women. Despite recognition of sex-specific differences in cardiovascular health, females are underrepresented across all aspects of cardiovascular research, playing a key role in reducing rigor and reproducibility in cardiovascular research and contributing to these poorer health outcomes. Therefore, we propose a framework to capture factors associated with the female sex at the preclinical, recruitment, data collection, and data analysis stages. In preclinical cardiovascular research, female experimental models are commonly excluded despite similar variability in findings compared with males. To reduce this sex bias, the inclusion of female models and the incorporation of sex as a biological variable are critical to improve reproducibility and inform clinical research and care. Although funding agencies have mandated the inclusion of women in clinical trials, greater efforts are needed to achieve optimal participation-to-prevalence ratio to increase the generalizability of results to real-world settings. Female participants face more stringent exclusion criteria in research compared with males owing to sex-specific factors. However, their routine exclusion from cardiovascular research is not only unethical but limits generalizability and applicability to clinical practice. Identifying sex assigned at birth, collecting information on female sex-specific and -predominant factors associated with cardiovascular health and risk, and stratifying data by sex, including adverse events, are essential to ensure reproducibility and relevance of findings to target populations. Increasing female representation and the incorporation of female sex-specific cardiovascular risk factors in cardiovascular research will not only lead to enhanced rigor and reproducibility but improved cardiovascular health for all.

Relationships between Age at Menarche and Risk of Cardiovascular Disease Mortality among Japanese Women: The Japan Collaborative Cohort Study for Evaluation of Cancer Risk (JACC) Study

AIM

In this study, we aimed to evaluate the association between age at menarche and risk of cardiovascular disease mortality.

METHODS

In total, 54,937 women aged 40-79 years old between 1988 and 1990 without a history of cardiovascular disease were eligible for analysis and were followed through December 2009. We used the Cox proportional hazards models to examine the association between age at menarche and risk of cardiovascular disease.

RESULTS

Compared with women with age at menarche of 15 years, the hazard ratios (95% confidence intervals) of stroke were 1.22 (0.85-1.75) for women with age at menarche of 9-12 years, 1.08 (0.85-1.36) for those of 13 years, 1.23 (1.02-1.47) for those of 14 years, 1.27 (1.07-1.50) for those of 16 years, 1.16 (0.95-1.41) for those of 17 years, and 1.39(1.16-1.68) for those of 18-20 years (P for trend=0.045). A similar pattern was observed for hemorrhagic stroke, ischemic stroke, and total cardiovascular disease. No such association was found for coronary heart disease. When stratified by age, for women aged 40-59 at baseline, the similar U-shaped association was observed. In contrast, for women aged 60-79 years at baseline, a significantly high hazard ratio was noted in the group of late age at menarche, but not in the group of early age at menarche.

CONCLUSIONS

Both women with early and late age at menarche were determined to have higher risk of death from stroke and cardiovascular disease.

Associations of reproductive factors with incidence of myocardial infarction and ischemic stroke in postmenopausal women: a cohort study

BACKGROUND

To assess the association between the reproductive factors of age at menarche, age at menopause, and reproductive span and the incidence of myocardial infarction (MI) and ischemic stroke (IS).

METHODS

We used a population-based retrospective cohort study from the National Health Insurance Service database of Korea including a total of 1,224,547 postmenopausal women. Associations between age at menarche (≤ 12, 13-14 [reference], 15, 16, and ≥ 17 years), age at menopause (< 40, 40-45, 46-50, 51-54 [reference], and ≥ 55 years), and reproductive span (< 30, 30-33, 34-36, 37-40 [reference], and ≥ 41 years) and the incidence of MI and IS were assessed by Cox proportional hazard models with adjustment for traditional cardiovascular risk factors and various reproductive factors.

