Symptom experiences of midlife women: observations from the Seattle Midlife Women's Health Study

Sleep disturbances and incident risk of major depressive disorder in a population-based cohort

Sleep disturbances are well-known symptoms of major depressive disorder (MDD). However, the prospective risk of MDD in the presence of sleep disturbances in a general population-based cohort is not well known. This study investigated associations between both polysomnography (PSG)-based or subjective sleep features and incident MDD. Participants representative of the general population who had never had MDD completed sleep questionnaires (n = 2000) and/or underwent PSG (n = 717). Over 8 years' follow-up, participants completed psychiatric interviews enabling the diagnosis of MDD. Survival Cox models were used to analyze associations between sleep features and MDD incidence. A higher Epworth Sleepiness Scale and presence of insomnia symptoms were significantly associated with a higher incidence of MDD (hazard ratio [HR] [95 % confidence interval (CI)]: 1.062 [1.022-1.103], p = 0.002 and 1.437 [1.064-1.940], p = 0.018, respectively). Higher density of rapid eye movements in rapid eye movement (REM) sleep was associated with a higher incidence of MDD in men (HR 1.270 [95 % CI 1.064-1.516], p = 0.008). In women, higher delta power spectral density was associated with a lower MDD incidence (HR 0.674 [95 % CI 0.463-0.981], p = 0.039). This study confirmed the associations between subjective and objective sleep features and the incidence of MDD in a large community dwelling cohort.

The association of race, ethnicity, and socioeconomic status on the severity of menopause symptoms: a study of 68,864 women

OBJECTIVE

This study aimed to evaluate if and how race, ethnicity, and socioeconomic status (SES) are associated with the severity of menopause symptoms in a large, diverse sample of women.

METHODS

For this cross-sectional study conducted between March 24, 2019, and January 13, 2023, a total of 68,864 women were enrolled from the Evernow online telehealth platform. Participants underwent a clinical intake survey, which encompassed demographic information, detailed medical questionnaires, and a modified Menopause Rating Scale. The modified scale was adapted for ease of use online and is available in the supplementary material along with the full intake. Symptom severity was evaluated using a multivariate binomial generalized linear model, accounting for factors such as race, ethnicity, age, body mass index, smoking status, bilateral oophorectomy status, and SES. Odds ratios (OR) and CIs were calculated based on the linear regression coefficients.

RESULTS

Of the participants, 67,867 (98.6%) were included in the analysis after excluding outliers and those with unknown oophorectomy status. The majority of respondents identified as White (77.4%), followed by Hispanic (9.0%), Black (6.7%), two or more races/ethnicities (4.4%), Asian (1.2%), Indigenous/First Nations (0.8%), Middle Eastern (0.3%), and South Asian (0.2%). Notably, individuals identifying as Black (hot flashes OR, 1.91; 97.5% CI, 1.75-2.09; P < 0.001), Hispanic (skin/hair changes OR, 1.58; 97.5% CI, 1.45-1.71; P < 0.001), Indigenous/First Nations (painful sex OR, 1.39; 97.5% CI, 1.19-2.75; P = 0.007), Middle Eastern (weight changes OR, 2.22; 97.5% CI, 1.25-4.37; P = 0.01), or with two or more races/ethnicities (skin/hair changes OR, 1.41; 97.5% CI, 1.26-1.58; P < 0.001) reported higher levels of symptom severity compared with their White counterparts. Conversely, Asian and South Asian participants reported lower symptom severity. Even after incorporating SES into the linear model, racial and ethnic groups with lower SES (Black, Hispanic, Indigenous, and multiple ethnicities) exhibited slight shifts in OR while maintaining high statistical significance (Black [hot flashes OR, 1.87; 97.5% CI, 1.72-2.04; P < 0.001], Hispanic [skin/hair changes OR, 1.54; 97.5% CI, 1.42-1.68; P < 0.001], Indigenous/First Nations [painful sex OR, 1.74; 97.5% CI, 1.17-2.70; P = 0.009], multiple ethnicities [skin/hair changes OR, 1.41; 97.5% CI, 1.26-1.58; P < 0.001]).

CONCLUSIONS

Our study suggests that the relationship between race and ethnicity and the severity of menopause symptoms is not solely explained by differences in SES but is itself an independent factor. Understanding and addressing social, cultural, and economic factors are crucial to reduce disparities in menopausal symptoms.

Physical activity and menopausal symptoms: evaluating the contribution of obesity, fitness, and ambient air pollution status

OBJECTIVE

The menopausal transition is accompanied by transient symptoms that have been linked to subclinical cardiovascular disease (CVD); CVD has also been linked to air pollution. Physical activity (PA) reduces CVD, improves body composition, and can reduce menopausal symptoms. The purpose of this study was to assess the links between PA and menopausal symptoms and whether obesity, fitness, and air pollution status play a role in this relationship.

METHODS

Women (40-60 y; N = 243; mean [SD] age, 47.8 [5.6] y) from areas with high versus low air pollution enrolled in the Healthy Aging in Industrial Environment Program 4 prospective cohort study completed psychological, cardiorespiratory fitness, body composition, and menopausal status screening followed by a 14-day prospective assessment of menopausal symptoms (Menopause Rating Scale) using a mobile application. Daily PA was assessed objectively across 14 days via Fitbit Charge 3 monitor. General linear mixed models were conducted and controlled for age, menopausal status, day in the study, wear time, and neuroticism.

RESULTS

Peri/postmenopausal women ( β = 0.43, P < 0.001) and those residing in a high-air-pollution environment ( β = 0.45, P < 0.05) reported more somatovegetative symptoms. Hot flashes alone were associated with peri/postmenopausal status ( β = 0.45, P < 0.001), and for women residing in a high-air-pollution environment, lower reporting of hot flashes was observed on days when a woman was more physically active than usual ( β = -0.15, P < 0.001). No associations were found for cardiorespiratory fitness and visceral fat with any of the symptoms.

CONCLUSIONS

PA may enhance resilience to hot flashes, especially when residing in high-air-pollution environments where we also observed higher reporting of somatovegetative menopausal symptoms.

Age Differences in Core Symptoms and Symptom Relationships in Patients With Irritable Bowel Syndrome: A Network Analysis

INTRODUCTION

Irritable bowel syndrome (IBS) is a common disorder of gut-brain interaction, characterized by symptoms of abdominal pain and changes in bowel habits. It often co-occurs with extraintestinal somatic and psychological symptoms. However, the nature of the interrelationships among these symptoms is unclear. Although previous studies have noted age differences in IBS prevalence and specific symptom severity, it remains unknown whether specific symptoms and symptom relationships may differ by age.

METHODS

Symptom data were collected in 355 adults with IBS (mean age 41.4 years, 86.2% female). Network analysis was used to examine the interrelationships among 28 symptoms and to identify the core symptoms driving the symptom structure between young (≤45 years) vs older (>45 years) adults with IBS. We evaluated 3 network properties between the 2 age groups: network structure, edge (connection) strength, and global strength.

RESULTS

In both age groups, fatigue was the top core symptom. Anxiety was a second core symptom in the younger age group, but not the older age group. Intestinal gas and/or bloating symptoms also exerted considerable influences in both age groups. The overall symptom structure and connectivity were found to be similar regardless of age.

DISCUSSION

Network analysis suggests fatigue is a critical target for symptom management in adults with IBS, regardless of age. Comorbid anxiety is likely an important treatment focus for young adults with IBS. Rome V criteria update could consider the importance of intestinal gas and bloating symptoms. Additional replication with larger diverse IBS cohorts is warranted to verify our results.

Sleep symptoms signaling the menopausal transition

STUDY OBJECTIVES

To describe changes in sleep quality and associated sleep symptoms as women begin menopausal transition compared with premenopausal controls.

