Vasomotor hot flushes and 24-hour ambulatory blood pressure in recently post-menopausal women

Vasomotor symptoms of menopause, autonomic dysfunction, and cardiovascular disease

Cardiovascular disease (CVD), the leading cause of death among US adults, is more prevalent in menopausal females compared with age-matched males. Vasomotor symptoms of menopause (VMS; hot flashes/flushes and night sweats) are common among females undergoing menopausal transition and have been associated with elevated blood pressure (BP) and increased CVD risk. Autonomic dysregulation of BP has been posited as a contributing factor to the elevated CVD risk in menopausal females with VMS. This review includes 1) a brief overview of the relationship between VMS and CVD, 2) mechanisms of hot flushes and their potential impact on short- and long-term BP regulation, and 3) how the disruption of autonomic function associated with VMS might provide a mechanistic pathway to CVD development. Finally, this review will highlight knowledge gaps and future directions toward better understanding of hot flush physiology and VMS contributions to CVD.

Relationship between vasomotor symptoms and metabolic syndrome in Chinese middle-aged women

PURPOSE

This study aimed to find the associations between vasomotor symptoms (VMS) and metabolic syndrome (MetS) in Chinese middle-aged women in a cross-sectional study.

METHODS

A total of 675 participants were recruited from an urban Chinese community. MetS was defined by the 2009 criteria of the Joint Interim Statement. VMS including hot flashes and sweats, blood pressure, weight, height, waist circumference (WC), serum glucose, triglycerides, high-density lipoprotein cholesterol (HDL), low-density lipoprotein cholesterol (LDL), estradiol, and follicle-stimulating hormone (FSH) were collected.

RESULTS

The presence of hot flashes was independently associated with the risk of MetS after adjusting for age, menopausal status, FSH_log, estradiol_log, and physical activity (odds ratio: 1.98, 95% confidence interval: 1.21-3.24, p = 0.006). Both hot flashes and sweats were also independently associated with WC (for hot flashes, p = 0.016; and for sweats, p = 0.007) and triglycerides (for hot flashes, p = 0.041; and for sweats, p = 0.014) significantly. However, VMS were not significantly associated with blood pressure, glucose, HDL, and LDL.

CONCLUSION

Women with hot flashes had a higher risk of MetS. Both hot flashes and sweats were related to a higher amount of central fat indicated by WC and higher triglycerides, but were not related to blood pressure, glucose, and HDL in Chinese women.

Perimenopause, body fat, metabolism and menopausal symptoms in relation to serum markers of adiposity, inflammation and digestive metabolism

BACKGROUND

Perimenopausal women gain weight that may alter inflammatory status, endocrine equilibrium, and the intensity of vasomotor symptoms.

OBJECTIVE

To measure serum levels of markers related to adiposity, inflammation/angiogenesis and digestive metabolism and correlate them with body mass index (BMI), waist-to-hip ratio (WHR), metabolic parameters and menopausal symptoms (assessed with the 10-item Cervantes Scale [CS-10]).

METHODS

Serum of perimenopausal women (n = 24), STRAW stages-2 and -1, was analyzed using the Bio-Plex 200 System technology to assess 30 proposed analytes. The MetS was defined by the American Heart Association criteria and women were divided as: normal BMI (NBMI), excessive BMI (EBMI), and EBMI with MetS (EBMI-MetS).

RESULTS

Weight, BMI, abdominal circumference, WHR, systolic blood pressure, glucose and triglyceride levels were significantly higher and high-density lipoprotein cholesterol (HDL-C) was lower in EBMI-MetS women compared to NBMI ones. Insulin, C-peptide, resistin, adipsin, GIP, leptin, IL-6, FGF21 and PAI-1 levels were significantly higher and ghrelin and IGFBP-1 lower in EBMI-MetS women as compared to NBMI ones. Spearman's correlation of pooled data showed a significant positive correlation between abdominal perimeter and WHR and C-peptide, insulin, adipsin, resistin, leptin, PAI-1 and FGF21 and a negative correlation with IGFBP-1 levels. Total CS-10 scores and hot flush intensity did not differ between studied groups, yet positively correlated with anthropometric values but not with studied analytes.

CONCLUSION

Perimenopausal women with EBMI and the MetS showed an altered metabolic profile, but no differences in menopausal symptoms which also did not correlate with changes in studied biomarkers.