RESULTS

During a median follow-up of 8.4 years, 25,181 MI and 38,996 IS cases were identified. Late menarche (≥ 16 years), early menopause (≤ 50 years), and short reproductive span (≤ 36 years) were linearly associated with a 6%, 12-40%, and 12-32% higher risk of MI, respectively. Meanwhile, a U-shaped association between age at menarche and risk of IS was found, with a 16% higher risk in early menarche (≤ 12 years) and a 7-9% higher risk in late menarche (≥ 16 years). Short reproductive span was linearly associated with an increased risk of MI, whereas both shorter and longer reproductive spans were associated with an increased risk of IS.

CONCLUSIONS

This study demonstrated different patterns of association between age at menarche and incidence of MI and IS: a linear association for MI versus a U-shaped association for IS. Female reproductive factors in addition to traditional cardiovascular risk factors should be considered when assessing overall cardiovascular risk in postmenopausal women.

Association of reproductive factors with cardiovascular disease risk in pre-menopausal women: nationwide population-based cohort study

BACKGROUND

Although the morbidity and mortality of cardiovascular diseases (CVD) are rising in young women, the risk factors of CVD among Korean pre-menopausal women have not been intensively investigated.

AIMS

To determine how age at menarche and other female reproductive factors are associated with the risk of CVD in pre-menopausal women.

METHODS AND RESULTS

A total of 1 088 992 pre-menopausal women who participated in health screening in 2009 were included. The study outcomes were myocardial infarction (MI) and ischaemic stroke. Cox proportional hazards regression analysis was conducted with adjustment of traditional CVD risk factors and reproductive factors.

RESULTS

Mean age was 43.8 ± 5.3 years (98.9%, < 55 years), 3.5% were current smokers, and 1.2% were heavy drinkers. During a mean follow-up of 8.3years [9 032 685.9 person-years (PY)], there were 10 876 CVD events (1.0 per 1000 PY).With later menarche, the risk of CVD increased; ≤12 years [adjusted hazard ratio (HR) 1.04, 95% confidence interval 0.93-1.16], 13 years (reference), 14 years (1.06, 0.98-1.14), 15 years (1.15, 1.07-1.24), 16 years (1.23, 1.14-1.34), and ≥17 years (1.33, 1.24-1.44). Compared with non-users, oral contraceptives (OC) users (≥1 year) had an increased risk of CVD (1.11, 1.01-1.22) (P for trend = 0.007).

CONCLUSIONS

Later menarche than the mean age at menarche (13 years old) and the use of OC (≥1 year) were associated with a higher risk of CVD, after adjusting for traditional cardiovascular risk factors. This study suggests that female reproductive factors could be unique risk factors for CVD in pre-menopausal women.

Assessment of Cardiovascular Risk in Women: Progress so Far and Progress to Come

Cardiovascular disease is the leading cause of death in women worldwide. Nonetheless, there exist several uncertainties in the prediction, diagnosis, and treatment of cardiovascular disease in women. A cornerstone in the prediction of cardiovascular disease is the implementation of risk scores. A variety of pregnancy- and reproductive-factors have been associated with lower or higher risk of cardiovascular disease. Consequently, the question has been raised, whether these female-specific factors also provide added value to cardiovascular risk prediction. In this review, we provide an overview of the existing literature on sex differences in the association of established cardiovascular risk factors with cardiovascular disease and the relation between female-specific factors and cardiovascular risk. Furthermore, we systematically reviewed the literature for studies that assessed the added value of female-specific factors beyond already established cardiovascular risk factors. Adding female-specific factors to models containing established cardiovascular risk factors has led to little or no significant improvement in the prediction of cardiovascular events. However, analyses primarily relied on data from women aged ≥40 years. Future investigations are needed to quantify whether pregnancy-related factors improve cardiovascular risk prediction in young women in order to support adequate treatment of risk factors and enhance prevention of cardiovascular disease in women.

Early Life Environmental Exposure to Cadmium, Lead, and Arsenic and Age at Menarche: A Longitudinal Mother-Child Cohort Study in Bangladesh

BACKGROUND

Several metals act as endocrine disruptors, but there are few large longitudinal studies about associations with puberty onset.

