The treatment-seeking woman at menopause

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.

Relationship of Medication Use to Health-Related Quality of Life Among a Group of Older American Indians

This cross-sectional study examines the relationship of polypharmacy to health-related quality of life (HRQoL) among a group of older American Indians. An in-home interview and survey were administered to 63 community-dwelling American Indians aged 50 or older who were taking four or more prescription medications regularly. With the component summary scores from the Medical Outcomes Study Short Form-36 instrument analyzed as dependent variables, only the Physical Component Summary (PCS) score (r = .30, p = .02), and not the Mental (r = .06, p = .67), was associated with degree of polypharmacy. This association with PCS score remained significant even after controlling for age, sex, and chronic disease score (adjusted β = -.91, p = .045). This study is the first to describe the relationship between polypharmacy and HRQoL among a group of American Indians, and the results support the need for larger and more comprehensive studies of medication use in this special population.

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.

Menopause Research and The Dominance of the Biomedical Model 1984-1994

Popular images and stereotypes of women in the menopausal age range are overwhelmingly negative. Because these stereotypes are likely both to influence and to be influenced by published scholarship, it is particularly important to examine conventional knowledge as it has been represented in science-based journals. In an effort to examine the extent and nature of the accepted knowledge base regarding menopause, a survey of both medical and psychological journal articles was conducted for the years 1984-1994. Publication trends revealed a predominance of articles based on a biomedical paradigm and the virtual absence of articles presenting alternative perspectives on midlife. Ten serious methodological problems common to this literature are delineated, including such fundamental errors as failure to acquire baseline data, lack of control groups, vague operational definitions, and blatantly pejorative language. We also discuss conceptual flaws implicit in the predominant paradigm, including the messages that women are different, sicker, and weaker than a normal, male, ideal. Finally, we consider the implications of these social constructions for the political, social, and psychological status of women.

Symptoms of depressed mood, disturbed sleep, and sexual problems in midlife women: cross-sectional data from the Study of Women's Health Across the Nation

BACKGROUND

Women report many nonvasomotor symptoms across the menopausal transition, including sleep disturbances, depressed mood, and sexual problems. The co-occurrence of these three symptoms may represent a specific menopausal symptom triad. We sought to evaluate the interrelatedness of disturbed sleep, depressed mood, and sexual problems in the Study of Women's Health Across the Nation (SWAN) and determine the characteristics of women exhibiting this symptom triad.

METHODS

SWAN is a multisite, multiethnic observational cohort study of the menopausal transition in the United States. Sleep disturbance, sexual problems, and depressed mood were determined based on self-report. Women who reported all three symptoms simultaneously were compared to those who did not. Logistic regression models estimated the association of demographic, psychosocial, and clinical characteristics with the symptom triad.

RESULTS

Study participants (n=1716) were 49.8 years old on average and primarily in very good or excellent health. Sixteen and a half percent had depressed mood, 36.6% had a sleep problem, and 42.2% had any sexual problem. Five percent of women (n=90) experienced all three symptoms. Women with the symptom triad compared with those without had lower household incomes, less education, were surgically postmenopausal or late perimenopausal, rated their general health as fair or poor, and had more stressful life events and lower social support.

CONCLUSIONS

The symptom triad of sleep disturbance, depressed mood, and sexual problems occurred in only 5% of women, and occurred most often among women with lower socioeconomic status, greater psychosocial distress, and who were surgically menopausal or in the late perimenopause.

Crosstalk between hormones and oral health in the mid-life of women: A comprehensive review

Oral health is constantly shaped by the cross-talk between behavioral, biological, and social forces. Menopause is that time in a woman's life when menstrual cycles cease by reduced secretion of the ovarian hormones, such as, estrogen and progesterone. Diseases of the mouth itself are the most common reasons for pain and discomfort in the mouth. However, there are certain situations where oral symptoms are caused as a result of systemic diseases. This review article has emphasized on the diverse oral presentations of postmenopausal women by descriptive analysis of various underlying mechanisms associated with these conditions. Dentists should be aware of the possible association of menopause and various oral health problems.

What midlife women want from gynecologists: a survey of patients in specialty and private practices

BACKGROUND

This study characterized the self-reported reason for a gynecology visit among midlife women in three different practice settings. We hypothesized that women seeking specialty care were more likely to report nonvasomotor symptoms potentially related to the menopausal transition.

METHODS

Participants were 625 women aged 40-60 seen by gynecologists at three sites: an urban, academic, gynecologic menopause practice (Midlife Practice, or MLP) and urban (site A) and suburban (site B) locations of a general, nonacademic obstetrics and gynecology practice. Participants completed a self-report questionnaire asking them to choose and weigh the reason for their visit as "very much," "somewhat," or "not at all" for 15 common gynecologic and menopausal concerns. Demographic questions included age, self-rated health status, race/ethnicity, difficulty of paying for basics, and education. Comparisons between the three groups were made using parametric and nonparametric tests as appropriate. The main outcome measure was the response to the reason for participants' visit compared across the three sites.

RESULTS

Women presenting to the MLP were significantly older and more likely to report vasomotor symptoms (VMS), moodiness, sexual problems, sleep problems, and weight and to learn more about menopause. When "very much" and "somewhat" reasons were combined, nearly 80% of the MLP responses listed sleep problems, 60% listed vaginal dryness or low desire, 34% listed weight gain, and 30.7% listed mood.

