Well-being and the menopausal transition

The role of physical activity in the link between menopausal status and mental well-being

Objective:

To examine the relationship between menopausal status and mental well-being, and whether this relationship varies as a function of physical activity (PA).

Methods:

Based on a hormonal analysis and bleeding diary, women aged 47 to 55 were categorized as pre (n = 304), early peri (n = 198), late peri (n = 209), or postmenopausal (n = 387). Mental well-being was assessed using the Centre for Epidemiologic Studies Depression Scale, the International Positive and Negative Affect Schedule Short Form, and the Satisfaction with Life Scale. PA was self-reported and categorized as low, medium, and high. Associations between variables were analyzed using multivariate linear regression adjusted for age, marital and employment status, parity, self-reported mental disorder, use of psycholeptics and psychoanaleptics, and menopausal symptoms.

Results:

Depressive symptoms were lower amongst the pre than postmenopausal women (B = 0.07, confidence interval 0.01-0.13). Menopausal symptoms attenuated these associations. Menopausal status showed no associations with life satisfaction, or with positive or negative affectivity.

Women with high PA scored higher on positive affectivity, and the pre, early peri, and postmenopausal women scored higher on life satisfaction (B = 0.79, P < 0.001; B = 0.63, P = 0.009; B = 0.42, P = 0.009, respectively) and scored lower on depressive symptoms (B = −0.13, P = 0.039; B = −0.18, P = 0.034; and B = −0.20, P < 0.001, respectively) than their low PA counterparts. The pre and postmenopausal women with medium PA scored higher on life satisfaction (B = 0.54, P = 0.001; B = 0.038, P = 0.004, respectively) than those with low PA.

Conclusions:

Postmenopausal women reported marginally higher depressive symptoms scores compared with premenopausal women, but menopause was not associated with positive mental well-being. However, this association varies with the level of PA.

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Mid-life predictors of late-life depressive symptoms; determining risk factors spanning two decades in the Women's Heathy Ageing Project

Background

Data available from longitudinal studies of adequate duration to explore midlife risk factors for late life higher depressive symptom scores in women is lacking. This study examines midlife (mean ages 50 years and 60 years) predictors of late life (mean age 70 years) depressive symptom scores to enrich our understanding of the role of changing risk factors across the lifespan.

Methods

This investigation was an assessment of the long-term impact of lifestyle and health variables on depressive symptoms. Data were drawn from an epidemiological prospective study of women's healthy ageing spanning two decades. Variables included assessment of mood, demographics, physical health, smoking status, attitudes towards ageing and menopause, alcohol consumption and employment. Analysis was conducted to determine the set of strongest predictors assessed in 1992 (mean age 50 years) and in 2002 (mean age 60 years) in relation to higher CESD-SF scores measured in 2012 (mean aged 70 years (n = 249)). A cross-sectional analysis determining concurrent associations at mean age 70 years was also conducted.

Results

An increase in positive mood at 50 and 60 years was associated with a 0.3 (95% CI 0.1-0.5) and 0.4 (95%CI 0.1-0.8) point reduction in CESD score at 70 years respectively. An increase in Hassles score at age 50 was associated with a 0.18-point increase in CESD (95% CI 0.01-0.05) 20 years later. However, no relationship was observed between Hassles score at 60 and CESD 10 years later. Analysis of concurrent risk factors demonstrated that bothersome symptom frequency and higher anxiety were associated with higher depressive symptom scores when women were 70 years.

Conclusion

Low levels of positive mood were consistently associated with depressive symptoms scores 10 and 20 years later, suggesting clinical interventions aimed at improving positive affect may be particularly useful across the midlife.

Depression During the Menopausal Transition

The perception that menopause leads to mood disturbances such as depression has a long history. How did these beliefs come about, and are they supported by the scientific literature? This article reviews the theories of menopause and depression, the scientific literature, and the implications of these findings for prevention and treatment. Epidemiologic studies of menopausal status and depression do not provide consistent evidence of an association between the menopausal transition and depression among the general population of women. Depression experienced by women transitioning through menopause may be attributed to factors unrelated to menopause. A subset of women, however, may be more vulnerable to the effects of hormonal changes. For some women, short-term estrogen replacement therapy to relieve vasomotor symptoms may be beneficial, although for others psychotherapy or antidepressants may be more appropriate. Additional research is needed to better understand the association between different stages of the menopausal transition and dysphoric mood or depression, and better identification of women potentially at risk for depression during the menopausal transition.