OBJECTIVES

We evaluated whether early life cadmium, lead, and arsenic exposure was associated with timing of menarche.

METHODS

In a mother-child cohort in rural Bangladesh (n=935), the exposure was assessed by concentrations in maternal erythrocytes in early pregnancy and in girls' urine at 5 and 10 years of age using inductively coupled plasma mass spectrometry. The girls were interviewed twice, at average ages 13.3 [standard deviation (SD)=0.43] and 13.8 (SD=0.43) y, and the date of menarche, if present, was recorded. Associations were assessed using Kaplan-Meier analysis and multivariable-adjusted Cox regression.

RESULTS

In total, 77% of the girls (n=717) had reached menarche by the second follow-up. The median age of menarche among all girls was 13.0 y (25th-75th percentiles: 12.4-13.7 y). At 10 years of age, median urinary cadmium was 0.25μg/L (5th-95th percentiles: 0.087-0.72μg/L), lead 1.6μg/L (0.70-4.2μg/L), and arsenic 54μg/L (19-395μg/L). Given the same age, girls in the highest quartile of urinary cadmium at 5 and 10 years of age had a lower rate of menarche than girls in the lowest quartile, with an adjusted hazard ratio of (HR) 0.80 (95% CI: 0.62, 1.01) at 5 years of age, and 0.77 (95% CI: 0.60, 0.98) at 10 years of age. This implies that girls in the highest cadmium exposure quartile during childhood had a higher age at menarche. Comparing girls in the highest to the lowest quartile of urinary lead at 10 years of age, the former had a higher rate of menarche [adjusted HR = 1.23 (95% CI: 0.97, 1.56)], implying lower age at menarche, whereas there was no association with urinary lead at 5 years of age. Girls born to mothers in the highest quartile of erythrocyte arsenic during pregnancy were less likely to have attained menarche than girls born to mothers in the lowest quartile [adjusted HR= 0.79 (95% CI: 0.62, 0.99)]. No association was found with girls' urinary arsenic exposure.

DISCUSSION

Long-term childhood cadmium exposure was associated with later menarche, whereas the associations with child lead exposure were inconclusive. Maternal exposure to arsenic, but not cadmium or lead, was associated with later menarche. https://doi.org/10.1289/EHP11121.

Age at menarche of adolescent girls and the neighbourhood socioeconomic status of their school area

PURPOSE

To assess the association between abnormal timing of menarche among adolescent girls and neighbourhood socioeconomic status of their school area.

MATERIALS AND METHODS

Our analysis included 187,024 girls aged 15-18 years from the Korea Youth Risk Behaviour Web-Based Survey (KYRBS) from 2007 to 2015. Early and late menarche were defined as menarche before 11 years and no menarche by age 14 years, respectively. The deprivation index values for the areas where the schools were located were used as an indicator of neighbourhood socioeconomic status based on the 2005 national census data. We calculated odds ratios (OR) for early and late menarche using a multinomial logistic regression model. Covariates included body mass index, parental education, single or stepparents, siblings, household wealth, year of birth, survey year, and urbanisation.

RESULTS

Mean age at menarche was 12 years. The overall proportions of early and late menarche were 11.3% and 3.3%, respectively. When divided into four quartile groups based on the socioeconomic deprivation index, 11.3% of girls in the most deprived quartile and 10.6% in the least deprived area showed early menarche. The prevalence of late menarche did not differ across the deprivation index quartiles of school area. Attendance at schools located in highly deprived areas was associated with up to 10% higher risk of early menarche. This positive association was not evident for late menarche.

CONCLUSION

Among contemporary Korean girls, socioeconomic deprivation of the school area was associated with earlier puberty. This finding highlights the potential role of the socioeconomic environment of schools in women's lifetime health.

Mendelian randomization identifies age at menarche as an independent causal effect factor for gestational diabetes mellitus

AIMS

The relationship between age at menarche (AAM) and gestational diabetes mellitus (GDM) risk is still inconclusive. This Mendelian randomization (MR) analysis was used to assess systematically the causal relationship between AAM and GDM risk in human beings.