CONCLUSIONS

Midlife women seeking care in a menopause gynecology practice had significantly more visits for vasomotor and nonvasomotor concerns than did women seeing general gynecologists. Women sought care for a broad range of concerns that are not typically in gynecologists' scope of practice, including sleep disturbances, moodiness, and weight management.

Dental implants in patients with osteoporosis: a clinical reality?

Osteoporosis is a systemic disorder characterized by generalized decrease in bone mineral density. Dental implantology is a specialty with high predictability when both quantity and quality of the bone are respected. Therefore, the diagnosis and the implant treatment in patients with osteoporosis are important. In the current study, a literature review about osteoporosis and dental implant therapy was conducted. PubMed, Cochrane, ISI, Dentistry Oral Science, SciELO, and Bireme databases were consulted over the last 20 years. English- and Portuguese-language articles were included in this revision. Some authors stated that the osteoporotic bone is similar to the proposed model of bone type IV. Randomized clinical studies reported implant failure in patients with osteoporosis after menopause. Studies that contraindicate the use of implants in patients with osteoporosis infer that the impaired bone metabolism led to reduction of bone healing around the implants. Nevertheless, other authors believe that the presence of osteoporosis is not a definitive condition to contraindicate the therapy with dental implants. In these cases, the dentist should perform a proper treatment planning, modifying the implant geometry, and use larger implant diameter and with surface treatment. Thus, osteoporosis is not a contraindication for implant surgery because an accurate analysis of bone quality by means tomography is performed.

The impact of bisphosphonates on oral health: lessons from the past and opportunities for the future

Osteonecrosis of the jaw (ONJ), a challenging medical condition seen primarily among intravenous bisphosphonate (BP) users, is characterized by exposed necrotic bone that persists for more than eight weeks. While rare among people with osteoporosis treated with oral BPs, ONJ has captured the public's attention and caused significant distress. For many, the risk-benefit scale has conceptually changed, tipping steeply toward risk, while for others the benefit of increased bone mass still outweighs the possibility of ONJ. While more than seven years have passed since the first cases were published, the scientific and medical communities are not yet ready to address with certainty the issue of causal inference, nor do they have any concrete recommendations for risk assessment or management of ONJ. Equally important, the dental literature has been skewed by the perceived risk associated with prolonged use of BPs and has neglected to explore how the antiosteoclastic activity of BPs may be utilized to improve dental outcomes. This article reviews critically the current state of knowledge about the impact of bisphosphonates on oral health. Using the principles of epidemiology, the article identifies scientific gains, research challenges, and future research opportunities on the topic.

The effect of oestrogen and alendronate therapies on postmenopausal bone loss around osseointegrated titanium implants

OBJECTIVES

This study evaluated the influence of oestrogen deficiency and its therapies on bone tissue around osseointegrated implants.

METHODS

Implants were placed in 66 female rats tibiae. The animals were assigned into five groups: control (CTL), sham, ovariectomy (OVX), oestrogen (EST), and alendronate (ALE). While CTL was sacrificed 60 days after implant placement, other groups were subjected to ovariectomy or sham surgery according to group and euthanized after 90 days. Blood and urine samples were collected at sacrifice day for osteocalcin (OCN) and deoxypyridinoline (DPD) quantification. Densitometry of femur and lumbar vertebrae was performed in order to evaluate rats' skeletal impairment. Non-decalcified sections were referred to fluorescent and light microscopy for analyses of mineral apposition rate (MAR), eroded and osteoclastic surfaces, bone-to-implant contact (BIC), and bone area fraction occupancy (BAFO).

RESULTS

Results from the OVX group showed significantly lower bone mineral density (BMD), BIC, BAFO, and MAR, while OCN, deoxipiridinoline, eroded surface and ostecoclastic surface were increased compared with the other groups of the study. ALE reduced OCN and DPD concentrations, MAR, osteoclastic and eroded surfaces, and no difference was in BIC and BAFO relative to SHAM. EST and CTL showed similar results to SHAM for measurements.

CONCLUSIONS

Oestrogen deficiency exerted a negative influence on bone tissue around implants, while oestrogen replacement therapy and alendronate were effective against its effects. Although alendronate therapy maintained the quantity of bone around implants, studies evaluating bone turnover kinetics are warranted.

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.

Stress, psychological distress, psychosocial factors, menopause symptoms and physical health in women

OBJECTIVES

Relatively few studies have evaluated relationships between stress, psychological distress, psychosocial factors and menopause symptoms, and none have evaluated emotional intelligence (EI) in relation to menopause. In this study, direct and indirect relationships were evaluated between stress, psychological distress, psychosocial factors (e.g. social support, coping, EI), menopause symptom severity and physical health in middle-aged women.

METHODS

One hundred and sixteen women aged 45-55 years were recruited through women's health centres and community organizations. They completed a short questionnaire asking about stress, psychological distress (i.e. anxiety, depression), EI, attitude to menopause, menopause symptoms and physical health.

RESULTS

Low emotional intelligence was found to be related to worse menopause symptoms and physical health, and these associations were partly mediated by high stress, anxiety and depression, a negative attitude to menopause and low proactive coping.

