Age at natural menopause and risk of ischemic stroke: the Framingham heart study

Reproductive hormones in relation to white matter hyperintensity volumes among midlife women

INTRODUCTION

Although reproductive hormones are implicated in cerebral small vessel disease in women, few studies consider measured hormones in relation to white matter hyperintensity volume (WMHV), a key indicator of cerebral small vessel disease. Even fewer studies consider estrone (E1), the primary postmenopausal estrogen, or follicle-stimulating hormone (FSH), an indicator of ovarian age. We tested associations of estradiol (E2), E1, and FSH to WMHV among women.

METHODS

Two hundred twenty-two women (mean age = 59) underwent hormone assays (E1, E2, FSH) and 3T brain magnetic resonance imaging. Associations of hormones to WMHV were tested with linear regression.

RESULTS

Higher E2 (B[standard error (SE)] = -0.17[0.06], P = 0.008) and E1 (B[SE] = -0.26[0.10], P = 0.007) were associated with lower whole-brain WMHV, and higher FSH (B[SE] = 0.26[0.07], P = 0.0005) with greater WMHV (covariates age, race, education). When additionally controlling for cardiovascular disease risk factors, associations of E1 and FSH to WMHV remained.

DISCUSSION

Reproductive hormones, particularly E1 and FSH, are important to women's cerebrovascular health.

HIGHLIGHTS

Despite widespread belief that sex hormones are important to women's brain health, little work has considered how these hormones in women relate to white matter hyperintensities (WMH), a major indicator of cerebral small vessel disease. We considered relations of estradiol (E2), estrone (E1), and follicle-stimulating hormone (FSH) to WMH in midlife women. Higher E2 and E1 were associated with lower whole-brain WMH volume (WMHV), and higher FSH with higher whole-brain WMHV. Associations of E1 and FSH, but not E2, to WMHV persisted with adjustment for cardiovascular disease risk factors. Findings underscore the importance of E2 and FSH to women's cerebrovascular health.

Age at natural menopause and development of chronic diseases in the female population of Kharameh, Iran: A historical cohort study

Background and Aims

Declines in estradiol levels after menopause have been reported to be associated with several health outcomes. This study aimed to determine the effect of age at natural menopause (ANM) on some of the most common chronic diseases.

Methods

This historical cohort study was performed on 2636 postmenopausal women aged 40-70 years participating in phase one of the PERSIAN cohort study in Kharameh, Iran, during 2015-2017. The effect of early (<45 years), intermediate (45-53 years), and late menopause (>53 years) on chronic diseases such as hypertension, diabetes, ischemic heart diseases, stroke, thyroid diseases, and depression was assessed using classic logistic regression for diseases with an incidence rate of more than 10% and Firth's logistic regression for diseases with an incidence of less than this amount.

Results

The mean age of women was 53.48 ± 8.59. Respectively, early and intermediate menopause was associated with ischemic heart disease (odds ratio [OR = 1.61, 95% confidence interval [CI]: 1.08-2.42; p = 0.020), (OR = 1.57, 95% CI: 1.13-2.21; p = 0.008) and thyroid diseases (OR = 3.10, 95% CI: 1.64-6.24; p < 0.001), (OR = 1.83, 95% CI: 1.02-3.57; p = 0.042). furthermore, early menopause was a risk factor for diabetes (OR = 1.46, 95% CI: 1.07-2.00; p = 0.018), depression (OR = 4.79, 95% CI: 2.20-11.79; p = <0.001) and stroke (OR = 3.00, 95% CI: 1.08-9.32; p = 0.034).

Conclusions

In this study, women with diabetes, ischemic heart diseases, stroke, thyroid disorders, and depression had a younger ANM compared to their healthy counterparts. Therefore, applying appropriate strategies to postpone the age of menopause, can reduce the incidence of these types of chronic diseases.

Cardiovascular multimodality imaging in women: a scientific statement of the European Association of Cardiovascular Imaging of the European Society of Cardiology

Cardiovascular diseases (CVD) represent an important cause of mortality and morbidity in women. It is now recognized that there are sex differences regarding the prevalence and the clinical significance of the traditional cardiovascular (CV) risk factors as well as the pathology underlying a range of CVDs. Unfortunately, women have been under-represented in most CVD imaging studies and trials regarding diagnosis, prognosis, and therapeutics. There is therefore a clear need for further investigation of how CVD affects women along their life span. Multimodality CV imaging plays a key role in the diagnosis of CVD in women as well as in prognosis, decision-making, and monitoring of therapeutics and interventions. However, multimodality imaging in women requires specific consideration given the differences in CVD between the sexes. These differences relate to physiological changes that only women experience (e.g. pregnancy and menopause) as well as variation in the underlying pathophysiology of CVD and also differences in the prevalence of certain conditions such as connective tissue disorders, Takotsubo, and spontaneous coronary artery dissection, which are all more common in women. This scientific statement on CV multimodality in women, an initiative of the European Association of Cardiovascular Imaging of the European Society of Cardiology, reviews the role of multimodality CV imaging in the diagnosis, management, and risk stratification of CVD, as well as highlights important gaps in our knowledge that require further investigation.

Estimation of Sarcopenia Indices in Women from Saudi Arabia in Relation to Menopause and Obesity: Cross-Sectional Comparative Study

Sarcopenia prevalence depends on the definition, and ethnicity must be considered when setting reference values. However, there is no specific cut-off for sarcopenia in Saudi women. Accordingly, we aimed to establish a cut-off value for sarcopenia in Saudi women. We determined the prevalence of sarcopenia in terms of low handgrip strength (HGS) in postmenopausal women using the EWGSOP2 value, redefined a specific cut-off for low HGS derived from Saudi premenopausal women, re-determined the prevalence of low HGS using the new cut-off, and analyzed the proportion of low HGS in women with obesity compared to those without obesity. Following EWGSOP2 guidelines, we defined probable sarcopenia and set new HGS values. We assessed HGS and body composition in 134 pre/postmenopausal women. Probable sarcopenia prevalence was calculated using EWGSOP2's HGS of 16 kg and new cut-offs from young premenopausal women without obesity. HGS 10 and 8 kg cut-offs were calculated from premenopausal Saudi women's mean -2 SDs and mean -2.5 SDs. Using the HGS 16 kg cut-off, sarcopenia prevalence was 44% in postmenopausal and 33.89% in premenopausal women. Applying the new HGS 10 kg and 8 kg cut-offs, the prevalence was 9.33% and 4%, respectively, in postmenopausal and 5% and 3.40%, respectively, in premenopausal women. Women with obesity had a higher proportion of low HGS across all cut-offs. We suggest that EWGSOP2 cut-offs may not be adaptable for Saudi women. Considering body composition differences between Saudis and Caucasians, our proposed HGS cut-offs appear more relevant.

Age at Menopause and the Risk of Stroke: Observational and Mendelian Randomization Analysis in 204 244 Postmenopausal Women

Background Observational studies have shown that women with an early menopause are at higher risk of stroke compared with women with a later menopause. However, associations with stroke subtypes are inconsistent, and the causality is unclear. Methods and Results We analyzed data of the UK Biobank and EPIC-CVD (European Prospective Investigation Into Cancer and Nutrition-Cardiovascular Diseases) study. A total of 204 244 postmenopausal women without a history of stroke at baseline were included (7883 from EPIC-CVD [5292 from the subcohort], 196 361 from the UK Biobank). Pooled mean baseline age was 58.9 years (SD, 5.8), and pooled mean age at menopause was 47.8 years (SD, 6.2). Over a median follow-up of 12.6 years (interquartile range, 11.8-13.3), 6770 women experienced a stroke (5155 ischemic strokes, 1615 hemorrhagic strokes, 976 intracerebral hemorrhages, and 639 subarachnoid hemorrhages). In multivariable adjusted observational Cox regression analyses, the pooled hazard ratios per 5 years younger age at menopause were 1.09 (95% CI, 1.07-1.12) for stroke, 1.09 (95% CI, 1.06-1.13) for ischemic stroke, 1.10 (95% CI, 1.04-1.16) for hemorrhagic stroke, 1.14 (95% CI, 1.08-1.20) for intracerebral hemorrhage, and 1.00 (95% CI, 0.84-1.20) for subarachnoid hemorrhage. When using 2-sample Mendelian randomization analysis, we found no statistically significant association between genetically proxied age at menopause and risk of any type of stroke. Conclusions In our study, earlier age at menopause was related to a higher risk of stroke. We found no statistically significant association between genetically proxied age at menopause and risk of stroke, suggesting no causal relationship.

Menopause causes metabolic and cognitive impairments in a chronic cerebral hypoperfusion model of vascular contributions to cognitive impairment and dementia

BACKGROUND

The vast majority of women with dementia are post-menopausal. Despite clinical relevance, menopause is underrepresented in rodent models of dementia. Before menopause, women are less likely than men to experience strokes, obesity, and diabetes-known risk factors for vascular contributions to cognitive impairment and dementia (VCID). During menopause, ovarian estrogen production stops and the risk of developing these dementia risk factors spikes. Here, we aimed to determine if menopause worsens cognitive impairment in VCID. We hypothesized that menopause would cause metabolic dysfunction and increase cognitive impairment in a mouse model of VCID.