METHODS

In a repeated-measures design, we analyzed data collected every 2-6 months from a community-based sample of 223 women aged 40-50 (45.6 ± 2.3) years old over a 2-year period. Each 6-month visit included urinary follicle-stimulating hormone (FSH) as a marker of ovarian function and the Pittsburgh Sleep Quality Index (PSQI) and other questionnaires (Center for Epidemiological Studies-Depression Scale; Perceived Stress Scale). Menstrual cycle and vasomotor symptoms (Seattle Women's Health Symptom Checklist) were tracked every 2 months by phone. For women entering menopausal transition (n = 68) we used data from the two consecutive visits prior to their FSH rise and the next two visits. Data from the last four consecutive visits were used for controls remaining premenopausal (n = 155).

RESULTS

The transition group did not differ from controls on age, vasomotor symptoms (hot flashes/night sweats), stress, or depression but did have a higher body mass index. Measures were stable over time for controls. However, the transition group experienced an increase in PSQI scores (initial PSQI = 5.7 ± 3.2 and final PSQI = 6.3 ± 3.8; P = .030) and frequency of trouble sleeping because of feeling too hot (P = .016), which lagged the FSH rise by 6 months with no notable change in report of hot flashes/night sweats.

CONCLUSIONS

Trouble sleeping because of feeling too hot, distinct from awareness of vasomotor symptoms, was the only uniform contribution to higher PSQI scores after the initial FSH increase and may signal the onset of the menopausal transition.

CITATION

Zak R, Zitser J, Jones HJ, Gilliss CL, Lee KA. Sleep symptoms signaling the menopausal transition. J Clin Sleep Med. 2023;19(8):1513-1521.

Menstrual cycle phase, menopausal transition stage, self-reports of premenstrual syndrome and symptom severity: observations from the Seattle Midlife Women's Health Study

OBJECTIVE

The aim of this study was to determine the effects of menstrual cycle phases (postmenses and premenses), self-report of premenstrual syndrome (PMS), late reproductive stages (LRS1 and LRS2), and early menopausal transition (EMT) stage (Stages of Reproductive Aging Workshop [STRAW]) on severity of five symptom groups.

METHODS

A subset of Seattle Midlife Women's Health Study participants (n = 290) in either LRS1 or LRS2 or EMT (STRAW+10 criteria) provided daily symptom data for at least one full menstrual cycle during the first year of the study and reported current PMS. Symptom severity was rated (1-4, least to most severe) in the daily diary for five symptom groups (dysphoric mood, neuromuscular, somatic, vasomotor, and insomnia) identified earlier with the same sample ( Maturitas 1996;25:1-10). A three-way analysis of variance was used to test for within- and between-participants effects on symptom severity.

RESULTS

Stage had no effect on severity for any of the five symptom groups. Dysphoric mood and neuromuscular and somatic symptom severity (but not vasomotor or insomnia severity) differed significantly across menstrual cycle phases, increasing from postmenses to premenses. Current PMS and premenses cycle phase had significant interactive effects on dysphoric mood and neuromuscular symptoms, but there were no significant interaction effects on somatic, vasomotor, or insomnia symptom severity.

CONCLUSIONS

Dysphoric mood, neuromuscular, and somatic symptoms exhibit cyclicity and are influenced by current PMS. Late reproductive stages and EMT stage do not have significant effects on the five symptom groups. Vasomotor or insomnia symptoms do not exhibit significant cyclicity from postmenses to premenses and are not affected by current PMS. Future studies of symptom cyclicity and reproductive aging including daily symptom data across an entire menstrual cycle in samples including women in late menopausal transition stage are essential to capture the effects of both cyclicity and self-reported PMS to capture symptom severity reports at their peak.

Examining negative affect, sleep duration, and using food to cope as predictors of weight in midlife women

Midlife women are vulnerable to developing obesity. Behavioral and psychosocial factors including sleep duration, stress eating, and negative emotionality are risk factors. However, little is known about the complex daily interplay between sleep, eating, emotion, and weight among midlife women. The current study examined how daily sleep, using food to cope, and negative emotionality are associated with weight using a daily process research design. An archival analysis was performed using the Midlife in the United States-II study (MIDUS II). The sample consisted of 489 midlife women (40-64 years of age). Variables included ecological momentary assessments of daily sleep duration, using food to cope, and negative affect (means and intraindividual variability) and a standardized measurement of BMI. Sleep duration variability was a significant predictor of BMI, albeit the model only accounted for .8% of the variance in BMI (b = .019, p < .05). In the final adjusted model, sleep duration variability, using food to cope, age, and physical activity were all significant predictors of BMI F(5, 559) = 21.503, p < .001, R² = .161, ⨂R² = .024, p = .001. Variability in negative affect, mean sleep duration or negative affect and the interactions between sleep duration (mean, variability) and negative affect (mean, variability) were not significant. Greater variability in sleep duration and greater use of food to cope predicted higher BMI in this sample across age and physical activity levels. Results highlight that daily health and psychosocial factors play an important role in weight.

Symptom experience during the late reproductive stage and the menopausal transition: observations from the Women Living Better survey

OBJECTIVE

The aim of this study was to examine the occurrence of a variety of symptoms, their frequency, bother, burden, and interference in the lives of women in the late reproductive stage (LRS) and compare their experiences to that of women in the menopausal transition (MT) stage.

METHODS

Women ages 35 to 55 years responded to an 82-question online survey offered by Women Living Better. Participants reported current menstrual patterns, recent changes and symptom frequency, bother, and interference. Women's cycles were classified as LRS or MT using Stages of Reproductive Aging Workshop +10 criteria.

RESULTS

Of 2,406 respondents, 946 met criteria for LRS and 583 for MT. Participants included 30% from outside the United States, 31% from diverse racial/ethnic groups, and 18% reported having difficulty paying for basics. A similar proportion of women in the LRS and MT+ groups reported each of the symptoms: there was a less than 10% difference for 54 of the 61 symptoms. Of mean bother ratings for all symptoms, only hot flashes differed significantly between the LRS and MT groups. LRS women experienced similar levels of symptom-related interference with personal relationships and daily living to those in the MT stage but did not anticipate these symptoms occurring until they were 50 years old.

CONCLUSIONS

Women in the LRS experience symptoms strikingly similar to those often associated with the MT. Women do not expect these changes until the age of 50 years or later and are surprised by such symptoms before cycle irregularity. Research about the epidemiology and management of LRS symptoms, anticipatory guidance for women, and education for clinicians who care for them warrant increased attention.

Irritable bowel syndrome in midlife women: a narrative review

Midlife women between the ages of 40 and 65 years have reported multiple challenges due to menopausal, developmental, and situational transitions from younger to older adulthood. During the midlife period, many women seek health care for gastrointestinal symptoms and irritable bowel syndrome (IBS). Multiple factors including stress, poor sleep, diet, and physical inactivity may contribute to IBS or gastrointestinal symptoms in midlife women. As such, a comprehensive assessment and treatment approach is needed for midlife women suffering gastrointestinal symptoms. This article reviews the main aspects of the menopausal transition, sex hormonal changes, abdominal and pelvic surgery, psychosocial distress, behavioral factors, and gut microbiome, as well as their relevance on IBS and gastrointestinal symptoms in midlife women. Also, management strategies for IBS in midlife women are discussed. To date, gastrointestinal symptoms during midlife years remain a critical area of women’s health. Additional research is needed to better understand the contributors to gastrointestinal symptoms in this group. Such efforts may provide a new window to refine or develop treatments of gastrointestinal symptoms for midlife women.