CONCLUSIONS

Women with high EI appear to hold more positive attitudes to menopause and experience less severe stress, psychological distress and menopause symptoms and better physical health. These results suggest that women who expect menopause to be a negative experience or are highly stressed or distressed may be more likely to experience a more negative menopause.

Quality-of-life assessment in community-dwelling, middle-aged, healthy women in Japan

OBJECTIVES

To determine the quality of life (QOL) of middle-aged Japanese healthy women during the menopausal transition, to identify the correlation between decreasing quality of life and the severity of menopausal symptoms in those women, and to evaluate the number of women who sought treatment/health-care support and their expectations for health-care services.

METHODS

This was a community-based study, performed in collaboration with the Munakata Women's Midlife Health Project. The participants attended an annual medical check-up and cancer screenings, and led an everyday life without receiving medical treatment. Their quality of life was assessed with the World Health Organization QOL assessment (WHOQOL) and the severity of menopausal symptoms was assessed with the Kupperman index. Their expectations for health-care services were determined with an open-ended questionnaire.

RESULTS

The mean scores of the Kupperman index in the peri- and postmenopausal states were significantly higher than that in the premenopausal states, whereas there was no significant difference of quality of life scored by the WHOQOL in the three groups. In spite of recruiting healthy middle-aged women, 24.4% of the perimenopausal and 26.6% of the postmenopausal women suffered from moderate or severe menopausal symptoms. The decreasing level of quality of life was correlated with the severity of the menopausal symptoms in the peri- and postmenopausal women. The participants did not receive medical support except in two cases, but 83.0% of them wished to participate in a seminar concerning menopause. Several of them sought treatment, health-care support and advice on how to maintain their health during and after the menopausal transition.

CONCLUSIONS

Nearly one-quarter of Japanese community-dwelling, healthy women in the peri- and postmenopausal states suffered from menopausal symptoms, which decreased their quality of life in everyday life.

Sexuality

This article reviews changes in sexual function in middle-aged women and discusses how these changes relate to aging, hormone alterations, and psychosocial and physical factors. A Medline search of population-based studies that measured sexual function, menopausal status and/or hormone levels was conducted. Longitudinal findings are from the Melbourne Women's Midlife Health Project, a population-based sample of 438 Australian-born white women, aged 45 to 55 years, who were menstruating at baseline. Annual assessments included hormone levels and the Short Personal Experiences Questionnaire. Few of the population-based studies of the menopausal transition measured sexual function or hormones. Aging and the length of the woman's relationship with her partner are associated with decline in sexual function. An additional decrement in sexual function occurs in midlife associated with menopause. Findings from the Melbourne Women's Midlife Health Project using structural equation modeling, found the most important factors influencing a woman's sexual function are prior level of sexual function; losing or gaining a sexual partner; feelings toward a partner; and estradiol level. When psychosocial and lifestyle status were added to the model, mood was the only additional variable affecting sexual function. There is a decline in all aspects of female sexual function with age. A further incremental decline in most aspects of sexual function occurs as women pass through the menopausal transition and is related to decreasing estradiol levels. Other factors such as prior sexual function and partner issues have larger effects on women's sexual function than do hormonal factors.

Memory after menopause: preliminary considerations of hormone influence on cognitive functioning

Oestrogen has been shown to have a wide variety of organisational and activating effects on brain structure and function. Despite the significant amount of research investigating the relation and effects of oestrogen to cognitive performance in menopausal women over the past two decades, studies have failed to produce consistent findings. This paper reports on evaluations of eighty-one community-based postmenopausal Australian women comparing current, past and never users of hormone therapy (HT) on a wide range of cognitive measures of general, verbal and visual memory, delayed recall, attention, concentration and verbal comprehension. Few significant differences were found among the three groups in the demographic profile, health status or psychological functioning. Although never users had significantly lower scores on verbal memory than past users, the differences were not statistically significant when adjustments were made controlling for age, education level, verbal comprehension, attention and concentration. These findings challenge long-held beliefs regarding the usefulness of oestrogen supplements as a protective factor against cognitive decline in older women's later years.

Women's views of the climacteric at the time of low menopausal hormone use, Estonia 1998

OBJECTIVES

This study examined women's opinions about the climacteric and hormone therapy (HT) after menopause and compared women's and physicians' opinions in a country of low-HT use.

METHODS

In 1998, a postal questionnaire was sent to a random sample of 2000 Estonian 45-64-year-old women; 69% (n=1312) responded. In 1999, a postal questionnaire was sent to a random sample of 500 Estonian gynaecologists and general practitioners; 68% (n=342) responded.

RESULTS

Mean age at menopause was 49.8 years (S.D. 4.0), and there was no difference by socioeconomic classes or by age in self-rated health. Ten percent of women reported having used HT, with 3% currently using it. Most women reported some symptoms, with vasomotor symptoms more frequently reported by 50-54 years old; women most often reported tiredness (48%). Half of the women but under a fifth of physicians considered the climacteric a normal phase of life. Women's awareness about HT was low and about half had no opinion on its health effects. Half of the women had visited a gynaecologist, older women less so. Women with contacts with health care were more aware of HT.

CONCLUSIONS

Women reported symptoms by age-group as similarly found in high-HT use countries and it verifies that many symptoms experienced were not due to menopause. As in other low-HT use countries, women were unfamiliar with HT and their attitudes were traditional, although physicians' attitudes were more positive. Estonian women seemed to have escaped the period of the preventive use of HT.