METHODS

We performed a unilateral common carotid artery occlusion surgery to produce chronic cerebral hypoperfusion and model VCID in mice. We used 4-vinylcyclohexene diepoxide to induce accelerated ovarian failure and model menopause. We evaluated cognitive impairment using behavioral tests including novel object recognition, Barnes maze, and nest building. To assess metabolic changes, we measured weight, adiposity, and glucose tolerance. We explored multiple aspects of brain pathology including cerebral hypoperfusion and white matter changes (commonly observed in VCID) as well as changes to estrogen receptor expression (which may mediate altered sensitivity to VCID pathology post-menopause).

RESULTS

Menopause increased weight gain, glucose intolerance, and visceral adiposity. VCID caused deficits in spatial memory regardless of menopausal status. Post-menopausal VCID specifically led to additional deficits in episodic-like memory and activities of daily living. Menopause did not alter resting cerebral blood flow on the cortical surface (assessed by laser speckle contrast imaging). In the white matter, menopause decreased myelin basic protein gene expression in the corpus callosum but did not lead to overt white matter damage (assessed by Luxol fast blue). Menopause did not significantly alter estrogen receptor expression (ERα, ERβ, or GPER1) in the cortex or hippocampus.

CONCLUSIONS

Overall, we have found that the accelerated ovarian failure model of menopause caused metabolic impairment and cognitive deficits in a mouse model of VCID. Further studies are needed to identify the underlying mechanism. Importantly, the post-menopausal brain still expressed estrogen receptors at normal (pre-menopausal) levels. This is encouraging for any future studies attempting to reverse the effects of estrogen loss by activating brain estrogen receptors.

Factors associated with the CVD risk factors and body fat pattern of postmenopausal Hindu caste and Lodha tribal populations living in India: An exploratory study

BACKGROUND

Loss in ovarian function during mid-life results in adverse changes in the cardiovascular profile of women. The association between CVD risk factors and menopause differ cross-culturally since several modifiable factors play significant roles in explaining CVD mortality in addition to differences in endogenous estrogen. Very few of the studies from the Indian subcontinent have been concerned with the menopause-specific CVD risk factors, particularly among the tribal groups. Thus, we intended to study the variations in body fat pattern and CVD risk factors between Hindu caste and Lodha tribal postmenopausal women and how these risk factors were associated with differential socio-economic, reproductive and menstrual characteristics and lifestyle variables. The Lodha tribal populations is considered a Particularly Vulnerable Group (PVTG) in this country.

METHODS

This cross-sectional study was conducted among the Bengali Hindu caste and Lodha tribal populations of the State of West Bengal, India covering three districts namely Howrah, Jhargram and East Midnapure. A total of 197 postmenopausal participants were recruited for this study (urban caste 69, rural caste 65 and rural Lodha 63). Data on blood glucose and total cholesterol levels, blood pressure, muscle mass, body fat distribution and sociodemographic, reproductive and menstrual history and lifestyle variables were collected following standard protocols. Analysis of variance (ANOVA) was applied to compare blood glucose, total cholesterol and blood pressure levels and body fat measures across the three populations. Stepwise multiple linear regression analysis was performed to find out the factors associated with CVD risk factors. The data were analyzed with the Statistical Package for Social Science version 20.0(IBM corporation, 2011).

RESULTS

This cross-sectional comparison of women at midlife, though exploratory in nature showed significant differences in body fat pattern and CVD risk factors between caste and tribal groups owing to socioeconomic disparities and, differences in reproductive characteristics and lifestyle factors.

CONCLUSION

The caste and tribal populations differed significantly in body fat pattern and CVD risk factors and in the factors associated with CVD risk suggesting interplay between menopause and modifiable factors in explaining CVD risk factors during mid-life.

Defining the Age of Young Ischemic Stroke Using Data-Driven Approaches

Introduction: The cut-point for defining the age of young ischemic stroke (IS) is clinically and epidemiologically important, yet it is arbitrary and differs across studies. In this study, we leveraged electronic health records (EHRs) and data science techniques to estimate an optimal cut-point for defining the age of young IS. Methods: Patient-level EHRs were extracted from 13 hospitals in Pennsylvania, and used in two parallel approaches. The first approach included ICD9/10, from IS patients to group comorbidities, and computed similarity scores between every patient pair. We determined the optimal age of young IS by analyzing the trend of patient similarity with respect to their clinical profile for different ages of index IS. The second approach used the IS cohort and control (without IS), and built three sets of machine-learning models—generalized linear regression (GLM), random forest (RF), and XGBoost (XGB)—to classify patients for seventeen age groups. After extracting feature importance from the models, we determined the optimal age of young IS by analyzing the pattern of comorbidity with respect to the age of index IS. Both approaches were completed separately for male and female patients. Results: The stroke cohort contained 7555 ISs, and the control included 31,067 patients. In the first approach, the optimal age of young stroke was 53.7 and 51.0 years in female and male patients, respectively. In the second approach, we created 102 models, based on three algorithms, 17 age brackets, and two sexes. The optimal age was 53 (GLM), 52 (RF), and 54 (XGB) for female, and 52 (GLM and RF) and 53 (RF) for male patients. Different age and sex groups exhibited different comorbidity patterns. Discussion: Using a data-driven approach, we determined the age of young stroke to be 54 years for women and 52 years for men in our mainly rural population, in central Pennsylvania. Future validation studies should include more diverse populations.

Age at natural menopause impacts cerebrovascular reactivity and brain structure

Menopause is associated with adverse changes in vascular health coinciding with an increased risk of stroke and vascular cognitive impairment. However, there is significant variation in the age at menopause. The present study examined how the age at natural menopause impacts cerebrovascular reactivity and structural biomarkers of brain aging. Thirty-five healthy postmenopausal women were classified as early-onset menopause (Early; n = 19, age at menopause: 47 ± 2 yr) or later-onset menopause (Late; n = 16, age at menopause: 55 ± 2 yr). Middle cerebral artery blood velocity (MCAv), mean arterial blood pressure (MAP), and end-tidal carbon dioxide (ETCO2) were recorded during a stepped hypercapnia protocol. Reactivity was calculated as the slope of the relationship between ETCO2 and each variable of interest. Brain volumes and white matter hyperintensities (WMHs) were obtained with 3T MRI. Resting MAP was greater in the Early group (99 ± 9 mmHg) compared with the Late group (90 ± 12 mmHg; P = 0.02). Cerebrovascular reactivity, assessed using MCAv, was blunted in the Early group (1.87 ± 0.92 cm/s/mmHg) compared with the Late group (2.37 ± 0.75 cm/s/mmHg; P = 0.02). Total brain volume did not differ between groups (Early: 1.08 ± 0.07 L vs. Late: 1.07 ± 0.06 L; P = 0.66), but the Early group demonstrated greater WMH fraction compared with the Late group (Early: 0.36 ± 0.14% vs. Late: 0.25 ± 0.14%; P = 0.02). These results suggest that age at natural menopause impacts cerebrovascular function and WMH burden in healthy postmenopausal women.

Women's reproductive traits and ischemic stroke: a two-sample Mendelian randomization study

OBJECTIVE

We conducted a Mendelian randomization (MR) study to disentangle causal associations between women's reproductive behaviors and ischemic stroke (IS) and investigate the roles of two modifiable risk factors (body mass index (BMI) and educational attainment (EA)) in these associations.

METHODS

Using summary-level data from large-scale genome-wide association studies, we performed univariable MR to examine whether there is genetic evidence that women's reproductive traits are causally associated with IS and its subtypes. Multivariable MR and MR mediation analysis were used to investigate whether BMI and EA are common mechanisms or mediators for these associations. A set of sensitivity analyses were conducted to test valid MR assumptions.

RESULTS

We observed consistent and statistically significant associations across female and sex-combined analyses for earlier age at first birth (AFB) and age at first sexual intercourse (AFS) with a higher risk of IS and large-artery atherosclerotic stroke (LAS) risk in the primary analysis. The odds ratios of IS per 1 SD increase in genetically predicted early AFB and AFS were 0.93 (95% CI, 0.86-0.99; p = 0.046) and 0.83 (95% CI, 0.70-0.97, p = 0.020), respectively. Further analyses indicated that BMI played a shared role in AFS and IS/LAS while EA played a shared role in AFS/AFB and IS/LAS as well as a mediator in the path from AFS to IS/LAS.

INTERPRETATION

These findings may inform prevention strategies and interventions directed toward relative women's reproductive behaviors and IS. Future studies are warranted to explore other factors related to EA which are responsible for these causalities.