MATERIALS AND METHODS

Single-nucleotide polymorphisms associated with AAM, oestradiol levels, sex hormone-binding globulin (SHBG) levels and bioavailable testosterone (BioT) levels were screened via the genome-wide association study enrolling individuals of European descent. Summary-level data for GDM (123 579 individuals) were extracted from the UK Biobank. An inverse-variance-weighted method was used for the primary MR analysis. Sensitivity analyses were examined via MR-Egger regression, heterogeneity tests, pleiotropy tests and leave-one-out tests. The directionality that exposure causes the outcome was verified using the MR-Steiger test.

RESULTS

Genetically predicted early AAM was found to have a causal positive association with a higher risk of GDM (odds ratio = 0.798, 95% confidence interval = 0.649-0.980, p = .031). In the multivariable MR analysis adjusted for oestradiol, SHBG and BioT levels, the causal association between AAM and GDM risk remained (odds ratio = 0.651, 95% confidence interval = 0.481-0.881, p = .006). A 1-SD increase in SHBG or BioT levels was significantly associated with a 41.4% decrease or 20.8% increase in the overall GDM risk (p = 3.71E-05 and .040), respectively. However, after controlling for AAM, oestradiol levels and BioT levels by multivariable MR analysis, there was no direct causal effect of SHBG levels on GDM risk (p = .084). Similarly, after adjusting for AAM, oestradiol levels and SHBG levels by multivariable MR analysis, there was no direct causal effect of BioT levels on the risk of GDM (p = .533). In addition, no direct causal association was identified between oestradiol levels and GDM risk in univariable MR analysis or multivariable MR analysis.

CONCLUSION

Genetic variants predisposing individuals to early AAM were independently associated with higher GDM risk. Further research is required to understand the mechanisms underlying this putative causative association. In addition, AAM may be helpful in clinical practice to identify women at risk for GDM; pregnant women who are young for menarche may need to take precautions before GDM develops.

Association of the consumption of common drinks with early puberty in both sexes

Background

We examined the effect of sugar-sweetened beverages (SSB) and common drink intake on pubertal development in both sexes.

Methods

Data were retrieved from Taiwan Children Health Study, which involved detailed pubertal stage assessments of 2,819 schoolchildren aged 11 years in 2011-2012. Drawings of secondary sexual characteristics and self-reported age at menarche or voice breaking were used to assess pubertal stages. Dietary intake was assessed using a detailed semi-quantitative food frequency questionnaire. Generalized estimating equation modeling was applied to obtain odds ratios (ORs) and 95% confidence intervals (CIs) to represent the effects of each drink on early pubertal development outcomes.

Results

In boys, an one cup/day increment of a SSB was associated with earlier voice breaking (β = -0.12; 95% CI = -0.20, -0.04), whereas consuming yogurt (≥2 cups/day) was a protective factor against early puberty (OR = 0.78; 95% CI = 0.73, 0.83). In girls, SSB consumption was associated with increased risk of early puberty in a dose-response manner, and a similar protective effect of yogurt consumption and fermented probiotic drink (≥2 cups/day) against early puberty was observed (OR = 0.96; 95% CI = 0.94, 0.99). Furthermore, the intake of both total sugar and added sugar within SSBs increased risk of early puberty in girls but not in boys.

Conclusions

Sugar-sweetened beverages were associated with early puberty, and probiotic drinks appeared to mitigate this link. These findings indicate that the gut-brain axis could play a crucial role in sexual maturation.

Association of Premature Menopause With Risk of Abdominal Aortic Aneurysm in the Women's Health Initiative

OBJECTIVE

To determine if premature menopause and early menarche are associated with increased risk of AAA, and to explore potential effect modification by smoking history.

SUMMARY OF BACKGROUND DATA

Despite worse outcomes for women with AAA, no studies have prospectively examined sex-specific risk factors, such as premature menopause and early menarche, with risk of AAA in a large, ethnically diverse cohort of women.

