Natural menopause and cardiovascular disease risk factors. The Poland and US Collaborative Study on Cardiovascular Disease Epidemiology

Association between serum lipid profile, body mass index and osteoporosis in postmenopausal Sudanese women

BACKGROUND

Epidemiological observations suggest links between osteoporosis and the risk of acute cardiovascular events. Whether the two clinical conditions are linked by common pathogenic factors or atherosclerosis per se remains incompletely understood. The reduction of bone density and osteoporosis in postmenopausal women contributes to elevated lipid parameters and body mass index (BMI).

OBJECTIVE

To investigate the relationship between serum lipid profile, BMI and osteoporosis in postmenopausal women.

MATERIALS AND METHODS

A prospective analytical case control-study conducted in Khartoum north hospital at Khartoum city, capital of the Sudan from April 2017 to March 2018 after ethical approval obtained from the local Research Ethics Committee of Faculty of Medical Laboratories, Alzaeim Alazhary University on the committee meeting number (109) on Wednesday 15th February 2017. A written informed consent was obtained from all participants to participate in the study.Two hundred postmenopausal women were enrolled in the study. The age was studied in one hundred osteoporosis postmenopausal women as a case group and one hundred non-osteoporosis postmenopausal women as control group. The serum lipid profiles were estimated using spectrophotometers (Mandry) and BMI calculated using Quetelet index formula. The data were analysed using SPSS version 16.

RESULTS

The BMI, serum total cholesterol, triglyceride, HDL and LDL in case group respectively were (24.846±2.1647, 251.190±27.0135 mg/dl, 168.790 ±45.774 mg/dl, 50.620 ± 7.174 mg/dl, 166.868 ±28.978 mg/dl). While the BMI, serum total cholesterol, triglyceride, HDL and LDL in control group respectively were (25.378 ±3.8115, 187.990 ± 26.611 mg/dl, 139.360±20.290 mg/dl, 49.480 ±4.659 mg/dl, 111.667 ±28.0045 mg/dl). All serum lipid profiles significantly increased (p=0.000) in the case group compared to the control group, except serum HDL was insignificant different between the case and control group and also BMI was insignificant different between the case and control group. There was a positive Pearson's correlation between BMD and serum total cholesterol (r= 0.832, P<0.01), serum LDL (r = 0.782, P<0.01) and serum triglyceride (r = 0.72, P<0.01).

CONCLUSIONS

Osteoporotic postmenopausal women had a significant increase in serum lipid profile and BMI. Moreover, we found a positive link between women with cardiovascular diseases and stroke.

A review of menopause nomenclature

Menopause nomenclature varies in the scholarly literature making synthesis and interpretation of research findings difficult. Therefore, the present study aimed to review and discuss critical developments in menopause nomenclature; determine the level of heterogeneity amongst menopause definitions and compare them with the Stages of Reproductive Aging Workshop criteria. Definitions/criteria used to characterise premenopausal and postmenopausal status were extracted from 210 studies and 128 of these studies were included in the final analyses. The main findings were that 39.84% of included studies were consistent with STRAW classification of premenopause, whereas 70.31% were consistent with STRAW classification of postmenopause. Surprisingly, major inconsistencies relating to premenopause definition were due to a total lack of reporting of any definitions/criteria for premenopause (39.84% of studies). In contrast, only 20.31% did not report definitions/criteria for postmenopause. The present findings indicate that there is a significant amount of heterogeneity associated with the definition of premenopause, compared with postmenopause. We propose three key suggestions/recommendations, which can be distilled from these findings. Firstly, premenopause should be transparently operationalised and reported. Secondly, as a minimum requirement, regular menstruation should be defined as the number of menstrual cycles in a period of at least 3 months. Finally, the utility of introducing normative age-ranges as supplementary criterion for defining stages of reproductive ageing should be considered. The use of consistent terminology in research will enhance our capacity to compare results from different studies and more effectively investigate issues related to women's health and ageing.

