Association of Vasomotor and Other Menopausal Symptoms with Risk of Cardiovascular Disease: A Systematic Review and Meta-Analysis

Health-related quality of life across menopausal stages among middle-aged Korean women

OBJECTIVES

We examined the health-related quality of life (HRQoL) during menopause transition (MT) among middle-aged Korean women.

METHODS

This cross-sectional study comprised 2,290 middle-aged women who completed web-based questionnaires between 2020 and 2022. Based on self-reported menstrual cycle patterns, menopause status was classified as premenopausal, early or late transition, or postmenopausal. HRQoL was assessed using the Patient-Reported Outcomes Measurement Information system, with all 29 items scored using a T-score metric. Multiple linear regression analyses were performed to investigate whether HRQoL varied based on MT stages. Antimüllerian hormone levels were used as an objective measure instead of self-reported menstrual status in the sensitivity analysis. Logistic regression models were used to estimate the prevalence ratios for moderate or severe HRQoL symptoms across menopausal stages.

RESULTS

The mean T-scores for anxiety, depression, and pain interference and intensity were significantly higher with advancing menopausal stage. Anxiety, depression, sleep disturbances, pain interference, and intensity were significantly and linearly positively correlated with MT stages after adjusting for potential confounders. Physical function significantly worsened in the late transition stage compared with premenopausal status ( β = -1.51 [95% CI, -2.72 to -0.31] in late MT and β = -1.92 [95% CI, -3.46 to -0.37] in postmenopause, P for trend = 0.007). However, no significant trends were observed in the sensitivity analysis using antimüllerian hormone levels. Women with moderate or severe symptoms in all domains except physical function had significantly higher prevalence ratios according to MT.

CONCLUSIONS

Overall HRQoL was lower with advancing menopausal stages. All symptoms should be monitored to control early transition symptoms. Thus, women undergoing MT should consistently assess and manage not only menopausal symptoms but also the overall quality of their health to prevent both menopause-specific and nonspecific conditions and their consequences.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Non-hormonal pharmacological interventions for managing vasomotor symptoms-how can we help: 2024 landscape

BACKGROUND

Vasomotor symptoms (VMS) affect 70% of menopausal women and are considered as hallmark symptoms of the menopausal transition experienced by over three quarters of women and severely by 25% of women. Estrogen withdrawal alone is not fully responsible for the onset of the menopausal vasomotor symptoms and the mechanism of altered thermoregulation appears to be centrally mediated with alterations in hypothalamic neurotransmitters playing a key part. The loss of thermoregulatory control coexists with the altered Kisspeptin- Neurokinin B-Dynorphin-expressing (KNDy) neurons of the arcuate nucleus signaling triggered by menopause.

OBJECTIVE

Aim of the review was to explore evidence-based non-hormonal pharmacological interventions for treating vasomotor symptoms.

METHODS

Comprehensive overview of relevant literature.

CONCLUSIONS

In the population where, hormonal options are contraindicated or not preferred by the patient, it is essential to explore evidence-based non-hormonal pharmacological interventions for treating vasomotor symptoms. The 2024 landscape of available treatments has expanded yet again, arming the providers with an even wider range of possibilities to help their patients. Fezolinetant, is the first NK3R antagonist developed for the purpose of treating hot flashes in menopausal women. NK3R antagonists provide a safe and effective treatment option for managing menopausal women with VMS.

A 2-year follow-up to a randomized controlled trial on resistance training in postmenopausal women: vasomotor symptoms, quality of life and cardiovascular risk markers

BACKGROUND

Most women experience vasomotor symptoms (VMS) during the menopausal transition. A 15-week resistance training intervention (RTI) significantly reduced moderate-to-severe VMS (MS-VMS) and improved health-related quality of life (HRQoL) and cardiovascular risk markers in postmenopausal women. Whether a short RTI could have long-term effects is unknown. We aimed to investigate whether there were intervention-dependent effects two years after a 15-week RTI on MS-VMS frequency, HRQoL, and cardiovascular risk markers in postmenopausal women.

METHODS

This observational prospective cohort study is a follow-up to a randomized controlled trial (RCT) on a 15-week RTI in postmenopausal women (n = 57). The control group had unchanged low physical activity during these first 15 weeks. At the follow-up contact two years post-intervention, 35 women agreed to participate in an additional physical visit at the clinic with clinical testing, blood sampling, and magnetic resonance imaging, identical to the protocol at the baseline visit at the start of the RCT.

RESULTS

Although all women showed reduced MS-VMS and increased moderate-to-vigorous physical activity (MVPA) over the 2-year follow-up compared to baseline, the groups from the original RCT (intervention group; IG, control group; CG) changed differently over time (p < 0.001 and p = 0.006, respectively) regarding MS-VMS. The IG maintained a significantly lower MS-VMS frequency than the CG at the 6-month follow-up. At the 2-year follow-up, there was no significant difference between the original RCT groups. No significant changes over time or differences between groups were found in HRQoL or cardiovascular risk markers. However, significant interactions between original RCT groups and time were found for visceral adipose tissue (p = 0.041), ferritin (p = 0.045), and testosterone (p = 0.010).

CONCLUSIONS

A 15-week resistance training intervention reduced MS-VMS frequency up to six months post-intervention compared to a CG, but the effect was not maintained after two years. The RTI did neither contribute to preserved improvements of cardiovascular risk markers nor improved HRQoL after two years compared to a CG.

TRIAL REGISTRATION

Clinical trials.gov registered ID: NCT01987778, trial registration date 2013-11-19.

Menopause transition and cardiovascular disease risk

The risk of cardiovascular disease (CVD) notably increases in the fifth decade of a woman's life, coinciding with the onset of menopause and occurring 10 years later than the similar age-related increase in men. Menopause marks a significant transition in a woman's life and is accompanied by cardiometabolic changes, including a shift in body composition, increased blood pressure, disruptions in lipoproteins, and insulin resistance. There is increasing evidence that the menopause transition is a risk factor for CVD, independent of age-related changes, especially considering that the earlier the onset of menopause, the greater is the CVD risk. Further, menopause-related symptoms such as vasomotor symptoms, sleep disturbances, and mood changes may all have a direct impact on CVD risk. In this review, we summarize the current literature regarding CVD in midlife women, focusing on the cardiometabolic changes related to ovarian aging versus chronological aging, as well as those related to specific menopause characteristics, including age, type of menopause and the use of menopause hormone therapy.

The menopausal transition period and cardiovascular risk

The menopausal transition period spans, on average, 2-8 years before the final menstrual period and is associated with an increase in clinical and subclinical cardiovascular risk. In this Review, we discuss the metabolic and cardiovascular changes that occur during the menopausal transition period and the role of ovarian ageing, chronological ageing and other ageing-related risk factors in mediating these changes. Disentangling the relative contributions of chronological and reproductive ageing to cardiovascular risk is challenging, but data from longitudinal studies in women transitioning from premenopause to post-menopause have provided valuable insights. We also discuss evidence on how cardiovascular risk is altered by premature or early menopause, surgical menopause, and vasomotor and other menopausal symptoms. Whether targeted interventions can slow the progression of atherosclerosis and subclinical disease during the menopausal transition, thus delaying or preventing the onset of cardiovascular events, remains to be determined. Furthermore, we consider the recommended strategies for cardiovascular risk reduction in women undergoing menopausal transition using the framework of the American Heart Association's Life's Essential 8 key measures for improving and maintaining cardiovascular health, and discuss the cardiovascular risks and benefits of menopausal hormone therapy. Finally, we also discuss novel therapies that might benefit this population in reducing cardiovascular risk.