Divergence and Convergence of Sex-Specific Time Trends in Ischemic Stroke: 10-Year Analysis of a State-Wide Registry in Germany

Background The incidence of ischemic stroke was previously expected to rise among countries with an aging population. Lately, several studies from developed countries have reported a decline in certain cohorts. Whether this applies to all sexes, however, is uncertain, with limited data on the temporal development in incidence, treatment, and recovery. Methods and Results We analyzed a prospective stroke inpatient quality-assurance registry of the federal state of Hesse, Germany. Recruitment of all patients with a final diagnosis of ischemic stroke at hospital discharge (International Classification of Diseases, Tenth Revision [ICD-10]: I63) is mandatory by law. Incidence rates were calculated based on census data of all inhabitants and stratified according to age. Between 2010 and 2019, there were 141 277 patients included, 73 770 (52.2%) male patients and 67 507 (47.8%) female patients. Overall, the incidence of ischemic stroke was 228 per 100 000 in 2010 and 226 per 100 000 in 2019 (-0.8%; odds ratio [OR], 0.99 [95% CI, 0.96-1.02]; P=0.50). For male patients, the incidence increased continuously from 236 per 100 000 to 245 per 100 000 (+3.8%); in female patients it decreased from 220 per 100 000 to 208 per 100 000 (-5.6%). After adjusting for age, the OR for ischemic stroke between male and female patients was 1.40 in 2010 (95% CI, 1.35-1.44; P<0.001) and 1.48 in 2019 (95% CI, 1.43-1.53; P<0.001). This development was most pronounced in male patients aged 45 to 59 years with an increase from 151 per 100 000 to 176 per 100 000. In this age group, male patients showed increasing rates of prior strokes and atrial fibrillation, surpassing the prevalence in female patients over time. After multivariable regression analysis, male patients had a lower modified Rankin Scale at discharge compared with female patients, but this difference has decreased since 2015 (common OR in 2010, 0.83 [95% CI, 0.78-0.88]; common OR in 2019, 0.90 [95% CI, 0.84-0.95]), which coincided with rising rates of endovascular treatment. Conclusions Over the past decade in the federal state of Hesse, the overall incidence of ischemic stroke has declined predominantly in the female population. In contrast, for male patients, the incidence has risen by about 4%, with a steeper increase of 16% in male patients aged 45 to 59 years, which might be related to increasing rates of recurrent strokes and atrial fibrillation in this cohort. This finding provides a cautionary tale for effective secondary prevention. Female patients were generally less likely to achieve a favorable outcome, but since the introduction of endovascular treatment, the outcome gap is decreasing.

Clinical scoring model based on age, NIHSS, and stroke-history predicts outcome 3 months after acute ischemic stroke

Background

The clinical nomogram is a popular decision-making tool that can be used to predict patient outcomes, bringing benefits to clinicians and patients in clinical decision-making. This study established a simple and effective clinical prediction model to predict the 3-month prognosis of acute ischemic stroke (AIS), and based on the predicted results, improved clinical decision-making and improved patient outcomes.

Methods

From 18 December 2021 to 8 January 2022, a total of 146 hospitalized patients with AIS confirmed by brain MR were collected, of which 132 eligible participants constituted a prospective study cohort. The least absolute shrinkage and selection operator (LASSO) regression was applied to a nomogram model development dataset to select features associated with poor prognosis in AIS for inclusion in the logistic regression of our risk scoring system. On this basis, the nomogram was drawn, evaluated for discriminative power, calibration, and clinical benefit, and validated internally by bootstrap. Finally, the optimal cutoff point for each independent risk factor and nomogram was calculated using the Youden index.

Results

A total of 132 patients were included in this study, including 85 men and 47 women. Good outcome was found in 94 (71.212%) patients and bad outcome in 38 (28.788%) patients during the follow-up period. A total of eight (6.061%) deaths were reported over this period, of whom five (3.788%) died during hospitalization. Five factors affecting the 3-month prognosis of AIS were screened by LASSO regression, namely, age, hospital stay, previous stroke, atrial fibrillation, and NIHSS. Further multivariate logistic regression revealed three independent risk factors affecting patient outcomes, namely, age, previous stroke, and NIHSS. The area under the curve of the nomogram was 0.880, and the 95% confidence interval was 0.818–0.943, suggesting that the nomogram model has good discriminative power. The p-value for the calibration curve is 0.925, indicating that the nomogram model is well-calibrated. According to the decision curve analysis results, when the threshold probability is >0.01, the net benefit obtained by the nomogram is the largest. The concordance index for 1,000 bootstrapping calculations is 0.869. The age cutoff for predicting poor patient outcomes using the Youden index was 76.5 years (specificity 0.777 and sensitivity 0.684), the cutoff for the NIHSS was 7.5 (specificity 0.936, sensitivity 0.421), and the cutoff for total nomogram score was 68.8 (sensitivity 81.6% and specificity 79.8%).

Conclusion

The nomogram model established in this study had good discrimination, calibration, and clinical benefits. A nomogram composed of age, previous stroke, and NIHSS might predict the prognosis of stroke after AIS. It might intuitively and individually predict the risk of poor prognosis in 3 months of AIS and provide a reference basis for screening the treatment plan of patients.

The association of age at natural menopause with pre- to postmenopausal changes in left ventricular structure and function: the Coronary Artery Risk Development in Young Adults (CARDIA) study

OBJECTIVE

The association between menopause and incident cardiovascular disease (CVD) is controversial. We evaluated the relationships of estrogen deficiency (ovarian reproductive aging) assessed by age at natural menopause (ANM), chronological aging, and antecedent CVD risk factors (biological aging) with left ventricular (LV) structure and function among women transitioning from pre- to postmenopause.

METHODS

We studied 771 premenopausal women (37% Black) from the Coronary Artery Risk Development in Young Adults Study with echocardiographic data in 1990 to 1991 (mean age: 32 y) who later reached natural menopause by 2015 to 2016 and had repeated echocardiographic measurements. Linear regression models were used to evaluate the association of ANM with parameters of LV structure and function.

RESULTS

Mean ANM was 50 (± 3.8) years and the average time from ANM to the last echocardiograph was 7 years. In cross-sectional analyses, a 1-year increase in ANM was significantly associated with lower postmenopausal LV mass (LVM), LVM indexed to body surface area, LV mass-to-volume ratio, and relative wall thickness. In age-adjusted longitudinal analyses, higher ANM was inversely associated with pre- to postmenopausal changes in LVM (β = -0.97; 95% CI: -1.81 to -0.13, P = 0.024) and LVM indexed (β = -0.48; 95% CI: -0.89 to -0.07, P = 0.021). Controlling for baseline LV structure parameters and traditional CVD risk factors attenuated these associations. Further adjustment for hormone therapy uses did not alter these results.

CONCLUSION

In this study, premenopausal CVD risk factors attenuated the association of ANM with changes in LV structure parameters. These data suggest that premenopausal CVD risk factors may predispose women to elevated future CVD risk more than ovarian aging.

Human cytomegalovirus infection is associated with stroke in women: the US National Health and Nutrition Examination Survey 1999-2004

BACKGROUND

Increasing evidence indicated that infection factors play important roles in stroke development. Human cytomegalovirus (HCMV) infection was positively associated with atherosclerosis and hypertension which are stroke risk factors. Therefore, we aimed to explore the relationship between HCMV infection and stroke using the data of US National Health and Nutrition Examination Survey (NHANES).

METHODS

We analysed data on 2844 men and 3257 women in the NHANES 1999-2004. We included participants aged 20-49 years who had valid data on HCMV infection and stroke.

RESULTS

54.1% of participants had serological evidence of HCMV infection and 0.8% of them had a previous diagnosis of stroke. There were ethnic differences in the prevalence of HCMV seropositivity (p<0.001). There was no significant association between HCMV seropositivity and stroke in men in any of the models. In women, HCMV seropositivity was associated with stroke before adjustment (OR=3.45, 95% CI 1.09 to 10.95, p=0.036). After adjusting for race/ethnicity, the association remained significant (OR=4.40, 95% CI 1.37 to 14.09, p=0.014). After further adjustment for body mass index, diabetes, hypercholesterolaemia, hypertension, alcohol consumption, smoking and physical activity, the association still existed (OR=3.58, 95% CI 1.14 to 11.25, p=0.030). The association was significant consistently in adjusted model for age (OR=3.39, 95% CI 1.08 to 10.64, p=0.037).

CONCLUSIONS

We found a strong association between HCMV and stroke in women from the nationally representative population-based survey. This provide additional motivation for undertaking the difficult challenge to reduce the prevalence of stroke.

Early Menopause and Cardiovascular Disease Risk in Women With or Without Type 2 Diabetes: A Pooled Analysis of 9,374 Postmenopausal Women

OBJECTIVE

Early menopause may be associated with higher cardiovascular disease (CVD) risk. Type 2 diabetes mellitus (T2DM), coupled with early menopause, may result in even greater CVD risk in women. We examined CVD risk in women with early compared with normal-age menopause, with and without T2DM overall, and by race/ethnicity.

RESEARCH DESIGN AND METHODS

We pooled data from the Atherosclerosis Risk in Communities study, the Multi-Ethnic Study of Atherosclerosis, and the Jackson Heart Study. We included women with data on menopausal status, menopausal age, and T2DM, excluding pre- or perimenopausal women and those with prevalent CVD. Outcomes included incident coronary heart disease (CHD), stroke, heart failure (HF), and atherosclerotic cardiovascular disease (ASCVD) (CHD or stroke). We estimated the risk associated with early (<45 years) compared with normal-age menopause using Cox proportional hazards models. Covariates included age, race/ethnicity, education, BMI, blood pressure, cholesterol, smoking, alcohol consumption, antihypertensive medication, lipid-lowering medication, hormone therapy use, and pregnancy history.