Development of a Chemical Reproductive Aging Model in Female Rats

Women are born with an abundant but finite pool of ovarian follicles, which naturally and progressively decreased during their reproductive years until menstrual periods stop permanently (menopause). Perimenopause represents the transition from reproductive to non-reproductive life. It is usually characterized by neuroendocrine, metabolic and behavioral changes, which result from a follicular depletion and reduced number of ovarian follicles. During this period, around 45-50 years old, women are more likely to express mood disorders, anxiety, irritability and vasomotor symptoms. The current animal models of reproductive aging do not successfully replicate human perimenopause and the gradual changes that occur in this phase. While the traditional rat model of menopause involves ovariectomy or surgical menopause consisting of the rapid and definitive removal of the ovaries resulting in a complete loss of all ovarian hormones, natural or transitional menopause is achieved by the selective loss of ovarian follicles (perimenopause period). However, the natural aging rodent (around 18-24 months) model fails to reach very low estrogen concentrations and overlaps the processes of somatic and reproductive aging. The chronic exposure of young rodents to 4-vinylcyclohexene diepoxide (VCD) is a well-established experimental model for perimenopause and menopause studies. VCD induces loss of ovarian small follicles (primary and primordial) in mice and rats by accelerating the natural process of atresia (apoptosis). The VCD, ovary-intact or accelerated ovarian failure (AOF) model is the experimental model that most closely matches natural human progression to menopause mimicking both hormonal and behavioral changes typically manifested by women in perimenopause. Graphical abstract: The female reproductive system is regulated by a series of neuroendocrine events controlled by central and peripheral components. (A). The mechanisms involved in this control are extremely complex and have not yet been fully clarified. In female mammals whose ovulation (the most important event in a reproductive cycle) occurs spontaneously, reproductive success is achieved through the precise functional and temporal integration of the hypothalamus-pituitary-ovary (HPO) axis. (B). In women, loss of fertility appears to be primarily associated with exhaustion of ovarian follicles, and this process occurs progressively until complete follicular exhaustion marked by the final menstrual period (FMP). (C). While in female rodents, reproductive aging seems to begin as a neuroendocrine process, in which changes in hypothalamic/pituitary function appear independently of follicular atresia. The traditional rat model of menopause, ovariectomy or surgical menopause consists of the rapid and definitive removal of the ovaries resulting in a complete loss of all ovarian hormones. (D). The chronic exposure (15-30 days) to the chemical compound 4-vinylcyclehexene diepoxide (VCD) in young rodents accelerates gradual failure of ovarian function by progressive depletion of primordial and primary follicles, but retains residual ovarian tissue before brain alterations that occurs in women in perimenopause. Low doses of VCD cause the selective destruction of the small preantral follicles of the ovary without affecting other peripheral tissues.

Age and leptinemia association with anxiety and depression symptoms in overweight middle-aged women

OBJECTIVE

The aim of the study was to investigate the effect of menopause and of postmenopausal stages on depression and anxiety symptoms, and whether these symptoms associate with anthropometric, metabolic, and hormonal parameters in midlife women.

METHODS

Postmenopausal women (age 50-65), either at early (EPM, n=33) or late (LPM, n = 23) postmenopause, and 23 premenopausal controls (PreM, age 40-50), matched for BMI with the PM groups, were studied. Blood biochemical and hormonal determinations, bioimpedance anthropometry, and depression and anxiety symptoms (Beck's depression [BDI] and anxiety [BAI] inventories) were conducted.

RESULTS

The BAI score was higher in both PM groups than in the PreM group. In contrast, only the LPM group showed a significantly elevated BDI score. All groups presented overweight and abdominal obesity, having similar BMI and waist/hip ratio values. Both PM groups showed insulin resistance, whereas only the LPM group presented decreased skeletal muscle mass and basal metabolic rate. Correlation analysis, including all 79 middle-aged women, showed age, percentage body fat, waist/hip ratio, and leptinemia to correlate positively with the anxiety and depression scores. Multivariate regression showed leptin and age to associate positively with depressive- and anxious-like symptoms.

CONCLUSIONS

Postmenopausal women presented impaired body composition, energy expenditure, insulin sensitivity, and mental symptoms, in comparison to similarly overweight premenopausal women. Among all the overweight midlife women, these symptoms were more strongly associated with age and leptin levels than with reproductive aging itself. The data indicate that, among overweight middle-aged women with abdominal obesity, the aging process and the development of leptin resistance are associated with impairment of mental health.

Analysis of the long‑term beneficial effects of menopausal hormone therapy on sleep quality and menopausal symptoms

A large number of menopausal women report sleep disturbances along with psychological, somatic and urogenital menopausal symptoms. The aim of this study was to evaluate the efficacy of menopausal hormonal therapy (MHT) in improving subjective sleep quality and the severity of menopausal symptoms. An institutional ethics committee approved this retrospective chart review of 342 women treated with MHT for menopausal symptoms. Standard 28-day MHT consisted of the oral administration of 2 mg estradiol daily for 14 days, followed by 2 mg estradiol and 10 mg dydrogesterone daily for the remaining 14 days. A subgroup of 14 participants with a family history of cancer and mammography scores of 3 and above, received only tibolone 2.5 mg daily. Perceived sleep quality was measured with the Pittsburgh Sleep Quality Index (PSQI), while the assessment of menopausal symptoms was performed using the Kupperman Menopause Index (KMI) and menopause rating scale (MRS). Of the 342 patients, 79 were followed-up for 3 years. Compared to the baseline scores, the mean decrease in PSQI scores was 1.53±0.29 points (P<0.0001) at 1 month, 2.21±0.187 points (P<0.0001) at 2 months and 2.26±0.6 points (P<0.0001) after 3 years of MHT. The KMI scores also decreased by a mean of 6.37±1.59 points (P<0.0001) at 1 month and by 8.73±1.92 points after 3 years (P<0.0001). The MRS scores decreased by a mean of 3.56±1.05 points (P<0.0001) at 1 month and by 4.28±2.01 points (P<0.0001) after 3 years, as compared to the baseline scores. Patients receiving tibolone MHT did not report any improvement in sleep quality (P=0.956). On the whole, the findings of this study indicate that conventional MHT has a rapid and prolonged beneficial effect on self-reported sleep quality and menopausal symptoms in women. However, further clinical studies are warranted to compare the effects of different MHT regimens.

Undesirable stressful life events, impact, and correlates during midlife: observations from the Seattle midlife women's health study

PURPOSE

To examine the undesirable stressful life events midlife women experience, including: 1) which life events midlife women reported most frequently; 2) which life events women rated as most undesirable; and 3) whether age, years of education, income, employment, race/ethnicity, marital status, being a parent, and the menopausal transition stage were associated with the impact scores of the life event categories.

BACKGROUND

In addition to the menopausal transition, midlife is a time of increased responsibilities for women related to multiple roles such as taking care of children, caring for elderly parents, managing households, and working outside the home. These multiple roles put midlife women at risk for increased stress with little time for themselves in order to relieve stress.

METHODS

The sample used in this study is part of a larger longitudinal study, The Seattle Midlife Women's Health Study. Women (N = 380 for Occasion 1) completed the 77-item Life Events Scale on four occasions during the course of the SMWHS: Occasion 1 (1990), Occasion 2 (1992), Occasion 3 (1997), and Occasion 4 (2000). In addition to descriptive analyses of frequency of life events and the undesirable impact of life events, demographic correlates (age, education, income, employment, being a parent as well as marital status, race/ethnicity, and menopausal transition stages) were examined in relation to the stressful life event scores.

RESULTS

Highest scores of undesirable life events were for categories of both Financial and Family/Friends over 3 of the 4 occasions. Health and Crime/Legal scores were among the highest for 2 occasions. Impact of the undesirable stressful life events was greatest for categories of Family/Friends; Personal/Social; Work; and, Health. Age, income, marital status, being a parent, and menopausal transition stage were each associated with specific categories of the stressful event impact scores.

CONCLUSION

Most commonly reported undesirable life events were not those women described as having the greatest impact. Impact of life event stress reflected women's social roles and connections as seen in the categories with the highest impact scores: Family/Close Friends, Personal/Social, and Work. Menopausal transition stages were related only to undesirable health events.

Menstrual Cycle Changes as Women Approach the Final Menses: What Matters?

Increased variability in menstrual cycle length marks the onset of the menopausal transition, with the likelihood of long cycles increasing as women approach menopause. This article describes the STRAW+10 bleeding criteria for recognizing onset of the early and late menopausal transition, as well as the specific bleeding changes a woman may experience during this life stage, including how women's bleeding experiences differ. The high probability of episodes of excessive and prolonged bleeding as women approach their final menstrual period is documented, as is the continuing probability of ovulation as women reach their final menstrual period.