Psychological Health and Ischemic Heart Disease in Women: A Review of Current Evidence and Clinical Considerations across the Healthspan

PURPOSE OF REVIEW

Psychological health encompasses a constellation of negative and positive factors-i.e., psychosocial stress, depression, anxiety, trauma, loneliness and social isolation, anger and hostility, optimism, and a sense of purpose. This narrative review presents current evidence at the intersection of psychological health, risk of ischemic heart disease (IHD), and IHD-related outcomes, with an emphasis on associations in women.

RECENT FINDINGS

For women, relations between psychological health and IHD reflect important sex and gender differences in biological and psychosocial factors. Although efforts devoted to understanding psychological health and IHD risk have varied by psychological factor-scientific evidence is strongest for psychosocial stress and depression, while anxiety, trauma, and positive psychological factors warrant more investigation-less optimal psychological health is consistently associated with an earlier and greater risk of IHD morbidity and mortality in women. Still, many past prospective studies of psychological factors and IHD risk had a limited representation of women, did not include analyses by sex, or failed to account for other influential, sex-specific factors. Thus, there are multiple pathways for further, rigorous investigation into psychological health-IHD associations, mechanisms, and empirically supported psychological interventions to mitigate IHD risk among women. Given the robust evidence linking psychological health with women's risk for IHD, implementing routine, brief, psychological screening is recommended. Significant life events, developmental milestones specific to women, and IHD diagnoses or events could cue further psychological assessment and referral, efforts which will mutually strengthen the evidence for integrated psychological and IHD care and delivery of such care to this vulnerable group.

Migraines, vasomotor symptoms, and cardiovascular disease in the Coronary Artery Risk Development in Young Adults study

OBJECTIVE

To examine whether vasomotor symptoms (VMS) and migraine headaches, hypothesized to be vasoactive conditions, are associated with greater risk for cardiovascular disease (CVD) events including strokes.

METHODS

We performed a secondary data analysis of a subset of women (n = 1,954) in the Coronary Artery Risk Development in Young Adults (CARDIA) study, a population-based cohort, which began data collection at 18 to 30 y of age. We examined whether migraine headaches and VMS trajectories (characterized as minimal, increasing, and persistent) at CARDIA year 15 examination were associated with higher risk of CVD events and stroke (both ischemic and hemorrhagic) using Cox proportional hazards regression models and adjustment for traditional CVD risk factors (age, cigarette use, and levels of systolic and diastolic blood pressure, fasting glucose, high- and low-density cholesterol, and triglycerides) and reproductive factors.

RESULTS

Among women with minimal VMS (n = 835), increasing VMS (n = 521), and persistent VMS (n = 598), there were 81 incident CVD events including 42 strokes. Women with histories of migraine and persistent VMS had greater risk of CVD (hazard ratio [HR], 2.25; 95% CI, 1.15-4.38) after adjustment for age, race, estrogen use, oophorectomy, and hysterectomy compared with women without migraine histories and with minimal/increasing VMS. After adjustment for CVD risk factors, these associations were attenuated (HR, 1.51; 95% CI, 0.73-3.10). Similarly, women with histories of migraine and persistent VMS had greater risk of stroke (HR, 3.15; 95% CI, 1.35-7.34), but these associations were attenuated after adjustment for CVD risk factors (HR, 1.70; 95% CI, 0.66-4.38).

CONCLUSIONS

Migraines and persistent VMS jointly associate with greater risk for CVD and stroke, although risk is attenuated with adjustment for traditional CVD risk factors.

Understanding of and clinical approach to cardiometabolic transition at the menopause

Cardiovascular disease (CVD) represents the leading cause of death and accounts for almost 50% of all deaths in women worldwide. The menopausal transition is associated with central body fat accumulation, a decrease in energy expenditure, weight gain, insulin resistance and a pro-atherogenic lipid profile. Moreover, menopause is independently associated with an adverse effect on functional and structural indices of subclinical atherosclerosis. Women with premature ovarian insufficiency have heightened CVD risk compared to women of natural age at menopause. Furthermore, women with severe menopausal symptoms may have a more adverse cardiometabolic profile than those without symptoms. We reviewed the latest evidence on the cardiovascular management of perimenopausal or postmenopausal women. Clinicians should aim for cardiovascular risk stratification, followed by dietary and lifestyle advice as required based on individual needs. The medical management of cardiometabolic risk factors at midlife should always be individualized, focusing on hypertension, diabetes and dyslipidemia. Menopausal hormone therapy, when prescribed for the management of bothersome menopausal symptoms or for the prevention of osteoporosis, has also a beneficial effect on cardiometabolic risk factors. This narrative review aims to summarize the cardiometabolic alternations occurring during the menopausal transition and to outline the appropriate prevention strategies to prevent future cardiovascular adverse outcomes.

Cardiovascular health and the menopause, metabolic health

Estrogen depletion following menopause predisposes to increased risk of cardiovascular disease (CVD), mainly due to ischemic heart disease. This is mostly evident in cases with premature menopause. The pathophysiological basis for this atherosclerotic process is the accumulation of several risk factors, such as abdominal obesity, atherogenic dyslipidemia, insulin resistance and arterial hypertension. The presence of vasomotor symptoms may further augment this risk, especially in women younger than 60 years. Menopausal hormone therapy (MHT) exerts many beneficial effects on lipid profile and glucose homeostasis as well as direct arterial effects, and may reduce CVD risk if initiated promptly (i.e.,<60 years or within ten years of the final menstrual period). Transdermal estradiol and micronized progesterone or dydrogesterone are the safest regimens in terms of venous thromboembolic events (VTE) and breast cancer risk. In any case, an individualized approach, taking into account the patient's total CVD, VTE and breast cancer risk, is recommended.

Menopausal symptoms and attitudes toward hormone replacement therapy among Israeli women

Menopause occurs around midlife and is an inevitable component of women's aging. The study aimed to investigate the associations between the lifetime prevalence of menopausal symptoms and health-related characteristics among Israeli postmenopausal women aged 55-75 years. Additionally, this study aimed to estimate the use of hormone replacement therapy (HRT) and women's attitudes toward this treatment. Data for this study were extracted from a cross-sectional national telephone survey conducted in Israel between 2018 and 2020. For the current study, only postmenopausal women aged 55-75 years were included. Multivariate analyses were used to identify demographic and health-related characteristics associated with menopausal symptoms. The study included 688 participants. Most (68.8%) reported one or more menopausal symptoms, specifically vasomotor symptoms (50.4%). According to the multivariate logistic regression analysis, menopausal symptoms were associated with moderate-high anxiety and/or depression symptoms (OR = 2.01, 95% CI 1.12-3.58) and with osteoporosis (OR = 1.78, 95% CI 1.08-2.92). Although most (78.3%) symptomatic women were bothered by their symptoms, 29.1% received any treatment for symptom relief and only 12.6% reported current or past use of HRT. The findings show that menopausal symptoms were associated with a higher prevalence of anxiety and/or depression symptoms and osteoporosis in the years following menopause. Most symptomatic women did not receive any treatment and the majority were against HRT. Knowledge and awareness about menopause and treatment options should be increased among Israeli women. Additionally, the promotion of positive attitudes toward menopause and HRT use among women and healthcare providers is strongly recommended.