The effects of postmenopausal hormone therapies on female sexual functioning: a review of double-blind, randomized controlled trials

Double-blind randomized controlled trials of estrogen and/or testosterone on sexual function among natural or surgical menopause in women are reviewed. Power, validity, hormone levels, and methodological issues were examined. Certain types of estrogen therapy were associated with increased frequency of sexual activity, enjoyment, desire, arousal, fantasies, satisfaction, vaginal lubrication, and feeling physically attractive, and reduced dyspareunia, vaginal dryness, and sexual problems. Certain types of testosterone therapy (combined with estrogen) were associated with higher frequency of sexual activity, satisfaction with that frequency of sexual activity, interest, enjoyment, desire, thoughts and fantasies, arousal, responsiveness, and pleasure. Whether specific serum hormone levels are related to sexual functioning and how these group effects apply to individual women are unclear. Other unknowns include long-term safety, optimal types, doses and routes of therapy, which women will be more likely to benefit from (or be put at risk), and the precise interplay between the two sex hormones.

Hot Flash, Hot Topic: Conceptualizing Menopausal Symptoms From a Cognitive-Behavioral Perspective

While most healthy women report that the menopausal transition is nondistressing, a subset of women does report that symptoms significantly interfere in their lives. The most common reason that women seek treatment during this time is for vasomotor symptoms, namely, hot flashes and night sweats. Research has suggested that reports of distress during flashing are only weakly related to more objective measures of the flash, including duration and frequency and that differences in treatment-seeking during the menopausal transition may be better accounted for by differences in symptom awareness mediated by a variety of personality and stress factors. This paper discusses hot flashes and night sweats from a cognitive-behavioral perspective, taking into account individual difference variables that may also affect the experience of menopausal symptoms.

The influence of age on symptoms of perimenopause

OBJECTIVE

To identify differences in the occurrence and severity of symptoms related to perimenopause in women ages 30 to 50 and to determine which of the symptoms were recognized as due to perimenopause and discussed with a health care professional.

DESIGN

Descriptive exploratory research design using a structured questionnaire.

PARTICIPANTS

A sample of women (N = 418) employed in institutions of higher learning and a health care facility.

MAIN OUTCOME MEASURES

The Menopause Symptom List was a 132-question survey used to identify occurrence and severity of symptoms in perimenopausal women, their recognition of the symptoms, and their level of discussion with a health care professional regarding the symptoms. One-way analysis of variance measures were applied to determine the differences between age groups and perimenopausal symptomology.

RESULTS

For both the measurement scales of frequency and severity of perimenopausal symptoms, the mean score increased as age increased. Significant differences were found between the age groups for the number of occurrences of sleeplessness, moodiness (p < .05) and depression, and poor concentration (p < .005). Significant differences in severity of symptoms were seen between age groups for depression (p < .05) and poor concentration (p < .005). Depressed feelings, headaches, moodiness, and palpitations were the symptoms most frequently discussed with health care providers.

CONCLUSIONS

Although the vaso-somatic symptom of headache ranked first for severity, the most frequently reported symptoms were psychological or general somatic in nature. Despite a proliferation of health education materials, the subjects in this study did not recognize many symptoms of perimenopause. The results of this study suggest that education and anticipatory guidance for perimenopausal women should begin with women in their 30s. With many symptoms occurring as early as age 35, recognition of symptoms can greatly reduce the discomfort and fears that women experience during the perimenopausal transition.

Discussing menopause in general practice

The dual objective is, first, to determine if menopausal women discuss the menopause with a doctor, and if so to which extent; second, to ascertain potential differences between those who do and those who do not.

METHODS

A postal questionnaire was sent to 1251 Danish women randomly selected among all 51-year-old women born and living in Denmark. Completed questionnaires were returned by 972 (77%) women.

RESULTS AND CONCLUSIONS

More than two thirds (71.8%) of the peri and postmenopausal women had discussed the menopause with a doctor; either with the general practitioner (GP) or with another doctor. There were significant differences between women who had discussed the menopause with a doctor and those who had not. The more problematic the symptoms the greater the likelihood that the woman would have discussed the menopause. Women who had not discussed the menopause with a doctor, had fewer symptoms and were more critical of hormone replacement therapy (HRT). Menopausal symptoms do not necessarily create problems for women in their daily lives. For example almost all women reported hot flushes (87.2%), but few felt very bothered by this symptom (13.8%). Doctors most often listen to menopausal women with severe symptoms. This "bias" may direct the focus upon the negative aspects of menopause. It is suggested that active intervention among women who have not consulted a doctor about menopause is inappropriate, partly because they apparently have chosen non-medical solutions and partly because they have so few symptoms that the use of resources in this way could be considered wasteful.

Associations between attitudes toward hormone therapy and current use of it in middle-aged women

OBJECTIVES

To investigate the association between attitudes toward hormone therapy (HT) and use of it and explanatory factors for the association found.

METHODS

All women in two primary healthcare districts aged 45, 50, 55 or 60 in 2000 or 2001 (n=771) received a questionnaire consisting of quality-of-life instruments and items concerning menopause, health, healthcare, symptoms, sociodemographic factors and attitudes toward HT.

