Symptoms, health behavior and understanding of menopause therapy in women with premature menopause

The sexual and reproductive health knowledge of women in Australia: A scoping review

ISSUE ADDRESSED

Sexual and reproductive health (SRH) knowledge influences health literacy and promotes positive health behaviours. This scoping review explores the SRH knowledge of women in Australia and reports on knowledge assessment, ways of learning, enablers and barriers, and interventions to improve knowledge.

METHODS

Seven databases were searched for eligible articles published in English between 2012 and 2022.

RESULTS

Eighty-five sources were included for analysis. Data were mapped by knowledge topic and population group and charted against four review objectives. Assessment of knowledge was the primary focus in 59% of sources. Two sources used a validated knowledge assessment tool. Knowledge was assessed using self-assessment, a measurement of correctness, or both. Women learnt about SRH through a range of sources, including healthcare providers, peers, family, internet, and school. Enablers and barriers spanned information content, delivery, timing, accessibility, interactions with those providing information, cultural and gendered norms, pre-migration experiences, and functional health literacy. Nine sources reported on interventions to facilitate SRH knowledge.

CONCLUSIONS

This review identified topics, population groups, and gaps in assessment of SRH knowledge of women in Australia. Overall, the measurement of women's SRH knowledge is largely conducted using unvalidated tools focusing on specific topics. SO WHAT?: It is recommended a validated tool be developed to comprehensively assess the SRH knowledge of women in Australia allowing for intersectional population analysis and exploration of knowledge conceptualisation. This would enable assessment of interventions aiming to improve SRH knowledge thereby facilitating improved health literacy and outcomes.

Introducing a value-based healthcare approach for women with premature ovarian insufficiency (POI): Recommendations for patient-centered outcomes in clinical practice

OBJECTIVE

To establish a set of clinician and patient-reported outcome measures (PROMs) and present the initial findings of a value-based healthcare (VBHC) program in patients with premature ovarian insufficiency (POI).

METHODS

Employing a four-phase approach, we identified the most crucial domains for patients with POI and translated these into PROMs. Prior to each visit, patients completed questionnaires to evaluate: depression (BDI-II), menopausal symptoms (GCS), work ability (WAS) and infertility (FertiQoL). During the visits, cardiovascular health assessments and dual-energy X-ray absorptiometry (DEXA) scans to measure bone mineral density were performed. Data at intake is presented, and comparisons are drawn between women using and those not using hormone replacement therapy (HRT). Patient-reported experience measures (PREMs) were evaluated by a questionnaire.

RESULTS

A total of 267 POI patients completed the PROM questionnaires, of whom 58.1 % were using HRT at intake. Over half of the patients (53.5 %), had a BDI-II score of 14 or higher, indicating mild to severe depression. The mean total GCS score was 20.9 (SD 11.3). The median work ability score was 7.5 (IQR 6.0-8.0) and the mean FertiQoL score 63.9 (SD 15.7). Additionally, 22.7 % of patients presented with hypertension, 6.2 % with hypercholesterolemia, and almost 50 % had low bone mass. Patients rated the VBHC program with a mean of 8.6 (SD 1.2).

CONCLUSIONS

These findings underscore the necessity of a multidisciplinary VBHC program incorporating standardized screening and psychological treatment. We advocate for the implementation of patient-centered outcomes for clinical practice, which have been found to be highly relevant by patients with POI.

Bone health in women with premature ovarian insufficiency/early menopause: a 23-year longitudinal analysis

STUDY QUESTION

What is the frequency of, and predictors for, osteoporosis, fractures, and osteoporosis management (investigation, treatment) in women with premature ovarian insufficiency (POI; menopause <40 years) and early menopause (EM; menopause 40-44years)?

SUMMARY ANSWER

Over the 23-year follow-up duration, at a mean age of 68 years, women with POI/EM had higher osteoporosis/fracture risk and prevalence, higher osteoporosis screening and anti-osteoporosis medication use compared to women with usual age menopause; increasing age was predictive of increased risk of osteoporosis/fracture and menopause hormone therapy (MHT) prior to or at study entry (aged 45-50 years) was protective.

WHAT IS KNOWN ALREADY

Women with POI/EM have increased risk of osteoporosis and fractures with limited data regarding risk factors for reduced bone density and fractures. Clinical guidelines recommend screening with dual X-ray absorptiometry (DXA) and treatment with MHT for most women with POI/EM to reduce osteoporosis and fracture risk; however, studies indicate gaps in osteoporosis knowledge, guideline uptake, and management adherence by clinicians and women.

STUDY DESIGN, SIZE, DURATION

The Australian Longitudinal Study on Women's Health is a prospective longitudinal study of Australian women. This study uses the cohort of women born between 1946 and 1951, surveyed nine times between 1996 and 2019. Data from the Australian administrative health records, including hospital admissions data (fractures, osteoporosis), Medicare Benefits Schedule (DXA), and the Pharmaceutical Benefits Scheme (PBS; MHT, anti-osteoporosis medication, available only from 2002) were linked to survey data.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Survey respondents with self-reported age of menopause were included. POI/EM was defined as menopause <45 years. T-test or chi-square were used for comparisons at baseline (P < 0.05 indicates significance). Generalized estimating equations for panel data explored predictors for the longitudinal outcomes of osteoporosis, fractures, DXA rates, MHT use, and anti-osteoporosis medication (in women with osteoporosis/fracture, from Survey 4 onwards only). Univariable regression was performed, and variables retained where P < 0.2, to form the multivariable model, and bootstrapping with 100 repetitions at 95% sampling of the original dataset to ensure robustness of results.