Obesity and Severity of Menopausal Symptoms: a Contemporary Review

PURPOSE OF REVIEW

Vasomotor symptoms are frequently experienced by women during menopause and have been linked to obesity. Severity of menopausal symptoms is a distinct construct from presence of symptoms, and the relation between severity of symptoms and obesity is less established. The purpose of this brief narrative review was to summarize evidence from recent studies on associations between menopausal symptom severity and measures of obesity.

RECENT FINDINGS

Sixteen articles were identified that specifically assessed and reported on the severity of menopausal symptoms in relation to measures of obesity including body mass index (BMI), waist circumference, and waist-to-hip ratio. Most studies to date show that greater BMI, waist size, and waist-to-hip ratio are associated with greater severity of menopausal symptoms. Given the large segment of women who will experience symptoms and that severity of symptoms influences treatment decisions, future studies are needed to determine how weight management efforts may reduce the severity of menopausal symptoms.

[Russian eligibility criteria prescribing menopausal hormonal hormones therapy for patients with cardiovascular and metabolic diseases. Consensus document of the Russian Cardiological Society, Russian Society of Obstetricians and Gynecologists, Russian Association of Endocrinologists, Eurasian Association of Therapists, Association of Phlebologists of Russia]

Menopausal symptoms can disrupt the life course of women at the peak of their career and family life. Currently, the most effective treatment for these manifestations is menopausal hormone therapy (MHT). The presence of cardiovascular and metabolic diseases in itself does not exclude the possibility of prescribing MHT to relieve menopausal symptoms and improve quality of life. However, often an obstacle to the use of this type of hormonal therapy is the fear of doctors who are afraid of doing more harm to patients than good. Caution is especially important when it comes to women with underlying health conditions. Moreover, it should be recognized that there is a lack of high-quality research regarding the safety of MHT for major chronic non-infectious diseases and common comorbid conditions. The presented consensus document analyzed all currently available data obtained from clinical trials of various designs and created a set of criteria for the acceptability of prescribing MHT to women with concomitant cardiovascular and metabolic diseases. Based on the presented document, doctors of various specialties who advise women in menopause will receive an accessible algorithm that will allow them to avoid potentially dangerous situations and reasonably prescribe MHT in real practice.

[Russian Eligibility Criteria for Prescribing Menopausal Hormone Therapy to Patients With Cardiovascular and Metabolic Diseases. Consensus Document of RSC, RSOG, RAE, EUAT, RAP]

Menopausal symptoms can impair the life of women at the peak of their career and family life. At the present time, the most effective treatment for these manifestations is menopausal hormone therapy (MHT). The presence of cardiovascular and metabolic diseases in itself does not exclude the possibility of prescribing MHT to relieve menopausal symptoms and improve quality of life. However, often an obstacle to the use of this type of hormone therapy is the fear of physicians to do more harm to patients than good. Caution is especially important when it comes to women with concurrent diseases. Moreover, it should be recognized that there is a shortage of high-quality research on the safety of MHT for underlying chronic non-infectious diseases and common comorbidities. The presented consensus analyzed all currently available data from clinical trials of various designs and created a set of criteria for the appropriateness of prescribing MHT to women with concomitant cardiovascular and metabolic diseases. Based on the presented document, physicians of various specialties who advise menopausal women will receive an accessible algorithm that will allow them to avoid potentially dangerous situations and reasonably prescribe MHT in real-life practice.

Combined Therapy with Anthracyclines and GnRH Analogues for Breast Cancer: Impact on Ischemic Heart Disease

The combination of classic chemotherapy agents like anthracyclines with novel targeted medications has had a positive impact on women's survival from breast cancer. GnRH analogues are primarily employed to temporarily suppress ovarian function in premenopausal women with hormone-receptor-positive (HR+) breast cancer. Despite their benefits, the true degree of their collateral effects has been widely understudied, especially when it comes to ischemic heart disease. This review aims at summarizing the current state of the art on this issue, with particular focus on the risk for cardiotoxicity associated with the combined use of GnRH analogues and anthracyclines.

The association between depression during perimenopause and progression of chronic conditions and multimorbidity: results from a Chinese prospective cohort

PURPOSE

The association between perimenopausal depression and many chronic conditions among women has been well-established. However, the role of depression during perimenopause in the progression of multiple chronic conditions (multimorbidity) remains poorly understood.

MATERIAL AND METHODS

A total of 1,216 community-dwelling women in their perimenopause period between 2010 and 2016 were enrolled in our analysis, and followed up for the progression of multimorbidity. Depression, as well as its severity, was evaluated by the Center for Epidemiologic Studies Depression 10-item scale (CES-D-10). Progression of multimorbidity was defined as the first report of two or more chronic conditions for participants without multimorbidity or the new report of one or more conditions for those with multimorbidity. Univariable and multivariable Cox proportional hazards model and the restricted cubic spline regression model were performed to assess the prospective association between perimenopausal depression and the progression of multimorbidity.

RESULTS

A total of 480 (39.5%) women reported depression during perimenopause, and 529 (43.5%) women progressed to multimorbidity. After adjusting for socio-demographic and lifestyle factors, perimenopausal depression was independently associated with the progression of multimorbidity (hazard ratio [HR]: 1.34; 95% confidence interval [CI]: 1.13 to 1.60). Moreover, the severity of depression was positively and linearly associated with the progression of multimorbidity (P < 0.05).

CONCLUSIONS

Our finding reveals a prospective association between perimenopausal depression and the progression of multimorbidity, indicating interventions targeting perimenopausal depression may reduce the burden of chronic diseases and multimorbidity in women's post-menopausal life.

Vasomotor and other menopause symptoms and the prevalence of ideal cardiovascular health metrics among premenopausal stage women

OBJECTIVE

We examined the association between menopause symptoms and the prevalence of ideal cardiovascular health (CVH) metrics among premenopausal women.

METHODS

This cross-sectional study comprised 4,611 premenopausal women aged 42 to 52 years. Data for CVH metrics were collected during health screening examinations. Menopause symptoms were measured using the Korean version of the Menopause-Specific Quality of Life questionnaire. For vasomotor, psychosocial, physical, and sexual symptoms, participants were divided into absent or symptomatic groups, further divided into tertiles (range, 0-7; 7 being the most bothersome). Ideal CVH metrics were defined according to the American Heart Association Life Simple 7 metrics, except dietary component. Cardiovascular health metrics were scored from 0 (unhealthy) to 6 (healthy) and classified as poor (0-2), intermediate (3-4), and ideal (5-6). Multinomial logistic regression models were used to estimate the prevalence ratios for intermediate and poor CVH metrics using ideal CVH as the reference.

RESULTS

The overall and 4 menopause-specific quality of life domain scores were significantly associated with poorer CVH metrics scores in a dose-response manner ( P < 0.05). After adjusting for age, parity, education level, anti-Mullerian hormone levels, and alcohol intake, women with the most bothersome degree for vasomotor, psychosocial, physical, and sexual symptoms had significantly higher prevalence of poor CVH metrics, with corresponding prevalence ratios (95% confidence interval) of 2.90 (1.95-4.31), 2.07 (1.36-3.15), 3.01 (1.19-7.65), and 1.66 (1.15-2.39), respectively, compared with those without each vasomotor, psychosocial, physical, and sexual symptom.

CONCLUSIONS

Premenopausal stage women with either vasomotor or nonvasomotor menopausal symptoms have significantly higher prevalence of poor CVH metrics, compared with those without any menopausal symptoms.