METHODS

This was a post-hoc analysis of Women's Health Initiative participants who were beneficiaries of Medicare Parts A&B fee-for-service. AAA cases and interventions were identified from claims data. Follow-up period included Medicare coverage until death, end of follow-up or end of coverage inclusive of 2017.

RESULTS

Of 101,119 participants included in the analysis, the mean age was 63 years and median follow-up was 11.3 years. Just under 10,000 (9.4%) women experienced premature menopause and 22,240 (22%) experienced early men-arche. Women with premature menopause were more likely to be overweight, Black, have >20 pack years of smoking, history of cardiovascular disease, hypertension, and early menarche. During 1,091,840 person-years of follow-up, 1125 women were diagnosed with AAA, 134 had premature menopause (11.9%), 93 underwent surgical intervention and 45 (48%) required intervention for ruptured AAA. Premature menopause was associated with increased risk of AAA [hazard ratio 1.37 (1.14, 1.66)], but the association was no longer significant after multivariable adjustment for demographics and cardiovascular disease risk factors. Amongst women with ≥20 pack year smoking history (n = 19,286), 2148 (11.1%) had premature menopause, which was associated with greater risk of AAA in all models [hazard ratio 1.63 (1.24, 2.23)]. Early menarche was not associated with increased risk of AAA.

CONCLUSIONS

This study finds that premature menopause may be an important risk factor for AAA in women with significant smoking history. There was no significant association between premature menopause and risk of AAA amongst women who have never smoked. These results suggest an opportunity to develop strategies for better screening, risk reduction and stratification, and outcome improvement in the comprehensive vascular care of women.

Defining preventive cardiology: A clinical practice statement from the American Society for Preventive Cardiology

Remarkable transformations in science and healthcare have resulted in declines in mortality from cardiovascular disease over the past several decades, largely driven by progress in prevention and treatment of persons at risk. However, these trends are now beginning to stall, as our county faces increases in cardiovascular risk factors including overweight and obesity, type 2 diabetes mellitus, and metabolic syndrome. Furthermore, poor long-term adherence to a healthy lifestyle and lifesaving pharmacotherapy have exacerbated these trends, with recent data suggesting unprecedented increases in cardiovascular morbidity and mortality. A paradigm shift is needed to improve the cardiovascular health of our nation. Preventive cardiology, a growing subspecialty of cardiovascular medicine, is the practice of primordial, primary, and secondary prevention of all cardiovascular diseases. Preventive cardiologists and preventive cardiology specialists are well equipped with the knowledge and skill-set necessary to reduce deaths related to the growing burden of heart disease and its risk factors. Despite dedicated efforts, cardiovascular disease remains the leading killer of men and women in the United States. Although there is little debate regarding the importance of prevention, many healthcare professionals question the need for preventive cardiology as a distinct subspecialty. Additionally, the field's growth has been hampered by a lack of organization and standardization, and variability of training within programs across the country. The purpose of this document is to delineate the key attributes that define the field of preventive cardiology according to the American Society for Preventive Cardiology.

Sibling group size and BMI over the life course: Evidence from four British cohort studies

Only children, here defined as individuals growing up without siblings, are a small but growing demographic subgroup. Existing research has consistently shown that, on average, only children have higher body mass index (BMI) than individuals who grow up with siblings. How this difference develops with age is unclear and existing evidence is inconclusive regarding the underlying mechanisms. We investigate BMI trajectories for only children and those with siblings up to late adolescence for four British birth cohorts and across adulthood for three cohorts. We use data on BMI from ages 2-63 years (cohort born 1946); 7-55 years (born 1958); 10-46 (born 1970) and 3-17 years (born 2000-2002). Using mixed effects regression separately for each cohort, we estimate the change in BMI by age comparing only children and those with siblings. The results show higher average BMI among only children in each cohort, yet the difference is substantively small and limited to school age and adolescence. The association between sibling status and BMI at age 10/11 is not explained by differential health behaviours (physical activity, inactivity and diet) or individual or family background characteristics in any of the cohorts. Although persistent across cohorts, and despite the underlying mechanism remaining unexplained, the substantively small magnitude of the observed difference and the convergence of the trajectories by early adulthood in all cohorts raises doubts about whether the difference in BMI between only children and siblings in the UK context should be of research or clinical concern. Future research could usefully be directed more at whether only children experience elevated rates of disease, for which high BMI is a risk factor, at different stages of the life course and across contexts.