The trajectory of negative mood and depressive symptoms over two decades

OBJECTIVE

Research aimed at understanding the temporal characteristics of depressive symptoms and negative mood in an older female population is lacking, despite the relationship between the two factors being well established. The aim of this study was to examine the characteristics of negative mood scores and depressive symptom scores in a longitudinal sample of women transitioning from mid-life to late life.

STUDY DESIGN

This study was a longitudinal assessment of variables drawn from an epidemiological prospective study of women's healthy ageing. Scores were analysed using General Linear Mixed Models.

MAIN OUTCOME MEASURES

Negative mood scores derived from the Affectometer 2 were assessed at 11 time points spanning 20 years. Depressive symptom scores were assessed using the Centre for Epidemiological Studies Depression Scale (CESD), administered in 2002, 2004 and 2012.

RESULTS

Mean negative mood scores reduced significantly between 1992 and 2012, as did mean CESD scores between 2002 and 2012. Mean negative mood scores reduced by 0.007 for each year of increasing age. For depressive symptoms, a reduction in mean score of 0.15 was found for each year of increase in age.

CONCLUSION

Depressive symptom scores and negative mood scores decreased significantly over time.

Cohort profile: Women's Healthy Ageing Project (WHAP) - a longitudinal prospective study of Australian women since 1990

Background

The cohort was commenced to examine women’s health from midlife (45–55 years) before the menopausal transition and into ageing.

Methods

Randomised selection and assessment of 2,001 women living in the Melbourne metropolitan area was conducted by the Roy Morgan Centre in 1990/91. Of the 779 women who met the entry criteria for the longitudinal follow-up (aged 45–55 years, menstruating, having a uterus and at least one ovary and not taking hormone therapy) 438 agreed to be seen annually across the menopausal transition from 1992 to 1999. Longitudinal prospective follow-up since 2000 has continued intermittently (2002/03, 2004/05, 2012/13, 2014/15). Data collection has included fasting biomarkers in each year since 1992, clinical assessment, lifestyle and quality of life data, physical measures and validated questionnaire data. Participants have consented to data linkage and, to date, mammogram and BioGrid data have been accessed. Biobank storage including serum, deoxyribonucleic acid (DNA) storage and PAXgene tubes are maintained.

Discussion

The WHAP has contributed to over 200 published research findings, several books, and book chapters in a variety of areas, including: health and wellbeing; mental and cognitive health; bone health; lifestyle, vascular risk and prevention; women’s health and hormonal transition; and cross-cultural research.

With all participants now aged over 70 years, the cohort is ideally placed to answer key questions of healthy ageing in women. With more than 25 years of longitudinal prospective follow-up this Australian dataset is unique in its duration, breadth and detail of measures including clinical review and specialized disease-specific testing and biomarkers. Ongoing follow-up into older ages for this long-running cohort will enable the association between mid to late-life factors and healthy ageing to be determined. This is particularly valuable for the examination of chronic diseases which have a 20–30 year prodrome and to provide knowledge on multiple morbidities. The dataset has a unique opportunity to improve our understanding of temporal relationships and the interactions between risk factors and comorbidities.

Electronic supplementary material

The online version of this article (doi:10.1186/s40695-016-0018-y) contains supplementary material, which is available to authorized users.

Predictive Factors for Verbal Memory Performance Over Decades of Aging: Data from the Women's Healthy Ageing Project

BACKGROUND

Abnormalities in brain structure and function can occur several decades prior to the onset of cognitive decline. It is in the preceding decades that an intervention is most likely to be effective, when informed by an understanding of factors contributing to the disease prodrome. Few studies, however, have sufficient longitudinal data on relevant risks to determine the optimum targets for interventions to improve cognition in aging. In this article we examine the timing and exposure of factors contributing to verbal memory performance in later life.

METHODS

387 participants from the population-based Women's Healthy Ageing Project, mean age at baseline of 49.6 years (range: 45-55 years), had complete neuropsychiatric assessments, clinical information, physical measures, and biomarkers collected at baseline, with at least three follow-up visits that included at least one cognitive reassessment. Mixed linear models were conducted to assess the significance of risk factors on later-life verbal memory. We explored the influence of early, contemporaneous, and cumulative exposures.