Menopausal symptoms and cardiometabolic risk factors in middle-aged women: A cross-sectional and longitudinal study with 4-year follow-up

OBJECTIVE

To study associations of menopausal symptoms with cardiometabolic risk factors.

STUDY DESIGN

A cross-sectional and longitudinal study of a representative population sample of 1393 women aged 47-55 years with a sub-sample of 298 followed for four years. The numbers of vasomotor, psychological, somatic or pain, and urogenital menopausal symptoms were ascertained at baseline through self-report. Their associations with cardiometabolic risk factors were studied using linear regression and linear mixed-effect models. Models were adjusted for age, menopausal status, body mass index, the use of hormonal preparations, education, smoking, and alcohol consumption.

MAIN OUTCOME MEASURES

Cardiometabolic risk factors included total cholesterol, low-density and high-density lipoprotein cholesterol, blood pressure, glucose, triglycerides, total and android fat mass, and physical activity.

RESULTS

All cholesterol and fat mass measures had modest positive associations with menopausal symptoms. The number of vasomotor symptoms, in particular, was associated with total cholesterol (B = 0.13 mmol/l, 95 % CI [0.07, 0.20]; 0.15 mmol/l [0.02, 0.28]) and low-density lipoprotein cholesterol (0.08 mmol/l [0.03, 0.14]; 0.12 mmol/l [0.01, 0.09]) in cross-sectional and longitudinal analyses, respectively. However, these associations disappeared after adjusting for confounders. The number of symptoms was not associated with blood pressure, glucose, triglycerides, and physical activity. Menopausal symptoms at baseline did not predict the changes in the risk factors during the follow-up.

CONCLUSIONS

Menopausal symptoms may not be independently associated with cardiometabolic risk, and they do not seem to predict the changes in risk factors during the menopausal transition.

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

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

Vasomotor symptoms and risk of cardiovascular disease in peri- and postmenopausal women: A systematic review and meta-analysis

INTRODUCTION

Vasomotor symptoms (VMS) are the symptoms most frequently experienced by women transitioning to menopause and are a primary indication for menopausal hormone therapy. A growing body of evidence has associated the presence of VMS with future risk for cardiovascular disease (CVD) events. This study aimed to systematically evaluate, qualitatively and quantitatively, the possible association between VMS and the risk for incident CVD.

METHODS

This systematic review and meta-analysis included 11 studies evaluating peri- and postmenopausal women in a prospective design. The association between VMS (hot flashes and/or night sweats) and the incidence of major adverse cardiovascular events, including coronary heart disease (CHD) and stroke, was explored. Associations are expressed as relative risks (RR) with 95 % confidence intervals (CI).

RESULTS

The risk for incident CVD events in women with and without VMS differed according to the age of participants. Women with VSM younger than 60 years at baseline had a higher risk of an incident CVD event than women without VSM of the same age (RR 1.12, 95 % CI 1.05-1.19, I² 0%). Conversely, the incidence of CVD events was not different between women with and without VMS in the age group >60 years (RR 0.96, 95 % CI 0.92-1.01, I² 55%).

CONCLUSION

The association between VMS and incident CVD events differs with age. VMS increases the incidence of CVD only in women under 60 years of age at baseline. The findings of this study are limited by the high heterogeneity among studies, pertaining mainly to different population characteristics, definitions of menopausal symptoms and recall bias.

Gender Differences and Cardiometabolic Risk: The Importance of the Risk Factors

Metabolic syndrome (Mets) is a clinical condition characterized by a cluster of major risk factors for cardiovascular disease (CVD) and type 2 diabetes: proatherogenic dyslipidemia, elevated blood pressure, dysglycemia, and abdominal obesity. Each risk factor has an independent effect, but, when aggregated, they become synergistic, doubling the risk of developing cardiovascular diseases and causing a 1.5-fold increase in all-cause mortality. We will highlight gender differences in the epidemiology, etiology, pathophysiology, and clinical expression of the aforementioned Mets components. Moreover, we will discuss gender differences in new biochemical markers of metabolic syndrome and cardiovascular risk.

Impact of lifetime lactation on the risk and duration of frequent vasomotor symptoms: A longitudinal dose-response analysis

OBJECTIVE

To examine the association between lifetime lactation and risk and duration of frequent vasomotor symptoms (VMS).

DESIGN

Prospective cohort.

SETTING

USA, 1995-2008.

SAMPLE

2356 parous midlife women in the Study of Women's Health Across the Nation.

METHODS

Lifetime lactation was defined as the duration of breastfeeding across all births in months. We used generalised estimating equations to analyse risk of frequent VMS and Cox regression to analyse duration of frequent VMS in years.

MAIN OUTCOME MEASURES

Frequent VMS (hot flashes and night sweats) were measured annually for 10 years, defined as occurring ≥6 days in the past 2 weeks.

RESULTS

Overall, 57.1% of women reported hot flashes and 43.0% reported night sweats during follow-up. Lifetime lactation was inversely associated with hot flashes plateauing at 12 months of breastfeeding (6 months: adjusted odds ratio [AOR] 0.85, 95% confidence interval (CI) 0.75-0.96; 12 months: AOR 0.78, 95% CI 0.65-0.93) and was inversely associated with night sweats in a downward linear fashion (6 months: AOR 0.93, 95% CI 0.81-1.08; 18 months: AOR 0.82, 95% CI 0.67-1.02; 30 months: AOR 0.73, 95% CI 0.56-0.97). Lifetime lactation was associated with shorter duration of hot flashes and night sweats in a quadratic (bell-shaped) fashion. The association was strongest at 12-18 months of breastfeeding and significant for hot flashes (6 months: adjusted hazard ratio [AHR] 1.35, 95% CI 1.11-1.65; 18 months: AHR 1.54, 95% CI 1.16-2.03; 30 months: AHR 1.18, 95% CI 0.83-1.68).

CONCLUSIONS

Longer lifetime lactation is associated with decreased risk and duration of frequent VMS.

Perception of higher frequency of daily hot flashes in 50-year-old women today: a study of trends over time during 48 years in the Population Study of Women in Gothenburg, Sweden

OBJECTIVE

The aim of this study was to examine if there are any differences in the prevalence of daily hot flashes in 50-year-old women in a longitudinal perspective (from 1968 to 2017).

METHODS

Cohort comparisons of four population-based samples of 50-year-old women born in 1918, 1930 (earlier-born cohorts), 1954, and 1966 (later-born cohorts) from the Prospective Population Study of Women in Gothenburg examined in 1968-1969, 1980-1981, 2004-2005, and 2016-2017. Questions about frequency of hot flashes have been formulated in the same way throughout all follow-up examinations. Changes between four generations of 50-year-old women were studied.

RESULTS

In the unadjusted model, we found an increased prevalence of daily hot flashes in 50-year-old women born in 1954 and 1966 compared with 50-year-old women born in 1918 and 1930 (odds ratio, 1.74; 95% confidence interval, 1.37-2.22). When considering potential predictors for daily hot flashes (smoking, perceived level of high stress, BMI, waist-to-hip ratio, hormone therapy, and hormonal contraceptives) in the adjusted model, there was a notable difference; odds ratio increases from 1.74 to 1.92 (95% confidence interval, 1.46-2.52). Smoking frequency was substantially lower in the later-born cohorts, 39% compared with 17%.