Gender Specific Differences in Prevalence and Risk Factors for Gastro-Esophageal Reflux Disease

BACKGROUND

Gender-related factors might play an important role in the development of reflux esophagitis (RE) and symptomatic gastro-esophageal reflux disease (GERD). We aimed to evaluate the prevalence and risk factors for RE and symptomatic GERD and determine whether gender specific differences exist.

METHODS

This study was conducted on a health cohort consisting of 10,158 participants who underwent comprehensive health screening. Lifestyles and gastrointestinal symptoms were investigated using a self-reported structured questionnaire. Questionnaires about menstrual status were added for the women.

RESULTS

The prevalence of RE in men was significantly higher than that in women (10.6% vs. 2.0%, P < 0.001); however, symptomatic GERD showed predominance in women (6.2% vs. 2.5%, P < 0.001). Although the prevalence of RE gradually increased with the duration of menopause stratified by decade (P = 0.007), that of symptomatic GERD rapidly increased across the menopausal transit in women. Apart from common risk factors of obesity and current smoking for RE, over 70 years of age in women and hiatal hernia and hypertriglyceridemia in men were significant risk factors. In symptomatic GERD, high somatization was a common risk factor. Excessive alcohol drinking was a significant risk factor in men, but not in women.

CONCLUSION

This study showed a predominance of RE in men, but a predominance of symptomatic GERD in women. In women, dynamic increase in the prevalence of GERD is closely related to the menopause conditions and its duration. There are specific risk factors for RE and symptomatic GERD according to gender differences.

Cardiovascular Implications of the Menopause Transition: Endogenous Sex Hormones and Vasomotor Symptoms

The menopause transition (MT) is a critical period of women's lives marked by several physiologic changes and menopause-related symptoms that have implications for health. Risk for cardiovascular disease, the leading cause of death in women, increases after menopause, suggesting a contribution of the MT to its development. This article focuses on the relationship between 2 main features of the MT and women's cardiovascular health: (1) dynamic alterations of sex hormones, particularly endogenous estradiol and follicle-stimulating hormone, and (2) vasomotor symptoms, the cardinal symptom of the menopause. Limitations and future directions are discussed.

Altered nocturnal blood pressure profiles in women with insomnia disorder in the menopausal transition

OBJECTIVE

Insomnia disorder is a risk factor for cardiovascular (CV) pathology. It is unknown whether insomnia that develops in the context of the menopausal transition (MT) impacts the CV system. We assessed nocturnal blood pressure (BP) and heart rate (HR) profiles in women with insomnia disorder in the MT.

METHODS

Twelve women meeting DSM-IV criteria for insomnia in the MT (age, mean ± SD: 50.5 ± 3.6 y) and 11 controls (age, mean ± SD: 49.0 ± 3.0 y) had polysomnographic recordings on one or two nights during which beat-to-beat BP and HR were assessed and analyzed hourly from lights-out across the first 6 hours of the night and according to sleep stage. Physiological hot flashes were identified from fluctuations in sternal skin conductance.

RESULTS

Women with insomnia and controls had similar distributions of sleep stages and awakenings/arousals across hours of the night, although insomnia participants tended to have more wakefulness overall. More women in the insomnia group (7 of 12) than in the control group (2 of 11) had at least one physiological hot flash at night (P < 0.05). Both groups showed a drop in BP in the first part of the night; however, systolic and diastolic BP patterns diverged later, remaining low in controls but increasing in insomnia participants 4 to 6 hours after lights-out (P < 0.05). Both groups showed a similar pattern of decline in HR across the night.

CONCLUSIONS

Our findings suggest altered regulatory control of BP during sleep in the MT insomnia. The causes and long-term consequences of this altered nocturnal BP profile remain to be determined.

Vasomotor symptoms and metabolic syndrome

A vast majority of menopausal women suffer from vasomotor symptoms, such as hot flushes and night sweats, the mean duration of which may be up to 7-10 years. In addition to a decreased quality of life, vasomotor symptoms may have an impact on overall health. Vasomotor symptoms are associated with overactivity of the sympathetic nervous system, and sympathetic overdrive in turn is associated with metabolic syndrome, which is a known risk factor for cardiovascular disease. Menopausal hot flushes have a complex relationship to different features of the metabolic syndrome and not all data point towards an association between vasomotor symptoms and metabolic syndrome. Thus, it is still unclear whether vasomotor symptoms are an independent risk factor for metabolic syndrome. Research in this area is constantly evolving and we present here the most recent data on the possible association between menopausal vasomotor symptoms and the metabolic syndrome.

