Correlates of Age at Natural Menopause in the Cohorts of Epic-Italy

Alcohol use at midlife and in menopause: a narrative review

Alcohol use disorder stands as a prevalent global issue, contributing to 140,000 annual deaths in the United States and causing numerous adverse health and socioeconomic outcomes. Despite being a natural physiological process, menopause often leads to troublesome symptoms that affect women's quality of life and exposes them to increased health risks. Our review delves into the intricate relationship between alcohol use disorder and the menopausal experience. We examine the impact of heightened alcohol consumption on the onset, severity, and burden of menopausal symptoms, particularly vasomotor symptoms. Additionally, we explore its effects on commonly experienced menopausal symptoms such as mood disturbances, sleep problems, and sexual dysfunction. Considering the chronic health conditions associated with both menopause and alcohol use disorder, our study also investigates the influence of alcohol use disorder on bone density. This is especially important due to the elevated risks and mortality linked to bone mineral density loss in menopausal women.

Is Alcohol Consumption Associated With Risk of Early Menopause?

Earlier age at menopause is associated with increased long-term health risks. Moderate alcohol intake has been suggested to delay menopause onset, but it is unknown whether alcohol subtypes are associated with early menopause onset at age 45 years. Therefore, we aimed to evaluate risk of early natural menopause among 107,817 members of the Nurses' Health Study II who were followed from 1989 to 2011. Alcohol consumption overall and by subtypes, including beer, red wine, white wine, and liquor, was assessed throughout follow-up. We estimated hazard ratios in multivariable models that were adjusted for age, body mass index, parity, smoking, and other potential confounders. Women who reported moderate current alcohol consumption had lower risks of early menopause than did nondrinkers. Those who reported consuming 10.0-14.9 g/day had a lower risk of early menopause than did nondrinkers (hazard ratio = 0.81, 95% confidence interval: 0.68, 0.97). Among specific beverages, evidence of lower early menopause risk was confined to consumption of white wine and potentially red wine and liquor, but not to beer. Data from this large prospective study suggest a weak association of moderate alcohol intake with lower risk of early menopause, which was most pronounced for consumption of white and red wine and liquor. High consumption was not related to lower risk of early menopause.

Association of alcohol consumption with the onset of natural menopause: a systematic review and meta-analysis

BACKGROUND

Early onset of menopause is associated with long-term health risks, including cardiovascular disease and premature death. Although alcohol intake has been suggested to affect the age at which natural menopause occurs, results from observational studies are not consistent.

OBJECTIVE AND RATIONALE

In the view of the differing risks to the health of early menopause and the increasing trends in alcohol consumption in women, in this systematic review, we aimed to quantify the association between all levels of alcohol consumption and menopause onset.

SEARCH METHODS

Six electronic databases (Medline, Embase, Cochrane, PubMed, Google Scholar and Web of Science) were systematically searched until 4 November 2015 to identify relevant studies assessing the association between alcohol consumption and onset of menopause. Two independent reviewers screened the titles and abstracts of all initially identified studies according to the selection criteria. Studies were sought if they (i) were observational cross-sectional, prospective and interventional studies, (ii) had reported on natural onset of menopause, (iii) had reported on alcohol consumption, (iv) had assessed the association between alcohol consumption and menopause onset, (v) were conducted in humans and (vi) were not conducted in patients with cancer. Data were extracted by two independent reviewers using a predesigned data-collection form. The primary exposure variable was the presence of active alcohol drinking at baseline compared with a reference group of non-drinkers. Pooled relative risks (RRs) were calculated.