Mediator or moderator? The role of obesity in the association between age at menarche and blood pressure in middle-aged and elderly Chinese: a population-based cross-sectional study

OBJECTIVE

We investigated the moderation/mediation between the age of menarche and obesity parameters in predicting blood pressure (BP) in middle-aged and elderly Chinese.

DESIGN

Our study is a population-based cross-sectional study.

SETTING

Participants in this study came from the China Health and Retirement Longitudinal Study (CHARLS).

PARTICIPANTS

The analytical sample included 4513 participants aged 45-96 years.

MAIN OUTCOME MEASUREMENTS

Data were selected from the CHARLS, a cross-sectional study. Between-group differences were evaluated using χ², t-test and one-way analysis of variance. The trend of related variables by characteristics was also tested using contrast analysis, as appropriate. Then, correlations between characteristics, moderator, mediator, and independent and dependent variables were used by Spearman's correlation test and Pearson's correlation test. Finally, the mediation analysis was performed by model 4 in PROCESS V3.3 macro for SSPSS, and moderation analysis was used by model 1 for assessment. All covariates were adjusted in the moderation or mediation models.

RESULTS

In the correlation analysis, body mass index (BMI) and waist circle (WC) level were positively correlated with both systolic blood pressure (SBP) and diastolic blood pressure (DBP) in women (BMI and DBP: r=0.221, p<0.001; WC and DBP: r=0.183, p<0.001; BMI and SBP: r=0.129, p<0.001; WC and SBP: r=0.177, p<0.001). Age of menarche was negatively correlated with DBP (r=-0.060, p<0.001). However, the age of menarche was not significantly correlated with SBP (r=-0.014, p=0.335). In the moderator analysis, after controlling for the potential confounders, the interaction term of obesity parameters×age of menarche was not significant for predicting either DBP (BMI: B=0.0260, SE=0.0229, p=0.2556, 95% CI -0.0189 to 0.071; WC: B=0.0099, SE=0.0074, p=0.1833, 95% CI -0.0047 to 0.0244) or SBP (BMI: B=0.0091, SE=0.0504, p=0.8561, 95% CI -0.0897 to 0.108; WC: B=-0.0032, SE=0.0159, p=0.8427, 95% CI -0.0343 to 0.028). All correlations were significant correlation between age of menarche, obesity parameters and BP except the path of the menarche age→SBP (with the addition of the BMI indicator: β=-0.0004, B=-0.0046, p=0.9797, 95% CI -0.3619 to 0.3526; with the addition of the WC indicator: β=0.0004, B=0.0044, p=0.9804, 95% CI -0.3439 to 0.3526) in crude model. In general, after controlling for potential confounders, BMI (DBP: β=-0.0471, B= -0.2682, p=0.0021, 95% CI -0.4388 to -0.0976; SBP: β=-0.0515, B=-0.6314, p<0.001, 95% CI -0.9889 to -0.2739) and WC (DBP: β=-0.0474, B= -0.2689, p<0.001, 95% CI -0.4395 to -0.0984; SBP: β=-0.0524, B=-0.6320, p<0.001, 95% CI -0.9832 to -0.2807) partly mediated the relationship between age of menarche and BP.

CONCLUSIONS

The interaction term of obesity parameters×age of menarche was not significant for predicting either DBP or SBP in women. Moreover, obesity parameters partly mediated the relationship between the age of menarche and BP.