Fat mass changes during menopause: a metaanalysis

OBJECTIVE

Data: Fat mass has been shown to increase in aging women; however, the extent to which menopausal status mediates these changes remains unclear. The purpose of this review was to determine (1) how fat mass differs in quantity and distribution between premenopausal and postmenopausal women, (2) whether and how age and/or menopausal status moderates any observed differences, and (3) which type of fat mass measure is best suited to the detection of differences in fat mass between groups.

STUDY

This review with metaanalyses is reported according to Metaanalysis of Observational Studies in Epidemiology guidelines.

STUDY APPRAISAL AND SYNTHESIS METHODS

Studies (published up to May 2018) were identified via PubMed to provide fat mass measures in premenopausal and postmenopausal women. We included 201 cross-sectional studies in the metaanalysis, which provided a combined sample size of 1,049,919 individuals and consisted of 478,734 premenopausal women and 571,185 postmenopausal women. Eleven longitudinal studies were included in the metaanalyses, which provided a combined sample size of 2472 women who were premenopausal at baseline and postmenopausal at follow up.

RESULTS

The main findings of this review were that fat mass significantly increased between premenopausal and postmenopausal women across most measures, which included body mass index (1.14 kg/m²; 95% confidence interval, 0.95-1.32 kg/m²), bodyweight (1 kg; 95% confidence interval, 0.44-1.57 kg), body fat percentage (2.88%; 95% confidence interval, 2.13-3.63%), waist circumference (4.63 cm; 95% confidence interval, 3.90-5.35 cm), hip circumference (2.01 cm; 95% confidence interval, 1.36-2.65 cm), waist-hip ratio (0.04; 95% confidence interval, 0.03-0.05), visceral fat (26.90 cm²; 95% confidence interval, 13.12-40.68), and trunk fat percentage (5.49%; 95% confidence interval, 3.91-7.06 cm²). The exception was total leg fat percentage, which significantly decreased (-3.19%; 95% confidence interval, -5.98 to -0.41%). No interactive effects were observed between menopausal status and age across all fat mass measures.

CONCLUSION

The change in fat mass quantity between premenopausal and postmenopausal women was attributable predominantly to increasing age; menopause had no significant additional influence. However, the decrease in total leg fat percentage and increase in measures of central fat are indicative of a possible change in fat mass distribution after menopause. These changes are likely to, at least in part, be due to hormonal shifts that occur during midlife when women have a higher androgen (ie, testosterone) to estradiol ratio after menopause, which has been linked to enhanced central adiposity deposition. Evidently, these findings suggest attention should be paid to the accumulation of central fat after menopause, whereas increases in total fat mass should be monitored consistently across the lifespan.

Lipid profile and plasma atherogenic index in postmenopausal osteoporosis

OBJECTIVE

The goal of this study was to investigate the relationship between the lipid profile, plasma atherogenic index (PAI), and osteoporosis in postmenopausal women.

METHODS

The data of age, duration of menopause, height, weight, lipid profile, bone mineral density (BMD) value, and history of oral contraceptive use of 407 postmenopausal women who had not been menstruating for at least 12 months, were between the ages 45 and 80, and presented at the obstetrics and gynecology polyclinic of Kartal Dr. Lutfi Kirdar Tr aining and Research Hospital were reviewed. The patients were divided into 2 groups according to the presence of osteoporosis, and the data compared. The level of significance was accepted as p<0.05.

RESULTS

A total of 142 postmenopausal patients with osteoporosis were included in the study. The mean age was 61.7±6.9 years. In the control group, there were 263 postmenopausal women without osteoporosis, with a mean age of 58.3±4.5 years. There was no statistically significant difference with respect to triglyceride level; however, in the osteoporosis group, the level of total cholesterol and low-density lipoprotein (LDL) were lower, and the level of high-density lipoprotein (HDL) was higher (p=0.762, p=0.002, p=0.01, p<0.001, respectively).