OUTCOMES

Of the 1193 references (all in English language) reviewed for eligibility, 22 articles based on 20 unique studies were included in the final analysis. A total of 41 339 and 63 868 non-overlapping women were included in the meta-analysis of cross-sectional and observational cohort studies, respectively. In cross-sectional studies, the pooled RR for earlier onset of menopause was 0.86 (95% confidence interval (CI): 0.78-0.96) between drinkers versus non-drinkers. Analysis of the levels of alcohol consumed showed that low and moderate alcohol consumption (more than one drink per week (RR = 0.60; 95% CI: 0.49-0.75) and three or fewer drinks per week (RR = 0.75; 95% CI: 0.60-0.94)) were associated with later menopause onset, compared to non-drinkers. In prospective studies, RR for earlier menopause onset was 0.95 (95% CI: 0.91-0.98) when comparing women who reported drinking alcohol versus women who did not. Analysis of the dose of alcohol consumed showed that low-to-moderate alcohol intake (0-8 g/day (RR = 0.95; 95% CI: 0.93-0.98), and 16 g/day (RR = 0.89, 95%CI: 0.86-0.92)) was associated with later menopause onset, compared to non-drinking.

WIDER IMPLICATIONS

The findings of this review indicate that alcohol consumption, particularly low and moderate alcohol intake, might be associated with later onset of menopause although the magnitude of the association is low. Further studies are needed to corroborate these findings, clarify the level of alcohol intake at which menopause is delayed and identify the potential mechanisms behind this association.

Dynamics of the ovarian reserve and impact of genetic and epidemiological factors on age of menopause

The narrow standard age range of menopause, ∼50 yr, belies the complex balance of forces that govern the underlying formation and progressive loss of ovarian follicles (the "ovarian reserve" whose size determines the age of menopause). We show here the first quantitative graph of follicle numbers, distinguished from oocyte counts, across the reproductive lifespan, and review the current state of information about genetic and epidemiological risk factors in relation to possible preservation of reproductive capacity. In addition to structural X-chromosome changes, several genes involved in the process of follicle formation and/or maintenance are implicated in Mendelian inherited primary ovarian insufficiency (POI), with menopause before age 40. Furthermore, variants in a largely distinct cohort of reported genes-notably involved in pathways relevant to atresia, including DNA repair and cell death-have shown smaller but additive effects on the variation in timing of menopause in the normal range, early menopause (age <45), and POI. Epidemiological factors show effect sizes comparable to those of genetic factors, with smoking accounting for about 5% of the risk of early menopause, equivalent to the summed effect of the top 17 genetic variants. The identified genetic and epidemiological factors underline the importance of early detection of reproductive problems to enhance possible interventions.

Relaxation for perimenopausal and postmenopausal symptoms

BACKGROUND

Since the time of publication of the Women's Health Initiative (WHI) study, menopausal symptom management has become more complex because of increased awareness of the risks associated with hormone replacement therapy (HRT). Currently, a wide range of management options is available. Some women take prescription drugs, and others use self care strategies, including lifestyle modifications, over-the-counter preparations and complementary and alternative therapies, such as herbal preparations, exercise programmes and relaxation techniques. Relaxation techniques consist of a group of behavioural interventions. They are considered relatively harmless, but their effectiveness in treating vasomotor symptoms and sleep disturbances remains debatable. 

OBJECTIVES

To determine the effectiveness of relaxation techniques as treatment for vasomotor symptoms and associated sleep disturbances in perimenopausal and postmenopausal women.

SEARCH METHODS

Searches of the following electronic bibliographic databases were performed in February 2014 to identify randomised controlled trials (RCTs): the Cochrane Menstrual Disorders and Subfertility Group Specialised Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, AMED, PsycINFO, Social Science Citation Index and CINAHL. Handsearches of trial registers, relevant journals and published conference abstracts were also performed.

SELECTION CRITERIA

RCTs were included if they compared any type of relaxation intervention with no treatment or other treatments (except hormones) for vasomotor symptoms in symptomatic perimenopausal/postmenopausal women.

DATA COLLECTION AND ANALYSIS

Two review authors selected studies, assessed quality and extracted data. Included studies were combined, if appropriate, by using a random-effects model to calculate pooled mean differences and 95% confidence intervals.