RESULTS

Younger age and better education were associated with baseline memory test performance (CERAD). Over the 20 years of study follow-up, cumulative mid- to late-life physical activity had the strongest effect on better later life verbal memory (0.136 [0.058, 0.214]). The next most likely contributors to verbal memory in late life were the negative effect of cumulative hypertension (-0.033 [-0.047, -0.0.18] and the beneficial effect of HDL cholesterol (0.818 [0.042, 1.593]).

CONCLUSIONS

Findings suggest that midlife interventions focused on physical activity, hypertension control, and achieving optimal levels of HDL cholesterol will help maintain later-life verbal memory skills.

Comparison of quality of life measures in Korean menopausal women

The psychometric properties of two menopause-specific quality of life (QoL) measures, the Menopausal Quality of Life (MQOL), and the Women's Health Questionnaire (WHQ), were evaluated and compared in a convenience sample of 304 Korean women in menopausal transition. Data were collected with a self-report questionnaire. Evaluation of validity included factor analysis, convergent and discriminant validity, and known-groups validity. Evaluation of reliability included internal consistency reliability and item analysis. The results indicated that both QoL instruments were valid, but the WHQ was more internally consistent in measuring QoL although with a factor structure different from previous research. Replication studies to identify factor structures are needed for both measures.

Measurement of Quality of Life in Menopausal Women

Use of a wide variety of quality of life (QoL) instruments, each measuring a different aspect of menopause with a different type of underlying scale, has been a major problem in menopause research. The aim of this review was to identify instruments developed for menopausal women and evaluate the psychometric properties and appropriateness of instruments for the study of QoL in menopausal women. Seven measures from 16 papers were chosen for the review. The psychometric evaluations were conducted based on quality judgment criteria. Of the seven measures reviewed in this study, the psychometric quality scores of Women’s Health Questionnaire (WHQ) was the highest. However, the result indicates that most instruments of menopause-specific QoL need further testing and evaluation of the various aspects of their psychometric properties. In addition, future research assessing psychometric properties with cross-cultural samples may be beneficial in adapting measures to specific context and study populations.

Gender issues in life event research in India: A critical appraisal of the presumptive stressful life events scale

Women are known to have an increased risk of common mental disorders. Much of this vulnerability has been attributed to psychosocial factors. Life event research is one of the ways in which the role of psychosocial factors in causing stress and illness can be assessed. The presumptive stressful life events scale (PSLES) is widely used in India for this purpose. This paper looks at the inherent weaknesses of this tool for use in Indian women. The issues raised here may be relevant to other Asian populations as well.

The menopausal transition: a 9-year prospective population-based study. The Melbourne Women's Midlife Health Project

OBJECTIVES

To describe the natural history of the menopause in Australian-born women. To determine the hormonal changes relating to the menopausal transition (MT) and how these affect quality of life, bone mineral density, body composition, cardiovascular disease (CVD) risk and memory.

DESIGN

A 9-year prospective, observational study of a population-based sample of 438 Australian-born women aged 45-55 years at baseline. By the 9th year, the retention rate was 88%. Interviews, blood sampling, menstrual calendars, quality of life and physical measures were taken annually, and bone mineral density was measured bi-annually.

RESULTS

The late MT coincides with changes in estradiol, follicle stimulating hormone, and free testosterone index, decreases in bone density and mastalgia, and increases in central adiposity, vasomotor symptoms, insomnia and vaginal dryness. Levels of total testosterone and dehydroepiandrosterone sulfate are unchanged by the MT. An increase in CVD risk was associated with increases in weight and free testosterone index and a decrease in estradiol. Depressed mood is increased by symptoms and by stressors occurring in the MT. Sexual functioning significantly deteriorates with the MT and aging, but relational factors have major effects. Menstrual cycles became more variable and longer closer to the final menstrual period.

CONCLUSIONS

As hormonal changes during the MT directly or indirectly adversely affect quality of life, body composition and CVD risk, maintenance of health parameters in the premenopausal years is crucial for a healthy postmenopause.

Change in health-related quality of life over the menopausal transition in a multiethnic cohort of middle-aged women: Study of Women's Health Across the Nation

OBJECTIVE

The aim of this study was to examine changes in health-related quality of life (HRQL) during the menopausal transition, controlling for chronological aging, symptoms, and other covariates.