MAIN RESULTS AND THE ROLE OF CHANCE

Eight thousand six hundred and three women were included: 610 (7.1%) with POI/EM. Mean (SD) baseline age was 47.6 (1.45) years in the entire cohort and mean (SD) age of menopause was 38.2 (7.95) and 51.3 (3.04) years in women with POI/EM and usual age menopause, respectively (P < 0.001). Over the 23 years, of women with POI/EM, 303 (49.7%) had osteoporosis/fractures, 421 (69.0%) had DXA screening, 474 ever used MHT (77.7%), and 116 (39.1%) of those with osteoporosis/fractures used anti-osteoporosis medication. Of women with usual age menopause, 2929 (36.6%) had osteoporosis/fractures, 4920 (61.6%) had DXA screening, 4014 (50.2%) used MHT, and 964 (33.0%) of those with osteoporosis/fractures used anti-osteoporosis medication. Compared to women with menopause at age ≥45 years and after adjusting for other risk factors, women with POI/EM had increased risk of osteoporosis (odds ratio [OR] 1.37; 95% CI 1.07-1.77), fractures (OR 1.45; 1.15-1.81), DXA testing (OR 1.64; 1.42-1.90), MHT use (OR 6.87; 5.68-8.30), and anti-osteoporosis medication use (OR 1.50; 1.14-1.98). In women with POI/EM women, increasing age was associated with greater risk of osteoporosis/fracture (OR 1.09; 1.08-1.11), and MHT prior to or at study entry (aged 45-50 years), was protective (OR 0.65, 0.45-0.96). In women with POI/EM, age (OR 1.11; 1.10-1.12), fractures (OR 1.80, 1.38-2.34), current smoking (OR 0.60; 0.43-0.86), and inner (OR 0.68; 0.53-0.88) or outer regional (OR 0.63; 0.46-0.87) residential location were associated with DXA screening. In women with POI/EM, increasing age (OR 1.02; 1.01-1.02), and currently consuming alcohol (OR 1.17; 1.06-1.28), was associated with having ever used MHT. In the 299 women with POI/EM and osteoporosis/fractures, only 39.1% ever received treatment with an anti-osteoporosis medication. Increasing age (OR 1.07; 1.04-1.09) and lower BMI (OR 0.95; 0.92-0.98) were associated with greater likelihood of treatment with anti-osteoporosis medication.

LIMITATIONS, REASONS FOR CAUTION

Survey data including age of menopause were self-reported by participants; fracture questions were not included in the 2001 survey, and location or level of trauma of self-reported fractures was not asked. Additional risk/protective factors such as vitamin D status, calcium intake, and exercise were not able to be included. Due to sample size, POI and EM were combined for all analyses, and we were unable to differentiate between causes of POI/EM. PBS data were only available from 2004, and hospital admissions data were state-based, with all of Australia were only available from 2007.

WIDER IMPLICATIONS OF THE FINDINGS

This study supports previous literature indicating increased risk of osteoporosis and fractures in women with POI, and adds evidence for women with POI/EM, where there was a relative paucity of data. This is the first study to analyse a variety of clinical and demographic risk factors for osteoporosis and fractures in women with POI/EM, as well as analysing investigation and treatment rates. In these women, using MHT prior to or at study entry, aged 45-50 years, was protective for osteoporosis/fractures; however, having ever used MHT was not, highlighting the importance of early treatment with MHT in these women to preserve bone strength. Although women with POI/EM and osteoporosis or fractures were more likely to use anti-osteoporosis medications than those with usual age menopause, overall treatment rates are low at <40%, demonstrating a significant treatment gap that should be addressed to reduce future fracture risk.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by The Australian NHMRC Centre of Research Excellence Women's Health in Reproductive Life (CRE-WHIRL, project number APP1171592). A.R.J. is the recipient of a National Health and Medical Research Council post-graduate research scholarship (grant number 1169192). P.R.E. is supported by a National Health and Medical Research Council grant 1197958. P.R.E. reports grants paid to their institution from Amgen, Sanofi, and Alexion, honoraria from Amgen paid to their institution, and honoraria from Alexion and Kyowa-Kirin.

TRIAL REGISTRATION NUMBER

N/A.

Femora of women with premature ovarian insufficiency exhibit reduced strength and misalignment with the transmitted vertical forces from the upper body

BACKGROUND

Women with premature ovarian insufficiency (POI) lack oestrogen, which is a key determinant of bone growth, epiphyseal closure, and bone tissue organisation. Although dual-energy X-ray absorptiometry (DXA)-derived areal bone mineral density (BMD) remains the gold standard for fracture risk evaluation, it does not fully characterise the skeletal abnormalities present in these women. Hence, we aimed to assess hip/femur anatomy, strength, and geometry and femoral alignment using advanced hip analysis (AHA).

METHODS

We conducted a cross-sectional, case-control study including 89 women with spontaneous normal karyotype POI (s-POI) or iatrogenic POI (i-POI), aged 20-50 years compared with 89 age- and body mass index (BMI)-matched population-based female controls. Hip anatomy, strength, geometrical parameters, and femur alignment were measured using hip DXA images and Lunar AHA software. Femoral orientation angle (FOA) was quantified as the overall orientation of the femur with respect to the axis of the forces transmitted from the upper body.