MAIN RESULTS

Four studies were eligible for inclusion (281 participants): Two studies compared relaxation with electroacupuncture or superficial needling, one study compared relaxation with paced respiration or placebo control (α-wave electroencephalographic biofeedback) and one study compared relaxation with no treatment.No evidence was found of a difference between relaxation and acupuncture or superficial needle insertion in the number of hot flushes per 24 hours (mean difference (MD) 0.05, 95% confidence interval (CI) -1.33 to 1.43, two studies, 72 participants, I(2) = 0%; very low-quality evidence). Nor did any evidence suggest a difference between the two interventions in hot flush severity, measured using the Kupperman Index (MD -1.32, 95% CI -5.06 to 2.43, two studies, 72 participants, I(2) = 0%; very low-quality evidence).The other two studies found no clear evidence of a difference in hot flush frequency between relaxation and paced respiration, placebo or no treatment. The data for these comparisons were unsuitable for analysis.None of these studies reported night sweats, sleep disturbances associated with night sweats or adverse effects as an outcome.The main limitations of identified evidence were lack of data, imprecision and failure to report study methods in adequate detail.

AUTHORS' CONCLUSIONS

Evidence is insufficient to show the effectiveness of relaxation techniques as treatment for menopausal vasomotor symptoms, or to determine whether this treatment is more effective than no treatment, placebo, acupuncture, superficial needle insertion or paced respiration.

Increased long-term recreational physical activity is associated with older age at natural menopause among heavy smokers: the California Teachers Study

OBJECTIVE

Although physical activity modulates the hypothalamic-pituitary-ovarian axis, the few studies that have investigated whether physical activity is associated with age at natural menopause have yielded mixed results. We set out to determine whether physical activity is associated with the timing of natural menopause in a large cohort of California women overall and by smoking history.

METHODS

We investigated the association between long-term physical activity (h/wk/y) and age at natural menopause among 97,945 women in the California Teachers Study. Multivariable Cox proportional hazards regression methods were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). The impact of cigarette smoking (never smoker, former light smoker, former heavy smoker, current light smoker, and current heavy smoker) as an effect modifier was evaluated.

RESULTS

In a multivariable model adjusted for body mass index at age 18 years, age at menarche, race/ethnicity, and age at first full-term pregnancy, increased physical activity was statistically significantly associated with older age at natural menopause (P(trend) = 0.005). Higher body mass index at age 18 years (P(trend) = 0.0003) and older age at menarche (P(trend) = 0.0003) were also associated with older age at natural menopause. Hispanic ethnicity (vs non-Hispanic whites; HR, 1.17; 95% CI, 1.09-1.26), current smokers (vs never smokers; HR, 1.68; 95% CI, 1.60-1.75 for current light smokers; HR, 1.38; 95% CI, 1.33-1.44 for current heavy smokers), and older age at first full-term pregnancy (HR(≥29, 2+ full-term pregnancies) vs HR(<29, 2+ full-term pregnancies), 1.10; 95% CI, 1.06-1.14) were associated with earlier age at natural menopause. Upon stratification by smoking history, increased physical activity was statistically significantly associated with older age at natural menopause among heavy smokers only (HR(highest quartile) vs HR(lowest quartile), 0.88; 95% CI, 0.81-0.97; P(trend) = 0.02 for former heavy smokers; HR(highest quartile) vs HR(lowest quartile), 0.89; 95% CI, 0.80-0.99; P(trend) = 0.04 for current heavy smokers).

CONCLUSIONS

Age at natural menopause is a complex trait; the determinants of age at natural menopause, including physical activity, may differ by smoking status.

Early age of natural menopause in India, a biological marker for early preventive health programs

OBJECTIVE

The objective of the study 'Women's health at menopause across India' was to understand the experience of menopause in urban Indian women. The study aimed to ascertain the average age of menopause and its symptomatology, to study the prevalence of chronic diseases, and to understand the health status, health behavior and health needs of Indian women.