Vascular function and cardiovascular risk factors in women with severe flushing

Cardiovascular disease is the leading cause of death in women of postmenopausal age worldwide. It is a relatively rare occurrence before the menopause and the increase in incidence coincides with the most common symptom associated with menopausal transition, hot flushing. Interest in cardiovascular disease post-menopause has largely focused on the effect of hormone therapy on risk of coronary events and stroke, with vasomotor symptoms considered merely a nuisance symptom, but recent work suggests that the presence of flushing may be a marker of underlying cardiovascular disease.

Hot flushes and night sweats are associated with coronary heart disease risk in midlife: a longitudinal study

OBJECTIVE

The purpose of this study was to investigate associations between vasomotor menopausal symptoms (VMS), i.e. hot flushes and night sweats, and the incidence of coronary heart disease (CHD).

DESIGN

A prospective cohort study.

SETTING AND POPULATION

11 725 women, aged 45-50 years at baseline in 1996, were followed up at 3-year intervals for 14 years.

METHODS

Self-reported VMS and incident CHD were measured at each survey.

MAIN OUTCOME MEASURE

We determined the association between VMS and CHD at the subsequent survey, using generalised estimating equation analysis, adjusting for time-varying covariates.

RESULTS

At baseline, 14% reported rarely, 17% reported sometimes, and 7% reported often having night sweats. During follow-up, 187 CHD events occurred. In the age-adjusted analysis, women who reported their frequency of experiencing hot flushes and night sweats as 'often' had a greater than two-fold increased odds of CHD (OR hot flushes 2.18, 95% CI 1.49-3.18; OR night sweats 2.38, 95% CI 1.62-3.50) compared with women with no symptoms (P trend < 0.001 for frequency of symptoms). Adjustment for menopausal status, lifestyle factors, body mass index, diabetes, and hypertension attenuated the associations (OR hot flushes 1.70, 95% CI 1.16-2.51, P trend = 0.01; OR night sweats 1.84, 95% CI 1.24-2.73), P trend = 0.004).

CONCLUSIONS

Women who report having hot flushes or night sweats 'often' have an increased risk of developing CHD over a period of 14 years, even after taking the effects of age, menopause status, lifestyle, and other chronic disease risk factors into account.

Menopausal hot flashes and insulin resistance

OBJECTIVE

Recent data have indicated that menopausal hot flashes may be a determinant for cardiovascular health. Therefore, we studied the impact of hot flashes on insulin resistance, one of the most powerful markers of cardiovascular health, in recently postmenopausal women.

METHODS

We studied 143 recently postmenopausal (amenorrhea 6-36 mo) healthy and normal-weight women without previous hormone therapy use. The women prospectively recorded the number and severity of hot flashes for 2 weeks, and a validated total symptom score, the hot flash weekly weighted score, was calculated for each woman. Insulin resistance was assessed from fasting blood levels of glucose and insulin with the homeostasis model assessment.

RESULTS

In 12 women, the assessment of insulin (n = 11) or glucose (n = 1) failed, and they were excluded from further analysis. Thus, hot flashes were absent in 19, mild in 32, moderate in 27, and severe in 53 women. The levels of glucose or insulin, or HOMA showed no differences between these groups, nor was insulin resistance related to the number or severity of hot flashes or to the levels of C-reactive protein or sex hormone-binding globulin. Overall, insulin resistance showed a positive association with body mass index (mean difference, 0.058; 95% CI, 0.015-0.102; P = 0.009) and a negative association with level of estradiol (mean difference, -0.002; 95% CI, -0.003 to -0.001; P = 0.009).

CONCLUSIONS

Insulin resistance may not be involved in hot flash-related changes in cardiovascular health. However, because of the small sample size, these findings need to be interpreted with caution.

Hot flushes and night sweats differ in associations with cardiovascular markers in healthy early postmenopausal women

OBJECTIVE

The aim of this study was to evaluate the associations between vasomotor symptoms ([VMS] hot flushes or flashes and night sweats) and markers of cardiovascular risk.

METHODS

Healthy postmenopausal women in a randomized controlled trial of progesterone for VMS recorded VMS frequency in the Daily Menopause Diary for 28 days at baseline. Accepted risks for cardiovascular disease were measured: body mass index (BMI), waist circumference (WC), waist-to-height ratio (WHtR), blood pressure (BP), endothelial function by venous occlusion plethysmography, fasting lipids, glucose, high-sensitivity C-reactive protein, albumin, and D-dimer. Relationships between risk variables and VMS frequency (24 h, day and night) were assessed by univariate and multivariate robust regressions with adjustment for age and WHtR.