RESULTS

The median age of POI diagnosis was 35 (18-40) years; the mean POI duration at the time of DXA was 2.07 (range 0-13) years, and 84% of POI women received oestrogen therapy. Areal BMD at all sites was significantly lower in the POI group (all P < .05). Indices of compressive and bending strength were lower in women with POI compared with controls, specifically the cross-sectional area (CSA, mm2) and section modulus (SM, mm3) (139.30 ± 29.08 vs 157.29 ± 22.26, P < .001 and 665.21 ± 129.54 vs 575.53 ± 150.88, P < .001, respectively). The FOA was smaller (124.99 ± 3.18) in women with POI as compared with controls (128.04 ± 3.80; P < .001) at baseline and after adjusting for height and femoral neck BMD.

CONCLUSION

Alongside lower BMD at multiple sites, the femora of women with POI demonstrate reduced strength and a misalignment with forces transmitted from the upper body. Further research is needed to establish the role of these newly identified features and their role in fracture risk prediction in this population.

Positive impact of a co-designed digital resource for women with early menopause

OBJECTIVE

To evaluate a co-designed early menopause digital resource, including audio/video clips, question prompt list, and information links.

METHODS

Pre/post-test study. Women with early menopause, defined as menopause before age 45 years, were recruited from the community. Following online informed consent, participants were emailed links to the digital resource and online surveys to complete before (baseline) and, immediately and 1 month after viewing the resource. Main outcome measures: Health-related empowerment (Health Education Impact Questionnaire), illness perception (Brief Illness Perception Questionnaire), menopause symptoms (Greene Climacteric Scale), risk perception, and knowledge change.

RESULTS

One hundred fifty women participated. Compared to baseline, at 1-month health-related empowerment, 'health directed behavior' scores increased (mean change: +0.13; 95% CI: 0.01-0.24; and P = 0.03), 'emotional distress' decreased (mean change: -0.15; 95% CI: -0.25 to -0.05; and P = 0.003) and physical and emotional menopause symptom scores decreased (P = 0.001 and P  = 0.02, respectively). Illness perception scores increased at both immediate and 1-month follow-up versus baseline for 'personal control' (P < 0.001 and P  = 0.02) and 'coherence' (P = 0.003 and P  < 0.001). After viewing the digital resource, more women perceived that hormone therapy decreases heart disease risk, reduces hot flashes, and prevents fractures versus baseline (all P  < 0.05). More women correctly answered questions regarding early menopause prevalence (60% vs 35%), cause (46% vs 33%), risk (76% vs 55%), effect of phytoestrogens (60% vs 27%), and osteoporosis prevention (64% vs 44%) at immediate or 1-month follow-up versus baseline (all P  < 0.05).

CONCLUSIONS

A co-designed early menopause digital resource may improve women's health-related empowerment, illness perception, menopause symptoms, risk perception, and knowledge.

Quality of life assessment in women with spontaneous premature insufficiency: A comparative cross-sectional study

OBJECTIVE

Premature ovarian insufficiency is cessation of ovarian function prior to 40 years of age. It is known to have varied short and long-term implications on the health of the women. The quality of life is affected in various domanins. The objective of this study is to evaluate QOL of women with POI and the factors associated with it, using WHO QOL-BREF scale.

METHODS

This is a cross sectional comparative study. Women with premature ovarian insufficiency with normal karyotype were included before initiation of hormone replacement therapy as cases and age matched women without any menstrual irregularity, infertility or any chronic illness were included as controls. Written informed consent was obtained from all patients. The pre-validated Tamil version of the WHOQOL-BREF (26 items, 4 domains) was filled through face-to-face interview. The score of each domain was transformed into 0-100 as per the guideline provided by WHOQOL-BREF. Statistical analysis was done using SPSS version 19.

RESULTS

A total of 100 (50 women with POI and 50 control women) completed the WHOQOL-BREF questionnaire. The mean age of the women who participated in the study was 29.6 ± 6.5 years. Among the cases, 72% were nulliparous. There was statistically significant difference in the median scores of overall QOL, physical, psychological and social domains between the two groups. Univariate analysis showed that nulliparity and infertility were the factors responsible for poor QOL, however, these were not independently associated with poor QOL after applying bivariate linear regression analysis.

CONCLUSION

The scores of overall QOL, physical, psychological and social domains were poorer in women with POI as compared to healthy controls.

Chronic and Cumulative Adverse Life Events in Women with Primary Ovarian Insufficiency: An Exploratory Qualitative Study

BACKGROUND AND PURPOSE

Primary ovarian insufficiency (POI) has serious physical and psychological consequences due to estradiol deprivation, leading to increased morbidity and mortality. However, the causes of most POI cases remain unknown. Psychological stress, usually caused by stressful life events, is known to be negatively associated with ovarian function. It is important to explore high-frequency adverse life events among women with POI for future interventions.

METHODS

Forty-three women (mean age=33·8 years) were recruited who were newly- diagnosed with idiopathic POI (FSH levels >40 IU/L) to participate in semi-structured interviews through convenience sampling. The main questions covered by the topic guide were designed to explore adverse life events prior to POI diagnosis. Interviews were audio recorded, transcribed and analyzed thematically. Data were analyzed from June 2019 to August 2020.