METHODS

This is a cross-sectional study of 1765 menopausal women carried out at ten clinical centers managed by gynecologists in urban India. Face-to-face interviews were conducted by gynecologists using a validated structured questionnaire in English.

RESULTS

A total of 1132 (64.14%) of the 1765 women had a natural menopause and 486 (27.54%) had a surgical menopause; 147 (12.99%) women (mean age 35.89 ± 3.02 years) were considered to have premature menopause. Out of 1765 women, 192 women were asymptomatic and 1573 reported symptoms. Vasomotor symptoms were reported by 1211 (75.3%) women and psychological symptoms by 999 (62.01%), physical ailments by 515 (32%) and genitourinary symptoms by 250 (15.53%). Diabetes mellitus was reported by 11.7% and hypertension by 21.9%.

CONCLUSION

The average age of menopause in the sample studied is 46 years. Chronic diseases are on the rise and osteoporosis presents a decade earlier than in Caucasians. These findings can be a basis for further research and help to understand the symptoms, health status and health needs, to formulate guidelines, and to establish menopause clinics for screening and managing women in the transition phase in India.

Variability of reproductive history across the Swiss SAPALDIA cohort – Patterns and main determinants

BACKGROUND

Reproductive characteristics play an aetiological role for many diseases, including reproductive cancers. They have been shown to vary internationally and nationally, but have not yet been described for the whole Swiss population.

AIM

The study investigated the variability of reproductive characteristics, their patterns, and main determinants across a population-based female study population in Switzerland.

METHODS

Reproductive characteristics obtained from 3119 women (28-72 years) participating in the SAPALDIA cohort survey in 2001-2003 are described across birth cohorts, study areas, language regions, and levels of urbanization. Determinants of age at menopause were analysed by Cox regression.

RESULTS

Reported median age at menarche was 13 years and median age at natural menopause was 52 years. The prevalence of nulliparity was 27%, and the fertility rate 1.6. Across birth cohorts there was a decline of menarcheal age and fertility rates, and an increase of nulliparity and age at last pregnancy. All characteristics varied across study areas, language regions, and levels of urbanization. Smoking, parity, and physical exercise were stronger predictors of earlier (<52 years) than older (>52 years) menopausal age.

CONCLUSION

Reproductive events show secular and geographic variation within Switzerland. Smoking, parity and physical activity significantly predict age at natural menopause, particularly before age 52. The secular trend of earlier menarche and increased nulliparity may result in a higher risk of reproductive cancers in younger generations.

The relationship between smoking and age at the menopause: A systematic review

CONTEXT AND OBJECTIVE

Increasing life expectancy has made it ever more important to study the factors that influence the age at the menopause, given that when it is reached outside of the normal range, it is associated with increased risk of osteoporosis and cardiovascular diseases, among other conditions. Among the factors studied in relation to early menopause, smoking is prominent. Destruction of the ovarian follicles is one of the mechanisms postulated for this effect. The aim of this study was to review and describe the associations between age at the menopause and the habit of smoking, its duration and its intensity.

METHOD

A systematic review of the literature indexed in the MEDLINE and LILACS databases was conducted, without restriction on publication date. After initially identifying 1325 articles and preselecting 161 articles for consideration of their complete texts, 96 articles reporting on the results from 109 studies were selected for analysis.

RESULTS

A great majority of the studies reported an association between the habit of smoking and early menopause, but there was no clear evidence that the duration of smoking and quantity of cigarettes smoked had any association with age at the natural menopause.

CONCLUSION

Additional studies are needed, preferably of prospective nature and with a large number of women, in order to deepen the knowledge of the effects of various aspects of smoking on age at the menopause. Experimental studies on animals may also contribute towards clarifying the physiopathological mechanisms through which smoking influences age at the menopause.