CONCLUSIONS

In this prospective longitudinal study of 50-year-old women, we found nearly twice as high odds of reporting daily hot flashes in the later-born women compared with earlier-born. When controlling for potential predictors, there was still an obvious difference, which cannot be explained in our study. These findings have not earlier been described, and there is a need for further longitudinal population studies investigating the prevalence of hot flashes over time. Moreover, additional research is required exploring the underlying mechanism of hot flashes, as well as studies that take into account potential risk factors in the environment and societal development over time, that is, impacts of endocrine-disrupting chemicals changes in lifestyle, environmental, and dietary factors, as well as working conditions.

High low-density lipoprotein cholesterol level is associated with an increased risk of incident early-onset vasomotor symptoms

We investigated the associations between serum lipid profiles and risk of early-onset vasomotor symptoms (VMSs) in premenopausal women. This cohort study comprised 2,540 premenopausal women aged 42-52 years without VMSs at baseline (median follow-up: 4.4 years). VMSs, including hot flashes and night sweats, were assessed using the Menopause-Specific Quality of Life questionnaire (Korean version). Early-onset VMSs were defined as VMSs that occurred premenopause; moderate/severe VMSs were defined as a score of ≥ 3 points (range: 0 to 6, 6 being most bothersome). Cox proportional hazard regression models were used to estimate hazard ratios with 95% confidence intervals (CI) for the development of VMSs across the lipid levels. Higher low-density lipoprotein (LDL) cholesterol levels were positively associated with increased risk of early-onset VMSs. Compared to the < 100 mg/dL LDL group, the multivariable-adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for incident VMSs were 1.19 (1.03-1.37) and 1.20 (1.03-1.40) in participants with LDL cholesterol levels of 100-129 mg/dL and ≥ 130 mg/dL, respectively (P for trend = 0.027). The multivariable-adjusted HR for incident moderate/severe VMSs was 1.37 (95% CI: 1.08-1.73) in participants with LDL ≥ 130 mg/dL, compared to those with LDL < 100 mg/dL. Meanwhile, triglycerides and total and high-density lipoprotein cholesterol levels were not significantly associated with early-onset VMSs risk in premenopausal women. Premenopausal women with high serum LDL cholesterol concentrations had a higher risk of incident early-onset VMSs. Further studies should confirm our findings and examine whether LDL-lowering interventions reduce the risk of early-onset VMSs among women during menopause transition.

Ideal Cardiovascular Health Metrics and Risk of Incident Early-Onset Vasomotor Symptoms Among Premenopausal Women

CONTEXT

The relationship of ideal cardiovascular health (CVH) behaviors with preventing early-onset vasomotor symptoms (VMSs) is unknown.

OBJECTIVE

We investigated the association between CVH metrics and the development of early-onset VMSs in premenopausal women.

METHODS

This cohort study included 2541 premenopausal women aged 42 to 52 years without VMSs at baseline. CVH metrics were defined according to the American Heart Association Life Simple 7 metrics. Owing to limited availability of dietary information, CVH metrics were scored from 0 (unhealthy) to 6 (healthy) and classified into 3 groups: poor (0-2), intermediate (3-4), and ideal (5-6) CVH. VMSs, including hot flashes and night sweats, were assessed using the Menopause-Specific Quality of Life questionnaire. Moderate/severe VMSs was defined as a score of 3 or more points (range, 0 to 6; 6 being most bothersome).

RESULTS

During a median follow-up of 4.5 years, 1241 women developed VMSs before menopause. After adjustment for age, parity, education level, and alcohol consumption, the hazard ratio (HR) (95% CI) for developing early-onset VMSs comparing poor CVH group to the ideal group was 1.41 (1.07-1.86). CVH scores were also inversely associated with moderate/severe VMSs in a dose-response manner (P for trend = .004); specifically, multivariable-adjusted HRs comparing intermediate and poor CVH groups to the ideal group were 1.20 (95% CI, 1.02-1.43) and 1.57 (95% CI, 1.08-2.29), respectively.

CONCLUSION

Unfavorable CVH metrics were significantly associated with an increased risk of early-onset VMSs and its more severe forms among premenopausal women.

Mediating effects of sleep duration on the association between natural menopause and stroke risk among Chinese women

Background

Sleep disturbance is commonly reported by menopausal women. Stroke risk and poor stroke outcomes in women have usually been attributed to menopause. This study aimed to investigate the mediating effect of sleep duration on relationship between menopause and risk of stroke in natural menopause women.

Materials and methods

A cross-sectional study was performed, and participants were recruited through a multistage, stratified, probability proportional to size sampling method in this research. The stroke risk was measured using the risk assessment form for high-risk stroke population. The average sleep duration was calculated by adding up night sleep and afternoon nap duration. Multivariate regression analysis was conducted to identify the association between menopause, sleep duration, and stroke risk. The direct and indirect effects of menopause on stroke risk were analyzed by using the sleep duration in a mediation framework.

Results

Perimenopause, menopause, average sleep duration, and night sleep duration were significantly associated with stroke risk (P < 0.001), after adjusting for covariates. Perimenopause and menopause were significantly related to average sleep duration (P < 0.001) and night sleep duration (P < 0.001). The average sleep duration (ab = 0.016, 95% CI: 0.003, 0.030; ab = −0.048, 95% CI: −0.070, −0.027) partially mediated the relationship between menopause and stroke risk. And night sleep duration (ab = 0.024, 95% CI: 0.009, 0.040; ab = −0.054, 95% CI: −0.077, −0.033) played a major mediating role, in which night sleep duration of ≤5 h mediated the link between both perimenopause (ab = 0.707, 95% CI: 0.392, 1.021) and menopause (ab = −0.787, 95% CI: −1.096, −0.478) and stroke risk; both night sleep duration of >8–9 h (ab = 0.079, 95% CI: 0.010, 0.193) and >9 h (ab = 0.379, 95% CI: 0.086, 0.712) had mediating effects on perimenopause and stroke risk.

Conclusion

A significant relationship between menopause and stroke risk factors among natural menopausal status was found in this study. The average sleep duration, especially night sleep duration, partially mediated the association between menopause and stroke risk, which is a novel insight to the progression of stroke risk in Women. Suitable prevention methods and interventions for sleep in menopausal women may reduce the risk of stroke.

Sex hormones and immune system: Menopausal hormone therapy in the context of COVID-19 pandemic

The fatal outcomes of COVID-19 are related to the high reactivity of the innate wing of immunity. Estrogens could exert anti-inflammatory effects during SARS-CoV-2 infection at different stages: from increasing the antiviral resistance of individual cells to counteracting the pro-inflammatory cytokine production. A complex relationship between sex hormones and immune system implies that menopausal hormone therapy (MHT) has pleiotropic effects on immunity in peri- and postmenopausal patients. The definite immunological benefits of perimenopausal MHT confirm the important role of estrogens in regulation of immune functionalities. In this review, we attempt to explore how sex hormones and MHT affect immunological parameters of the organism at different level (in vitro, in vivo) and what mechanisms are involved in their protective response to the new coronavirus infection. The correlation of sex steroid levels with severity and lethality of the disease indicates the potential of using hormone therapy to modulate the immune response and increase the resilience to adverse outcomes. The overall success of MHT is based on decades of experience in clinical trials. According to the current standards, MHT should not be discontinued in COVID-19 with the exception of critical cases.