RESULTS

Among the women with POI, mean age at diagnosis of POI was 33·8 years (range from 19 to 39 years), and the average time between the onset of irregular menstruation and POI diagnosis was 2.3 years. These women with POI had a relatively normal menstrual cycle before the diagnosis. A number of stressful life events prior to POI diagnosis were discussed by them as important factors influencing their health. Four core themes emerged: 1) persistent exposure to workplace stress, 2) persistent exposure to family-related adverse life events, 3) sleep problem/disturbance existed in women with POI before diagnosis, and 4) participants' general cognition and concerns about POI.

CONCLUSIONS

Persistent exposures to adverse life events related to work stress, family stress and sleep problem existed in women with POI. Our findings are consistent with the hypothesis that adverse life events play a role in the development of POI. Future research should investigate how social environmental factors influence POI disease risks, and whether provision of tailored interventions (i.e. preventing or mitigating impact of adverse life events) aimed at high-risk populations may help prevent new POI cases and improve conditions of women with POI. We gained an in-depth understanding of the experiences of these women via 1:1 qualitative method, and find adverse life events are frequent in women with POI prior to the diagnosis.

Association of Salpingectomy With Delayed Oophorectomy Versus Salpingo-oophorectomy With Quality of Life in BRCA1/2 Pathogenic Variant Carriers: A Nonrandomized Controlled Trial

Importance

Most women with a BRCA1/2 pathogenic variant undergo premature menopause with potential short- and long-term morbidity due to the current method of ovarian carcinoma prevention: risk-reducing salpingo-oophorectomy (RRSO). Because the fallopian tubes play a key role in ovarian cancer pathogenesis, salpingectomy with delayed oophorectomy may be a novel risk-reducing strategy with benefits of delaying menopause.

Objective

To compare menopause-related quality of life after risk-reducing salpingectomy (RRS) with delayed oophorectomy with RRSO in carriers of the BRCA1/2 pathogenic variant.

Design, Setting, and Participants

A multicenter nonrandomized controlled preference trial (TUBA study), with patient recruitment between January 16, 2015, and November 7, 2019, and follow-up at 3 and 12 months after surgery was conducted in all Dutch university hospitals and a few large general hospitals. In the Netherlands, RRSO is predominantly performed in these hospitals. Patients at the clinical genetics or gynecology department between the ages of 25 and 40 years (BRCA1) or 25 to 45 years (BRCA2) who were premenopausal, had completed childbearing, and were undergoing no current treatment for cancer were eligible.

Interventions

Risk-reducing salpingo-oophorectomy at currently recommended age or RRS after completed childbearing with delayed oophorectomy. After RRSO was performed, hormone replacement therapy was recommended for women without contraindications.

Main Outcomes and Measures

Menopause-related quality of life as assessed by the Greene Climacteric Scale, with a higher scale sum (range, 0-63) representing more climacteric symptoms. Secondary outcomes were health-related quality of life, sexual functioning and distress, cancer worry, decisional regret, and surgical outcomes.

Results

A total of 577 women (mean [SD] age, 37.2 [3.5] years) were enrolled: 297 (51.5%) were pathogenic BRCA1 variant carriers and 280 (48.5%) were BRCA2 pathogenic variant carriers. At the time of analysis, 394 patients had undergone RRS and 154 had undergone RRSO. Without hormone replacement therapy, the adjusted mean increase from the baseline score on the Greene Climacteric Scale was 6.7 (95% CI, 5.0-8.4; P < .001) points higher during 1 year after RRSO than after RRS. After RRSO with hormone replacement therapy, the difference was 3.6 points (95% CI, 2.3-4.8; P < .001) compared with RRS.

Conclusions and Relevance

Results of this nonrandomized controlled trial suggest that patients have better menopause-related quality of life after RRS than after RRSO, regardless of hormone replacement therapy. An international follow-up study is currently evaluating the oncologic safety of this therapy.

Trial Registration

ClinicalTrials.gov Identifier: NCT02321228.

Urinary phthalate metabolite concentrations and hot flashes in women from an urban convenience sample of midlife women

CONTEXT

Phthalate exposure is associated with altered reproductive function, but little is known about associations of phthalate exposure with risk of hot flashes.

OBJECTIVE

To investigate associations of urinary phthalate metabolite levels with four hot flash outcomes in midlife women.

DESIGN

A cross-sectional study of the first year of a prospective cohort of midlife women, the Midlife Women's Health Study (2006-2015), a convenience sample from an urban setting.

PARTICIPANTS

728 multi-racial/ethnic pre- and perimenopausal women aged 45-54 years.

OUTCOME MEASURES

Women completed questionnaires about hot flash experience and provided 1-4 urine samples over four consecutive weeks that were pooled for analysis. Phthalate metabolites were assessed individually and as molar sums representative of common compounds (all phthalates: ƩPhthalates; DEHP: ƩDEHP), exposure sources (plastics: ƩPlastic; personal care products: ƩPCP), and modes of action (anti-androgenic: ƩAA). Covariate-adjusted logistic regression models were used to assess associations of continuous natural log-transformed phthalate metabolite concentrations with hot flash outcomes. Analyses were conducted to explore whether associations differed by menopause status, body mass index (BMI), race/ethnicity, and depressive symptoms.

RESULTS

Overall, 45% of women reported a history of hot flashes. Compared to women who never experienced hot flashes, every two-fold increase in ƩPlastic was associated with 18% (OR: 1.18; 95%CI: 0.98, 1.43) and 38% (OR: 1.38; 95%CI: 1.11, 1.70) higher odds of experiencing hot flashes in the past 30 days and experiencing daily/weekly hot flashes, respectively. Some associations of phthalates with certain hot flash outcomes differed by menopause status, BMI, race/ethnicity, and depressive symptoms.