CONCLUSION

A high level of HDL, and low LDL and PAI values, which are important for the prevention of cardiovascular disease, were found to be negative factors for BMD.

Identification of a CYP19 Gene Single-Nucleotide Polymorphism Associated with a Reduced Risk of Coronary Heart Disease

OBJECTIVE

An imbalance in sex hormone ratios has been identified in coronary heart disease (CHD), and as a key enzyme in the conversion of androgen to estrogen, aromatase plays an important role in the balance of sex hormone levels. However, there is a paucity of research into the potential roles of aromatase in CHD. In this study, we investigated associations between single-nucleotide polymorphisms (SNPs) in the CYP19 gene, which encodes aromatase, and CHD.

METHODS

We collected 1706 blood samples from CHD patients and control participants and used propensity score matching techniques to match case and control groups with respect to confounding factors. In a final study population, including 596 individuals, we conducted a case-control study to identify associations between three SNPs in CYP19 and CHD using χ(2) or Fisher exact tests, and binary logistic regression analysis. Differences in lipid levels and parameters of echocardiography among individuals with different genotypes were assessed by one-way analysis of variance.

RESULTS

The distributions of rs2289105 alleles in the CYP19 gene differed significantly between the CHD and control groups (p = 0.014), and the heterozygote CT genotype was associated with a significantly lower risk of CHD compared to the homozygous wild-type CC genotype (p = 0.0063 and odds ratio = 0.575). However, blood lipid levels and echocardiographic parameters among individuals with different genotypes did not differ between the CHD and control groups.

CONCLUSIONS

The CT genotype of the rs2289105 polymorphism in the CYP19 gene is associated with a decreased risk of CHD and may be a genetic marker of protection from CHD.

Surgical menopause versus natural menopause and cardio-metabolic disturbances: A 12-year population-based cohort study

PURPOSE

Menopausal status exposes women to increased risk of cardiovascular disease. This study was performed to compare the effect of menopausal types, including surgical and natural, on metabolic syndrome and other metabolic disorders 3 years before and after menopause.

METHODS

Of 437 postmenopausal women, who participated in the Tehran Lipid and Glucose Study, 13 women with surgical menopause and 39 age-matched controls with natural menopause were selected. During the follow-up period, changes in metabolic and biochemical profiles were compared between surgical and natural menopause women.

RESULTS

Odds of incidence of metabolic syndrome in surgical menopause women, compared to natural menopause women, was 9.7 (95 % CI 1.8-51.8).

CONCLUSIONS

Metabolic disturbances after menopause are highly influenced by type of menopause and are more prevalent in those undergoing surgical menopause.

Myocardial Infarction in a Premenopausal Woman on Leuprolide Therapy

Premenopausal women with chest pain syndrome may have nonatherosclerotic coronary arteries with abnormal coronary flow. Estrogens have cardioprotective effect improving coronary vasodilatation. This case report discusses the consequences of leuprolide use by decreasing estrogen levels which led to acute myocardial infarction.

The prevalence of metabolic syndrome in premenopausal and postmenopausal women in Southern Thailand

OBJECTIVE

To assess the prevalence of metabolic syndrome (MetS) in premenopausal and postmenopausal women in Southern Thailand.

METHODS

A cross-sectional study was conducted with 361 healthy women (218 premenopausal women and 143 postmenopausal women) in Southern Thailand. Blood pressure, anthropometric indices, fasting plasma glucose and serum lipid levels were measured. MetS was defined according to criteria of the "National Cholesterol Education Program Adult Panel Treatment III" (NCEP ATPIII). Logistic regression analysis was used to evaluate factors associated with MetS.

RESULTS

Waist circumference, systolic blood pressure, diastolic blood pressure, and levels of total cholesterol, triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and fasting plasma glucose (FPG) were significantly higher in postmenopausal women, when compared with premenopausal women (p < 0.05). The prevalence of MetS in postmenopausal women (29.37%), was significantly higher than that of premenopausal women (16.97%) (p = 0.005). The most frequent component of MetS in postmenopausal women was central obesity (58.74%), followed by hypertension (58.04%), high triglyceride (27.97%), low HDL-C (23.08%), and high FPG (11.19%). Multivariate analysis revealed that age and higher body mass index (BMI) increased the risk of developing MetS.