Management of menopause: a view towards prevention

Women spend approximately one-third of their lives with menopause, which occurs around 50 years of age. It is now appreciated that several important metabolic and cardiovascular disease risks emerge during the menopausal transition. Many important conditions occur 10-15 years after menopause, including weight gain and obesity, metabolic syndrome, diabetes, osteoporosis, arthritis, cardiovascular disease, dementia, and cancer; therefore, the occurrence of menopause heralds an important opportunity to institute preventative strategies. These strategies will lead to improved quality of life and decreased mortality. Various strategies are presented for treating symptoms of menopause and diseases that are asymptomatic. Among several strategies is the use of hormone therapy, which has efficacy for symptoms and osteoporosis, and can improve metabolic and cardiovascular health. When instituted early, which is key, in younger postmenopausal women (under 60 years) oestrogen has been found to consistently decrease mortality with a favourable risk-benefit profile in low-risk women. Prospective data show that long-term therapy might not be required for this benefit.

Comparison of urinary adiponectin in the presence of metabolic syndrome in peri- and postmenopausal women

Objectives

To find the association between urinary adiponectin and metabolic syndrome (MetS) in peri- and postmenopausal women and its potential application as a noninvasive screening for MetS.

Methods

A cross-sectional study was conducted in healthy peri- and postmenopausal women (defined by STRAW + 10 staging) aged at least 40 years who attended annual check-ups or menopause clinics were recruited. Baseline demographic data, MENQOL, anthropometric measurements, blood pressure, laboratory (FBS, total cholesterol, HDL-C, LDL-C, TG), and urinary adiponectin were collected. The MetS was diagnosed according to JIS 2009.

Results

290 peri- and postmenopausal women had participated. The prevalence of Mets among our participants was 18%. Urinary adiponectin levels were similar in peri- and postmenopausal women with and without MetS (2.6 ± 2.2 vs. 2.3 ± 1.9 ng/mL, respectively, P = 0.55). Urinary adiponectin provides no diagnostic value for MetS (AUC = 0.516).

Conclusions

Urinary adiponectin has no role in screening and diagnosing MetS in peri- and postmenopausal women. The quest toward noninvasive screening for MetS is still going on.

Prevalence of Psychosomatic and Genitourinary Syndrome Among Menopausal Women: A Systematic Review and Meta-Analysis

Introduction

The menopausal transition represents the passage from reproductive to non-reproductive life and is characterized by a number of menstrual disturbances. We systematically reviewed the evidence on the prevalence of psychosomatic and genitourinary syndrome among menopausal women and compared the risk of symptoms between premenopausal, perimenopausal, and post-menopausal women.

Methods

We performed a systematic search in MEDLINE, CINAHL, and ScienceDirect through March 2021. Case series/reports, conference papers and proceedings, articles available only in abstract form, editorial reviews, letters of communication, commentaries, systematic reviews, and qualitative studies were excluded. Two reviewers independently extracted and assessed the quality of data using the Joanna Briggs Institute Meta-Analysis. The outcomes were assessed with random-effects model using the Review Manager software.

Results

In total, 29 studies had a low risk of bias and were included in the review. Our findings showed that the pooled prevalence of somatic symptoms in post-menopausal women (52.6%) was higher than in the premenopausal and perimenopausal stages (34.6 and 39.5%, respectively). There was a low prevalence of psychological symptoms in premenopausal women (28.4%). The genitourinary syndrome was highest among post-menopausal women (55.1%), followed by perimenopausal (31.9%) and premenopausal (19.2%) women.

Conclusion

Post-menopausal women have a higher risk of experiencing menopausal symptoms particularly genitourinary syndrome than premenopausal and perimenopausal women. It is pertinent for healthcare professionals to evaluate the symptoms in order to provide them with a better quality of life.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021235958

Pregnancy and Reproductive Risk Factors for Cardiovascular Disease in Women

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

Relation between blood pressure and genito-urinary symptoms in the years across the menopausal age

OBJECTIVES

This study aimed to evaluate the relation between blood pressure (BP) or heart rate and genito-urinary symptoms in 504 women across the menopausal age (40-55 years old).

METHODS

In this multicenter, cross-sectional study, data of office systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate were related to the presence of vaginal dryness, dyspareunia, vaginal atrophy (VA), recurrent urinary infection (RUI), hot flushes (HF) or menopausal status.

RESULTS

Vaginal dryness (coefficient of linear regression β = 5.45, 95% confidence interval [CI] 2.01-8.89; p = 0.0001), VA (β = 3.79, 95% CI 0.84-6.74; p = 0.002) and RUI (β = 3.91, 95% CI 0.72-7.09; p = 0.0163) were independently related to SBP. Vaginal dryness (β = 3.28, 95% CI 0.95-5.61; p = 0.0058), and HF (β = 2.29, 95% CI 0.29-4.28; p = 0.025) were independently related to DBP. Dyspareunia (β = 2.11, 95% CI 0.50-3.72; p = 0.010) was independently related to heart rate. Hypertension was present in 17% of women. When corrected for body mass index (BMI), risk factors for hypertension were VA (OR 2.50, 95% CI 1.43-4.40; p = 0.0014), RUI (OR 1.94 95% CI 1.06-3.52; p = 0.0302) and HF (OR 2.01, 95% CI 1.15-3.50; p = 0.0141).

CONCLUSIONS

In women across the menopausal age, genito-urinary symptoms, more than HF, are associated with higher values of SBP, DBP, heart rate and hypertension.

Treatment of menopausal symptoms: concomitant modification of cortisol

OBJECTIVES

To evaluate whether change in menopausal symptoms is related to modification of 24-hour urinary cortisol.

METHODS

Sixty-nine postmenopausal women were treated for their menopausal symptoms with either estrogen progestin therapy (0.3 mg conjugate equine estrogens and 1.5 mg medroxyprogesterone acetate; n = 25), phytoestrogens (75 mg isoflavones, twice daily; n = 21) or acupuncture (once a week; n = 23). Baseline and treatment-induced changes of total and subscale scores (vasomotor, depression, anxiety, somatization, sexuality) of the Greene's Climacteric Scale and of 24-hour urinary cortisol were evaluated.

RESULTS

At baseline, 24-hour urinary cortisol was related to Greene's Climacteric Scale score (P < 0.0001). Independent determinants (R2 = 0.319) were the Greene's subscales scores of depression (with a mean difference of 24-h cortisol for score unit expressed as beta coefficient of regression (b) of 4.91, 95% CI 2.14-7.7; P = 0.0007), and of somatization (b 3.04 95% CI 0.69-5.4; P = 0.012). The Greene's Climacteric Scale score (-5.67 ± 6.8; P = 0.0001) and 24-hour cortisol (-23.6 ± 45.7 μg/24 h; P = 0.0001) declined after 3 months of treatment. Changes of 24-hour cortisol values were linearly related to changes of total Greene's Climacteric Scale score with a mean change for unit score (b) of 2.10, 95% CI 0.47-3.73; P = 0.012).

CONCLUSIONS

Present data indicate that greater reduction in menopausal symptoms is associated with a larger decrease in cortisol levels. Possible implication of this finding on the long-term consequences for women's health needs to be explored.