METHODS

This was a prospective, longitudinal study of women aged 42 to 52 years at baseline recruited at seven US sites (N = 3,302) in the multiethnic Study of Women's Health Across the Nation. Women eligible for the cohort had an intact uterus, had at least one ovary, were not currently using exogenous hormones, were either premenopausal or early perimenopausal, and were self-identified as one of the study's designated racial/ethnic groups. Data from the baseline interview and six annual follow-up visits are reported. HRQL was assessed with five subscales from the Medical Outcomes Study Short-Form Health Survey, with reduced functioning defined as being in the lowest 25% on a subscale. Covariates included symptoms, medical conditions, sociodemographics variables, physical activity, and psychological factors.

RESULTS

With adjustment for baseline age, chronological aging, and relevant covariates, the odds of reduced role-physical functioning were significantly greater at late perimenopause (odds ratio, 1.46; 95% CI, 1.08-1.99) and postmenopause (odds ratio, 1.49; 95% CI, 1.09-2.04) compared with premenopause. Menopause status was unrelated to bodily pain, vitality, role-emotional, or social functioning. Hormone therapy users were more likely to report reduced functioning. Other variables significantly related to HRQL across all domains included vasomotor symptoms, urine leakage, poor sleep, arthritis, depressed mood, perceived stress, and stressful life events.

CONCLUSIONS

The menopausal transition showed little impact on HRQL when adjusted for symptoms, medical conditions, and stress.

Self-reported arthritis and the menopause

OBJECTIVES

To determine the prevalence of self-reported arthritis in a population-based cohort of mid-aged women and to identify health, social and lifestyle factors associated with self-reported arthritis.

DESIGN

Cross-sectional population-based survey.

METHOD

Data were obtained from a telephone-administered questionnaire of 2001 Australian-born women between 45 and 55 years old and residing in Melbourne. Information was collected on demographics, lifestyle factors and health conditions.

RESULTS

The most commonly reported symptom in this cohort was aches and stiff joints, reported by 51.7% of the women; 34.4% of participants reported they had been diagnosed with arthritis. More postmenopausal women (39%) reported that they were diagnosed with arthritis compared to premenopausal women (27%, p < 0.001). Women who reported arthritis were more likely to be older (odds radio (OR), 1.09; 95% confidence interval (CI), 1.05-1.13), have a higher body mass index (OR, 1.04; CI, 1.02-1.07), be postmenopausal (OR, 1.88; CI, 1.33-2.66), have a higher negative mood (OR, 1.80; CI, 1.13-2.87), and report a decreased interest in sex (OR, 1.58; CI, 1.26-1.97).

CONCLUSIONS

Aches and stiff joints are the most frequently reported symptom of mid-aged women. Reported arthritis is associated with postmenopausal status, age, body mass index, less interest in sex and lowered mood. Further longitudinal research is needed to determine the role of these factors in the development and impact of arthritis.

Quality of Sexual Life and Menopause

The importance of female sexual fulfillment is increasingly recognized in today's society. Women's sexual lives continue well into the menopausal years and beyond; however, the impact of menopause on the quality of that sexual life has not been comprehensively studied in the medical literature. This review attempts to clarify the impact of the physiological, psychological and psychosocial changes occurring at midlife that may affect women's quality of sexual life. Pharmaceutical and psychological interventions that may assist in improving the quality of sexual life of menopausal women are discussed. Female sexuality is complex and not fully understood and, consequently, controversy frequently arises in the discussion of female sexual problems and their treatment. This article highlights some of these controversies and provides a future perspective on how the impact of menopause on the quality of sexual life may be more cohesively investigated.

Changing healthcare issues and context for elderly women in Asia: implications for a research agenda for nursing

In this descriptive review, the current healthcare issues and context for elderly women in Asia are discussed and a nursing research agenda to promote better health security is proposed. Chesney and Ozer's multilevel circular framework of key content areas of women's health was applied to organize and critique the literature. The results indicate that elderly Asian women display morbidity and mortality differentials and are influenced by gender and social factors, as well as health policy issues. The research agenda for nursing that is proposed in this article includes activating health promotion research, employing family and community-based participatory approaches, supporting gender-sensitive social and health policies, and promoting comprehensive and culturally competent international research on health transitions for elderly women.