CONCLUSION

The prevalence of MetS is higher in postmenopausal women than in premenopausal women, and its significant predictors include age and BMI.

Arterial stiffness and related variables across menopausal status: an epidemiologic study

OBJECTIVES

To determine if postmenopausal women have different arterial stiffness, blood pressure (BP) values, or metabolic patterns in comparison to fertile women and to men at a population level.

METHODS

This is a population-based epidemiologic study of 1853 representative men and women aged 18-95 years. Clinostatic humeral BP was measured using Omron 705CP. Aortic BP, augmentation index (AI), and pulse wave velocity (PWV) were determined using applanation tonometry. Body mass index (BMI) and subscapular skinfold thickness were used as measures of adiposity. Fasting and postload blood glucose, homeostasis model assessment (HOMA), low-density and high-density lipoprotein serum cholesterol (LDL-C and HDL-C) and triglycerides were assessed.

RESULTS

Age was higher in postmenopausal women than in fertile women (68.8 ± 9.5 vs. 35.7 ± 10.2 years, p<0.001), and BMI was 16% higher (p<0.01) in the postmenopausal women after age adjustment. Humeral and aortic BP, carotid and radial AI, carotid-femoral PWV, BMI, LDL-C, LDL-C/HDL ratio, triglycerides, glucose tolerance, HOMA, and skinfold thickness were apparently higher in postmenopausal than in fertile women. Using multivariate analysis, however, all these differences were abolished after adjusting for confounders (age and, when appropriate, BMI), except for LDL-C, which remained 19% higher (p<0.01) in postmenopausal women than in fertile women after adjusting for many confounders (age, BMI, cholesterol, ethanol intake, caloric intake, and triiodothyronine).

CONCLUSIONS

Only LDL-C increases in postmenopausal women, whereas other differences attributed to menopause, including BP and arterial stiffness, seem to be confounding effects of age and BMI.

Age, menopause, and cardiovascular risk factors among korean middle-aged women: the 2005 Korea National Health and Nutrition Examination Survey

OBJECTIVE

This study examined the effects of menopause and age on cardiovascular disease (CVD) risk factors in a nationally representative sample of middle-aged Korean women.

METHODS

This study used the data of 1169 perimenopausal Korean women (mean age 50.1 +/- 7.2 years, 44% postmenopausal) from the 2005 Korea National Health and Nutrition Examination Survey (KNHANES). Menopausal status was confirmed by self-reports. Risk factors of CVD included reported lifestyle characteristics (smoking, physical activity level, and dietary and alcohol intake) and measured anthropometry, blood pressure, fasting glucose, and serum lipid levels. Sociodemographic characteristics and general health conditions were assessed by interviews. Descriptive statistics and multiple regression models were used to assess the effects of age and menopause on various CVD risk factors.

RESULTS

The mean age of natural menopause in Korean women was 50.2 +/- 3.7 years. Lifestyle risk factors of CVD were not significantly different by menopausal status or age except the percent of energy intake from fat, which decreased by menopause and age. Waist circumference increased with both age and menopause; blood pressure was elevated only with age, and serum lipids were associated only with menopausal status. However, fasting serum glucose was not related to either age or menopausal status.

CONCLUSIONS

This study showed the increasing CVD risk burdens with menopause and aging in Korean middle-aged women. More study is warranted to better understand ways to attenuate the deleterious changes.