Genetically Determined Lifestyle and Cardiometabolic Risk Factors Mediate the Association of Genetically Predicted Age at Menarche With Genetic Predisposition to Myocardial Infarction: A Two-Step, Two-Sample Mendelian Randomization Study

Background

Observational studies have shown an association between early age at menarche (AAM) and myocardial infarction (MI) with recorded cases. In this Mendelian randomization (MR) study, we used large amounts of summary data from genome-wide association studies (GWASs) to further estimate the association of genetically predicted AAM with genetically predicated risk of MI and investigate to what extent this association is mediated by genetically determined lifestyles, cardiometabolic factors, and estrogen exposure.

Methods

A two-step, two-sample MR study was performed by mediation analysis. Genetic variants identified by GWAS meta-analysis of reproductive genetics consortium (n = 182,416) were selected for genetically predicted AAM. Genetic variants identified by the Coronary ARtery DIsease Genome-wide Replication and Meta-analysis plus The Coronary Artery Disease Genetics Consortium (n = 184,305) were selected for genetically predicted risk of MI. Genetic variants from other international GWAS summary data were selected for genetically determined mediators.

Results

This MR study showed that increase in genetically predicted AAM was associated with lower risk of genetically predicted MI (odds ratio 0.91, 95% confidence interval 0.84–0.98). Inverse variance weighted (IVW) MR analysis also showed that decrease in genetically predicted AAM was associated with higher genetically predicted alcohol intake frequency, current smoking behavior, higher waist-to-hip ratio, and higher levels of systolic blood pressure (SBP), fasting blood glucose, hemoglobin A1c (HbA1c), and triglycerides (TGs). Furthermore, increase in genetically predicted AAM was associated with genetically predicted longer sleep duration, higher levels of high-density lipoproteins, and older age at which hormone replacement therapy was started. The most essential mediators identified were genetically predicted current smoking behavior and levels of HbA1c, SBP, and TGs, which were estimated to genetically mediate 13.9, 12.2, 10.5, and 9.2%, respectively, with a combined mediation proportion of 37.5% in the association of genetically predicted AAM with genetically predicted increased risk of MI in an MR framework.

Conclusion

Our MR analysis showed that increase in genetically predicted AAM was associated with lower genetically predicted risk of MI, which was substantially mediated by genetically determined current smoking behavior and levels of HbA1c, SBP, and TGs. Intervening on the above mediators may reduce the risk of MI.

High Prevalence of Asymptomatic Intracranial Atherosclerosis in Elder Women With Tubal Ligation: Result From a Community-Based Study in Shandong, China

Background

In addition to traditional cardiovascular risk factors, gender-specific factors may also contribute to intracranial atherosclerosis. This study aimed to comprehensively investigate the association between asymptomatic intracranial atherosclerosis (aICAS) and menstrual or reproductive history (MRH), namely, menstruation, pregnancy, childbirth, menopause, and contraception.

Methods

Participants in this study were selected from the Kongcun town aICAS study. MRH was collected through structured case report forms, in which menarche age, menstrual regularity, dysmenorrhea, number of pregnancies, number of childbirths, age of first pregnancy, breastfeeding, menopause, menopause age, and contraceptive methods were all involved. All characteristics were compared by chi-squared and nonparametric tests as applicable. Logistic regression model and sensitivity analysis were used to analyze the association between aICAS and MRH.

Results

A total of 1,052 female participants were involved in this study, of which 5.7% had moderate to severe aICAS. Tubal ligation was significantly associated with aICAS in univariate analysis [crude odds ratio (OR), 2.85; 95% CI, 1.22–6.62; P = 0.015]. This association was still significant among female participants over 60 years old after multivariate adjustment (adjusted OR, 4.36; 95% CI, 1.55–12.24; P = 0.005). Sensitivity analysis showed a similar result (adjusted OR, 3.76; 95% CI, 1.24–11.41; P = 0.020). Menopause lost significant association with aICAS after multivariate adjustment (adjusted OR, 1.68; 95% CI, 0.66–4.24; P = 0.275). No other MRH factors were found to be associated with aICAS.