New findings from non-linear longitudinal modelling of menopausal hormone changes

Changes in FSH and estradiol (E2) across the menopausal transition are clearly not linear. The present study utilizes data from 204 women who completed the 13-year prospective Melbourne Women's Midlife Health Project. E2, FSH, symptoms, self-rated health, mood, sexual function and coronary heart disease (CHD) risk were measured longitudinally. We presumed an s-shaped curve for each hormone and estimated five parameters for each hormone curve for each woman: baseline, final value, range, slope at inflexion point and age at inflexion point. These parameters were found to adequately estimate the curve for each hormone. The median age of transition observed for E2 occurs >1 year later than the median age of transition observed for FSH. FSH parameters did not affect any of the health outcomes analysed. Hot flushes, night sweats, sleeping problems, vaginal dryness and to a lesser extent self-rated health were highly significantly associated with E2 range and slope. Sexual response and CHD risk were highly significantly associated with final E2 level (post-menopausally). These findings have clinical relevance in identifying which symptoms will be triggered by steep transitions of E2 such as sudden withdrawal and which health parameters may require a maintenance level of E2.

The association between menopausal symptoms and quality of life in midlife women

This cross-sectional study examined 1,096 midlife women, associating menopausal symptoms, including hot flashes, vaginal dryness, sore joints, incontinence, irritability, mood changes, and headache, with quality of life (QOL), as measured using Cantril's Ladder of Life. The results showed that low QOL may be significantly associated with feeling tense and mood changes, but not the other selected symptoms.

Physical activity, symptoms, esteem, and life satisfaction during menopause

OBJECTIVE

The present study examined the relationships among physical activity (PA), symptom reporting, self-esteem, and satisfaction with life (SWL) in 133 women (M age=51.12, S.D.=4.10) of varying menopausal status.

RESULTS

Multivariate analyses of co-variance (MANCOVA) revealed that independent of menopausal status, women who were more physically active reported significantly less severe vaso-somatic and general somatic symptoms, and higher levels of physical self-worth (PSW). Subsequent hierarchical regression analyses indicated that expended MET-h/week, reported symptoms (frequency and severity, respectively), and PSW accounted for significant variance in SWL (R2 model=0.32, for symptom frequency, and 0.33, for symptom severity). Physical activity was significantly related to SWL through the mediation of PSW. However, both reported symptom frequency and severity retained significant association with SWL after controlling for PSW, although the original associations were significantly reduced. Finally, both symptoms and MET-h/week were independent contributors to the variance in PSW (R2 model=0.33 and 0.34).

CONCLUSION

The results suggest that being physically active may reduce perceived severity of menopausal symptoms and enhance psychological well-being, and that the relationship between physical activity and QOL in mid-life women may be mediated by factors such as physical self-perceptions and menopausal symptoms.

Monitoring reproductive aging in a 5-year prospective study: aggregate and individual changes in steroid hormones and menstrual cycle lengths with age

OBJECTIVE

We describe a 5-year prospective study of reproductive aging, and present analyses of steroid hormone and menstrual cycle changes with age.

DESIGN

Participants were college-educated white women, primarily of northern European ancestry, recruited from the Tremin Research Program on Women's Health (n = 156, 25-58 years). In each of 5 consecutive years, they collected daily urine specimens for 6 months and recorded menstrual bleeds for all months. Urine specimens were assayed for estrone-3-glucuronide (E1G) and pregnanediol-3-glucuronide (PDG), urinary metabolites of estradiol and progesterone. Using multilevel models, we estimated hormone and cycle-length trajectories for individual women and within- and between-woman variance by age.

RESULTS

At the aggregate level, PDG declined beginning in the 30s, E1G increased into the 40s before declining, and cycle length became more variable with age. Individual-level models revealed substantial hormonal variation across women, in both absolute levels and rates of change. Most women showed declining E1G by the late 40s, declining PDG in the 30s, and increasing mean cycle length in the 40s. Hormonal variation decreased with age; cycle length variation decreased and then increased. Within individual women, cycle lengths were highly variable while hormone levels were more stable. Women differed more from each other in hormone levels than for cycle lengths.

CONCLUSIONS

Aggregate-level analyses show general changes in steroid hormones and cycle length but cannot show variation within and across women. Individuals' cycle lengths were too variable to predict hormone levels. Clinicians should obtain more data on individual women's hormonal patterns when determining fertility or menopause treatments.

Health-related quality of life in a multiethnic sample of middle-aged women: Study of Women's Health Across the Nation (SWAN)

BACKGROUND

Relatively little is known about the association between menopause and health-related quality of life (HRQL) across ethnic groups.

OBJECTIVES

To examine the association between HRQL and early perimenopause and ethnicity, adjusting for health, lifestyle, psychosocial, and sociodemographic factors.

RESEARCH DESIGN

Questionnaires were administered to pre- and early perimenopausal women.