RESULTS

Data were available for 145 healthy, nonsmoking women without heart disease, hypertension, or diabetes who were 1 to 11 years past their final menstruation and were aged 43 to 65 years, with a mean (SD) BMI of 25.0 (2.9) kg/m and WC of 79.1 (7.1) cm. Anthropometric variables (BMI, WC, and WHtR) were significantly negatively associated with total (24-h day) VMS frequency and with day VMS but not with night VMS frequency. Systolic BP decreased with greater 24-hour VMS frequency, and both systolic and diastolic BPs were inversely related to day but not night VMS frequency. Albumin was positively associated with night VMS frequency but not with day or 24-hour VMS frequency. Other variables showed little association with VMS frequency.

CONCLUSIONS

Hot flushes, but not night sweats, were associated with lower cardiovascular risk factors in these healthy postmenopausal women. Future research should differentiate night sweats from hot flushes.

Effect of aerobic training on menopausal symptoms--a randomized controlled trial

OBJECTIVE

The aim of this study was to assess whether aerobic training affects menopausal symptoms in recently postmenopausal sedentary women.

METHODS

Symptomatic women aged 45 to 63 years (N = 176; 3-36 months since last menstruation) were randomly assigned to an aerobic training or a control group. The intervention included unsupervised aerobic training for 50 minutes four times weekly for 24 weeks, whereas the control group attended health lectures twice a month. Symptoms were reported twice a day using a mobile phone. The perceived disturbance of menopausal symptoms (night sweats, mood swings, irritability, depressive mood, headache, vaginal dryness, and urinary symptoms) was evaluated on a scale from 1 (low) to 5 (high). Multilevel mixed-effect ordinal regression models were based on 17,000 responses during 24 weeks.

RESULTS

One hundred fifty-four women continued until the end of the study (88% compliance rate). Baseline prevalence was as follows: night sweats, 50% to 60%; irritability and depression, 20% to 25%; mood swings, 25% to 30%; headache and urinary problems, 15% to 20%; and vaginal dryness, 10% to 15%. The prevalence of all symptoms except vaginal dryness decreased among intervention groups. According to multilevel mixed-effect ordinal regression analysis, night sweats and mood swings (P < 0.001) and disturbance of the mood swings (P < 0.001) and irritability (P < 0.001) were reduced more among the women in the intervention group than in the control group.

CONCLUSIONS

In sedentary women, aerobic training for 6 months may decrease the typical menopausal symptoms, especially night sweats, mood swings, and irritability.

Effect of aerobic training on hot flushes and quality of life--a randomized controlled trial

BACKGROUND AND OBJECTIVE

To estimate whether aerobic training has an effect on frequency of hot flushes or quality of life.

DESIGN

A randomized controlled trial.

PARTICIPANTS AND SETTING

Symptomatic, sedentary women (n = 176), 43-63 years, no current use of hormone therapy.

INTERVENTION

Unsupervised aerobic training for 50 minutes four times per week during 6 months.

OUTCOMES

Hot flushes as measured with Women's Health Questionnaire (WHQ) and Health-Related Quality of Life (HRQoL, SF-36), daily reported hot flushes on phone-based diary, cardiorespiratory fitness (CRF), and body composition.

RESULTS

Intervention group had larger decrease in the frequency of night-time hot flushes based on phone diary (P for month × group = 0.012), but not on WHQ scale. Intervention group had less depressed mood (P = 0.01) than control women according to change in WHQ score. Changes in WHQ score in depressed mood (P = 0.03) and menstrual symptoms (P = 0.01) in the intervention group were significantly dependent on frequency of training sessions. HRQoL was improved among the intervention group women in physical functioning (P = 0.049) and physical role limitation (P = 0.017). CRF improved (P = 0.008), and lean muscle mass increased (P = 0.046) significantly in the intervention group as compared to controls.

CONCLUSIONS

Aerobic training may decrease the frequency of hot flushes and improve quality of life among slightly overweight women.

Vasomotor hot flashes and heart rate variability: a placebo-controlled trial of postmenopausal hormone therapy

OBJECTIVE

The aim of the study was to compare the responses of heart rate variability (HRV) with hormone therapy in recently postmenopausal women with and without vasomotor hot flashes.