RESULTS

We included 9,374 postmenopausal women for a median follow-up of 15 years. We observed 1,068 CHD, 659 stroke, 1,412 HF, and 1,567 ASCVD events. T2DM significantly modified the effect of early menopause on CVD risk. Adjusted hazard ratios for early menopause and the outcomes were greater in women with T2DM versus those without (CHD 1.15 [95% CI 1.00, 1.33] vs. 1.09 [1.03, 1.15]; stroke 1.21 [1.04, 1.40] vs. 1.10 [1.04, 1.16]; ASCVD 1.29 [1.09, 1.51] vs. 1.10 [1.04, 1.17]; HF 1.18 [1.00, 1.39] vs. 1.09 [1.03, 1.16]). The modifying effect of T2DM on the association between early menopause and ASCVD was only statistically significant in Black compared with White women.

CONCLUSIONS

Early menopause was associated with an increased risk for CVD in postmenopausal women. T2DM may further augment the risk, particularly in Black women.

Assessment of Cardiovascular Safety of Anti-Osteoporosis Drugs

The incidence of osteoporosis and cardiovascular disease increases with age, and there are potentially shared mechanistic associations between the two conditions. It is therefore highly relevant to understand the cardiovascular implications of osteoporosis medications. These are presented in this narrative review. Calcium supplementation could theoretically cause atheroma formation via calcium deposition, and in one study was found to be associated with myocardial infarction, but this has not been replicated. Vitamin D supplementation has been extensively investigated for cardiac benefit, but no consistent effect has been found. Despite findings in the early 21st century that menopausal hormone therapy was associated with coronary artery disease and venous thromboembolism (VTE), this therapy is now thought to be potentially safe (from a cardiac perspective) if started within the first 10 years of the menopause. Selective estrogen receptor modulators (SERMs) are associated with increased risk of VTE and may be related to fatal strokes (a subset of total strokes). Bisphosphonates could theoretically provide protection against atheroma. However, data from randomised trials and observational studies have neither robustly supported this nor consistently demonstrated the potential association with atrial fibrillation. Denosumab does not appear to be associated with cardiovascular disease and, although parathyroid hormone analogues are associated with palpitations and dizziness, no association with a defined cardiovascular pathology has been demonstrated. Finally, romosozumab has been shown to have a possible cardiovascular signal, and therefore post-market surveillance of this therapy will be vital.

Stroke in women: When gender matters

Stroke in women may be considered as a distinct entity due to numerous differences compared with men, including specific epidemiological, etiological, and outcome features along with unique pathophysiological mechanisms. Stroke is the second cause of death in women worldwide with sex-specific causes of stroke in youger women such as pregnancy, post-partum period, oral contraception and migraine. Substitutive hormone treatment in older women is no more recommended in regard of the increased thromboembolic risk it generates. Venous thrombolysis with rtPA and mechanical thrombectomy are now proven to be as efficacious in women as in men. After a stroke, women present poorer quality of life than men attributable to age, more severe stroke, pre-stroke dependency and depression. Recent data concerning the latest epidemiological surveys reveal a shift in trends with the rise of incidence of strokes in young women (≤55 years and 64 years) contrasting with the stability of incidence rates in older women. As science is unvealing sex-related differences in cardiovascular disorders, health policies need to be adapted accordingly to improve stroke prevention and pre-stroke health in women. In the meantime, therapeutical trials should include more women in order to be able to formulate adequate management.

Age at Menopause and Risk of Ischemic and Hemorrhagic Stroke

BACKGROUND AND PURPOSE

The few epidemiological studies that addressed the association between age at menopause and ischemic and hemorrhagic stroke risk in women had conflicting findings. We aimed to investigate whether age at (natural and surgical) menopause is a risk factor for total, ischemic, and hemorrhagic stroke in women.

METHODS

We analyzed data from 16 244 postmenopausal women, aged 26 to 70 years at recruitment who were enrolled in the European Prospective Investigation into Cancer and Nutrition-Netherlands cohort between 1993 and 1997. Participants were followed for the occurrence of stroke until January 1, 2011. At baseline, participants filled in questionnaires about health, reproductive history including age at menopause, diet, and lifestyle. Cox regression was used to investigate the association between age at menopause and stroke. All analyses were adjusted for age, smoking, systolic blood pressure, and body mass index.

RESULTS

Mean age of menopause was 46.4 (7.0) years. A total of 830 strokes (571 ischemic, 162 hemorrhagic, 97 unclassified) were identified. Earlier menopause was associated with an increased risk of total stroke. Compared with women who experienced menopause between 50 and 54 years old, women who underwent menopause before age 40 years had 1.48× higher risk (95% CI, 1.19-1.85) of total stroke. In continuous analyses, we observed a 2% lower total stroke risk for each year menopause was delayed (hazard ratio, 0.98 [95% CI, 0.97-0.99]). The risk between earlier menopause and stroke was confined to ischemic stroke, earlier menopause was not associated with hemorrhagic stroke. The association with age at menopause was stronger for natural menopause (hazard ratio <40 versus 50-54 years, 1.74 [95% CI, 1.12-2.70]) than for surgical menopause (hazard ratio <40 versus 50-54 years, 1.26 [95% CI, 0.84-1.89]).

CONCLUSIONS

The risk of total and ischemic stroke decreased with an increase in age at menopause. Whether this should have clinical consequences such as intensified risk factor control should be subject of further studies.

Excess heart age in young breast cancer survivors over 2-year follow-up

BACKGROUND

Breast cancer survivors are at risk for developing cardiovascular disease due to cardiotoxic cancer treatment. Research on young breast cancer survivors (diagnosed < 45 years old) are limited.

METHODS

Young breast cancer survivors diagnosed between age 30 and 44, stage I-III, and treated at the University of Alabama at Birmingham Hospital between 2012 and 2015 were included. Cardiovascular disease risk was estimated using excess heart age (calculated using age, systolic blood pressure, blood pressure medication, diabetes, smoking, body mass index) and examined at two time points: diagnosis and 2-year follow-up. Statistical analyses included within-group mean comparison tests and linear regression to examine predictors of excess heart age.

RESULTS

A total of 152 young breast cancer survivors were included; 95 received anthracyclines and/or trastuzumab, and 57 did not. Overall excess heart age was 4.2 at diagnosis and 5.4 years at 2-year follow-up (p = 0.08). Change in excess heart age from diagnosis to 2-year follow-up among those receiving or not receiving anthracyclines and/or trastuzumab was 4.3-4.4 years, p = 0.93; and 4.0-7.1 years, p < 0.01; respectively. Factors that predicted excess heart age included endocrine therapy (p = 0.049) and change from premenopausal to postmenopausal status (p = 0.048).

CONCLUSIONS

Anthracyclines and trastuzumab were not predictors of excess heart age. Subclinical changes undetected by heart age may still occur. Future research is needed to evaluate heart age over longer follow-up and to develop a modified heart age tool, that incorporates treatment risk, that facilitates identification of high-risk cancer patients for early intervention in cardiac risk prevention.

Stroke in women: Is it different?

In the last decades, there has been great progress in the field of stroke. With the introduction of acute therapies (intravenous thrombolysis and intra-arterial treatment), the outcome after stroke has improved significantly. Better prevention, improved acute therapy, and acute rehabilitation improved the morbidity and mortality rate after stroke. Gender differences in risk factors and epidemiology have been known for a long time, but lately attention to gender differences in stroke has increased. The aim of this mini-review is to demonstrate gender disparities in stroke with a focus on epidemiology, specific risk factors (gender-specific and unspecific), and outcomes. The influence of some risk factors for stroke is stronger in women (atrial fibrillation and hypertension) and there are risk factors exclusive to women such as pregnancy, pregnancy-associated hypertensive disorders, oral contraceptives, and hormonal replacement treatment. Data on the impact of other risk factors are inconsistent. The worse outcome after a stroke is mainly caused by demographic characteristics in women. Specific gender research is needed to better understand gender disparities in stroke to improve prevention strategies and treatment for women.

Effects of the Menstrual Cycle on Neurological Disorders

PURPOSE OF REVIEW

The menstrual cycle involves recurrent fluctuations in hormone levels and temperature via neuroendocrine feedback loops. This paper reviews the impact of the menstrual cycle on several common neurological conditions, including migraine, seizures, multiple sclerosis, stroke, and Parkinson's disease.

RECENT FINDINGS

The ovarian steroid hormones, estrogen and progesterone, have protean effects on central nervous system functioning that can impact the likelihood, severity, and presentation of many neurological diseases. Hormonal therapies have been explored as a potential treatment for many neurological diseases with varying degrees of evidence and success. Neurological conditions also impact women's reproductive health, and the cessation of ovarian function with menopause may also alter the course of neurological diseases. Medication selection must consider hormonal effects on metabolism and the potential for adverse drug reactions related to menstruation, fertility, and pregnancy outcomes. Novel medications with selective affinity for hormonal receptors are desirable. Neurologists and gynecologists must collaborate to provide optimal care for women with neurological disorders.