Sleep Disturbances in Midlife Women at the Cusp of the Menopausal Transition

STUDY OBJECTIVES

To compare causes of sleep disturbance and to compare self-reported sleep duration among groups of late premenopausal women and early perimenopausal women.

METHODS

In a longitudinal study of a community-based sample of healthy women 40 to 50 years of age, menstrual cycle and symptom data were collected every 2 months; anthropometric measures, a urine sample for follicle stimulating hormone (FSH), and the Pittsburgh Sleep Quality Index (PSQI) measures were collected every 6 months.

RESULTS

At 12 to 18 months, 206 women remained premenopausal and 69 women became perimenopausal. Poor sleep quality (PSQI score > 5) was experienced by 42% of the total cohort. Awakening to use the bathroom was the most frequent reason (81%) for sleep disturbance in the entire cohort, followed by feeling too hot (26%). However, premenopausal women were significantly more likely to awaken to use the bathroom than perimenopausal women (P = .047), and perimenopausal women were more likely than premenopausal women to awaken because of feeling too hot (P = .002). Women in early perimenopause reported shorter sleep duration (P = .007) and worse sleep quality (P = .05) than premenopausal women of similar age.

CONCLUSIONS

Sleep disturbance is a significant issue for midlife women regardless of age or reproductive stage. Identification of salient factors that disrupt sleep, such as nocturia prior to menopausal transition or feeling too hot early in menopausal transition, will provide direction for developing tailored intervention strategies to improve sleep and quality of life.

COMMENTARY

A commentary on this article appears in this issue on page 1095.

The challenges of midlife women: themes from the Seattle midlife Women's health study

Background

Midlife, the period of the lifespan between younger and older adulthood, has been described as a period of transition in women’s lives. Investigators studying midlife have focused on women 40 to 65 years of age, who typically experience multiple social, psychological and biological challenges, among them the menopausal transition. Investigators have reported a diverse array of stressful events, for example, health concerns, family problems, work-related issues, deaths, frustrated goal attainment, and financial worries; however, none have identified which life events midlife women experience as the most salient. The purpose of this study was to understand the meaning behind the experiences that midlife women identify as the most challenging.

Methods

Participants were enrolled in The Seattle Midlife Women’s Health Study, a longitudinal study spanning up to 23 years. Summative content analysis, incorporating manifest and latent analysis approaches, was used to identify life experiences that women described as the most challenging looking back over 15 years of being in the study. Eighty-one women responded to the question, “Since you have been in our study (since 1990 or 1991), what has been the most challenging part of life for you?”

Results

Women identified the most challenging aspects of midlife as changing family relationships, re-balancing work/personal life, re-discovering self, securing enough resources, and coping with multiple co-occurring stressors. Within these themes the most frequently reported challenges were: multiple co-occurring stressors, divorce/breaking up with a partner, health problems of self, and death of parents. Few women mentioned menopause as the most challenging aspect of their lives.

Conclusion

Women found themselves searching for balance in the midst of multiple co-occurring stressors while coping with losses and transitions, for some in a context of limited resources. Menopause was infrequently mentioned. Future research to identify the challenges experienced by more diverse populations of women and further understanding of the dynamics among multiple co-occurring stressors is needed to provide individualized health care appropriately to midlife women.

Polymorphisms in Estrogen Synthesis Genes and Symptom Clusters During the Menopausal Transition and Early Postmenopause: Observations From the Seattle Midlife Women's Health Study

During the menopausal transition and early postmenopause, participants in the Seattle Midlife Women's Health Study (SMWHS) experienced one of the three symptom severity clusters identified through latent class analysis: severe hot flashes with moderate sleep, mood, cognitive, and pain symptoms (high-severity hot flash); low-severity hot flashes with moderate levels of all other symptom groups (moderate severity); and low levels of all symptom groups (low severity). In an effort to determine whether gene polymorphisms were associated with these symptom severity classes, we tested associations between gene polymorphisms in the estrogen synthesis pathways (cytochrome P450 19 [CYP 19] and 17 beta hydroxysteroid dehydrogenase [ 17HSDB1]) and the three symptom severity clusters. SMWHS participants ( N = 137) recorded symptoms monthly in diaries and provided buccal smears for genotyping. Multilevel latent class analysis with multinomial regression was used to determine associations between gene polymorphisms and symptom severity clusters. Only the 17HSDB1 polymorphisms ( rs615942 and rs592389) were associated significantly with the high-severity hot flash cluster versus the low-severity symptom cluster. None of the polymorphisms was associated with the moderate-severity cluster versus the low-severity symptom cluster. Findings of associations of the 17HSDB1 polymorphisms with the high-severity hot flash symptom cluster are consistent with those of an association between 17HSDB1 polymorphisms and hot flashes in the Study of Women and Health Across the Nation population and our previous findings of associations between these polymorphisms with greater estrone levels.

Effects of Estrogen Therapy on the Serotonergic System in an Animal Model of Perimenopause Induced by 4-Vinylcyclohexen Diepoxide (VCD)

Chronic exposure to 4-vinylcycloxene diepoxide (VCD) in rodents accelerates the natural process of ovarian follicular atresia modelling perimenopause in women. We investigated why estrogen therapy is beneficial for symptomatic women despite normal or high estrogen levels during perimenopause. Female rats (28 d) were injected daily with VCD or oil for 15 d; 55-65 d after the first injection, pellets of 17β-estradiol or oil were inserted subcutaneously. Around 20 d after, the rats were euthanized (control rats on diestrus and estradiol-treated 21 d after pellets implants). Blood was collected for hormone measurement, the brains were removed and dorsal raphe nucleus (DRN), hippocampus (HPC), and amygdala (AMY) punched out for serotonin (5-HT), estrogen receptor β (ERβ), and progesterone receptor (PR) mRNA level measurements. Another set of rats was perfused for tryptophan hydroxylase (TPH) immunohistochemistry in the DRN. Periestropausal rats exhibited estradiol levels similar to controls and a lower progesterone level, which was restored by estradiol. The DRN of periestropausal rats exhibited lower expression of PR and ERβ mRNA and a lower number of TPH cells. Estradiol restored the ERβ mRNA levels and number of serotonergic cells in the DRN caudal subregion. The 5-HT levels were lower in the AMY and HPC in peristropausal rats, and estradiol treatment increased the 5-HT levels in the HPC and also increased ERβ expression in this area. In conclusion, estradiol may improve perimenopause symptoms by increasing progesterone and boosting serotonin pathway from the caudal DRN to the dorsal HPC potentially through an increment in ERβ expression in the DRN.

Prevalence of Sleep Disturbances and Their Associations With Demographic and Clinical Characteristics and Quality of Life in Older Adults in Macao

PURPOSE

To examine the prevalence of sleep disturbances (difficulty initiating sleep [DIS], difficulty maintaining sleep [DMS], and early morning awakening [EMA]), their socio-demographic and clinical correlates, and quality of life (QOL) in older adults in Macao.

DESIGN AND METHODS

Four hundred fifty-one subjects were interviewed using standardized instruments.

FINDINGS

The prevalence of at least one type of sleep disturbance was 38.1%; the figures of DIS, DMS, and EMA were 18.6, 31.3, and 23.9%, respectively. Female sex and depressive symptoms were independently associated with more frequent sleep disturbances. Sleep disturbances were independently associated with lower physical QOL.

PRACTICE IMPLICATIONS

Sleep disturbances are common in older adults in Macao. Appropriate strategies should be implemented to prevent and treat sleep disturbances and concerted attempts should be made to improve access to treatment.

Vasomotor, urogenital, psychological, and somatic symptoms in association with CYP1B1 polymorphisms in Slovak women of different menopausal status

OBJECTIVES

The aim of this study was to examine if the Arg48Gly, Ala119Ser, Leu432Val, and Asn453Ser polymorphisms in the CYP1B1 estrogen-metabolizing gene are associated with menopausal symptom experience in healthy Slovak women aged 40-60 years. We also investigated the possible association of other factors with menopausal symptoms, including health status, physical activity, reproductive history, psychological status, and smoking.