The Metabolic Syndrome among Postmenopausal Women in Gorgan

Introduction. The present study aimed to assess the metabolic syndrome among postmenopausal women in Gorgan, Iran. Materials and Methods. The study was conducted on hundred postmenopausal women who were referred to the health centers in Gorgan. Metabolic syndrome was diagnosed using Adult Treatment Panel III (ATP III) guidelines. Results. The mean body mass index, waist circumference, hip, circumference waist-to-hip ratio, diastolic blood pressure, and triglyceride and fasting blood glucose levels were significantly high among postmenopausal women with metabolic syndrome, but the mean HDL-cholesterol was significantly low (P < 0.05). Overall prevalence of metabolic syndrome was 31%. Body mass index and waist circumference had a positive correlation with a number of metabolic syndrome factors (P < 0.001). Body mass index, waist circumference, and waist-to-hip ratio had a positive correlation with each other (P < 0.001). BMI had relatively high correlation with WC (P < 0.001). Conclusions. Our results show that postmenopausal status might be a predictor of metabolic syndrome. Low HDL-cholesterol level and high abdominal obesity are the most frequent characteristics in comparison to other metabolic components. Our study also showed some related factors of metabolic syndrome among postmenopausal women. These factors may increase cardiovascular risk among postmenopausal women with metabolic syndrome.

Lipid changes during the menopause transition in relation to age and weight: the Study of Women's Health Across the Nation

Few studies have prospectively examined lipid changes across the menopause transition or in relation to menopausal changes in endogenous hormones. The relative independent contributions of menopause and age to lipid changes are unclear. Lipid changes were examined in relation to changes in menopausal status and in levels of estradiol and follicle-stimulating hormone in 2,659 women followed in the Study of Women's Health Across the Nation (1995-2004). Baseline age was 42-52 years, and all were initially pre- or perimenopausal. Women were followed annually for up to 7 years (average, 3.9 years). Lipid changes occurred primarily during the later phases of menopause, with menopause-related changes similar in magnitude to changes attributable to aging. Total cholesterol, low density lipoprotein cholesterol, triglycerides, and lipoprotein(a) peaked during late peri- and early postmenopause, while changes in the early stages of menopause were minimal. The relative odds of low density lipoprotein cholesterol (> or =130 mg/dL) for early postmenopausal, compared with premenopausal, women were 2.1 (95% confidence interval: 1.5, 2.9). High density lipoprotein cholesterol also peaked in late peri- and early postmenopause. Results for estradiol and follicle-stimulating hormone confirmed the results based on status defined by bleeding patterns. Increases in lipids were smallest in women who were heaviest at baseline.

High density lipoprotein-cholesterol levels increase with age in American women but not in Hong Kong Chinese women

OBJECTIVES

High-density lipoprotein (HDL) cholesterol is a powerful cardiovascular risk factor. Important gender and ethnic differences in plasma HDL levels exist and warrant investigation.

DESIGN

Cross-sectional survey in two different general populations. Patients 7700 participants of the National Health and Nutrition Examination Survey (NHANES) 1999-2002 and 1944 participants of the Hong Kong Cardiovascular Risk Factor Prevalence Study-2 (CRISPS2) 2000-2004.

MEASUREMENTS

Plasma HDL levels.

RESULTS

Plasma HDL levels were higher in women than in men in both populations. In the United States women, it increased with age, whereas in Chinese women, it declined with age and converged with male HDL levels. In the United States, 37.1 +/- 1.2% men and 38.9 +/- 1.1% women had low HDL levels. In Hong Kong, 34.3 +/- 1.6% men and 34.5 +/- 1.5% women had low HDL levels. In Americans, the independent predictors of low HDL levels were lower age, being non-Mexican Hispanic, waist circumference, triglycerides and not drinking alcohol in men, and lower age, being Hispanic, waist circumference, triglycerides, current smoking and not drinking alcohol in women. In Hong Kong Chinese, the independent predictors of low HDL levels were body mass index, triglycerides, current smoking and not drinking alcohol in men, and lower age, waist circumference, triglycerides, diabetes and former smoking in women.

CONCLUSIONS

The decline in plasma HDL with age in Chinese women is opposite to that seen in American women. The increased cardiovascular risk in elderly Chinese women requires further study.