SUBJECTS

We studied a cohort of 3302 black, Chinese, Hispanic, Japanese, and white women aged 42 to 52 years from the multisite Study of Women's Health Across the Nation (SWAN).

MEASURES

We measured HRQL, menstrual regularity, and a variety of covariates. HRQL was assessed with 5 subscales from the Short Form-36; impaired functioning was defined as being in the 25% most impaired on a subscale.

RESULTS

In unadjusted, but not adjusted, analyses, significantly more early perimenopausal women, as compared with premenopausal women, were classified as having impaired functioning on each of the 5 subscales. For 4 of the subscales, the effect of menopausal status was explained by menopause-related symptoms. There were significant ethnic group differences across all 5 subscales in unadjusted analyses. Ethnicity was no longer significant for the Vitality or Role-Emotional subscales when adjusted for health variables or for the Role-Physical subscale when analyses were adjusted for socioeconomic status, health, lifestyle, or social circumstances. Ethnicity remained significant for the Bodily Pain and Social Functioning subscales, even in adjusted analyses.

CONCLUSIONS

Early perimenopause is not associated with impaired functioning when adjusted for symptoms. Significant ethnic differences in HRQL exist. Some, but not all, differences can be explained by differences in health, lifestyle, and social circumstances.

Can Acupuncture Ease the Symptoms of Menopause?

In a randomized, 2-group clinical study, acupuncture was used for the relief of menopausal hot flushes, sleep disturbances, and mood changes. The experimental acupuncture treatment consisted of specific acupuncture body points related to menopausal symptoms. The comparison acupuncture treatment consisted of a treatment designated as a general tonic specifically designed to benefit the flow of Ch'i (energy). Results from the experimental acupuncture treatment group showed a decrease in mean monthly hot flush severity for site-specific acupuncture. The comparison acupuncture treatment group had no significant change in severity from baseline over the treatment phase. Sleep disturbances in the experimental acupuncture treatment group declined over the study. Mood changes in both the experimental acupuncture treatment group and the comparison acupuncture treatment group showed a significant difference between the baseline and the third month of the study. Acupuncture using menopausal-specific sites holds promise for nonhormonal relief of hot flushes and sleep disturbances.

Statistical techniques for the analysis of change in longitudinal studies of the menopause

OBJECTIVE

Critical review of statistical techniques used to analyze data from longitudinal studies.

METHOD

Literature search and classification of statistical methods and their utilization evaluated against known underlying assumptions.

RESULTS

One hundred and twenty-three papers found: 1. cross-sectional reduction of data (56%); 2. multifactorial techniques (26%); 3. repeated measurement analysis of variance (14%); 4. other (time series and structural equation modelling) (4%).

CONCLUSIONS

Cross-sectional reduction violates underlying statistical assumptions. A simple and powerful technique is to mean values prior to and following an event such as the final menstrual period. To allow for the influence of multiple factors, linear regression is preferred to logistic regression where continuous data are available. For more information about evolution in time, more complex techniques are needed. A suitable technique is repeated measurement multivariate analysis of variance using a number of contrasts to estimate various effects. Split plot or randomized block designs cannot be recommended as they violate compound symmetry assumptions. For series involving more than 100 observations for each subject, time series and spectral analysis techniques should be considered. Structural equation modelling is recommended for examination in detail of a range of factors that may influence the studied end-point, the presence of feedback and of latent or non-measurable variables.

Patterns of depressed mood across the menopausal transition: approaches to studying patterns in longitudinal data

To date many researchers have focused on depression as a discrete episode, attempting to relate its occurrence to a transition in menopausal stage or other factors that might account for its occurrence. Characterizing change over time requires consideration of pattern or trajectory, not merely discrete events. The purposes of this paper are to: 1) to explore methods for intraindividual and interindividual (group) analysis of patterns of depressed mood among midlife women 2) to identify challenges for analytic strategies for understanding depressed mood as it is experienced by midlife women, with special concern for its relationship to the menopausal transition. Data from the Seattle Midlife Women's Health Study were used to illustrate approaches to intraindividual and interindividual analysis of patterns of depressed mood. For most women, menopausal transition was not a time when there was a new episode of depression. Instead, a minority of women showed evidence of becoming depressed once the transition had begun. The most prevalent pattern was that of non-depressed mood across the years of the menopausal transition. Association of several factors with a pattern of depressed mood included life stressors, perceived poor health, and vasomotor symptoms.