RESULTS

A total of 564 women (74%) responded to the questionnaire. In the women with a positive or a neutral attitude, rather than a negative one, the age- and menopause-adjusted odds ratios for current HT use were 18.55 (95% CI 8.55, 40.11) and 2.61 (1.15, 5.93), respectively. Health-related factors, factors concerning one's own person and psychosocial factors were the groups of factors found to contribute to explaining the association between attitudes and current HT use. Together, the three groups of factors explained 42 and 98%, respectively, of a positive and a neutral attitude's association with current use of HT. Individual factors of importance in these factor groups were a feeling of being appreciated outside the home, satisfaction with one's work, marital status, own climacteric period, visits to a physician and past use of hormonal contraceptives. In contrast, level of education and the occurrence of cold sweats/hot flushes was not found to contribute to the explanation.

CONCLUSIONS

Factors concerned with women's everyday life, contentment with oneself and use of healthcare services were of importance in explaining the associations between attitudes toward HT and current use of it. Consideration at these factors in counselling women about HT is recommended.

Sexual functioning and practices in a multi-ethnic study of midlife women: baseline results from SWAN

This study examined the sexual practices and function of midlife women by ethnicity (African American, Caucasian, Chinese, Hispanic, Japanese) and menopausal status. Sexual behavior was compared in 3,262 women in the baseline cohort of SWAN. Participants were 42 to 52 years old, premenopausal or early perimenopausal, and not hysterectomized or using hormones. Analysis used multivariate proportional odds regression. In our sample, 79% had engaged in sex with a partner in the last 6 months, and a third considered sex to be very important. Common reasons for no sex (n = 676) were lack of partner (67%), lack of interest (33%), and fatigue (16%). Compared with Caucasians, Japanese and Chinese women were less likely, and African Americans more likely, to report sex as very important (p < 0.005). Significant ethnic differences were found for frequency of all practices. Perimenopause status was associated only with higher frequencies of masturbation and pain during intercourse.

Symptom experience in Australian men and women in midlife

OBJECTIVE

To compare the experience of vasomotor, psychological and somatic symptoms in Australian men and women in midlife, to investigate whether symptoms often attributed to endocrine changes in midlife are associated with health and psychological well-being, and to evaluate their relationship to menopausal status in women.

METHODS

A cross-sectional, correlational, population-based study based on self-report questionnaires. Participants comprised 451 men and 766 women, aged between 39 and 65, from urban and rural South Australia, who responded to invitations to participate, or who volunteered to participate following media releases. Outcome measures used comprised a 47-item symptom checklist of current presence and severity of vasomotor, somatic and psychological symptoms experienced by men and women during midlife, and measures of health and psychological well-being.

RESULTS

The majority of men and women reported that they were not 'bothered' by vasomotor, psychological and somatic symptoms. For those symptoms in which men and women differed significantly, women generally reported being more 'bothered' than men, although the pattern of association between symptoms and measures of health and psychological well-being was the same for both men and women. Items from all three symptom clusters were independently related to menopausal status.

CONCLUSIONS

Health and psychological well-being play a role in the genesis of symptoms experienced by men and women in midlife. Both men and women experience similar symptoms, although women are more distressed by them signifying support for a menopausal syndrome in women. The finding of an independent relationship between menopausal status and psychological and somatic symptoms, in addition to the vasomotor symptoms, contradicts the narrow-estrogen hypothesis of climacteric symptoms.

Vasomotor symptoms are associated with depression in perimenopausal women seeking primary care

OBJECTIVE

To compare the relationship between vasomotor symptoms (hot flushes and night sweats) and depression in perimenopausal women with that in postmenopausal and older premenopausal women.

DESIGN

Questionnaire data assessing current depressive symptoms (Center for Epidemiologic Studies Depression Scale), hot flushes, night sweats, menopausal status, depression history, hormonal therapy use, and demographic characteristics were collected from women aged 40 to 60 years seeking primary care. Multivariable logistic regression models were used to examine the relationship between vasomotor symptoms and depression.

RESULTS

Depression (defined by a Center for Epidemiologic Studies Depression Scale score >/= 25) was observed in 14.9% of 141 perimenopausal women, 13.9% of 151 postmenopausal women, and 7.6% of 184 older premenopausal women. Recent vasomotor symptoms were reported by 53.9% of perimenopausal women, 43.7% of postmenopausal women, and 20.7% of older premenopausal women. Perimenopausal women with vasomotor symptoms were 4.39 times more likely to be depressed than those without vasomotor symptoms (95% CI, 1.40-13.83), an association that did not change after controlling for depression history. In contrast with perimenopausal women, postmenopausal and older premenopausal women with vasomotor symptoms did not have a significantly greater risk for depression than women of the same menopausal status without vasomotor symptoms (adjusted odds ratios, 1.28 and 1.77; 95% CI, 0.47-3.46 and 0.53-5.89, respectively).

CONCLUSIONS

Hot flushes and night sweats are associated with depression in perimenopausal women. Further investigation is warranted to elucidate the mechanism by which hot flushes may be associated with depression in perimenopausal women and not in postmenopausal or older premenopausal women.

Relieving discomforts: the help-seeking experiences of Chinese perimenopausal women in Taiwan

BACKGROUND

Although studies show that women view perimenopause as a natural process, few studies explore the experiences of Taiwanese mid-life women who visit clinics for perimenopausal health problems. Research is required to understand the patterns and explanations for the women's behaviours in the process of seeking medical help. Such understanding will help guide teaching and care-giving approaches.