Gender-specific differences in the kinetics of nonfasting TRL, IDL, and LDL apolipoprotein B-100 in men and premenopausal women

OBJECTIVE

To investigate mechanisms underlying gender differences in serum lipoprotein concentrations, the kinetic behavior of apoB-100 was assessed.

METHODS AND RESULTS

Twenty subjects (<50 years; 12 men and 8 premenopausal women) were provided a Western diet for 4 to 6 weeks, after which the kinetics of apoB-100 in triglyceride-rich, intermediate-density, and low-density lipoprotein (TRL, IDL, and LDL) were determined in the fed state. Nonfasting plasma TC, LDL-C, and triglyceride concentrations were 23%, 34%, and 57% lower, respectively, in the women compared with men. Plasma TRL and LDL apoB 100 pool sizes were lower by 40% and 30%, respectively. These differences were accounted for by higher TRL and LDL apoB 100 fractional catabolic rates (FCR), rather than differences in production rates (PR). Plasma TRL-C and LDL-C were positively correlated with TRL and LDL apoB 100 concentrations and pool size, and negatively correlated with TRL and LDL apoB 100 FCR (women: r=-0.59, P<0.01 and r=-0.54, P<0.04, and men: r=-0.43, P<0.05 and r=-0.44, P<0.05). No significant associations were observed between plasma TRL-C and LDL-C and PR.

CONCLUSIONS

These data suggest the mechanism for lower TRL-C and LDL-C concentrations in women was determined predominantly by higher TRL and LDL FCR rather than lower PR. This could explain, in part, the lower CVD risk in premenopausal women relative to men.

Prevalence of metabolic syndrome during menopausal transition Tehranian women: Tehran Lipid and Glucose Study (TLGS)

OBJECTIVE

This study was conducted to assess the prevalence of metabolic syndrome (MetS) in Tehranian women during menopausal transition.

DESIGN

In this cross sectional study 2182 subjects, pre-menopausal (pre-M) n=537, menopausal (M) n=311 and post-menopausal (post-M) n=1334 were selected from 15005 participants of the TLGS and assessed for MetS risk factors. All MetS components were evaluated following age adjustment according to the ATPIII criteria.

RESULTS

The mean ages of post-M, M and pre-M women were 61.0+/-4.3, 53.0+/-4.0 and 47.0+/-1.9 years, respectively. The prevalence of MetS in subjects was 63% (53%, 54% and 69%) in pre-M, M and post-M women respectively. HDL-c levels was significantly higher in post-M women in comparison to pre-M women (p<0.001). TG levels, FPG and waist circumference was significantly higher in post-M women in comparison to pre-M women (p<0.05). The most frequent markers of MetS were low HDL-c and high diastolic blood pressure in post-M women.

CONCLUSION

It is concluded that the frequency of MetS is significantly higher in post-M women as compared to pre-M women; low HDL-c and high diastolic blood pressure is the most frequent feature in comparison to other factors.

Estrogen receptor-1 genotype is related to coronary intima thickness in young to middle-aged women

OBJECTIVE

The incidence of coronary disease in premenopausal women is about one-half that in men of similar age. The estrogen receptor-1 (ESR1, c.454-397T>C) CC variant genotype is associated with the severity of coronary artery disease (CAD) and an increased risk of myocardial infarction in men. The purpose of the present study was to investigate whether this ESR1 CC variant also disposes to atherosclerosis in women in terms of increased total coronary artery intima thickness.

MATERIAL AND METHODS

A total of 125 forensic autopsy cases of women aged 15 to 49 years were investigated. The thickness of the coronary intima, which reflects the severity of atherosclerosis, was measured by computerized image analysis. The ESR1 c.454-397T>C genotype was determined by polymerase chain reaction (PCR).