Associations between polygenic risk score for age at menarche and menopause, reproductive timing, and serum hormone levels in multiple race/ethnic groups

OBJECTIVE

We assessed associations of genetic loci that contribute to age at menarche and menopause with sentinel menopausal traits in multiple race/ethnic groups.

METHODS

Genetic data from the Study of Women's Health Across the Nation include 738 White, 366 Black, 139 Chinese, and 145 Japanese women aged 42 to 52 at baseline. We constructed standardized polygenic risk scores (PRSs) using single nucleotide polymorphisms identified from large-scale genome-wide association studies meta-analyses of ages at menopause and menarche, evaluating associations with each trait within each race/ethnic group.

RESULTS

Menopause PRS was significantly associated with age at menopause in White women after Bonferroni correction (P < 0.004) and nominally associated in Chinese and Japanese women (P < 0.05) (7.4-8.5 mo delay for one standard deviation [SD] increase in PRS). Menarche PRS was significantly associated with age at menarche in White (P < 0.004) and nominally associated in Black and Japanese women (P < 0.05) (2.6-4.8 mo delay for one SD increase). In White women, menarche and menopause PRSs were significantly associated (P < 0.004) with shorter and longer (5.9 and 9.6 mo for one SD increase) reproductive lifespans, respectively, and menopause PRS with a longer menopausal transition (7.1 mo for one SD increase). We observed a significant positive association (P < 0.004) between menopause PRS and E2 level 2 years before menopause and a nominal association (P < 0.05) 2 years after menopause in Japanese women.

CONCLUSIONS

In addition to menopausal timing, PRSs associated with onset and ending of reproductive life were associated with reproductive lifespan, length of the menopausal transition, and E2 levels in different race/ethnic groups.

Predictors of the age at which natural menopause occurs in women with type 1 diabetes: the Pittsburgh Epidemiology of Diabetes Complications (EDC) study

OBJECTIVE

Women with type 1 diabetes (T1D) are thought to experience menopause earlier than women without diabetes, although not all studies agree. We assessed metabolic predictors of the age at which natural menopause occurs among women with T1D participating in the Epidemiology of Diabetes Complications study.

METHODS

Women with childhood-onset (<17 y) of T1D who underwent natural menopause without use of hormone therapy during their menopausal transition were included in the analysis (n = 105; mean baseline age, 29.5 and diabetes duration, 20.2 y). Self-reported reproductive history and the Women's Ischemia Syndrome Evaluation hormonal algorithms were used to determine menopause status. Linear regression was used to ascertain whether time-weighted metabolic factors (eg, BMI, lipids, HbA1c, insulin dose, albumin excretion rate [AER]) were associated with age at natural menopause.

RESULTS

Univariately, only insulin dose (β = -4.87, P = 0.04) and log (AER) (β = -0.62, P = 0.02) were associated (negatively) with age at natural menopause. Adjusting for BMI, smoking status, lipids, HbA1c, number of pregnancies, and oral contraceptive use, each 0.1 unit increase in the daily dose of insulin per kilogram body weight was associated with 0.64 years younger age at natural menopause (P = 0.01), while for every 30% increase in AER, age at natural menopause decreased by 0.18 years (P = 0.03).

CONCLUSION

Higher average levels of insulin dose and AER over time were significantly associated with a younger age at which natural menopause occurred among women with T1D. The biologic mechanisms underlying the observed associations between exogenous insulin dose and AER on reproductive health should be investigated among women with T1D.

Genetic Regulation of Physiological Reproductive Lifespan and Female Fertility

There is substantial genetic variation for common traits associated with reproductive lifespan and for common diseases influencing female fertility. Progress in high-throughput sequencing and genome-wide association studies (GWAS) have transformed our understanding of common genetic risk factors for complex traits and diseases influencing reproductive lifespan and fertility. The data emerging from GWAS demonstrate the utility of genetics to explain epidemiological observations, revealing shared biological pathways linking puberty timing, fertility, reproductive ageing and health outcomes. The observations also identify unique genetic risk factors specific to different reproductive diseases impacting on female fertility. Sequencing in patients with primary ovarian insufficiency (POI) have identified mutations in a large number of genes while GWAS have revealed shared genetic risk factors for POI and ovarian ageing. Studies on age at menopause implicate DNA damage/repair genes with implications for follicle health and ageing. In addition to the discovery of individual genes and pathways, the increasingly powerful studies on common genetic risk factors help interpret the underlying relationships and direction of causation in the regulation of reproductive lifespan, fertility and related traits.

Association Between Liver Fat and Bone Density is Confounded by General and Visceral Adiposity in a Community-Based Cohort

OBJECTIVE

Nonalcoholic fatty liver disease (NAFLD) is associated with low bone mineral density (BMD); however, it is not known whether early-stage NAFLD may be associated with BMD after accounting for BMI or visceral adipose tissue (VAT).

METHODS

This was a cross-sectional study of 3,462 Framingham Heart Study participants who underwent computed tomographic measurement of liver fat, VAT volume, volumetric spine BMD, vertebral cross-sectional area (CSA), and vertebral compressive strength. This study excluded heavy alcohol consumers. Multivariable linear regression models were used to assess the association between NAFLD and volumetric BMD, CSA, and vertebral compressive strength after accounting for covariates, including BMI or VAT.

RESULTS

A total of 2,253 participants (mean age, 51.2  [SD 10.7] years; 51.1% women) were included. In multivariable-adjusted models, positive associations between NAFLD and integral BMD, trabecular BMD, and vertebral compressive strength were observed. However, results were attenuated and no longer significant after additionally adjusting for BMI or VAT. NAFLD was observed to be weakly associated with a lower vertebral CSA in adjusted models.

CONCLUSIONS

In a community-based cohort, the associations between NAFLD and BMD and vertebral strength were confounded by BMI and VAT. However, NAFLD was associated with a reduced vertebral CSA in adjusted models.

Women with Type 1 diabetes (T1D) experience a shorter reproductive period compared with nondiabetic women: the Pittsburgh Epidemiology of Diabetes Complications (EDC) study and the Study of Women's Health Across the Nation (SWAN)

OBJECTIVE

Evidence suggests that insulin deficiency and hyperglycemia may disrupt the female reproductive system's normal function, leading to delayed menarche and premature ovarian aging. We thus compared the length of the reproductive period of women with type 1 diabetes (T1D) to women without diabetes.

METHODS

Women with childhood-onset T1D (diagnosed in 1950-80) from the prospective Epidemiology of Diabetes Complications (EDC) study and nondiabetic women from the Pittsburgh site of the Study of Women's Health Across the Nation (SWAN) were studied. Exclusion criteria comprised not having reached natural menopause, hysterectomy/oophorectomy before menopause, and sex hormone therapy during the menopausal transition. Reproductive history was self-reported. The historical and Women's Ischemia Syndrome Evaluation hormonal algorithms were also used to assess menopause status.

RESULTS

Women in the T1D cohort (n = 105) were younger, more likely to be White, never smokers, with lower BMI and higher high-density lipoprotein cholesterol levels (all P values < 0.05) compared with women without diabetes (n = 178). After covariate adjustment, T1D women were also older at menarche (0.5-y delay, P = 0.002) but younger at natural menopause (-2.0 y, P < 0.0001). Women with T1D thus experienced 2.5 fewer reproductive years compared to those without diabetes (P < 0.0001). These findings were restricted to the subgroup of women who were diagnosed with T1D before reaching menarche (n = 80).

CONCLUSION

Women with T1D onset before menarche have a shorter reproductive period compared with nondiabetic women, exhibiting delayed menarche and earlier natural menopause. Factors that may be related to a shorter reproductive period in T1D should be investigated.

Association of age at diabetes complication diagnosis with age at natural menopause in women with type 1 diabetes: The Pittsburgh Epidemiology of Diabetes Complications (EDC) Study

OBJECTIVE

Vascular damage is thought to have a role in premature ovarian aging. We thus assessed the association between the presence, and age at onset of, vascular diabetes complications and age at natural menopause in women with type 1 diabetes.

METHODS

Female participants of the Epidemiology of Diabetes Complications study with type 1 diabetes who experienced natural menopause and who never received hormone therapy during their menopausal transition were included in the analysis (n=105). Microalbuminuria (MA), overt nephropathy, proliferative retinopathy, confirmed distal symmetric polyneuropathy, and coronary artery disease, were assessed during biennial clinical exanimations for the first 10 years of follow-up and at year 18, 25 and 30. Menopausal status was determined via self-report and sex hormone data. For each complication, separate linear regression models were used to assess whether, compared with women without the complication of interest, an earlier age at complication development (i.e., <30 years of age) was associated with an earlier age at natural menopause.