CONCLUSIONS

This study suggests that phthalates are associated with hot flash experience and may impact hot flash risk in women who are susceptible to experiencing hot flashes.

Musculoskeletal Health in Premature Ovarian Insufficiency. Part Two: Bone

Accelerated bone loss and muscle loss coexist in women with premature ovarian insufficiency (POI), but there are significant gaps in our understanding of musculoskeletal health in POI. This review describes estrogen signaling in bone and its role in skeletal health and disease. Possible mechanisms contributing to bone loss in different forms of POI and current evidence regarding the utility of available diagnostic tests and therapeutic options are also discussed. A literature review from January 2000 to March 2020 was conducted to identify relevant studies. Women with POI experience significant deterioration in musculoskeletal health due to the loss of protective effects of estrogen. In bone, loss of bone mineral density (BMD) and compromised bone quality result in increased fracture risk; however, tools to assess bone quality such as trabecular bone score (TBS) need to be validated in this population. Timely initiation of HRT is recommended to minimize the deleterious effects of estrogen deficiency on bone in the absence of contraindications; however, the ideal estrogen replacement regimen remains unknown. POI is associated with compromised bone health, regardless of the etiology. Ongoing research is warranted to refine our management strategies to preserve bone health in women with POI.

Co-designing an Early Menopause Digital Resource: Model for Interdisciplinary Knowledge Translation

Early menopause/premature ovarian insufficiency is associated with negative health impacts, unmet information needs, delayed diagnosis, and variation in management. Co-designed digital resources for women with early menopause/premature ovarian insufficiency and health practitioners were developed to address information needs and support management. A five-phase mixed methods multidisciplinary research, co-design and translation process comprised: (1) survey/interviews with women and health practitioners to explore early menopause/premature ovarian insufficiency needs, experiences, and management; (2) appraisal of clinical guidelines to develop management algorithms; (3) digital resource development (https://healthtalkaustralia.org/early-menopause-experiences-and-perspectives-of-women-and-health-professionals/; (4) evaluation; and (5) dissemination/implementation. The digital resources included audio/video clips of women with early menopause/premature ovarian insufficiency and health practitioners providing early menopause/premature ovarian insufficiency care, a question prompt list, health practitioner algorithms, information links, and a list of services for women, achieving high satisfaction ratings from women and health practitioners. Engaging our stakeholder partners, multimodal dissemination has included community and conference presentations, social media, lay and professional publications, and webinars. This project provides a model for successful interdisciplinary co-design research translation to improve women's health.

Perceptions and experiences of women with premature ovarian insufficiency about sexual health and reproductive health

BACKGROUND

Premature ovarian insufficiency (POI) is a condition with impaired ovarian function that occurred in women before the age of 40. Considering that women with POI are in reproductive age and their fertility and sexual life are afflicted by this disorder directly, the present study aimed to investigate perception and experience of women with POI of sexual and reproductive health (SRH).

METHODS

This is a qualitative that was implemented based on the conventional content analysis approach. The data were collected using semi-structured in-depth interviews with 16 women having POI, based on purposeful sampling and continued until data saturation. The participants were women with POI that referred to the three infertility center in Tehran, Iran. The audio recorded data were transcribed verbatim and then analyzed using conventional content analysis based on the method proposed by Zhang and Wildmouth.

RESULTS

After content analysis of the interviews with a focus on the perception and experience of women with POI of SRH, four main categories emerged i.e. endangerment of women's health, psychological agitation, disruption of social life and disturbance in sexual life.

CONCLUSION

POI affects different aspects of women SRH (women physical, psychological, social and sexual heath). Therefore, knowledge of patients' concerns by health professionals is helpful to improve service delivery and increasing the effectiveness of treatment interventions by a comprehensive health care attitude.

Women's Experiences of Diagnosis and Treatment of Early Menopause and Premature Ovarian Insufficiency: A Qualitative Study

Early menopause (EM) and premature ovarian insufficiency (POI) affect an estimated 10% of women and can precipitate a wide range of physiological and personal impacts. Receiving a diagnosis of EM/POI and navigating treatment can be complex experiences for women; however, qualitative research exploring these aspects of the condition is limited. Our study aimed to increase understanding of women's lived experiences of EM/POI encompassing its medical, social, and emotional dimensions. We conducted narrative interviews with 30 women aged 28 to 51 years with spontaneous and iatrogenic EM/POI and menopausal symptoms resulting from ovarian suppression therapy, and analyzed transcripts thematically. This article examines the prominent and under-researched themes of women's experiences of navigating "diagnosis" and treatment. Diagnosis emerged as a complex and changeable process wherein women had to negotiate a diagnosis of spontaneous EM/POI and grasp the meaning and probability of iatrogenic EM/POI. Navigating treatment entailed further complexity as women grappled with the risks and efficacy of hormonal and non-hormonal medications. The findings underline the intricacies of EM/POI as a biomedical phenomenon and highlight the need for health practitioners to recognize and respond to the challenges women face in coming to terms with the condition and managing its embodied effects.

Menopausal symptoms in women with premature ovarian insufficiency: prevalence, severity, and associated factors

OBJECTIVE

To comprehensively investigate and evaluate the prevalence, severity, and associated factors of menopausal symptoms in women with premature ovarian insufficiency (POI). In this study, the specific symptomatology experienced by women with POI and women with natural menopause was also compared.