METHODS

Seventy-two women with and 78 women without hot flashes were randomized to receive transdermal estradiol gel (1 g/day), oral estradiol alone (2 mg/day), oral estradiol combined with medroxyprogesterone acetate (MPA; 5 mg/day), or placebo for 6 months. Time- and frequency-domain measures of HRV were assessed using 24-hour electrocardiographic recordings at baseline and after hormone therapy.

RESULTS

At baseline, the cardiac variables were similar in women with and without hot flashes. In women with hot flashes, the mean 24-hour heart rate and nighttime heart rate showed a tendency toward reduction in estradiol-only users compared with those taking placebo and those taking estradiol combined with MPA. In women with hot flashes, oral estradiol versus transdermal estradiol reduced nighttime HRV in the time domain (triangular index, -27 ± 36 vs +8 ± 36, P = 0.042). In women without hot flashes, the use of oral estradiol with MPA reduced time-domain HRV (SD of all normal-to-normal intervals; -11 ± 13 ms, P = 0.048, and square root of the mean of the sum of the squares of differences between adjacent normal-to-normal intervals; -6 ± 8 ms, P = 0.036). The women with hot flashes had more supraventricular ectopic beats when using oral estradiol with MPA than when using oral estradiol only (71 ± 128 vs 12 ± 11, P = 0.018).

CONCLUSIONS

Oral estrogen, especially when combined with MPA, may have adverse effects on HRV in women with and without hot flashes, whereas transdermal estradiol showed no such effects. Furthermore, women with hot flashes receiving oral estrogen combined with MPA are possibly more prone to cardiac arrhythmias than are women using estrogen only.

Menopausal hot flushes and vascular health

Hot flushes are complained of by approximately 75% of all postmenopausal women, and hormone therapy (HT) is the most effective way to alleviate them. Hot flushes are characterized by altered vascular function and sympathetic nervous system activity. Hot flushes occurred more often in women attending large, non-randomized observational studies (e.g. Nurses' Health Study), where HT use protected against cardiovascular disease (CVD). However, they were absent (or mild) in randomized HT trials where HT use was accompanied with an elevated risk for CVD. Hot flushes, if a factor for cardiovascular health, could partly explain the conflict between observational and randomized trials. Several cross-sectional studies imply that hot flushes are detrimental to the cardiovascular system. However, the data are not uniform, and hot flushes were recalled retrospectively or during HT use. In our prospective study hot flushes were accompanied with a vasodilatory effect during endothelial testing, and this was related to the severity of hot flushes. Night-time hot flushes were followed with transient rises in ambulatory blood pressure (BP). However, no effect of hot flushes on diurnal BP was detected. The use of estradiol showed no harmful effects on endothelial function in women with hot flushes, but in non-flushing women oral, but not transdermal, estradiol led to vasoconstrictive changes. Estradiol complemented with medroxyprogesterone acetate eliminated the vasoconstrictive effect of sole oral estradiol. Thus, both oral and transdermal estradiol are applicable in flushing women, whereas a transdermal route should be favored in non-flushing women if used e.g. for bone protection.

Vasomotor hot flushes and 24-hour ambulatory blood pressure in normotensive women: A placebo-controlled trial on post-menopausal hormone therapy

BACKGROUND

Blood pressure (BP) is one of the most powerful determinants of cardiovascular risk in women. This risk may differ between post-menopausal women with and without vasomotor hot flushes, possibly indicating different vascular responses to hormone therapy (HT). Thus, we compared in a clinical trial the effect of HT on ambulatory BP in normotensive, recently post-menopausal women with or without severe hot flushes.

METHODS

A total of 147 women recorded prospectively their hot flushes for 2 weeks; 70 women were symptomatic (>or=7 moderate/severe hot flush episodes/day), whereas 77 women were defined as asymptomatic (<or=3 mild hot flush episodes/day). Women were treated for 6 months with either transdermal estradiol, oral estradiol with or without medroxyprogesterone acetate, or placebo.

RESULTS

In symptomatic women decreases in BPs were seen during estradiol use. In contrast, in asymptomatic women receiving oral but not transdermal estradiol, increases in 24-h and day-time systolic and diastolic BPs were encountered.

CONCLUSION

Hot flushes modify the HT-mediated responses in ambulatory BP. In asymptomatic women oral but not transdermal estradiol show potentially harmful cardiovascular effect by increasing BP. Our results give additional justification to prescribing HT primarily for the treatment of troublesome hot flushes and avoiding HT in women without vasomotor symptoms.