Midlife development and menopause in African American and Caucasian women

Little is known about factors that enhance midlife women's well-being and even less about whether these factors differ for African Americans and Caucasians. We conducted focus groups with 30 women, grouped by ethnicity and menopausal status. Women identified midlife as a time of opportunity for self-development. Pre/perimenopausal women expressed more fears about severe emotional changes than did their postmenopausal counterparts. These fears were in sharp contrast to the women's descriptions of enhanced self-esteem. Caucasian women were primarily concerned about menopause as a harbinger of physical aging and the ensuing disadvantage of divergence from society's ideal of a youthful appearance, while African American women viewed menopause as a normal, even welcome, part of life. A language of emancipation and awareness of gender bias were prominent in the women's stories regardless of menopausal status or race. Further study should assess the role that feminist insights may play in the well-being of midlife women.

Psychologic distress and natural menopause: a multiethnic community study

OBJECTIVES

This study examined the association between psychologic distress and natural menopause in a community sample of African American, White, Chinese, Hispanic, and Japanese women participating in a national women's health study.

METHODS

A cohort of 16,065 women aged 40 to 55 years provided information on menstrual regularity in the previous year, psychosocial factors, health, and somatic-psychologic symptoms. Psychologic distress was defined as feeling tense, depressed, and irritable in the previous 2 weeks.

RESULTS

Rates of psychologic distress were highest in early perimenopause (28.9%) and lowest in premenopause (20.9%) and postmenopause (22%). In comparison with premenopausal women, early perimenopausal women were at a greater risk of distress, with and without adjustment for vasomotor and sleep symptoms and covariates. Odds of distress were significantly higher for Whites than for the other racial/ethnic groups.

CONCLUSIONS

Psychologic distress is associated with irregular menses in midlife. It is important to determine whether distress is linked to alterations in hormone levels and to what extent a mood-hormone relationship may be influenced by socioeconomic and cultural factors.

Relationships between catastrophic thoughts, perceived control and distress during menopausal hot flushes: exploring the correlates of a questionnaire measure

OBJECTIVES

Many studies have established that highly negative or catastrophic thoughts about chronic health problems such as pain are associated with greater distress, lower self-efficacy for dealing with the problem and depressed mood. This study examined whether highly negative (or 'catastrophic') appraisals of hot flush experiences were associated with greater distress and lower perceived control regarding this menopausal problem.

DESIGN

A postal survey was carried out, with a follow-up 12 months later.

METHODS

Two questionnaires were initially completed by a volunteer sample of 61 women currently experiencing hot flushes. A mixture of qualitative and quantitative data were collected, including a Catastrophic Thoughts Questionnaire (CTQ) measure of catastrophic thoughts, based in part on Rosenstiel AK and Keefe FJ. The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment. Pain 1983;17:33-44. Thirty nine women who continued to report hot flushes were followed up 12 months later.

RESULTS

Ratings to each item of the CTQ were highly intercorrelated. Women reporting more catastrophic thoughts tended to be lower in perceived control over flushes. Respondents' reported distress during hot flushes was more closely related to their frequency of negative thoughts about the problem, than to perceived control, flush chronicity or daily frequency of flushes. Over 12 months, respondents showed a highly stable pattern of catastrophic thoughts, and continued links with levels of distress during flush episodes.

CONCLUSIONS

Cognitive appraisal processes that undermine coping with other chronic health problems seem also relevant to understanding the distress triggered by intermittent, unpredictable flush episodes. The findings imply that women may develop improved tolerance for menopausal flushing through challenging negative interpretations of the experience.

Psychosocial factors, attitude to menopause and symptoms in Swedish perimenopausal women

OBJECTIVES

To analyze attitude to menopause from women's own accounts and to examine whether psychosocial factors and attitude are associated with symptom reporting.

METHODS

The data form part of a population-based longitudinal study of a cohort of women who have been followed annually for 5 years using psychological interviews and rating scales, health screening and hormonal characterization. The data reported here were collected at the fourth follow-up when the women (n = 148) were 53 years old.

RESULTS

Women were classified as perimenopausal (27%), postmenopausal (15%), hormone replacement therapy (HRT) users (52%) and hysterectomized (6%), based on self-reports. More than half the women (51%) had a positive attitude to menopause, 24% had a negative attitude and 25% had a neutral attitude. Menopausal status was not associated with attitude to menopause. Factor analysis of symptom ratings yielded ten independent factors comprising negative mood, vasomotor symptoms, decreased sexual desire, memory problems, sleep-related symptoms, vaginal dryness, urogenital problems, joint pain, vitality and increased sexual desire. Only vasomotor symptoms and joint pain were associated with menopausal status. The other symptoms were more strongly related to psychosocial factors, life-style and attitude to menopause.