RESULTS

The mean intima thicknesses in the three genotype groups were 428+/-298 microm (TT), 494+/-371 microm (CT) and 636+/-436 microm (CC). We found that, on average, women with the CC genotype had a thicker coronary intima compared with that of women with the TT genotype, even after adjusting for age and body mass index (BMI) (p = 0.030). The intermediate group (TC) did not significantly differ from either the CC or the TT genotype group in this respect.

CONCLUSION

Our results point to the importance of ESR1 genotype in relation to cardiovascular disease susceptibility.

Hot flashes are associated with increased ambulatory systolic blood pressure

OBJECTIVE

To determine the association between ambulatory blood pressure (BP) and hot flash experience.

DESIGN

The participants in the study were 154 women (mean age=46 years, range=18-65 years), who were evaluated as part of a cross-sectional study on ethnicity, socioeconomic status, and diurnal BP patterns. Participants could be either normotensive or mildly hypertensive. Participants wore an ambulatory BP monitor for 24 hours and recorded their awake and sleep times. Hot flashes were assessed using an everyday complaint questionnaire that embeds symptoms associated with menopause into a list of everyday complaints.

RESULTS

Thirty-three percent of participants reported having had hot flashes during the 2 weeks before they completed the questionnaire. Compared with women who did not report hot flashes, mean awake and sleep systolic BP values were significantly higher (P<0.004 and P=0.007, respectively) in women who reported having had hot flashes. Hot flashes continued to independently predict average awake and sleep systolic BP (both P=0.03) after controlling for age, race/ethnicity, body mass index, and menopausal status. Hot flashes were not associated with diastolic BP or nocturnal dipping of BP.

CONCLUSIONS

Hot flashes are associated with increased awake and sleep systolic BP independent of menopausal status. Further investigation is warranted to elucidate the mechanisms by which hot flashes are associated with BP.

Blood pressure and the global burden of disease 2000. Part 1: Estimates of blood pressure levels

OBJECTIVE

To provide global estimates of blood pressure by age and sex for adults aged > or = 30 years, by WHO subregion.

DESIGN AND METHODS

Data were obtained from studies identified in a literature review of population-based surveys. These were complemented by data from MONICA and INTERSALT studies. Estimates of the shape of the age-systolic blood pressure (SBP) association were made from survey data utilizing parametric and non-parametric analyses. A linear sex-specific association of SBP with age was demonstrated from 30 to 70 years in females and 20 to 70 years for males in each subregion. Mean age- and sex-specific estimates of SBP were estimated for each WHO subregion separately, based on study and country-weighted SBP data.

RESULTS

Analyses were based on data from about 230 surveys and over 660 000 participants. Age-specific mean SBP values ranged from 114 to 164 mmHg for females, and 117-153 mmHg for males. Females typically had lower SBP levels than males in the 30-44-year age groups, but in all subregions, SBP levels rose more steeply with age for females than males. Therefore, SBP levels in those aged > or = 60 years tended to be higher in females. Subregions with consistently high mean SBP levels included parts of eastern Europe and Africa. Mean SBP levels were lowest in south-east Asia and parts of the western Pacific.

CONCLUSIONS

These global estimates of blood pressure by age, sex and subregion show considerable variation in estimated levels. The lack of data in developing countries is substantial, and this is an important limitation given the role of blood pressure in increasing cardiovascular disease levels.

Severity of cardiovascular disease in women: relation with exposure to endogenous estrogen

OBJECTIVES

Coronary artery disease (CAD) is more common in men than in women. Endogenous sex steroids may be the main factor responsible, as long-term estrogen action appears to be protective. The aim of the study was to investigate the predisposing factors responsible for the severity of CAD in women.

METHODS

One hundred and eight women (100 menopausal) undergoing coronary angiography were studied. Reproductive function was recorded. The severity of CAD was assessed by the number of arteries with severe stenosis, the presence of angina and myocardial infarctions (MI).