Conclusion

Tubal ligation may be associated with a higher prevalence of aICAS in Chinese elderly women. This provides a new perspective to study the epidemiological characteristics of ICAS.

Pregnancy and Reproductive Risk Factors for Cardiovascular Disease in Women

Beyond conventional risk factors for cardiovascular disease, women face an additional burden of sex-specific risk factors. Key stages of a woman's reproductive history may influence or reveal short- and long-term cardiometabolic and cardiovascular trajectories. Early and late menarche, polycystic ovary syndrome, infertility, adverse pregnancy outcomes (eg, hypertensive disorders of pregnancy, gestational diabetes, preterm delivery, and intrauterine growth restriction), and absence of breastfeeding are all associated with increased future cardiovascular disease risk. The menopause transition additionally represents a period of accelerated cardiovascular disease risk, with timing (eg, premature menopause), mechanism, and symptoms of menopause, as well as treatment of menopause symptoms, each contributing to this risk. Differences in conventional cardiovascular disease risk factors appear to explain some, but not all, of the observed associations between reproductive history and later-life cardiovascular disease; further research is needed to elucidate hormonal effects and unique sex-specific disease mechanisms. A history of reproductive risk factors represents an opportunity for comprehensive risk factor screening, refinement of cardiovascular disease risk assessment, and implementation of primordial and primary prevention to optimize long-term cardiometabolic health in women.

Residential green space and age at menarche in German and Australian adolescent girls: A longitudinal study

BACKGROUND

A large multicentre European study reported later onset of menopause among women residing in greener areas. This influence on the timing of a reproductive event like menopause, raises the question whether similar associations can be observed with timing of menarche. We investigated whether exposure to residential green space was related to the age at menarche in German and Australian adolescent girls.

METHODS

The analytic samples comprised of 1706 German and 1474 Australian adolescent girls. Percentage of green space was calculated in 1000 m buffers around a residential address or its surrogate at the previous follow-up. Mixed effects Cox proportional hazard models were used to explore the associations. The survival object was the occurrence of menarche at the time of follow-up (15-year follow-up of the German cohorts and the study wave at 14-15 years in the Australian cohort) and number of years since baseline (10-year follow-up in the German cohort and the study wave at 10-11 years in the Australian cohort). Participants who did not reach menarche were included as censored observations.

RESULTS

A greener residence was not associated with the age at menarche. Null findings were consistent in the general population and in analyses stratified by socioeconomic status or urbanicity in both countries. Urban residents were more likely to have earlier menarche, and this association was consistent across Germany and Australia.

CONCLUSION

The results of our analysis do not support the hypothesis that residing in places with more green space can influence timing of menarche. However, given the limitations of our study, researchers should not be discouraged to further explore environmental risk factors of early menarche.

Challenges in Optimizing Lipid Management in Women

While there are physiologic differences in lipid metabolism in men and women, pharmacologic therapy is very effective in both with similar management strategies recommended in the current guidelines for the management of dyslipidemia. Despite similar guidelines for treatment, studies have shown that women have worse control of dyslipidemia than their male counterparts. This may stem from multiple contributing factors including underestimation of cardiovascular disease risk in women, decreased prescription and utilization of lipid-lowering therapies, decreased medication adherence, and higher risk of statin intolerance, all of which may contribute to lower attainment of lipid targets. Furthermore, heart disease is the leading cause of mortality in women, with heart disease noted an average of 7-10 years later than in men. This has historically led to the misperception that women are protected from heart disease and can be treated less aggressively. In fact, traditional risk factors for atherosclerotic cardiovascular disease often impact risk in women to a greater extent than they do in men. Unique risk factors such as pregnancy-related disorders also contribute to the level of risk and therefore warrant consideration in risk stratification. This review summarizes the efficacy of contemporary lipid-lowering therapies in women versus men and discusses the challenges that arise with lipid management in women along with potential ways to tackle these obstacles.