AIMS

To generate a descriptive theoretical framework about the experiences of women who visited traditional Chinese and Western medicine clinics in Taiwan to seek medical help for perimenopausal symptoms.

METHODS

A grounded theory research design was used. Thirty Taiwanese women, aged 48-55 years, participated in two face-to-face audio-taped interviews. Trained staff nurses conducted the interviews. Data collection, coding of interviews and field notes, and data analysis occurred simultaneously.

FINDINGS

Relieving the discomforts' was the core theme for describing and guiding the process of seeking medical help during the perimenopausal period. During the process, 'Feeling the discomforts' was identified as the antecedent condition. Analyses showed five dimensions to the women's help-seeking behaviours: (1) searching for medical help, (2) taking medicine, (3) reassurance of health, (4) desiring to be understood, and (5) emotional swings.

CONCLUSIONS

Women in this study expected to relieve their perimenopausal discomforts by finding treatment to match their body constitution. They hoped to find a caring and understanding doctor or staff member who would carefully explain health-related issues to them. Health care providers need to consider women's individual health values and, based on these values, use different approaches to treat and teach women with perimenopausal symptoms and concerns.

[Climacteric women seeking medical care, Brazil]

OBJECTIVE

To study the causes and factors associated with climacteric women seeking medical care.

METHODS

A descriptive exploratory cross-sectional population-based study was carried out. Subjects were 456 women aged 45 to 60 years resident in a metropolitan area of Southeastern, Brazil, selected through area cluster sampling. Data were collected through home interviews using a structured, pre-tested questionnaire. Statistical analysis were performed using Chi-square test, Cramer's coefficient and logistic multiple regression.

RESULTS

About 80% sought medical care due to menstrual irregularities and climacteric symptoms. The main factors associated with women seeking medical care were hormone replacement therapy, marital status, and stronger psychological symptoms. The main reason for not seeking medical care was women's thought that their complaint did not justify medical attention.

CONCLUSIONS

There was a high demand for medical care by climacteric women, but a significant percentage did not seek medical attention because they believed their symptoms were ordinary.

Exploring self-image during hot flushes using a semantic differential scale: associations between poor self-image, depression, flush frequency and flush distress

OBJECTIVES

This study developed a semantic differential scale for assessing self-image during hot flushes, based on a previously published scale (Nursing Res. 35 (1986) 81). The objectives were to explore the sensitivity and validity of this scale, and to examine whether poor self-image during hot flushes is linked to flush distress, perceived control, flush frequency, flush chronicity, self-esteem and depression.

METHOD

Two community samples of women with current experience of hot flushes completed a postal questionnaire.

RESULTS

The semantic differential scale was sensitive to individual differences in self-image, and was validated through its association with measured self-esteem using a standardised scale. Defining the self in negative ways during flushes was highly predictive of flush distress. Poor self-image was also closely associated with depression. Correlations with perceived control, and flush frequency were weaker and did not reach significance in the second, smaller sample.

CONCLUSION

The study extends previous findings that women low in self-esteem have more difficulty coping with menopausal changes, by showing that negative self-appraisal during flushes (e.g. defining self as unattractive or dirty) are highly demoralising and associated with distress. The findings suggest that cognitive behavioural strategies of challenging and re-interpreting thoughts about self could be helpful in moderating the discomfort and stressfulness of hot flushes for women not taking HRT. However, the findings are based on relatively small, volunteer samples and require further replication.

The physiology, medical management and oral implications of menopause

BACKGROUND

Approximately 36 million women in the United States are in the postmenopausal phase of life. The vast majority of these women experienced spontaneous cessation of menses between the ages of 47 and 55 years when the production of estrogen decreased because of an inadequate number of functioning follicles within their ovaries. Fewer women entered menopause after surgical removal of both ovaries. This procedure usually is performed prophylactically to prevent ovarian cancer in conjunction with a hysterectomy, which is required to treat abnormal bleeding, endometriosis or pelvic inflammatory disease. The physiological changes associated with spontaneous or surgical menopause cause some women to experience uncomfortable symptoms such as hot flashes, night sweats and vaginal dryness. In addition, estrogen deprivation arising from menopause in association with age-related factors disproportionately increases the risk of developing cardiovascular disease (that is, myocardial infarct, stroke), osteoporosis, Alzheimer's disease and oral disease. Hormone replacement therapy, or HRT (estrogen or estrogen and progestin), often is prescribed on a short-term basis to alleviate the uncomfortable symptoms associated with estrogen deficiency and on a long-term basis to prevent some of the chronic illnesses common to postmenopausal women.

CONCLUSIONS

Dentists who treat women entering menopause need to consider the stressful phase of life their patients are experiencing. Clinical findings of postmenopausal problems on dental examination may include a paucity of saliva, increased dental caries, dysesthesia, taste alterations, atrophic gingivitis, periodontitis and osteoporotic jaws unsuitable for conventional prosthetic devices or dental implants. Panoramic dental radiographs may reveal calcified carotid artery atheromas.

CLINICAL IMPLICATIONS

Dentists have an opportunity to refer women who are not under the care of a gynecologist for an evaluation to determine the appropriateness of HRT for its systemic and oral health benefits.