METHODS

The total sample consisted of 367 women (mean age 49.11 ± 5.86 years), encompassing 180 premenopausal (mean age 45.06 ± 3.81 years), 29 peri-menopausal (mean age 49.41 ± 3.94 years), and 158 postmenopausal (mean age 53.71 ± 4.54 years) women. The research comprised anthropometric and bioelectrical impedance analysis measurements (BIA), blood or saliva samples collected for DNA analysis, and a specific menopausal questionnaire.

RESULTS

CYP1B1 Arg48Gly is significantly associated with vasomotor, psychological, and somatic symptoms. It appears that the Gly/Gly genotype is a risk factor during the postmenopause and protective in the pre- and peri-menopause. CYP1B1 Ala119Ser was associated with all menopausal symptoms, with the Ser/Ser genotype increasing risk in the premenopause and offering protection in the peri- and postmenopause. Polymorphisms Leu432Val and Asn453Ser gave unequivocal results; independent of menopausal status, the Leu/Leu genotype was associated with increasing risk of vasomotor, urogenital, and psychological symptoms and the Asn/Asn genotype provided a protective effect against psychological symptoms.

CONCLUSIONS

Our results suggest possible associations of CYP1B1 polymorphisms with the occurrence and manifestation of particular menopausal symptoms in healthy mid-life Slovak women.

Differences in symptom clusters before and twelve months after breast cancer surgery

PURPOSE

Given the inter-relatedness among symptoms, research efforts are focused on an evaluation of symptom clusters. The purposes of this study were to evaluate for differences in the number and types of menopausal-related symptom clusters assessed prior to and at 12-months after surgery using ratings of occurrence and severity and to evaluate for changes in these symptom clusters over time.

METHODS

Prior to and at 12 months after surgery, 392 women with breast cancer completed the Menopausal Symptoms Scale. Exploratory factor analyses were used to identify the symptom clusters.

RESULTS

Of the 392 women evaluated, the mean number of symptoms (out of 46) was 13.2 (±8.5) at enrollment and 10.9 (±8.2) at 12 months after surgery. Using occurrence and severity, three symptom clusters were identified prior to surgery. Five symptom clusters were identified at 12 months following surgery. Two symptom clusters (i.e., pain/discomfort and hormonal) were relatively stable across both dimensions and time points. Two symptom clusters were relatively stable across both dimensions either prior to surgery (i.e., sleep/psychological/cognitive) or at 12 months after surgery (i.e., sleep). The other four clusters (i.e., irritability, psychological/cognitive, cognitive, psychological) were identified at one time point using a single dimension.

CONCLUSIONS

While some menopausal-related symptom clusters were consistent across time and dimensions, the majority of symptoms clustered together differently depending on whether they were evaluated prior to or at 12 months after breast cancer surgery. An increased understanding of how symptom clusters change over time may assist clinicians to focus their symptom assessments and management strategies.

Depression and Quality of Life among Postmenopausal Women in Bangladesh: A Cross-sectional Study

OBJECTIVES

The aims of the research are to examine the problems of abnormal menopausal women: the relationship between depression and menopausal-specific quality of life (MENQOL)-symptoms among postmenopausal women; the association of MENQOL-symptoms between pre- and postmenopausal female society in Bangladeshi real community.

METHODS

This cross sectional study was conducted on 435 women of Tangail, aged (≥ 17) years, using a structured questionnaire where is inaacluded the information of MENQOL and one of the main outcomes "depression" is measured by beck depression inventory.

RESULTS

Menopausal status and MENQOL symptoms (except pain) are significantly (P < 0.05) associated. By using post-hoc analysis, the proportion of menopausal women, classified as having a depressive mood of early menopause is significantly higher than natural-menopause. Among postmenopausal women, there is a significant correlation between "concentration problem" and "depression". Here mean depression score (29.40 ± 6.42) of menopausal women who have any difficulty in concentrating is higher than mean depression score (20.89 ± 6.64) of menopausal women who have no difficulty in concentrating. Another six factors (osteoporosis, heart-beating, fatigue, pressure, tingling, headaches) of MENQOL-symptoms were significantly correlated with depression and P-values are 0.000, 0.000, 0.000, 0.033, 0.006, and 0.002, respectively. Finally the presence of "difficulty in concentrating" and "fatigue" are strongly associated factors with depression score (P < 0.001).

CONCLUSIONS

The early postmenopausal women have to face more psychological problems (e.g., depression) compare to others. Among postmenopausal women, there is no significant relation between depression and vasomotor symptom (e.g., hot-flashes) perspective to menopausal female society of Bangladesh.

The Seattle Midlife Women's Health Study: a longitudinal prospective study of women during the menopausal transition and early postmenopause

Background

The need for longitudinal, population-based studies to illuminate women’s experiences of symptoms during the menopausal transition motivated the development of the Seattle Midlife Women’s Health Study.

Methods

Longitudinal, population-based study of symptoms women experienced between the Late Reproductive stage of reproductive aging and the early postmenopause. Data collection began in 1990 with 508 women ages 35–55 and continued to 2013. Entry criteria included age, at least one period in past 12 months, uterus intact and at least 1 ovary. Women were studied up to 5 years postmenopause. Data collection included yearly health questionnaires, health diaries, urinary hormonal assays, menstrual calendars and buccal cell smears.

Results

Contributions of the study included development of a method for staging the menopausal transition; development of bleeding criteria to differentiate bleeding episodes from intermenstrual bleeding from menstrual calendars; identification of hormonal changes associated with menopausal transition stages; assessment of the effects of menopausal transition factors, aging, stress-related factors, health factors, social factors on symptoms, particularly hot flashes, depressed mood, pain, cognitive, sexual desire, and sleep disruption symptoms, and urinary incontinence symptoms; identification of naturally occurring clusters of symptoms women experienced during the menopausal transition and early postmenopause; and assessment of gene polymorphisms associated with events such as onset of the early and late menopausal transition stages and symptoms.

Conclusions

Over the course of the longitudinal Seattle Midlife Women's Health Study, investigators contributed to understanding of symptoms women experience during the menopausal transition and early postmenopause as well as methods of staging reproductive aging.

Electronic supplementary material

The online version of this article (doi:10.1186/s40695-016-0019-x) contains supplementary material, which is available to authorized users.

Lifestyle Practices and Nocturnal Sleep in Midlife Women with and without Insomnia

Relationships between common lifestyle practices important to sleep hygiene (e.g., smoking cigarettes, drinking alcohol, ingesting caffeine, exercising, bedtimes, getting-up times) and nocturnal sleep have not been documented for women with insomnia in their home environments. This community-based sample of 121 women, ages 40 to 55 years, included 92 women who had experienced insomnia for at least 3 months and 29womenwith good-quality sleep. Women recorded lifestyle practices and sleep perceptions (time to fall asleep, awakenings during sleep, feeling rested after sleeping, and overall sleep quality) in diaries while undergoing 6 nights of somnographic sleep monitoring at home. Compared to women with good-quality sleep, women with insomnia reported greater nightto-night variation in perceived sleep variables, poorer overall sleep quality (M = 2.8,SD = 0.7 vs.M = 1.9,SD = 0.5,P < 0.05), and longer times to fall asleep (M = 25 min,SD = 14.2 vs.M = 12.9 min,SD = 5.8,P < 0.05). Correlations between mean individual lifestyle practice scores and mean perceived or somnographic sleep variables were low, ranging from 0 to 0.20. An aggregated sleep hygiene practice score was not associated with either perceived or somnographic sleep variables. Regression analysis using dummy variables showed that combinations of alcohol, caffeine, exercise, smoking, and history of physical disease explained 9% to 19% of variance in perceived or somnographic sleep variables. Lifestyle practices, and combinations thereof, do warrant consideration when assessing or treating insomnia, but these data fail to support a dominant relationship between lifestyle practices and either perceived or somnographic sleep variables.

Midlife women's symptom cluster heuristics: evaluation of an iPad application for data collection

OBJECTIVE

This study aims to elicit midlife women's heuristics about symptom clusters they were experiencing, as identified by the Computerized Symptom Capture Tool for Menopause (C-SCAT M).