Menopause in Egypt: past and present perspectives

The mean age of the menopause in Egypt is 46.7 years, which is low compared to many countries, but this age has been rising recently. The incidence of menopause-associated symptoms in Egyptian women is higher than in the West, probably because of the different 'sociocultural attitudes' towards the menopause in different communities. Bone mineral density charts have been constructed for Egyptian women and show that, in general, they have a lower bone mineral density compared to their Western counterparts. After the menopause, they suffer from osteoporosis, particularly at the femoral neck. Egyptian women do not know much about the menopause, except that the incidence of osteoporosis is increased. Their attitude towards the menopause is generally positive and about one-third of them regard the menopause as 'a normal physiological change'. Nevertheless, there exists a need for an awareness campaign in order to educate them about this important stage of their lives.

Menopausal status and factors affecting cessation of menses in the region of Bonn, Germany

Because of the high prevalence of hormone use and reproductive surgeries in Western women natural menopause is a less frequent condition. Our aim was to examine the influences of hormonal and other factors on timing of cessation of menses. We analysed population controls of a German case-control study on breast cancer risks. The sample comprised N=829 women without hysterectomy or bilateral oophorectomy. We estimated the risk for the occurrence of last menses by Cox proportional hazard modelling. For calculating hazard rate ratios (HRR) and 95% confidence intervals (CI) women with menstrual cycles up to one year before interview were censored at that age. Median age at cessation of menses was 50 years (inter-quartile range 47–53 years). A significant later cessation of menses resulted from oral contraceptive use (HRR 0.74, 95% CI 0.59–0.93 for up to 10 years), and hormone therapy use until last menses (HRR 0.57, 95% CI 0.47–0.70). Also, thyroidal medications were associated with a delayed cessation of menses (HRR 0.64, 95% CI 0.42–0.96 for more than 10 years of use). Smoking until at least two years before last menses and allergies revealed an earlier cessation of bleedings (HRR 1.50, 95% CI 1.22–1.83 and HRR 1.28, 95% CI 1.07–1.53 respectively). Natural menopause is difficult to determine. Factors affecting the ovaries or the endocrine system can modulate timing of menopause. Endocrine biomarkers should be additionally taken into account when defining menopausal status.

Premenopausal factors influencing premature ovarian failure and early menopause

OBJECTIVES

We conducted this study to examine premenopausal risk factors associated with premature ovarian failure (POF) and early menopause (EM) among Korean women.

METHODS

A 73% of total women aged 30-69 at four districts in the KMCC (Korean Multi-center Cancer Cohort) was participated in this study during 2002-2003. We selected 137 POF and 281 EM cases who had menopause before age 40 and at age 40-44, respectively, and 1318 normal menopause (NM) controls that experienced menopause at age 45-60, and among them, selected idiopathic POF (n=84) and EM (n=261) after excluding surgical/medical menopause. We collected the information of premenopausal lifestyle and reproductive risk factors. Multivariate and polytomous logistic regression were used to estimate POF and EM risk and to differentiate POF and EM risk using ordinal and nominal scale.

RESULTS

Cigarette smoking was associated with an increased risk of idiopathic POF (OR=1.82 [1.03-3.23]), whereas oral contraceptive use was associated with a reduced risk of natural EM (OR=0.62 [0.43-0.90]). Idiopathic POF risk by both factors differed from idiopathic EM risk (p-nominal<0.05). Factors related to ovulation, such as later menarche, irregular menstruation and longer breast feeding cumulatively reduced the risk of natural EM and POF (p-ordinal<0.05). In analysis including medical and surgical menopause, lung tuberculosis, hysterectomy, past cancers, and lower number of deliveries before menopause were associated with POF.

CONCLUSIONS

Our findings indicate that etiology in POF development may partly differ from that in EM.

Predictive factors for age at menopause in Caucasian females

OBJECTIVE

Early onset of menopause results in the premature exposure to low estrogen levels and is associated with a number of postmenopausal health problems and higher risk of mortality. The aim of this study was to determine genetic and environmental factors associated with age at natural and surgical menopause.

METHODS

Multiple regression analysis using a sample of Caucasians composed of 154 females with surgical and 248 with natural menopause.