METHODS

In this cross-sectional study, 293 Chinese women with POI from an outpatient clinic were recruited between June 2014 and January 2019. The prevalence and severity of menopausal symptoms were assessed with modified Kupperman Menopausal Index. Participants completed a structured questionnaire, including medical history, menstrual characteristics, and sociodemographic data. Serum levels of reproductive hormones were measured.

RESULTS

Among 293 women with POI (33.76 ± 5.47 y), the most prevalent symptoms were mood swings (73.4%), insomnia (58.7%), sexual problems (58.7%), and fatigue (57.3%). Moderate-to-severe mood swings were most frequently reported (23.9%), followed by formication (17.4%) and hot flashes/sweating (17.1%). Compared with women with natural menopause, women with POI exhibited significantly higher risks for fatigue (odds ratio  = 1.42; 95% confidence interval, 1.04-1.94), melancholia (3.12; 1.94-5.01), mood swings (3.57; 2.33-5.45), insomnia (1.41; 1.02-1.96), and significantly lower risks for moderate-to-severe sexual problems (0.40; 0.23-0.69), any and moderate-to-severe muscle/joint pain (0.41; 0.27-0.62 and 0.45; 0.25-0.78, respectively). Living in urban areas and higher gravidity were independently associated with menopausal symptoms in women with POI.

CONCLUSIONS

Women with POI experienced a high prevalence of menopausal symptoms, particularly related to psychological and sexual domains. Furthermore, women with POI tended to have more distressing menopausal symptoms compared with women with natural menopause.

'My relationships have changed because I've changed': biographical disruption, personal relationships and the formation of an early menopausal subjectivity

Early menopause (EM) or premature ovarian insufficiency (POI) can disrupt gendered and age-related expectations associated with perceived 'normative' biographies for young adult women, with implications for subjectivity and relationships. While previous qualitative research has concentrated on the impacts of EM/POI on biography and sense of self, in this article, we examine the enmeshment of personal relationships with the formation of early menopausal subjectivities. Drawing on research exploring concepts of 'biographical disruption' and personal relationships, and theoretical work on social norms and subject formation, we present findings from a narrative thematic analysis of 25 interviews with women diagnosed with spontaneous or medically induced EM/POI. We identify three main narrative 'types' of subjective and relational experience in response to the 'disruption' of EM/POI: interlude and continuity; disruption and adaptation; and disruption and ambivalence. Women's accounts of their experience of EM/POI indicate that the formation of early menopausal selves is mediated by the extent to which women and those around them identify with gendered norms related to reproduction and age. Consistent with theoretical perspectives that consider the self as relationally produced, we argue that the subjective and relational dimensions of EM/POI are intertwined and must be understood in tandem.

Osteoporosis and premature ovarian insufficiency: geographic variation in clinicians' and consumers' knowledge gaps and barriers to care

PURPOSE

To determine whether geographic variation exists in osteoporosis knowledge, management, and barriers to care in the setting of premature ovarian insufficiency (POI), among general practitioners (GPs) and women with POI.

METHODS

Australian GPs completed an online questionnaire regarding osteoporosis knowledge, barriers to care and educational preferences for managing osteoporosis in POI. Women with POI/early menopause (EM) completed an online questionnaire regarding osteoporosis knowledge, risk factors and health beliefs. Clinicians and consumers in metropolitan areas were compared to those in rural areas.

RESULTS

Of 688 GP respondents, 62.2% practised in major capital cities, 13.1% in major regional cities, 7.8% in regional centres, 8.7% in rural areas and 8.1% in remote areas. Mean ± SD osteoporosis knowledge score was 9.1 ± 1.5/13, with no difference by location. Forty-one percent of GPs reported barriers to care which varied by location. Of 316 women with POI/EM, 61.1% lived in metropolitan, 22.5% in regional, 11.7% in rural and 4.4% in remote locations. The mean osteoporosis knowledge score was 8.2 ± 3.1/20, with lower scores in women living in rural and remote versus metropolitan locations (difference - 1.3; 95% CI - 2.3, - 0.25; p = 0.02). Women in rural areas were less likely to use vitamin D supplements and more likely to have a family history of osteoporosis (both p < 0.05).

CONCLUSIONS

GP knowledge gaps and specific, location-dependent care barriers for osteoporosis in POI were identified. Geographic differences in osteoporosis knowledge and risk factors exist in women with POI/EM. These factors require consideration when designing programs to improve bone health in POI.

Health-related quality-of-life among patients with premature ovarian insufficiency: a systematic review and meta-analysis

PURPOSE

To systematically review studies investigating health-related quality-of-life (HrQoL) in patients with premature ovarian insufficiency (POI), to examine questionnaires used and to conduct a meta-analysis of control studies with normal ovarian function.

METHODS

Data sources: PubMed, Embase, Web of science, CNKI, and CQVIP, searched from inception until June 2018. The search strategy was a combination of medical (e.g. POI), subjective (e.g. well-being) and methodological (e.g. questionnaires) keywords. PRISMA guidelines were used to assess outcome data quality/validity by one reviewer, verified by a second reviewer. Risk of bias within studies was evaluated. A meta-analysis compared HrQoL in patients and non-patients. Due to measurement differences in the studies, the effect size was calculated as standard mean difference.