Are changes in sexual functioning during midlife due to aging or menopause?

OBJECTIVE

To determine whether changes in women's sexual functioning during midlife are due to aging or menopause.

DESIGN

Prospective, observational study.

SETTING

Population-based sample assessed in own homes.

PATIENT(S)

Four hundred thirty-eight Australian-born women aged 45-55 years and still menstruating at baseline. One hundred ninety-seven were studied for effects of the natural menopausal transition. Control group A (n = 44) remained premenopausal or early perimenopausal for 7 years. Control group B (n = 42) remained postmenopausal over 5 years.

INTERVENTION(S)

Nil; questionnaires and blood sampling annually.

MAIN OUTCOME MEASURE(S)

Shortened version of the Personal Experiences Questionnaire.

RESULT(S)

By the late perimenopause, there was a significant decline in the factors we had derived of sexual responsivity and total score, and there was an increase in the partner's problems factor. By the postmenopausal phase, there was a further decline in the factors sexual responsivity, frequency of sexual activities, libido, and in the total score, and a significant increase in vaginal dyspareunia and partner's problems. Sexual responsivity significantly declined in both control groups.

CONCLUSION(S)

Sexual responsivity is adversely affected by both aging and the menopausal transition. Other domains of female sexual functioning were significantly adversely affected when the women became postmenopausal. The relationship with the partner and his ability to perform sexually is adversely affected by the menopausal transition.

The perimenopause, depressive disorders, and hormonal variability

CONTEXT

Several investigations have postulated that the perimenopause may represent a period of increased psychiatric vulnerability, particularly for mood disorders. This review characterizes the perimenopause, including biological changes, the influence of psychosocial factors and the most common clinical manifestations. Clinic-based studies and community-based surveys addressing the prevalence of depressive symptoms in perimenopausal women are critically reviewed. We also discuss the potential greater vulnerability to mood disturbance during the perimenopause in response to hormonal variability. A therapeutic algorithm for management of depressive symptoms in middle-aged perimenopausal women is also presented. The role of estrogen in the treatment of perimenopausal depressive symptoms is particularly discussed. In addition, we review the existing data regarding the potential efficacy of estrogen as an antidepressant agent (monotherapy, augmentation strategy or prophylaxis).

DESIGN

Narrative review.

Reported current use of prescription drugs and some of its determinants among 35 to 65-year-old women in mid-Sweden: A population-based study

To investigate prescribed drug utilization in a middle-aged female population and factors possibly related to drug consumption in this population. A random sample of 4200 women aged 35-65 years, drawn from the population register of seven countries in mid-Sweden, received a postal questionnaire. Two thousand nine hundred ninety one (2991) (71.2%) women responded. Forty percent (40%) of the women were currently using drugs and 12% of the users were taking four drugs or more. Polypharmacy increased by age. A large number of factors were correlated with current drug use. In multivariate analyses age, perceived health, body mass index, and educational level remained significantly related to drug use, while factors such as menopausal state, smoking habits, employment status, marital status, and physical activity lost their significance. Current drug use among women increased by age, bad perceived health status, obesity, and college or university education.

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.

Associação entre depressão na perimenopausa e níveis séricos de estradiol e hormônio folículo-estimulante

OBJETIVOS: A perimenopausa é freqüentemente associada ao surgimento de alterações físicas e emocionais. Estudos prévios indicam uma associação entre variações dos hormônios folículo-estimulante (FSH), luteinizante (LH) bem como de estrógenos e o surgimento de transtornos do humor, particularmente depressão. Este estudo investigou a correlação entre mudanças nos níveis de estradiol (E2) e FSH e a sintomatologia depressiva em mulheres na perimenopausa. MÉTODOS: Cinqüenta mulheres foram recrutadas nos atendimentos de uma clínica de menopausa e de um serviço psiquiátrico para realização de ensaio clínico com uso de 17 b-estradiol ou placebo. Selecionaram-se mulheres em perimenopausa (idade entre 40 e 55 anos, presença de alterações vasomotoras, irregularidade menstrual nos últimos 6 meses e/ou amenorréia há no máximo 12 meses, níveis de FSH>20 UI/L) e com diagnóstico de transtorno depressivo pelo DSM-IV (transtorno depressivo maior, transtorno distímico ou transtorno depressivo sem outra especificação). Dosagens séricas iniciais e finais (semana 12) de FSH e E2, bem como avaliações da sintomatologia depressiva (escores da MADRS) foram analisadas e suas correlações investigadas. RESULTADOS: As pacientes apresentaram mudanças (p<0,05) entre os níveis séricos de FSH e E2 colhidos pré e pós-intervenção (placebo ou 17 b-estradiol). Observou-se, também, mudança significativa na sintomatologia depressiva (p<0,05). Houve correlação significativa entre as mudanças na sintomatologia depressiva e as mudanças nos níveis de E2 (r de Pearson=0,436, p=0,003) e de FSH (r= 0,554, p<0,001), independentemente do tipo de tratamento empregado. CONCLUSÕES: Embora limitado pelo tamanho da amostra e a subpopulação estudada, este estudo preliminar identificou uma correlação significativa entre sintomatologia depressiva e níveis séricos de FSH e E2. Seguimentos populacionais prospectivos poderão esclarecer o papel da variabilidade hormonal no surgimento/exacerbação dos transtornos depressivos na perimenopausa.