Susceptibility of Women to Cardiovascular Disease and the Prevention Potential of Mind-Body Intervention by Changes in Neural Circuits and Cardiovascular Physiology

Women have been reported to be more vulnerable to the development, prognosis and mortality of cardiovascular diseases, yet the understanding of the underlying mechanisms and strategies to overcome them are still relatively undeveloped. Studies show that women's brains are more sensitive to factors affecting mental health such as depression and stress than men's brains. In women, poor mental health increases the risk of cardiovascular disease, and conversely, cardiovascular disease increases the incidence of mental illness such as depression. In connection with mental health and cardiovascular health, the presence of gender differences in brain activation, cortisol secretion, autonomic nervous system, vascular health and inflammatory response has been observed. This connection suggests that strategies to manage women's mental health can contribute to preventing cardiovascular disease. Mind-body interventions, such as meditation, yoga and qigong are forms of exercise that strive to actively manage both mind and body. They can provide beneficial effects on stress reduction and mental health. They are also seen as structurally and functionally changing the brain, as well as affecting cortisol secretion, blood pressure, heart rate variability, immune reactions and reducing menopausal symptoms, thus positively affecting women's cardiovascular health. In this review, we investigate the link between mental health, brain activation, HPA axis, autonomic nervous system, blood pressure and immune system associated with cardiovascular health in women and discuss the effects of mind-body intervention in modulating these factors.

Machine Learning Approaches to Identify Factors Associated with Women's Vasomotor Symptoms Using General Hospital Data

BACKGROUND

To analyze the factors associated with women's vasomotor symptoms (VMS) using machine learning.

METHODS

Data on 3,298 women, aged 40-80 years, who attended their general health check-up from January 2010 to December 2012 were obtained from Korea University Anam Hospital in Seoul, Korea. Five machine learning methods were applied and compared for the prediction of VMS, measured by the Menopause Rating Scale. Variable importance, the effect of a variable on model performance, was used for identifying the major factors associated with VMS.

RESULTS

In terms of the mean squared error, the random forest (0.9326) was much better than linear regression (12.4856) and artificial neural networks with one, two, and three hidden layers (1.5576, 1.5184, and 1.5833, respectively). Based on the variable importance from the random forest, the most important factors associated with VMS were age, menopause age, thyroid-stimulating hormone, and monocyte, triglyceride, gamma glutamyl transferase, blood urea nitrogen, cancer antigen 19-9, C-reactive protein, and low-density lipoprotein cholesterol levels. Indeed, the following variables were ranked within the top 20 in terms of variable importance: cancer antigen 125, total cholesterol, insulin, free thyroxine, forced vital capacity, alanine aminotransferase, forced expired volume in 1 second, height, homeostatic model assessment for insulin resistance, and carcinoembryonic antigen.

CONCLUSION

Machine learning provides an invaluable decision support system for the prediction of VMS. For managing VMS, comprehensive consideration is needed regarding thyroid function, lipid profile, liver function, inflammation markers, insulin resistance, monocyte count, cancer antigens, and lung function.

A review of the impact of hormone therapy on prefrontal structure and function at menopause

The menopause transition arises mainly from a decline in ovarian function characterized by a decrease in levels of ovarian estrogens (estradiol) and progesterone in women. Menopausal hormone therapy (MHT) has been used to counteract menopause-associated symptoms in postmenopausal women. With the development of advanced brain imaging methods, understanding MHT-related effects on brain structures and functions could help advance our understanding of the biological consequence of MHT-related effects on behavior, thereby contributing to developing new strategies for optimizing brain health during the menopause transition. This review focuses on the human research related to the impact of MHT on structural and functional organization of the prefrontal cortex in postmenopausal women. Although such MHT-related effects on brain structures and functions have only begun to be understood, it may be useful to examine present findings to identify areas for future research.

Cardiovascular health after menopause transition, pregnancy disorders, and other gynaecologic conditions: a consensus document from European cardiologists, gynaecologists, and endocrinologists

Women undergo important changes in sex hormones throughout their lifetime that can impact cardiovascular disease risk. Whereas the traditional cardiovascular risk factors dominate in older age, there are several female-specific risk factors and inflammatory risk variables that influence a woman's risk at younger and middle age. Hypertensive pregnancy disorders and gestational diabetes are associated with a higher risk in younger women. Menopause transition has an additional adverse effect to ageing that may demand specific attention to ensure optimal cardiovascular risk profile and quality of life. In this position paper, we provide an update of gynaecological and obstetric conditions that interact with cardiovascular risk in women. Practice points for clinical use are given according to the latest standards from various related disciplines (Figure 1).

Age at menarche and risk of vasomotor menopausal symptoms: a pooled analysis of six studies

OBJECTIVE

To examine the association between age at menarche and risk of vasomotor menopausal symptoms (VMS) and whether midlife body mass index (BMI) modified the association.

DESIGN

A pooled analysis of six cohort studies.

SETTING

The International collaboration on the Life course Approach to reproductive health and Chronic disease Events (InterLACE).

POPULATION

18 555 women from the UK, USA and Australia.

METHODS

VMS frequency data (never, rarely, sometimes and often) were harmonised from two studies (n = 13 602); severity data (never, mild, moderate and severe) from the other four studies (n = 4953). Multinominal logistic regression models were used to estimate relative risk ratios (RRRs) and 95% CIs adjusted for confounders and incorporated study as random effects.

MAIN OUTCOME MEASURES

Hot flushes and night sweats.

RESULTS

Frequency data showed that early menarche ≤11 years was associated with an increased risk of 'often' hot flushes (RRR 1.48, 95% CI 1.24-1.76) and night sweats (RRR 1.59, 95% CI 1.49-1.70) compared with menarche at ≥14 years. Severity data showed similar results, but appeared less conclusive, with RRRs of 1.16 (95% CI 0.94-1.42) and 1.27 (95% CI 1.01-1.58) for 'severe' hot flushes and night sweats, respectively. BMI significantly modified the association as the risk associated with early menarche and 'often' VMS was stronger among women who were overweight or obese than those of normal weight, while this gradient across BMI categories was not as strong with the risk of 'severe' VMS.

CONCLUSIONS

Early age at menarche is a risk factor for VMS, particularly for frequent VMS, but midlife BMI may play an important role in modifying this risk.

TWEETABLE ABSTRACT

Overweight and obesity exacerbate the risk of vasomotor symptoms associated with early menarche.

Aerobic or resistance training improves autonomic control of circulation in oophorectomized rats with cardiometabolic dysfunctions: Impact on renal oxidative stress

Cardiovascular autonomic dysfunction is associated with end organ damage and increased risk of mortality. Menopause and metabolic syndrome increase the risk for cardiorenal complications. In this study, we investigated the effects of aerobic or resistance exercise training on autonomic control of circulation and renal oxidative stress in a model of menopause and metabolic syndrome. Female Wistar rats and spontaneously hypertensive rats (SHR) were divided into 5 groups (n = 8): control (C), hypertensive (H), and sedentary (FHO), aerobic trained (FHOTa) and resistance trained (FHOTr) oophorectomized hypertensive treated with fructose (100 mg/mL drink water for 19 weeks). The FHO group presented increased vascular sympathetic modulation (LF-SBP), impaired baroreflex sensitivity (BRS) associated with increased blood pressure (BP) when compared to the H group. Aerobic exercise training enhanced tachycardic responses, while resistance training improved bradycardic responses to BP changes, thus ameliorating BRS. Moreover, despite unchanged BP, both exercise training protocols were effective in preventing increase in LF-SBP, reduction in systemic nitric oxide bioavailability (NOx), and increase in oxidative stress in the renal tissue, by decreasing lipid and protein oxidation in renal tissue. Positive correlation between LF-SBP and renal lipoperoxidation (r = 0.63, p < 0.05), as well as a negative correlation between NOx and renal lipoperoxidation (r = -0.66, p < 0.05) were observed. In conclusion, both aerobic and resistance exercise training were effective in improving autonomic control of circulation and reducing renal oxidative stress, thus attenuating the deleterious effects induced by arterial hypertension and fructose overload in female rats after ovarian hormone deprivation.