CONCLUSIONS

The results support the view of the menopause as a developmental phase associated with an increased self-awareness and a stronger personal identity. More than half the women held a positive view of the menopause, whereas the remaining proportion of women had either a negative or a neutral attitude. Only vasomotor symptoms and joint pain were associated with postmenopausal status. Other symptoms were significantly related to psychosocial factors, life-style and attitude to menopause.

Factors affecting sexual functioning of women in the mid-life years

OBJECTIVE

To model the interaction of hormones, symptoms and psychosocial factors on women's sexuality during the menopausal transition.

DESIGN AND METHODS

A prospective, observational study was carried out of a community-based sample of 438 Australian-born women aged 45-55 years at baseline. The study comprised six annual assessments in the women's own homes utilizing a core questionnaire, with rating scales for well-being and daily hassles, and a Personal Experiences Questionnaire as a measure of sexual functioning. Levels of follicle stimulating hormone (FSH), estradiol and inhibin were measured annually. Statistical analysis was performed by structural equation modelling.

RESULTS

The retention rate was 90% (final sample size after exclusions, n = 354). The normal fit index for the global model obtained was 0.92. There is a significant direct effect of menopausal status on vaginal dryness/dyspareunia, and an indirect effect on sexual responsivity via a direct effect of menopausal status on symptoms, which then affect well-being. Menopausal status reflects hormonal status. Feelings for the partner and the partner's sexual problems have direct effects on different aspects of sexual functioning. Other social variables such as paid work, interpersonal stress, daily hassles and educational level affect sexual functioning indirectly via effects on symptoms and well-being.

CONCLUSIONS

Psychosocial factors, symptoms and the menopausal transition affect women's sexual functioning during the mid-life years.

Psychological effects of hormone replacement therapy: a comparison of tibolone and a sequential estrogen therapy

Hormone replacement therapy (HRT) is effective in alleviating vasomotor symptoms but the effect on psychological symptoms is less clear. This study aimed to compare the psychological effects of two regimens of HRT in perimenopausal women in a randomized, initially double-blind, controlled trial. Thirty-eight women reporting climacteric symptoms were randomly allocated into either oral conjugated equine estrogen 0.625 mg daily plus progestogen (norgestrel) 150 micrograms for the last 12 days of each 28 day cycle, or tibolone 2.5 mg/day for 28 days. They were assessed using standardized psychological assessments. There were no significant differences in changes from baseline between the two types of therapy. For both groups combined there were significant improvements compared with baseline in vasomotor symptoms in the first month, plus anxiety, sleep, memory and somatic dysfunction by the second and third months, but not in scores of depression. Log linear analysis of weekly scores showed that depression scores were significantly related to improvement in vasomotor scores independent of type of therapy and time on HRT. Memory problems were related to vasomotor symptoms independent of depression. No difference between the two types of therapy was found, nor any direct effect of HRT on anxiety or depression. The results support the domino theory, suggesting that psychological improvement follows alleviation of vasomotor symptoms.

Life satisfaction and health-related quality of life (SF-36) of middle-aged men and women

OBJECTIVES

To investigate life satisfaction and health-related quality of life (SF-36) in a general population sample of middle-aged women and men. The effects of menopausal status and hormone replacement therapy (HRT) use upon life satisfaction and health-related quality of life (HrQOL) were also examined for the female sample.

DESIGN

All men and women aged 49-55 years from the age/sex register of a large general practice in London were contacted and asked to complete a questionnaire about their health.

SUBJECTS

A total of 103 women (55%) and 86 men (40%) participated; of the women, 15% were premenopausal, 68% peri- or postmenopausal and 17% taking HRT.

RESULTS

Women and men reported similar levels of HrQOL, life satisfaction and general health, although women reported more physical problems (SF-36). The significant predictors of HrQOL were serious illness, employment and marital status, but HRT use and menopausal status were not significantly associated with life satisfaction nor HrQOL (for women).

CONCLUSIONS

Gender differences in health and HrQOL may be less apparent during mid-life, although there were some subtle differences between men and women in reported health concerns and reasons given for (dis)satisfaction with their lives.