METHODS

Women aged 40 to 60 years who were experiencing symptoms that they associated with menopause were recruited through flyers posted on campus and in clinics. Women completed the C-SCAT M application (app), using an iPad, by identifying and drawing symptom clusters they experienced during the last 24 hours, indicating relationships among symptoms, prioritizing the clusters and symptoms within them, making causal attributions, and identifying exacerbating and ameliorating factors. They were asked to prioritize the clusters and a symptom within each cluster. While women were completing the app, they were asked to "think aloud" about their experience using the app. Data generated from the C-SCAT M app were transmitted securely to an Amazon Web Services account and saved as screen images and Excel files to preserve both graphical images and text elicited from the app. Qualitative data were saved in verbatim phrases. Conventional content analysis was used to analyze qualitative data.

RESULTS

Thirty women completed the app. Most women (77%) stated that the final diagrams were very/extremely accurate in depicting their symptoms and their connections. Women reported between 1 and 22 symptoms (median, 11). Hot flashes, waking up during the night, night sweats, and early morning awakening were the most commonly reported symptoms. Women rated hot flashes as their most bothersome symptom, followed by waking up during the night and fatigue. They reported more than 300 different bivariate relationships between their symptoms and more than 150 unique causal paths. They believed that hot flashes caused several symptoms, especially sleep disruption, and most could describe the time order of their symptoms. Women reported clusters consisting of 2 to 18 symptoms. Women also named each cluster based on their response to their symptoms ("really annoying"), time of occurrence ("night problem"), and symptoms included in the cluster ("hot flash"). They attributed their clusters to menopause, life demands, and other symptoms, among other causes. Management strategies that women used included over-the-counter preparations, sleep, rest, and other lifestyle changes. Some women requested for a copy of their final symptom cluster diagram to discuss with their healthcare providers.

CONCLUSIONS

Use of the C-SCAT M affords women an opportunity to depict their symptoms and clusters and the relationships between them and to provide narrative data about their heuristics. Women's unsolicited comments about using the cluster diagram to facilitate conversations (about their symptoms) with their healthcare providers suggest the potential value of modifying the C-SCAT M and evaluating its use in a healthcare setting.

Navigating the Journey to Menses Cessation

Purpose: This article explores contemporary women’s perceptions of the experience of the menopausal process within the Western industrialized culture, describes and synthesizes the processes used by women to evaluate available information, and explores and facilitates processes used by women to envision and create change in their life world. Method: An emancipatory group process was designed to facilitate dialogue between the investigator and nine women who met as a group eight times during a 10-week period in the home of one of the participants. Findings: Participants identified menses cessation as a time of change in all aspects of their lives. They employed decision making to cope with these changes and, as a result of the awareness that came through the research process, invited other women to celebrate the collective wisdom of women at all stages of life. Conclusion: Women experiencing menses cessation need information and time to process that information internally and in relation with others. Implications: Nurses can facilitate the process by providing knowledge, assisting women in decision making, and intervening in ways that contribute to a holistic quality of life for women.

Sex differences in sleep: impact of biological sex and sex steroids

Men and women sleep differently. While much is known about the mechanisms that drive sleep, the reason for these sex differences in sleep behaviour is unknown and understudied. Historically, women and female animals are underrepresented in studies of sleep and its disorders. Nevertheless, there is a growing recognition of sex disparities in sleep and rhythm disorders. Women typically report poorer quality and more disrupted sleep across various stages of life. Findings from clinical and basic research studies strongly implicate a role for sex steroids in sleep modulation. Understanding how neuroendocrine mediators and sex differences influence sleep is central to advancing our understanding of sleep-related disorders. The investigation into sex differences and sex steroid modulation of sleep is in its infancy. Identifying the mechanisms underlying sex and gender differences in sleep will provide valuable insights leading to tailored therapeutics that benefit each sex. The goal of this review is to discuss our current understanding of how biological sex and sex steroids influence sleep behaviour from both the clinical and pre-clinical perspective.

Feasibility of an iPad application for studying menopause-related symptom clusters and women's heuristics

PURPOSE

To evaluate feasibility, including usability and utility, of the Computerized Symptom Capture Tool for Menopause (C-SCAT-M), a symptom heuristics application (app) for the iPad, with midlife women.

METHODS

Thirty midlife women aged 40-60 and experiencing symptoms they associated with menopause were recruited through flyers posted on a university campus, primary care and women's health clinics. The C-SCAT-M guided participants to identify symptoms they experienced, draw temporal and causal relationships between symptoms and identify symptom clusters. Women were encouraged to think aloud as they encountered questions or problems and their comments were audio recorded. After completing the C-SCAT-M, they completed a 22-item acceptability survey and a demographic survey. Data were downloaded from catalyst website and analyzed using SPSS.

RESULTS

Women completed the C-SCAT-M with minimal difficulty, with most indicating that using the app was very/extremely easy and most (57%) preferred using the iPad app to paper. Most women stated that the final diagrams were very/extremely accurate depictions of their symptom clusters and relationships (77%).

CONCLUSION

The C-SCAT-M demonstrated initial feasibility, including usability and utility, for collecting data about symptom clusters experienced by midlife women.

Social class and gender patterning of insomnia symptoms and psychiatric distress: a 20-year prospective cohort study

BACKGROUND

Psychiatric distress and insomnia symptoms exhibit similar patterning by gender and socioeconomic position. Prospective evidence indicates a bi-directional relationship between psychiatric distress and insomnia symptoms so similarities in social patterning may not be coincidental. Treatment for insomnia can also improve distress outcomes. We investigate the extent to which the prospective patterning of distress over 20 years is associated with insomnia symptoms over that period.

METHODS

999 respondents to the Twenty-07 Study had been followed for 20 years from approximately ages 36-57 (73.2% of the living baseline sample). Psychiatric distress was measured using the GHQ-12 at baseline and at 20-year follow-up. Gender and social class were ascertained at baseline. Insomnia symptoms were self-reported approximately every five years. Latent class analysis was used to classify patterns of insomnia symptoms over the 20 years. Structural Equation Models were used to assess how much of the social patterning of distress was associated with insomnia symptoms. Missing data was addressed with a combination of multiple-imputation and weighting.

RESULTS

Patterns of insomnia symptoms over 20 years were classified as either healthy, episodic, developing or chronic. Respondents from a manual social class were more likely to experience episodic, developing or chronic patterns than those from non-manual occupations but this was mostly explained by baseline psychiatric distress. People in manual occupations experiencing psychiatric distress however were particularly likely to experience chronic patterns of insomnia symptoms. Women were more likely to experience a developing pattern than men, independent of baseline distress. Psychiatric distress was more persistent over the 20 years for those in manual social classes and this effect disappeared when adjusting for insomnia symptoms. Irrespective of baseline symptoms, women, and especially those in a manual social class, were more likely than men to experience distress at age 57. This overall association for gender, but not the interaction with social class, was explained after adjusting for insomnia symptoms. Sensitivity analyses supported these findings.

CONCLUSIONS

Gender and socioeconomic inequalities in psychiatric distress are strongly associated with inequalities in insomnia symptoms. Treatment of insomnia or measures to promote healthier sleeping may therefore help alleviate inequalities in psychiatric distress.

Variability of bothersome menopausal symptoms over time--a longitudinal analysis using the Estonian postmenopausal hormone therapy trial (EPHT)

BACKGROUND

Very little data are available on the natural course or level of disturbance of vasomotor symptoms among middle-aged women. Using readily collected trial data we studied the persistence of vasomotor symptoms among untreated women.

METHODS

In a trial comparing combined hormone therapy to placebo or no treatment (control groups), a cohort of women aged 50-59 at recruitment were followed annually by questionnaires. Women in the control groups (n = 486) were grouped by the number of years followed, with the prevalence and severity of symptoms calculated both cross-sectionally and longitudinally.