RESULTS

We identified 6869 HrQoL studies. Nineteen geographically diverse studies met inclusion criteria, dated from 2006, using 23 questionnaires. The meta-analysis included six studies with 645 POI participants (age 33.3 ± 5.47) and 492 normal-ovarian control subjects (age 32.87 ± 5.61). Medium effect sizes were found for lower overall HrQoL (pooled SMD = - 0.73, 95% CI - 0.94, - 0.51; I² = 54%) and physical function (pooled SMD = - 0.54, 95% CI - 0.69, - 0.39; I² = 55%). Heterogeneity was investigated. Effect sizes varied for sexual function depending on the measure (SMD = - 0.27 to - 0.74), overall HrQoL (SF-36) had the largest effect size (- 0.93) in one study. The effect sizes for psychological and social HrQoL were small.

CONCLUSION

POI is associated with low-to-medium effect size on HrQoL compared to normal ovarian controls. The greatest effects are found in general HrQoL and most sexual function areas. Condition-specific questionnaires and RCTs are recommended for further investigation.

Identifying and addressing osteoporosis knowledge gaps in women with premature ovarian insufficiency and early menopause: A mixed-methods study

OBJECTIVE

Osteoporosis associated with premature ovarian insufficiency (POI) and early menopause (EM) is a major concern for women. We aimed to (a) identify information and knowledge gaps and behaviours regarding bone health in women with POI/EM and (b) co-design an osteoporosis fact sheet.

DESIGN

Mixed-methods study: survey of women and online resource appraisals to develop and refine, using semi-structured interviews, an osteoporosis fact sheet.

PATIENTS

Women with POI/EM (menopause before ages 40 and 45 years respectively).

MEASUREMENTS

Demographics, comorbidities, information needs, calcium intake, exercise, osteoporosis knowledge (OKAT), beliefs and self-efficacy, DISCERN appraisal (validated scales).

ANALYSIS

descriptive statistics, logistic regression and thematic analysis of interviews.

RESULTS

Median age of survey respondents (n = 316) was 54(IQR47-63) years, median age of menopause was 40(IQR38-43) years, and osteoporosis diagnosis was reported in 19%. Most reported inadequate dietary calcium intake (99%) and exercise (65%). Median OKAT score 8 [IQR6-10]/19 indicated knowledge gaps regarding risk factors and treatment options. Adjusting for age and education, OKAT predicted calcium intake (OR 1.126 [CI 1.035-1.225]; P = 0.006) and screening (OR 1.186 [CI 1.077-1.305]; P = 0.001); beliefs predicted screening (OR 1.027 [CI 1.004-1.050]; P = 0.019); and self-efficacy predicted calcium intake (OR1.040 (CI 1.013-1.069); P = 0.003] and exercise (OR 1.117 [CI 1.077-1.160]; P < 0.001). Current online resources have deficiencies. Five themes identified from two interview rounds (n = 10/ round) were as follows: content, emotional response, design, perceived usefulness and clinical considerations. The final fact sheet was considered acceptable and useful in addressing knowledge gaps, promoting information-seeking, impacting behaviours and facilitating healthcare discussions.

CONCLUSION

A co-designed fact sheet is acceptable and addresses identified osteoporosis knowledge gaps in women with POI/EM.

Mood disorders in women with premature ovarian insufficiency

Premature ovarian insufficiency (POI) and related oestrogen deficiency is a cause of many psychological symptoms, including: depression, psychological tension, anxiety, mood lability, loss of libido, feelings of loss of femininity and attractiveness, and decreased self- and sexual esteem. Distress related to POI diagnosis may be even more confusing when POI is diagnosed in relation to serious health complications such as cancer, due to surgery or chemotherapy. Every case of POI requires coordinated medical advice with special attendance of a gynaecological endocrinologist, psychotherapist, and sometimes even a psychiatrist.

Neurological health and premature ovarian insufficiency - pathogenesis and clinical management

Premature ovarian insufficiency (POI) is related to neurological problems through neurological symptoms of oestrogen deficiency, diseases caused by oestrogen deficiency, and neurological genetic diseases. Neurological symptoms of oestrogen deficiency are usually reported as climacteric symptoms. Diseases caused by oestrogen deficiency are dementia, cognitive decline, and Parkinsonism. Among genetic neurological disorders, ovarioleukodystrophy and fragile X-associated tremor/ataxia syndrome (FXTAS) are reported.

Effect of Japanese Kampo Medicine Therapy for Menopausal Symptoms after Treatment of Gynecological Malignancy

Loss of ovarian function by the treatment for gynecological malignancy results in a drastic decrease of estrogen causing physical and mental symptoms. The purpose of this study is to evaluate the effect of Japanese Kampo Kamikihito (KKT) and Kamishoyosan (KSS) on menopausal symptoms in gynecological cancer patients. Patients who had menopausal symptoms after gynecologic malignancy treatment were enrolled and randomly divided into a KKT or a KSS group. Kupperman Menopausal Index (KI) questionnaires were obtained before tumor treatment, at baseline, and at 4 and 8 weeks. Changes in KI scores and severity of each symptom were evaluated. A total of 33 patients were enrolled: 18 in the KKT group and 15 in the KSS group. The KI scores significantly decreased at 4 and 8 weeks compared with baseline in both groups. Although no significant difference was found in change in KI scores between the KKT and KSS groups, efficacy showed some differences. Both KKT and KSS were effective for insomnia, vertigo, and palpitation. KSS was also effective for vasomotor symptoms and arthralgia/myalgia. In conclusion, both KKT and KSS were effective for menopausal symptoms in patients after gynecological tumor treatment. Tailor-made Kampo therapy may contribute to improve patients' physical and mental symptoms.