RESULTS

Although results from multivariable linear regression models suggested a similar age at menopause between women with normo-albuminuria and those diagnosed with MA after 30 years of age, menopause occurred 2.06 years earlier (β±SE=-2.06±1.08) among women diagnosed with MA before age 30 (p=0.06). No significant association was observed for other complications.

CONCLUSION

Among women with type 1 diabetes, menopause appears to occur earlier in those diagnosed with MA before age 30 compared to those with normo-albuminuria, suggesting that vascular dysfunction associated with early microvascular disease may affect ovarian aging.

Combined effect of menopause and cardiovascular risk factors on death and cardiovascular disease: a cohort study

BACKGROUND

Observational studies suggest that early menopause is associated with increased risk of death and cardiovascular disease (CVD); however, the results of these studies have been inconsistently. We aimed to assess the association of menopause with death and CVD and whether this association was modified by cardiovascular risk factors.

METHODS

The study population was women age 35-64 years living in two communities of Beijing who were enrolled in the Chinese Multi-provincial Cohort Study in 1992. Participants were followed until first cardiovascular event, death, or the end of follow-up (2018). Self-reported age at menopause was recorded. Multivariate Cox regression models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) of death and CVD after adjusting for baseline covariates of age, family history of CVD, and white blood cell count, as well as time-varying covariates of menopause, use of oral estrogen, and conventional risk factors. Additionally, we assessed the combined effect of age at menopause and risk factors on the primary endpoint.

RESULTS

Of 2104 eligible women, 124 died and 196 had a first CVD event (33 fatal CVD and 163 non-fatal CVD). Compared with women who experienced menopause at age 50-51 years, the risk of death was higher in women with menopause at age 45-49 years (HR 1.99, 95% CI 1.24-3.21; P = 0.005), and the risk of ischemic stroke was higher in women with menopause at age < 45 years (HR 2.16, 95% CI 1.04-4.51; P = 0.04) and at age 45-49 years (HR 2.05, 95% CI 1.15-3.63; P = 0.01). Women who had menopause before age 50 years and at least one elevated risk factor at baseline had a higher risk of death (HR 11.10, 95% CI 1.51-81.41; P = 0.02), CVD (HR 3.98, 95% CI 1.58-10.01; P = 0.003), ischemic CVD (HR 4.53, 95% CI 1.63-12.62; P = 0.004), coronary heart disease (HR 8.63, 95% CI 1.15-64.50; P = 0.04), and stroke (HR 2.92, 95% CI 1.03-8.29; P = 0.04) than those with menopause at age 50-51 years and optimal levels of all risk factors.

CONCLUSIONS

Earlier menopause may predict death and ischemic stroke. Furthermore, there is a combined effect of earlier menopause and elevated risk factors on death and CVD.

Premature and Early Menopause in Relation to Cardiovascular Disease

Postmenopausal women have an increased risk for cardiovascular diseases. It has been postulated that the loss of ovarian function and subsequent deficiency of endogenous estrogens after menopause contributes to this elevated risk of cardiovascular disease in postmenopausal women. Compared with woman entering menopause at the mean age of 51 years, in women with early menopause or premature ovarian insufficiency the risk for cardiovascular disease is even greater. These women lack the cardioprotective effect of endogenous estrogens for many more years than do women entering natural menopause. The majority of data assessing the risk of cardiovascular disease in relation to age at menopause and specifically premature menopause are derived from large epidemiological cohort studies. In addition, observations in women undergoing bilateral oophorectomy at an early age provide convincing evidence regarding association between early menopause or POI and the development of cardiovascular events and mortality. Moreover, genetic variants associated with earlier age at menopause have also been found to increase the risk of cardiovascular events in women. It has been substantiated that hormone replacement therapy (HRT) decreases the risk for ischemic heart disease and eliminates the increased cardiovascular disease mortality. It is therefore crucial to start HRT as soon as possible, particularly in women with premature ovarian insufficiency.

Osteocalcin, ovarian senescence, and brain health

Menopause, an inevitable event in a woman's life, significantly increases risk of bone resorption and diseases such as Alzheimer's, vascular dementia, cardiac arrest, and stroke. The sole role of bones, as traditionally regarded, is to provide structural support for skeletal muscles and allow for ambulation, however this concept is becoming quickly outdated. New literature has emerged that suggests the bone cell-derived hormone osteocalcin (OCN) plays a pivotal role in cognition. OCN levels are correlated with bone mass density and bone turnover, and thus are strongly influenced by the changes associated with menopause. The goal of the current review is to discuss potential gaps in our knowledge of OCN and cognition, discrepancies in methods of OCN quantification, and therapies to enhance circulating OCN. A discussion on implementing exercise or low frequency vibration interventions at the menopausal transition to reduce risk and severity of neurological diseases and associated cognitive decline is included.

Sex Dimorphisms in Ischemic Stroke: From Experimental Studies to Clinic

Sex dimorphisms are important factors that influence the outcomes after ischemic stroke, which include basic health status, cerebrovascular anatomy, hormone levels, and unique factors such as pregnancy and menopause. It is widely recognized that male and female respond differently to stroke. Women aged 45–74 years old showed a lower risk of stroke incidence compared to age-matched man. This kind of protection is lost with aging. Hence, there is increasing requirement to get a more comprehensive understanding of sex-based factors to stroke on stroke incidence, symptoms, and treatments. This review focuses on sex-specific mechanisms in response to stroke based on experimental studies and highlights recent findings in clinical studies including sex-differential evaluation and outcomes of stroke. Sex-based personalized medicine should be promising in stroke therapies.

Neuroprotective and neurotoxic outcomes of androgens and estrogens in an oxidative stress environment

BACKGROUND

The role of sex hormones on cellular function is unclear. Studies show androgens and estrogens are protective in the CNS, whereas other studies found no effects or damaging effects. Furthermore, sex differences have been observed in multiple oxidative stress-associated CNS disorders, such as Alzheimer's disease, depression, and Parkinson's disease. The goal of this study is to examine the relationship between sex hormones (i.e., androgens and estrogens) and oxidative stress on cell viability.

METHODS

N27 and PC12 neuronal and C6 glial phenotypic cell lines were used. N27 cells are female rat derived, whereas PC12 cells and C6 cells are male rat derived. These cells express estrogen receptors and the membrane-associated androgen receptor variant, AR45, but not the full-length androgen receptor. N27, PC12, and C6 cells were exposed to sex hormones either before or after an oxidative stressor to examine neuroprotective and neurotoxic properties, respectively. Estrogen receptor and androgen receptor inhibitors were used to determine the mechanisms mediating hormone-oxidative stress interactions on cell viability. Since the presence of AR45 in the human brain tissue was unknown, we examined the postmortem brain tissue from men and women for AR45 protein expression.

RESULTS

Neither androgens nor estrogens were protective against subsequent oxidative stress insults in glial cells. However, these hormones exhibited neuroprotective properties in neuronal N27 and PC12 cells via the estrogen receptor. Interestingly, a window of opportunity exists for sex hormone neuroprotection, wherein temporary hormone deprivation blocked neuroprotection by sex hormones. However, if sex hormones are applied following an oxidative stressor, they exacerbated oxidative stress-induced cell loss in neuronal and glial cells.

CONCLUSIONS

Sex hormone action on cell viability is dependent on the cellular environment. In healthy neuronal cells, sex hormones are protective against oxidative stress insults via the estrogen receptor, regardless of sex chromosome complement (XX, XY). However, in unhealthy (e.g., high oxidative stress) cells, sex hormones exacerbated oxidative stress-induced cell loss, regardless of cell type or sex chromosome complement. The non-genomic AR45 receptor, which is present in humans, mediated androgen's damaging effects, but it is unknown which receptor mediated estrogen's damaging effects. These differential effects of sex hormones that are dependent on the cellular environment, receptor profile, and cell type may mediate the observed sex differences in oxidative stress-associated CNS disorders.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Symptomatic menopausal transition and risk of subsequent stroke

Objective

To examine the long-term risk of stroke in women who have experienced symptomatic menopausal transition.

Methods

In this nationwide, population-based cohort study conducted from January 1, 2000 to December 31, 2013, we identified 22,058 women with no prior history of stroke, who experienced symptomatic menopausal transition at ≥45 years of age. Moreover, 22,058 women without symptomatic menopause were matched by propensity scores and enrolled as a comparison group. The propensity score was calculated by using all characteristic variables of each subject, including demographics (age and monthly income), comorbidities (hypertension, hyperlipidemia, diabetes mellitus, obesity, chronic kidney disease, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, dysrhythmia, peripheral artery occlusive disease), Charlson’s comorbidity index score, clinic visit frequency, and long-term medications (antihypertensives, antidiabetic agents, statins, antiplatelets, aspirin, warfarin, and hormone replacement therapy). The primary endpoint was the development of stroke after the onset of symptomatic menopausal transition. The Fine and Gray’s proportional subhazards model was performed to assess the association between symptomatic menopausal transition and subsequent stroke. All subjects were followed up until December 31, 2013.