RESULTS

About two thirds of the women (67%) reported vasomotor symptoms and half (46%) bothersome symptoms at recruitment. In the cross-sectional analysis, their prevalence declined between recruitment and 1-year follow-up (32% bothersome symptoms) and 2-year follow-up (27%). Thereafter it remained about the same level. In the longitudinal analysis, there was a notable variation in the prevalence of disturbing vasomotor symptoms over time, time entering the study and the compliance to the surveys. In the two groups having most follow-up times, the proportion of women with bothersome symptoms first increased and then decreased.

CONCLUSIONS

There was a notable variability in the development of disturbing vasomotor symptoms over time in a selected group of women aged 50-59. Population-based follow-up studies of untreated women would be useful to estimate the symptom burden.

Identifying symptom clusters during the menopausal transition: observations from the Seattle Midlife Women's Health Study

OBJECTIVES

First, to explore the variability in how symptoms clustered together over the late reproductive stage, early and late menopausal transition (MT) stages, and early postmenopause; second, to determine whether the symptom factor structure of the preceding MT stage would predict the symptom factor structure of the MT stage immediately following.

METHODS

The sample consisted of a subset of Seattle Midlife Women's Health Study participants who were in late reproductive or early or late menopausal transition stages or early postmenopause and provided self-reported data on symptoms experienced between 1990 and 2005. Principal components analysis was used to determine how symptoms clustered together across the stages. Variables predicting the symptom factor structure were analyzed by multiple regression.

RESULTS

Principal components analysis with varimax rotation revealed different factor structures for each of the four stages. The three-factor solution in the late reproductive stage explained a total of 54.9% of the variance. The four-factor solutions in the early and late menopausal transition stages and postmenopause explained a total of 56.5%, 59.3%, and 60.7%, respectively.

CONCLUSIONS

This analysis revealed similar factor structures across the four stages in that each stage revealed a mood component, a vasomotor component, and a pain component. However, the symptoms differed somewhat in how they grouped from stage to stage. Regression analysis demonstrated that a relationship exists between the symptom factor structures across stages. Controlling for demographic and lifestyle variables, it was revealed that the symptom clusters at the early and late menopausal transition stages and early postmenopause were best predicted by the symptom factor structure of the previous stage.

The longitudinal course of insomnia symptoms: inequalities by sex and occupational class among two different age cohorts followed for 20 years in the west of Scotland

STUDY OBJECTIVES

The natural history of insomnia symptomatology is poorly understood. Cross-sectional associations have been demonstrated among socioeconomic disadvantage, female sex, and poor sleep but it is unclear how these social factors predict patterns of insomnia symptoms over time. The aim of this article is to describe longitudinal patterns of insomnia symptoms as people age and investigate how they vary by sex and occupational class.

DESIGN

A prospective cohort study with 20 yr of follow-up from 1987 to 1988.

SETTING

West of Scotland.

PARTICIPANTS

One cohort approximately 36 yr of age at baseline aging to 57 yr (n = 1,444), and another aging from approximately 56 to 76 yr (n = 1,551).

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

At approximately 5-yr intervals, respondents self-reported trouble initiating and maintaining sleep. Latent class analysis identified 4 main sleep patterns: a healthy pattern with little sleeping trouble across the 20 yr; an episodic pattern, characterized by trouble maintaining sleep; a chronic pattern with trouble maintaining and initiating sleep throughout the study; and a pattern where symptoms developed during the 20-yr follow-up. Chronic patterns were more likely in the older cohort than the younger one, for women than men in the older cohort, and for those from a manual rather than a nonmanual occupational class in both cohorts. In the middle-aged cohort a developing pattern was more likely for women than men.

CONCLUSIONS

Chronic symptoms, characterized by both trouble maintaining and initiating sleep, are patterned by social factors.

Symptom clusters at midlife: a four-country comparison of checklist and qualitative responses

OBJECTIVE

The purpose of this study was to examine the frequency and clustering of somatic symptoms as reported by women aged 45 to 55 years in four countries, to compare women's responses to open-ended questions with those derived from structured checklists, and to assess the extent to which bodily symptoms grouped with emotional complaints.

METHODS

The Decisions at Menopause Study recruited 1,193 women from the general population in Beirut, Lebanon; Rabat, Morocco; Madrid, Spain; and central Massachusetts. Women participated in semistructured interviews on health, menopause, and bodily changes at midlife. The women's responses to symptom checklists and their statements in response to open-ended questions were analyzed through factor and textual analyses.

RESULTS

There was considerable consistency between the frequencies of quantitative and qualitative responses, and analyses of qualitative data illustrate the extent to which women associate somatic and emotional complaints. As shown in their responses to the open-ended questions, the women in Massachusetts and Spain did not often cluster somatic with emotional symptoms. In Morocco, dizziness, fatigue, and headaches were clustered with emotional symptoms. Women in Lebanon explicitly associated shortness of breath, chest pain, palpitations, dizziness, fatigue, gastrointestinal complaints, headaches, and, to a lesser extent, joint pain and numbness with emotional symptoms.

CONCLUSIONS

The number of volunteered symptom responses was small because the respondents were relatively healthy; however, the extent and pattern of association between somatic and emotional symptoms varied across sites. Certain somatic symptoms may be more likely to communicate psychosocial distress in particular cultures. These results have implications for patterns of healthcare utilization.

Menstruation and the menopausal transition

This paper characterizes changes in menstrual bleeding during perimenopause,including bleeding changes that represent markers of the menopausal transition. Recent results from the Study of Women's Health Across the Nation and other cohort studies are reviewed. Emerging data describing subpopulation differences in the transition experience are highlighted. When treating women in the midlife, clinicians should pay careful attention to medical factors, including both conditions and treatments, that may increase menstrual blood loss or alter menstrual cycle characteristics sufficiently to obscure the onset of the menopausal transition or the final menstrual period.

Suan zao ren tang as an original treatment for sleep difficulty in climacteric women: a prospective clinical observation

Little scientific evidence supports the efficacy of herbal medicines in the treatment of women with sleep difficulty during the climacteric period. The purpose of this study is to evaluate the efficacy and safety of Suan Zao Ren Tang (SZRT) in reducing the impact of sleep disturbance on climacteric women, as measured by Pittsburg sleep quality index (PSQI) and the World Health Organization quality of life (WHOQOL). Sixty-seven climacteric women with sleep difficulty intending to treat received SZRT at a rate of 4.0 g, thrice daily for four weeks (MRS < 16, n = 34; MRS ≥ 16, n = 33). After taking into account potential confounding factors, the mean PSQI total scores had fallen from 13.0 (±2.9) to 9.0 (±3.2) (95% confidence interval -4.93, -3.10). Further analyses showed that SZRT produced superior benefit of daytime dysfunction in women with severe menopausal symptoms (MRS ≥ 16). There were three of the withdrawals involved treatment-related adverse events (stomachache, diarrhea, and dizziness). Excluding women with a past history of stomachache, diarrhea, or dizziness, four weeks of therapy with SZRT appears to be a relatively safe and effective short-term therapeutic option in improving daytime function of climacteric women with poor sleep quality.

Symptom clusters during the late menopausal transition stage: observations from the Seattle Midlife Women's Health Study

OBJECTIVE

The aims of this study were to identify groups of women in the late menopausal transition stage who experienced the same cluster of symptoms and to identify indicators that predicted membership in these distinct groups.

METHODS

The sample consisted of a subset of Seattle Midlife Women's Health Study participants who were in the late menopausal transition stage and provided self-report data on symptoms experienced between 1990 and 2005. Latent class analysis (LCA) was used to identify groups of women who experienced similar clusters of the following five symptoms: problem concentrating, hot flashes, joint ache, mood changes, and awakening at night. LCA with multivariate logistic regression was used to identify covariates that predicted membership in each group.

RESULTS

Four groups of women were identified: (1) low severity for all symptoms except for joint ache, which was moderate (65%); (2) high severity for all symptoms except for hot flashes, which was moderate (13%); (3) high severity for hot flashes, joint ache, and awakening at night (12%); and (4) high severity for problem concentrating and joint ache (10%). A clear delineation between groups based on individual characteristics was not fully elucidated.