Vasomotor menopausal symptoms and risk of cardiovascular disease: a pooled analysis of six prospective studies

BACKGROUND

Menopausal vasomotor symptoms (ie, hot flashes and night sweats) have been associated with unfavorable risk factors and surrogate markers of cardiovascular disease, but their association with clinical cardiovascular disease events is unclear.

OBJECTIVE

To examine the associations between different components of vasomotor symptoms, timing of vasomotor symptoms, and risk of cardiovascular disease.

STUDY DESIGN

We harmonized and pooled individual-level data from 23,365 women in 6 prospective studies that contributed to the International Collaboration for a Life Course Approach to Women's Reproductive Health and Chronic Disease Events consortium. Women who experienced cardiovascular disease events before baseline were excluded. The associations between frequency (never, rarely, sometimes, and often), severity (never, mild, moderate, and severe), and timing (before or after age of menopause; ie, early or late onset) of vasomotor symptoms and incident cardiovascular disease were analyzed. Cox proportional hazards models were used to estimate hazard ratios and 95% confidence intervals.

RESULTS

In the adjusted model, no evidence of association was found between the frequency of hot flashes and incident cardiovascular disease, whereas women who reported night sweats "sometimes" (hazard ratio, 1.22; 95% confidence interval, 1.02-1.45) or "often" (hazard ratio, 1.29; 95% confidence interval, 1.05-1.58) had higher risk for cardiovascular disease. Increased severity of either hot flashes or night sweats was associated with higher risk of cardiovascular disease. The hazards ratios of cardiovascular disease in women with severe hot flashes, night sweats, and any vasomotor symptoms were 1.83 (95% confidence interval, 1.22-2.73), 1.59 (95% confidence interval, 1.07-2.37), and 2.11 (95% confidence interval, 1.62-2.76), respectively. Women who reported severity of both hot flashes and night sweats had a higher risk for cardiovascular disease (hazard ratio, 1.55; 95% confidence interval, 1.24-1.94) than those with hot flashes alone (hazard ratio, 1.33; 95% confidence interval, 0.94-1.88) and night sweats alone (hazard ratio, 1.32; 95% confidence interval, 0.84-2.07). Women with either early-onset (hazard ratio, 1.38; 95% confidence interval, 1.10-1.75) or late-onset (hazard ratio, 1.69; 95% confidence interval, 1.32-2.16) vasomotor symptoms had an increased risk for incident cardiovascular disease compared with women who did not experience vasomotor symptoms.

CONCLUSION

Severity rather than frequency of vasomotor symptoms (hot flashes and night sweats) was associated with increased risk of cardiovascular disease. Vasomotor symptoms with onset before or after menopause were also associated with increased risk of cardiovascular disease.

Menopause Transition and Cardiovascular Disease Risk: Implications for Timing of Early Prevention: A Scientific Statement From the American Heart Association

Cardiovascular disease (CVD) is the leading cause of death in women, who have a notable increase in the risk for this disease after menopause and typically develop coronary heart disease several years later than men. This observation led to the hypothesis that the menopause transition (MT) contributes to the increase in coronary heart disease risk. Over the past 20 years, longitudinal studies of women traversing menopause have contributed significantly to our understanding of the relationship between the MT and CVD risk. By following women over this period, researchers have been able to disentangle chronological and ovarian aging with respect to CVD risk. These studies have documented distinct patterns of sex hormone changes, as well as adverse alterations in body composition, lipids and lipoproteins, and measures of vascular health over the MT, which can increase a woman's risk of developing CVD postmenopausally. The reported findings underline the significance of the MT as a time of accelerating CVD risk, thereby emphasizing the importance of monitoring women's health during midlife, a critical window for implementing early intervention strategies to reduce CVD risk. Notably, the 2011 American Heart Association guidelines for CVD prevention in women (the latest sex-specific guidelines to date) did not include information now available about the contribution of the MT to increased CVD in women. Therefore, there is a crucial need to discuss the contemporary literature on menopause and CVD risk with the intent of increasing awareness of the significant adverse cardiometabolic health-related changes accompanying midlife and the MT. This scientific statement provides an up-to-date synthesis of the existing data on the MT and how it relates to CVD.

Resistance training decreases plasma levels of adipokines in postmenopausal women

Physical inactivity and the onset of menopause increase the risk of cardiovascular disease amongst postmenopausal women. We aim to investigate the effect of resistance training (RT) on plasma levels of selected cytokines, adipokines, myokines, and sex hormones in postmenopausal women with vasomotor symptoms. This was a sub-study of a randomised controlled trial investigating the effects of RT on vasomotor symptoms in postmenopausal women. Women were randomised to join a 15-week RT program (n = 26) or remain sedentary as control (n = 29). Venous blood samples were taken at week-0 and week-15 for all participants. Enzyme-linked immunosorbent assays and multiple bead assays were used to measure cytokines, adipokines, myokines, and sex hormones in plasma. Plasma measurements of 16 of 33 analytes were within detectable limits. After adjusting for good compliance in the RT group (58% of RT participants), after 15 weeks, significantly lower plasma levels of adiponectin (p < 0.001), lipocalin-2 (p < 0.01) and resistin (p = 0.04) were found. Comparing control and RT women, using change-over-time values, significant increases in median testosterone and sex hormone binding globulin levels were seen in RT women. RT intervention lowers the levels of adipokines, particularly adiponectin, in postmenopausal women with vasomotor symptoms. These results were secondary outcomes of a clinical trial, and further investigations in a larger cohort are essential with the additional control of diet control and body composition analyses. Nevertheless, our study shows RT may be a beneficial intervention in reducing inflammation amongst postmenopausal women.

Perimenopausal vasomotor symptoms and the cortisol awakening response

OBJECTIVE

Vasomotor symptoms (VMS) are associated with a poorer cardiovascular risk profile. Although the mechanisms underlying this relationship are poorly understood, alterations of the hypothalamic-pituitary-adrenal (HPA) stress axis have been hypothesized to play a role. This study examined the within- and between-subject relationship between VMS and cortisol in a sample of healthy perimenopausal women.

METHODS

A total of 101 perimenopausal women, ages 45 to 55 years, were included in the study. Once a week for 12 weeks, participants completed a 24-hour hot flash diary assessing frequency and severity of VMS. They also provided two saliva samples for the measurement of the cortisol awakening response (CAR) - immediately upon waking and 30 minutes postwaking - and collected a urine sample for the measurement of a urinary metabolite of estradiol and progesterone: estrone-3-glucuronide and pregnanediol glucuronide, respectively. General linear models examined the between-subject relationship between mean VMS symptoms and mean CAR, whereas multilevel modeling was used to examine the relationship between within-person weekly changes on weekly CAR.

RESULTS

Within-subject weekly change in VMS bother, frequency, and severity were not significantly related to weekly CAR. Several significant between-subject effects of VMS on the CAR were, however, observed such that total number of hot flashes, overall VMS severity, and VMS bother, were each associated with a blunted CAR. Results remained significant despite statistically adjusting for levels of estrone-3-glucuronide, pregnanediol glucuronide, and self-reported sleep quality.

CONCLUSION

Findings suggest that women who suffer from more severe and bothersome perimenopausal VMS exhibit alterations in HPA axis activity. Within an individual, short-term changes in VMS are, however, not associated with concurrent changes in HPA axis functioning. Further research investigating the role of the HPA axis in linking VMS and increased cardiovascular disease risk is warranted. : Video Summary:http://links.lww.com/MENO/A607.