Results

During a mean follow-up of 8.5 years (standard deviation 4.7 years, maximum 14 years), 2,274 (10.31%) women with symptomatic menopausal transition, and 1,184 (5.37%) matched comparison participants developed stroke. The incidence rates were 11.17 per 1,000 person-years in the symptomatic menopausal transition group compared with 8.57 per 1,000 person-years in the comparison group. The risk of developing stroke was significantly higher in women with symptomatic menopausal transition (crude subhazard ratio, 1.31; 95% confidence interval (CI) [1.22–1.41]; P < 0.001). After adjusting for demographics, comorbidities, clinic visit frequency, and long-term medications, the risk of stroke remained statistically significant (adjusted subhazard ratio, 1.30; 95% CI [1.21–1.40]; P < 0.001). Moreover, subgroup analyses revealed no evidence for inconsistent effects for symptomatic menopausal transition on subsequent risk of stroke across all subgroups except age, comorbidities, hypertension, and use of antihypertensives. Women with early menopausal transition (before age 50), without comorbid condition, without hypertension, or without use of antihypertensives are at a higher risk of stroke. The longer duration of symptomatic menopausal transition was associated with higher risk of stroke (P for trend < 0.001).

Conclusion

In this large-scale retrospective cohort study, symptomatic menopausal transition was statistically significantly associated with a 30% increased risk of stroke. Further prospective studies are required to confirm our findings.

Age at natural menopause and risk of incident cardiovascular disease: a pooled analysis of individual patient data

Background

Early menopause is linked to an increased risk of cardiovascular disease mortality; however, the association between early menopause and incidence and timing of cardiovascular disease is unclear. We aimed to assess the associations between age at natural menopause and incidence and timing of cardiovascular disease.

Methods

We harmonised and pooled individual-level data from 15 observational studies done across five countries and regions (Australia, Scandinavia, the USA, Japan, and the UK) between 1946 and 2013. Women who had reported their menopause status, age at natural menopause (if postmenopausal), and cardiovascular disease status (including coronary heart disease and stroke) were included. We excluded women who had hysterectomy or oophorectomy and women who did not report their age at menopause. The primary endpoint of this study was the occurrence of first non-fatal cardiovascular disease, defined as a composite outcome of incident coronary heart disease (including heart attack and angina) or stroke (including ischaemic stroke or haemorrhagic stroke). We used Cox proportional hazards models to estimate multivariate hazard ratios (HRs) and 95% CIs for the associations between age at menopause and incident cardiovascular disease event. We also adjusted the model to account for smoking status, menopausal hormone therapy status, body-mass index, and education levels. Age at natural menopause was categorised as premenopausal or perimenopausal, younger than 40 years (premature menopause), 40–44 years (early menopause), 45–49 years (relatively early), 50–51 years (reference category), 52–54 years (relatively late), and 55 years or older (late menopause).

Findings

Overall, 301 438 women were included in our analysis. Of these 301 438 women, 12 962 (4·3%) had a first non-fatal cardiovascular disease event after menopause, of whom 9369 (3·1%) had coronary heart disease and 4338 (1·4%) had strokes. Compared with women who had menopause at age 50–51 years, the risk of cardiovascular disease was higher in women who had premature menopause (age <40 years; HR 1·55, 95% CI 1·38–1·73; p<0·0001), early menopause (age 40–44 years; 1·30, 1·22–1·39; p<0·0001), and relatively early menopause (age 45–49 years; 1·12, 1·07–1·18; p<0·0001), with a significantly reduced risk of cardiovascular disease following menopause after age 51 years (p<0·0001 for trend). The associations persisted in never smokers, and were strongest before age 60 years for women with premature menopause (HR 1·88, 1·62–2·20; p<0·0001) and early menopause (1·40, 1·27–1·54; p<0·0001), but were attenuated at age 60–69 years, with no significant association observed at age 70 years and older.

Interpretation

Compared with women who had menopause at age 50–51 years, women with premature and early menopause had a substantially increased risk of a non-fatal cardiovascular disease event before the age of 60 years, but not after age 70 years. Women with earlier menopause need close monitoring in clinical practice, and age at menopause might also be considered as an important factor in risk stratification of cardiovascular disease for women.

Funding

Australian National Health and Medical Research Council.

Age at natural menopause and physical functioning in postmenopausal women: the Canadian Longitudinal Study on Aging

OBJECTIVE

The aim of this study was to evaluate the association between categories of age at natural menopause (ANM) and gait speed (slowness) and grip strength (weakness), common measures of physical functioning in older women.

METHODS

We analyzed data from the Canadian Longitudinal Study on Aging, which included participants from seven cities across Canada collected in 2012. The sample was restricted to women who reported to have entered menopause (N = 9,920). Women who had a hysterectomy before menopause were excluded since the age at which this surgical procedure was performed was not available. ANM was categorized into five groups: less than 40 (premature), 40 to 44 (early), 45 to 49, 50 to 54, and more than 54. We conducted linear regressions to assess the association between ANM and gait speed (m/s) and grip strength (kg) adjusting for participant age, education, body mass index, smoking, use of hormone therapy, height, and province of residence.

RESULTS

Mean ANM was 49.8 (95% confidence interval [CI]: 49.7-50.0), with 3.8% of women having a premature menopause; the average gait speed was 0.98 m/s (standard deviation: 0.22), the average grip strength was 26.6 kg (standard deviation: 6.39). Compared to women with ANM of 50 to 54, women with premature menopause had 0.054 m/s (95% CI -0.083, -0.026) lower gait speed when adjusting for age and study site. In the fully adjusted model, the association was attenuated, 0.032 m/s (95% CI -0.060, -0.004). ANM was not associated with grip strength.

CONCLUSION

Our study suggests that premature menopause (<40 years) may be associated with lower gait speed (slowness) among Canadian women. No association was observed between ANM and grip strength. Future studies should include a life course approach to evaluate whether social and biological pathways modify the association between age at menopause and physical function in populations from different contexts.

Psychosomatic and vasomotor symptom changes during transition to menopause

Menopause is the condition in which the gradual decline in ovarian function finally leads to the permanent cessation of menstruation. Oestrogen deficiency may cause early symptoms during the menopausal transition and late symptoms after menopause. Menopause is a normal period of life. During this period, women need adaptation to new biological, social, and psychological parameters. Vasomotor symptoms are among the most common menopausal symptoms. Menopause per se is not correlated with specific psychiatric disorders, but data suggest that perimenopausal women are more likely to develop depressive disorders even without a previous history. Vasomotor symptoms are correlated with mood and sleep disturbances, neuroticism, anxiety, decreased cognitive function, and stress. Personality traits, social, and other factors are also important mediators of vasomotor symptoms during the menopausal transition phase.

This is a review based on the existing evidence concerning the correlation between psychosomatic and vasomotor symptoms of menopause during the menopausal transition period. Healthcare providers should take these correlations into consideration when planning the treatment of vasomotor symptoms. Vasomotor symptoms during menopause are associated with significant social costs. There are numerous traditional hormone therapy, and complementary and alternative therapy including over-the-counter treatments and dietary supplements for managing menopause-related vasomotor symptoms. Additional costs include follow-up physician visits, laboratory testing, management of adverse events, and loss of productivity at work. Social support and planning may help women to deal with menopausal symptoms and may reduce overall social costs during this transitional phase.

Age at natural menopause in Koreans: secular trends and influences thereon

OBJECTIVES

Age at natural menopause (ANM) has become an important health issue in older women. We explored secular trends in ANM in Korea during the past decade, and defined factors predicting ANM.

METHODS

A total of 12,761 naturally menopausal women were selected from the 2001 to 2014 data of the Korea National Health and Nutrition Examination Survey, stages II to VI. The participants were divided into four groups based on 5-year ANM categories: <45, 45 to 49, 50 to 54, and ≥55 years. To identify factors associated with ANM, the regression analysis was used.

RESULTS

Both the mean (SE) and median (SE) ANM were 49.30 (0.07) years. The cumulative proportion of women experiencing menopause before the age of 40, 45, 50, and 55 years was 3.6%, 11.8%, 46.0%, and 90.3%, respectively. The mean (SE) ANM in women born in 1929 or earlier, and between 1930 to 1934, 1935 to 1939, 1940 to 1944, and 1945 to 1949, was 47.9 (0.3), 48.1 (0.2), 48.8 (0.2), 50.1 (0.2), and 50.5 (0.1) years, respectively (P < 0.001). Residence in a rural area (odds ratio [OR] 1.82), low weight status (OR 1.61), a history of or current smoking, a low educational level, being without a partner, and participating in at least moderate physical activity (OR 1.47, 1.33, 1.32, and 1.26, respectively) were more likely to result in an early ANM. Women with prior childbirth were less likely to experience early menopause (OR 0.34). In contrast, late menopause was associated with obesity and being overweight (OR 1.63 and 1.27).

CONCLUSIONS

We found that the mean ANM exhibited upward secular trends. Socioeconomic status and lifestyle factors were the principal independent factors affecting ANM.