CONCLUSIONS

This analysis demonstrates that LCA may be useful to identify women who may experience poorer outcomes related to a higher propensity for severe symptoms. Shifting the focus from single symptoms to symptom clusters will aid in the identification of phenotypic profiles, thus facilitating symptom management strategies that can be tailored to meet the needs of individual women.

The effects of pain, gender, and age on sleep/wake and circadian rhythm parameters in oncology patients at the initiation of radiation therapy

To date, no studies have evaluated for differences in subjective and objective measures of sleep disturbance in oncology outpatients with and without pain. This descriptive study, recruited 182 patients from 2 radiation therapy (RT) departments at the time of the patient's simulation visit. Approximately 38% of the sample reported moderate to severe pain (ie, worst pain intensity of 6.2 ± 2.4). After controlling for age, patients in pain reported worse sleep quality and more sleep disturbance using the Pittsburgh Sleep Quality Index. With the General Sleep Disturbance Scale, patients in pain reported poorer sleep quality, increased use of sleep medications, and more daytime sleepiness. In addition using an objective measure of sleep disturbance (ie, actigraphy), significant gender × pain interactions were found for sleep onset latency, percentage of time awake at night, wake duration, total sleep time, and sleep efficiency. While no differences were found in female patients, males in pain had worse scores than males without pain. Findings from this study suggest that pain and sleep disturbance are prevalent in oncology outpatients and that a patient's age and gender need to be considered in any evaluation of the relationship between pain and sleep.

PERSPECTIVE

The effects of pain on subjective and objective sleep parameters appear to be influenced by both patients' age and gender.

Associations of depression with the transition to menopause

OBJECTIVES

The aims of this study were to identify the risk of depression in the transition to menopause in women with and without a history of depression and to consider that the changing hormonal milieu is one of multiple risk factors for perimenopausal depression.

METHOD

A review of epidemiologic studies of depressed mood in the menopausal transition since the State-of-Science Report of the National Institutes of Health in 2005 was conducted.

RESULTS

Recent longitudinal cohort studies indicate that the likelihood of depressed mood in the menopausal transition is approximately 30% to three times greater compared with that during premenopause. Women with a history of depression are nearly five times more likely to have a diagnosis of major depression in the menopausal transition, whereas women with no history of depression are two to four times more likely to report depressed mood compared with premenopausal women. In some studies, the changing hormonal milieu is significantly associated with depressive symptoms in the menopausal transition. Other risk factors for depressed mood in perimenopausal women include poor sleep, hot flashes, stressful or negative life events, employment status, age, and race.

CONCLUSIONS

The findings support the concept that the menopausal transition is a "window of vulnerability" for some women and is framed by the changing hormonal milieu of ovarian aging.

Effects of hepatitis C virus infection on menopause status and symptoms

OBJECTIVE

To examine the relationship between hepatitis C virus (HCV) infection with menopause status and vasomotor symptoms among middle-aged, impoverished women.

METHODS

The baseline interview and laboratory data from a study on menopause were used for a cross-sectional analysis of HCV antibody and HCV-RNA levels and their relationship to menopause status and symptoms, using logistic regression. For HCV-infected and HCV-uninfected women, menopause status was defined according to the World Health Organization criteria.

RESULTS

Of 559 participants, 48% were black, 38.6% were Hispanic, and 267 (47.8%) were HCV seropositive; of these, 189 (72.1%) had detectable HCV-RNA levels. The median age was 43 years [interquartile range (IQR), 40-46 years]; 50.2% of the women were premenopausal, 31.8% were perimenopausal, and 18% were postmenopausal. Median age at natural menopause was 46 years (IQR, 42.25-49 years) in HCV-infected women compared with 47 years (IQR, 40.25-48 years) in uninfected controls. Women infected with HCV were more likely to be postmenopausal than were uninfected women (adjusted odds ratio [ORadj], 1.68; 95% CI, 1.02-2.77). Human immunodeficiency virus status (ORadj, 1.69; 95% CI, 1.04-2.75), drug use (ORadj, 2.34; 95% CI, 1.42-3.86), and nulliparity (ORadj, 2.74; 95% CI, 1.42-5.29) were independently associated with natural menopause, whereas being more physically active (ORadj, 0.90; 95% CI, 0.85-0.95) was inversely associated with menopause. Women infected with HCV were more likely than uninfected women to report vasomotor symptoms (ORadj, 1.52; 95% CI, 1.06-2.18).

CONCLUSIONS

Hepatitis C virus infection is independently associated with natural menopause, controlling for age. In addition, HCV was associated with vasomotor symptoms. Further studies are warranted to better understand the menopausal transition in HCV-infected women.

Cortisol levels during the menopausal transition and early postmenopause: observations from the Seattle Midlife Women's Health Study

OBJECTIVE

Cortisol levels rise among some women during the late stage of the menopausal transition (MT), but we know little about changes in cortisol levels in relation to menopause-related factors (MT stage, urinary estrone glucuronide [E1G], testosterone, follicle-stimulating hormone [FSH]), stress-related factors (epinephrine, norepinephrine, and perceived stress), symptoms (hot flashes, mood, memory, and sleep), social factors (income adequacy, role burden, social support, employment, parenting, and history of sexual abuse), and health-related factors (depressed mood, perceived health, physical appraisal, body mass index, and smoking). The aim of the study was to examine the influence of menopause-related factors, stress-related factors, symptoms, social factors, and health-related factors on cortisol levels during the MT.

METHODS

Participants were a subset of Seattle Midlife Women's Health Study who provided data during the late reproductive, early and late MT stages, or early postmenopause and who were not using hormone therapy or corticosteroids (N = 132 women, up to 5,218 observations). Data provided included menstrual calendars for staging the MT, annual health reports, health diaries, and overnight urine specimens (assayed for cortisol, catecholamines, E1G, and FSH) between 1990 and 2005 were included. Perceived stress, symptoms, and health behaviors were assessed in a health diary. Health-related and social factors were assessed in an annual health update. Multilevel modeling was used to test the effects of menopause-related and other factors on overnight cortisol levels.

RESULTS

When tested with age as a measure of time, menopause-related covariates, including E1G, FSH, and testosterone, were associated with significant increases in overnight cortisol levels (P < 0.0001). Likewise, epinephrine and norepinephrine were each associated significantly with overnight cortisol levels (P < 0.0001). In multivariate analyses, E1G, FSH, and testosterone constituted the best set of predictors.

CONCLUSIONS

Overnight cortisol levels during the MT were associated with E1G, testosterone, and FSH levels. In addition, they were significantly and positively associated with epinephrine and norepinephrine. MT stage, symptoms, and social, stress-related, and health-related factors had little relationship to overnight cortisol levels when other biological indicators were considered.

Quality of life and climacteric complaints amongst women seeking medical advice in Taiwan: assessment using the WHOQOL-BREF questionnaire

OBJECTIVE

To determine the impact of the climacteric transition on health-related quality of life amongst women, between the ages of 45 and 55 years, seeking medical advice in Taiwan.

METHOD

A total of 203 women seeking medical advice (SMA) were drawn from a special integrated clinic, with a further 349 healthy referents of the same age, range and gender, with no history of hormone replacement therapy and living in the same municipality, also being recruited from a national health survey sample for comparison. Each one was asked to fill out the brief questionnaire of the Taiwan version of the World Health Organization Quality of Life (WHOQOL-BREF), assessing quality of life on 26 items in four domains (physical, psychological, social and environmental). SMA subjects were also questioned about the 21 most frequent symptoms. Multiple regression analyses were conducted to control variables such as age, marital status, religion and educational attainment.

RESULTS

The mean scores for the physical, psychological and social domains were significantly lower than those of the healthy referents, as was the overall quality of life for SMA women. Although usual vasomotor symptoms did not significantly predict quality of life in the SMA subjects, after controlling for demographic factors, insomnia and emotional disturbance were found to be major determinants of the scores in the different domains.

CONCLUSION

Insomnia and emotional disturbance should be taken into consideration in the management of climacteric women seeking medical advice.