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.

Hormone therapy use in Australian-born women: a longitudinal study

OBJECTIVES

To describe the pattern of use of hormone therapy (HT) among Australian women, and its side-effects and benefits, and to compare baseline characteristics of HT users with never users.

DESIGN

Longitudinal community-based study with annual interviews.

SETTING

Melbourne, May 1991-October 1997.

PARTICIPANTS

357 Australian-born women aged 45-55 years who were pre- or perimenopausal and not using HT at baseline.

MAIN OUTCOME MEASURES

Rates of HT use; baseline characteristics of users and non-users; side effects and benefits of HT use.

RESULTS

151 women (42%) used HT over the six years and 93 (26%) were current users at six-year follow-up. HT users did not differ significantly from non-users in lifestyle, sociodemographic and cardiovascular risk factors or in most health status factors at baseline. However, HT users were significantly more likely to have had a breast examination by a health professional (odds ratio [OR], 2.60; 95% CI, 1.62-4.17), to have had a tubal ligation (OR, 1.73; 95% CI, 1.09-2.74), to report a history of premenstrual complaints (OR, 1.72; 95% CI, 1.08-2.74), to agree that women "regret when their period stops for the last time" (OR, 1.69; 95% CI, 1.04-2.74), and to report that they took non-prescription medications (OR, 1.62; 95% CI, 1.02-2.59). Most (84%) HT users described benefits (most commonly relief of hot flushes and improved wellbeing), while 53% complained of side effects (most commonly weight gain and breast tenderness).

CONCLUSIONS

HT users did not differ significantly from non-users at baseline in most characteristics. Long-term follow-up of this cohort is now required to assess any difference in cardiovascular events or other health outcomes between HT users and non-users.

Mental health among perimenopausal women attending a menopause clinic: possible association with premenstrual syndrome?

BACKGROUND

Psychiatric symptoms are frequent in the perimenopause. They are similar to symptoms observed at different stages of a woman's life cycle, suggesting that there may be an association between mental disturbances of the perimenopause and those observed during premenstrual and postnatal periods.

METHODS

This study aimed to determine the reliability of using a modified version of the Steiner premenstrual tension self-rating scale (PMTS) questionnaire for assessing retrospectively the presence of premenstrual complaints and to evaluate the association between previous premenstrual complaints and psychiatric symptoms at the time of the menopause. Forty-one perimenopausal women were selected to establish the reliability of the questionnaire to assess premenstrual symptoms retrospectively (4-8-week interval between measures); agreement between measurements was assessed using the kappa statistic. Ninety-six women were later recruited from a gynecological menopause outpatient clinic to study the association between premenstrual complaints and the presence of psychiatric symptoms at the time of the menopause (as measured by another self-reporting questionnaire, the SRQ-20); SRQ-20 total scores greater than 7 were considered to be indicative of psychiatric morbidity.

RESULTS

All 36 PMTS items showed moderate to very good test-retest reliability (0.44 < kappa < 1.0). There was a significant correlation between total PMTS and SRQ-20 scores (Spearman correlation coefficient 0.75, p < 0.001), correlation coefficient and SRQ-20 total scores greater than 7 were found in 47.9% of patients.

CONCLUSIONS

Premenstrual symptoms can be reliably measured in perimenopausal women. Women who report having experienced premenstrual dysphoria are more likely to present with psychiatric symptoms at the time of the menopause.

Relationships between premenstrual complaints and perimenopausal experiences

This study evaluates whether a history of menstrually-related problems, termed premenstrual complaints (PMCs), is a significant predictive marker for a more symptomatic perimenopausal experience. Two hundred and ninety-one randomly selected urban women, aged between 45 and 55 years were interviewed yearly for three consecutive years to record their individual experiences and changes as they progressed through the menopause transition. Repeated measures were obtained on a range of physical, psychological and social indicators. The experiences of women who reported a self-defined history of premenstrual complaints (n = 104) were compared with those women with no prior premenstrual problems (n = 187) and predictors of perimenopausal symptoms were assessed. Relationships were found between a prior history of both physical and psychological premenstrual complaints and a more symptomatic perimenopause characterised by dysphoria, skeletal, digestive and respiratory symptoms (all ps < 0.05). The more symptomatic women also reported pronounced interpersonal stress (p < 0.001), significant 'hassles', current smoking and low exercise (ps < 0.05). The findings support predictive relationships between a prior history of premenstrual problems and a more problematic menopause transition. The issues of vulnerability and help-seeking behaviors are discussed.

Menopause and hormone replacement therapy

Menopause is a normal part of life of most women and can be made easier with appropriate information about the events that occur. For those women who desire help for bothersome menopausal symptoms, effective therapy can be offered. The use of HRT for prevention is more complex. Several large randomized clinical trials, including the Women's Health Initiative (WHI) and the Heart and Estrogen Replacement Therapy Study (HERS) in the United States, are currently underway. These trials, which have as end points clinical events such as myocardial infarction, sudden death, fractures, and cancer, will provide answers to many of the questions raised in this discussion. Until the results of these trials are available, clinicians must be prudent in their recommendations and should keep their patients apprised of the relevant uncertainties of preventive HRT.