Sex-Specific Outcome Disparities in Patients Receiving Continuous-Flow Left Ventricular Assist Devices: A Systematic Review and Meta-analysis

Continuous-flow left ventricular assist devices (CF-LVADs) decrease mortality and improve quality of life in patients with advanced heart failure (HF). Their widespread utilization has led to concerns regarding increased adverse effects, especially in women. Nevertheless, sex-specific data remain limited. We searched Medline, Embase, Scopus, and the Cochrane Library for publications reporting sex-specific outcomes after CF-LVADs from January 2008 through January 2017. Outcomes were compared under the random-effects model and heterogeneity examined via χ test and I statistics. A total of 10 studies including 4,493 CF-LVAD recipients were included in the analysis (23.5% women). The overall rate of stroke was significantly higher in women (odds ratio [OR] 1.94; 95% confidence interval [CI] 1.32-2.84; p = 0.0007). This was true for ischemic strokes (OR 2.03; 95% CI 1.21-3.42; p = 0.008) and hemorrhagic strokes (OR 2.03; 95% CI 1.21-3.42; p = 0.008). Women were also more likely to develop right HF necessitating right ventricular assist device (RVAD) implantation (OR 2.12; 95% CI 1.08-4.15; p = 0.03). Other adverse events including renal failure, bleeding, and device-related infection were comparable for both genders. The overall mortality while on CF-LVAD was similar in both groups (OR 1.05; 95% CI 0.81-1.36; p = 0.71). Our analysis suggests that women are at greater risk of significant complications such as cerebrovascular events and right HF necessitating RVAD after CF-LVAD implantation. Further research is needed to better understand the mechanisms underlying these sex-specific outcome disparities.

Sex Differences in Ischemia/Reperfusion Injury: The Role of Mitochondrial Permeability Transition

Brain and heart ischemia are among the leading causes of death and disability in both men and women, but there are significant sex differences in the incidence and severity of these diseases. Ca²⁺ dysregulation in response to ischemia/reperfusion injury (I/RI) is a well-recognized pathogenic mechanism leading to the death of affected cells. Excess intracellular Ca²⁺ causes mitochondrial matrix Ca²⁺ overload that can result in mitochondrial permeability transition (MPT), which can have severe consequences for mitochondrial function and trigger cell death. Recent findings indicate that estrogens and their related receptors are involved in the regulation of MPT, suggesting that sex differences in I/RI could be linked to estrogen-dependent modulation of mitochondrial Ca²⁺. Here, we review the evidence supporting sex differences in I/RI and the role of estrogen and estrogen receptors in producing these differences, the involvement of mitochondrial Ca²⁺ overload in disease pathogenesis, and the estrogen-dependent modulation of MPT that may contribute to sex differences.

The role of smoking in the relationship between intimate partner violence and age at natural menopause: a mediation analysis

Background

Age at natural menopause (ANM) is considered as a biologic marker of health and ageing. The relationship between intimate partner violence (IPV) and ANM is currently unknown, and whether smoking plays a role in this relationship is unclear. The aim of this study was to examine the association between IPV and ANM and to quantify the effect mediated through smoking.

Methods

Data were drawn from the 1946–51 cohort of the Australian Longitudinal Study on Women’s Health, a prospective cohort study first conducted in 1996. History of IPV (yes or no) was self-reported at baseline. ANM was confirmed by at least 12 months of cessation of menses where this was not a result of medical interventions such as bilateral oophorectomy or hysterectomy and categorised as <45 (early menopause), 45–49, 50–51, 52–53, and ≥54 years. Regression models and mediation analyses based on the counterfactual framework were performed to examine the relationship between IPV and ANM and to quantify the proportion mediated through smoking (never, past, current <10, 10–19 and ≥20 cigarettes/day).

Results

Of 6138 women in the study with natural menopause, 932 (15%) reported a history of IPV and 429 (7.0%) had an early ANM (before age 45 years). Women with IPV were more likely to smoke and be heavy smokers (Odds Ratio: 2.77, 95% CI 2.19–3.51). Women with IPV were also at increased risk of early menopause (ANM <45 years) (Relative Risk Ratio: 1.36, 95% CI 1.03–1.80) after accounting for education level, income difficulties, age at menarche, parity, body mass index, and perceived stress, compared to the reference group (women without IPV and ANM at 50–51 years). This relationship was attenuated after adjusting for smoking (Relative Risk Ratio: 1.20, 95% CI 0.90–1.59). Mediation analysis showed that cigarette smoking explained 36.7% of the association between IPV and early menopause (ANM <45 vs. ≥45 years).

Conclusion

Cigarette smoking substantially mediated the relationship between IPV and early menopause. Findings suggest that as part of addressing the impact of IPV, timely interventions that result in cessation of smoking will partly mitigate the increased risk of early menopause.

Electronic supplementary material

The online version of this article (10.1186/s40695-017-0031-9) contains supplementary material, which is available to authorized users.

Prevalence and Correlates of Cognitive Impairment in Kidney Transplant Patients Using the DemTect-Results of a KTx360 Substudy

Cognitive impairment in kidney transplantation (KTx) patients is associated with allograft survival and mortality. However, the prevalence of cognitive impairment after KTx is still understudied. Thus, we aimed to assess the prevalence of cognitive impairment in KTx patients and to identify sociodemographic, medical, donation-specific, and psychological variables associated with cognitive impairment. In this cross-sectional two-center study, 583 KTx patients participated in a structured post-transplant care program. The DemTect was used to assess cognition, and cognitive impairment was defined as a score of < 13. Mean age was 52.11 years, 59% were male, 27.4% had ≥12 years of school attendance, and 85.9% had hypertension. The prevalence of cognitive impairment was 15.6%. Cognitive impairment was significantly associated with higher age, male sex, lower educational level, subjective perception of cognitive decline, higher rates of hypertension, lower kidney functioning, and obesity (BMI > 30 kg/m²). Using logistic regression analysis, all variables except age remained significant. Our results suggest that cognitive impairment affects a significant number of patients after KTx. Transplant centers may consider screening for cognitive impairment using objective tests, especially in patients with a high-risk profile. Furthermore, studies with longitudinal designs are required in order to assess moderators and mediators for cognitive trajectories.

Age at natural menopause and physical function in older women from Albania, Brazil, Colombia and Canada: A life-course perspective

OBJECTIVE

Grip strength and gait speed are objective measures of physical function, which in turn is an indicator of biological aging. We evaluate the association between age at natural menopause (ANM) and physical functioning in a sample of postmenopausal women drawn from the International Mobility in Aging Study (IMIAS).

STUDY DESIGN

Retrospective cohort study of 775 women aged 65-74, from Albania, Brazil, Colombia and Canada, who had experienced natural menopause.

MAIN OUTCOME MEASURES

Gait speed and grip strength were obtained following standardized protocols. The association between self-reported ANM (<40, 40-44, 45-49, 50-54 and ≥55) and gait speed (m/s) and grip strength (kg) was assessed by linear regression analyses adjusting for several life-course economic and reproductive exposures, height, BMI and smoking.

RESULTS

Overall, women with ANM ≥ 55 had higher gait speed than those with ANM 50-54 (β = 0.05; 95%CI: 0.01, 0.10). Women with ANM < 40 had significantly lower grip strength compared with all other groups (β= -2.58; 95%CI: -4.43, -0.74). In region-specific analyses, ANM was associated with grip strength in Albania and Latin America and with gait speed in Albania only. No associations were observed in Canada.

CONCLUSIONS

ANM is associated with markers of physical functioning. Differences across study sites suggest that women in socially disadvantaged areas may reach menopause with different physiological reserves than those from more advantaged settings, leading to greater losses in muscle strength in postmenopausal years. More work comparing distinct populations is needed to better understand the underlying mechanisms.

Contributions of sex to cerebrovascular function and pathology

Sex differences exist in how cerebral blood vessels function under both physiological and pathological conditions, contributing to observed sex differences in risk and outcomes of cerebrovascular diseases (CBVDs), such as vascular contributions to cognitive impairment and dementia (VCID) and stroke. Throughout most of the lifespan, women are protected from CBVDs; however, risk increases following menopause, suggesting sex hormones may play a significant role in this protection. The cerebrovasculature is a target for sex hormones, including estrogens, progestins, and androgens, where they can influence numerous vascular functions and pathologies. While there is a plethora of information on estrogen, the effects of progestins and androgens on the cerebrovasculature are less well-defined. Estrogen decreases cerebral tone and increases cerebral blood flow, while androgens increase tone. Both estrogens and androgens enhance angiogenesis/cerebrovascular remodeling. While both estrogens and androgens attenuate cerebrovascular inflammation, pro-inflammatory effects of androgens under physiological conditions have also been demonstrated. Sex hormones exert additional neuroprotective effects by attenuating oxidative stress and maintaining integrity and function of the blood brain barrier. Most animal studies utilize young, healthy, gonadectomized animals, which do not mimic the clinical conditions of aging individuals likely to get CBVDs. This is also concerning, as sex hormones appear to mediate cerebrovascular function differently based on age and disease state (e.g. metabolic syndrome). Through this review, we hope to inspire others to consider sex as a key biological variable in cerebrovascular research, as greater understanding of sex differences in cerebrovascular function will assist in developing personalized approaches to prevent and treat CBVDs.