RESULTS

Breastfeeding is a significant predictor of earlier natural menopause (P<0.05). Use of oral contraceptives and smoking were not significantly associated with age at menopause. Females who did not have history of pregnancies are at significantly higher risk (P<0.001) of getting early surgical menopause than those who did. We also tested the association of seven single nucleotide polymorphisms (SNPs) of the estrogen receptor alpha (ER-alpha) gene with age at menopause. No association was observed with age at menopause but the PvuII p allele was overrepresented in women with surgical menopause and associated with menopause per se (P=0.029; OR=1.8, 95% CI=1.1-3.0).

CONCLUSIONS

Breastfeeding and alcohol consumption are significantly associated with earlier natural menopause. No significant effects of the ER-alpha genotypes were observed on the age of menopause. Given the important role of the ER-alpha in estrogen signaling, which directly influences the menopausal process, further studies are required to better define the relationship between this gene and age at menopause.

Age at natural menopause in Spain and the United States: results from the DAMES project

Our research was undertaken to determine the median age of natural menopause and correlates of the timing of menopause in Spain and the United States (U.S.). A population-based sample of 300 women from Madrid, Spain and a random sample of 293 women from Fallon Community Health plan (FCHP), a health maintenance organization (HMO) in central Massachusetts, were interviewed using a semi-structured questionnaire. Logit analysis and logistic regression were used to estimate the median age at menopause and identify factors associated with it. The median age of natural menopause in Spain is estimated at 51.7 years, and in the U.S., it is 52.6 years. In Spain, women with any children (OR = 0.58, 95% CI: 0.25, 1.36) and a lower body mass index (BMI) (OR = 0.45, 95% CI: 0.27, 0.78) had later ages at menopause while current smokers (OR = 5.51, 95% CI: 1.82, 16.7) had earlier ages of menopause in a multivariate model. A multiplicative interaction between smoking status and parity was identified, and an interaction term included in the multivariate model (OR = 0.58, 95% CI: 0.35, 0.94). In the U.S., household income, marital status, and education level were statistically associated with age at natural menopause in bivariate models. These factors were no longer statistically significant after adjustments in a multivariate model. Oral contraceptive use, cycle length, and cycle regularity were not statistically associated with the age of menopause in either country. The ages of natural menopause in Spain and the U.S. are comparable to other industrialized nations. The factors associated with the timing of natural menopause, in particular smoking and BMI, are consistent with those identified in previous studies.

Serum dioxin concentrations and age at menopause

2,3,7,8-Tetrachlorobenzo-p-dioxin (TCDD), a halogenated compound that binds the aryl hydrocarbon receptor, is a by-product of numerous industrial processes including waste incineration. Studies in rats and monkeys suggest that TCDD may affect ovarian function. We examined the relationship of TCDD and age at menopause in a population of women residing near Seveso, Italy, in 1976, at the time of a chemical plant explosion. We included 616 of the women who participated 20 years later in the Seveso Women's Health Study. All women were premenopausal at the time of the explosion, had TCDD levels measured in serum collected soon after the explosion, and were > or = 35 years of age at interview. Using proportional hazards modeling, we found a 6% nonsignificant increase in risk of early menopause with a 10-fold increase in serum TCDD. When TCDD levels were categorized, compared with women in the lowest quintile (< 20.4 ppt), women in quintile 2 (20.4-34.2 ppt) had a hazard ratio (HR) of 1.1 (p = 0.77), quintile 3 (34.3-54.1 ppt) had an HR of 1.4 (p = 0.14), quintile 4 (54.2-118 ppt) had an HR of 1.6 (p = 0.10), and quintile 5 (> 118 ppt) had an HR of 1.1 (p = 0.82) for risk of earlier menopause. The trend toward earlier menopause across the first four quintiles is statistically significant (p = 0.04). These results suggest a nonmonotonic dose-related association with increasing risk of earlier menopause up to about 100 ppt TCDD, but not above.