Vasomotor symptoms in menopause: a biomarker of cardiovascular disease risk and other chronic diseases?

Menopausal disorders may include shorter-term symptoms, such as hot flushes and night sweats (vasomotor symptoms, VMS) and longer-term chronic conditions such as cardiovascular disease (CVD), osteoporosis, and cognitive impairment. Initially, no clear link between the shorter-term symptoms and longer-term chronic conditions was evident and these disorders seemed to occur independently from each other. However, there is a growing body of evidence demonstrating that VMS may be a biomarker for chronic disease. In this review, the association between VMS and a range of chronic postmenopausal conditions including CVD, osteoporosis, and cognitive decline is discussed. Prevention of CVD in women, as for men, should be started early, and effective management of chronic disease in postmenopausal women has to start with the awareness that VMS during menopause are harbingers of things to come and should be treated accordingly.

Premature ovarian insufficiency: the context of long-term effects

PURPOSE

Premature ovarian insufficiency (POI) is defined as the cessation of the ovarian function before the age of 40 years. POI aetiology may be related to iatrogenic or endogenous factors and in many cases remains unclear. The aim of this review was to characterize the long-term consequences of POI.

METHODS

The available literature regarding the long-term consequences of POI from MEDLINE has been reviewed.

RESULTS

Lack of ovarian steroids synthesis has serious consequences for women's health. The short-term effects are similar to spontaneous menopause and refer mainly to the climacteric syndrome. In a longer perspective, POI affects a variety of aspects. It obviously and drastically reduces the chances for spontaneous pregnancies. Oestrogen loss leads also to urogenital atrophy. The most common urogenital symptoms include vaginal dryness, vaginal irritation and itching. The urogenital atrophy and hypoestrogenism interferes also with sexual functioning. Patients with POI are threatened by a decrease in bone mineral density (BMD). POI women also experience psychological distress and some studies have shown an increased risk of neurodegenerating diseases. Overall, POI women have a shortened life expectancy, mainly due to cardiovascular disease. Some studies have reported a reduced risk of breast cancer in this group of patients.

CONCLUSIONS

In conclusion there are several well-characterized health risks in POI women. With every patient, an individualized approach is required to properly recognize and prevent these risks.

Compounded bioidentical hormone therapy: identifying use trends and knowledge gaps among US women

OBJECTIVE

Two surveys (Harris and Rose surveys) were conducted to quantify the use of compounded hormone therapy (CHT; or bioidentical hormone therapy) among perimenopausal and postmenopausal women in the United States, to assess women's knowledge of CHT versus Food and Drug Administration (FDA)-approved hormone therapy, and to gather information on menopausal experience.

METHODS

The Harris survey was administered to 801 women aged 45 to 60 years who had experienced at least one menopausal symptom. The Rose survey was administered to 2,044 women aged 40 years or older who were ever users of hormone therapy. Women were queried about menopausal symptoms, hormone therapy use, and knowledge of CHT. Findings from the Rose survey were extrapolated using US Census Bureau data and prescription claims for FDA-approved hormone therapy to estimate the prevalence of CHT use.

RESULTS

According to extrapolations using Rose data, up to 2.5 million US women aged 40 years or older may use CHT annually, accounting for 28% to 68% of hormone therapy prescriptions. Harris data showed that 86% of women surveyed were unaware that CHT products are not FDA-approved. The Rose survey asked a subset of 1,771 women whether their hormone therapy had been personalized based on hormone levels; 21% (378) answered "yes" whereas 27% (476) did not know. In both surveys, most hormone therapy users stated that their physician had recommended the treatment.

CONCLUSIONS

We estimate that 1 million to 2.5 million US women aged 40 years or older use CHT. The data suggest that many women are unaware that compounded hormones have not been evaluated or approved by the FDA. Providers have an educational opportunity to ensure that women considering hormone therapy understand the risks and benefits of inadequately regulated CHT.

Phthalate metabolite levels and menopausal hot flashes in midlife women

During the menopausal transition, a woman's reproductive capacity declines, her hormone milieu changes, and her risk of hot flashes increases. Exposure to phthalates, which can be found in personal care products, can also result in altered reproductive function. Here, we investigated the associations between phthalate metabolite levels and midlife hot flashes. Eligible women (45-54 years of age) provided detailed information on hot flashes history and donated urine samples (n=195). Urinary phthalate metabolite levels were measured by HPLC-MS/MS. A higher total sum of phthalate metabolites commonly found in personal care products was associated with an increased risk of ever experiencing hot flashes (odds ratio (OR)=1.45; 95% confidence interval (CI)=1.07-1.96), hot flashes in the past 30days (OR=1.43; 95%CI=1.04-1.96), and more frequent hot flashes (OR=1.47; 95%CI=1.06-2.05). These data suggest that some phthalate exposures from personal care products are associated with menopausal hot flashes in women.

Current Concepts in Premature Ovarian Insufficiency

Premature ovarian insufficiency (POI) is a life-changing diagnosis, with profound physical and psychological consequences. Unfortunately, there are many deficiencies in our understanding of the condition as the underlying etiology and optimum management strategies are poorly understood. Improved awareness of POI and its long-term implications has led to increased research interest in recent years. Current research has allowed a greater understanding of the changing epidemiology in POI, genetic factors in its etiology and randomized controlled trials of hormone therapy are underway to provide evidence for treatment. This article reviews the latest literature on POI to summarize current understanding and future directions.