RESULTS

The time since menopause (TSM) was significantly longer in women with angina and with MIs compared to those without (20.3+/-8.7 years versus 15.8+/-8.7 years and 22.6+/-8.6 years versus 18.1+/-8.9 years, p<0.05), independently of chronological age. The age at menopause was significantly younger in women who had 2 MIs compared to those with 1 or 0 MI (41.5+/-3.5, 47.5+/-5.3 and 48.4+/-5.4 years, respectively; p=0.04); the total duration of menstrual cyclicity was inversely related to the number of MIs (35.6+/-5.8, 34.2+/-5.3 and 28.3+/-3.3 years, 0, 1 and 2 MIs, respectively; p=0.03).

CONCLUSIONS

The severity of CAD in women referred for coronary angiography is correlated with measures of exposure to endogenous estrogen. Both the TSM and the age at menopause are aggravating factors for MI, independently of age. There is an independent protective effect of the duration of estrogen exposure on the number of MIs; this has not been reported before and supports the protective role of the length of exposure to endogenous estrogen, especially for the occurrence of MI in this selected group of women.

TRL, IDL, and LDL Apolipoprotein B-100 and HDL Apolipoprotein A-I Kinetics as a Function of Age and Menopausal Status

Objective— To determine mechanisms contributing to the altered lipoprotein profile associated with aging and menopause, apolipoprotein B-100 (apoB-100) and apoA-I kinetic behavior was assessed.

Methods and Results— Eight premenopausal (25±3 years) and 16 postmenopausal (65±6 years) women consumed for 6 weeks a standardized Western diet, at the end of which a primed-constant infusion of deuterated leucine was administered in the fed state to determine the kinetic behavior of triglyceride-rich lipoprotein (TRL), intermediate-density lipoprotein (IDL), and low-density lipoprotein (LDL) apoB-100, and high-density lipoprotein (HDL) apoA-I. Data were fit to a multicompartmental model using SAAM II to calculate fractional catabolic rate (FCR) and production rate (PR). Total cholesterol, LDL cholesterol (LDL-C), TRL-C, and triglyceride levels were higher (50%, 55%, 130%, and 232%, respectively) in the postmenopausal compared with the premenopausal women, whereas HDL-C levels were similar. Plasma TRL, IDL, and LDL-apoB-100 levels and pool sizes (PS) were significantly higher in the postmenopausal than premenopausal women. These differences were accounted for by lower TRL, IDL, and LDL apoB-100 FCR ( P <0.05), with no difference in PR. There was no significant difference between groups in HDL-C levels or apoA-I kinetic parameters. Plasma TRL-C concentrations were negatively correlated with TRL apoB-100 FCR ( r =−0.46; P <0.05) and positively correlated with PR ( r =0.62; P <0.01). Plasma LDL-C concentrations were negatively correlated with LDL apoB-100 FCR ( r =−0.70; P <0.001) but not PR.

Conclusions— The mechanism for the increase in TRL and LDL apoB-100 PS observed in the postmenopausal women was determined predominantly by decreased TRL and LDL catabolism rather than increased production. No differences were observed in HDL apoA-I kinetics between groups.

Is serum ferritin an additional cardiovascular risk factor for all postmenopausal women?

BACKGROUND

Most of the studies on cardiovascular disease (CVD) risk factors in menopause have focused on serum lipid(lipoprotein) abnormalities and were conducted in populations which were not well controlled for several important influential factors.

METHODS

Two homogenous groups of 30 apparently healthy Caucasian premenopausal women and 3-5 years postmenopausal women who were nonobese, nonsmoking and not using estrogen were compared in a well-controlled cross-sectional design. Fasting serum ferritin and plasma total homocysteine (tHcy) were evaluated concomitantly to classical serum lipid(lipoprotein) risk factors. Relationships between risk factors and the influence of other contributing variables such as diet and body weight were also examined.

RESULTS

Serum total cholesterol (p < 0.01), low-density lipoproteins (LDL; p < 0.05) and triglycerides (p < 0.05) of postmenopausal women were greater than that of their menstruating counterparts, even though they ate a CVD-preventive diet, had similar body weight and body fat distribution. Their serum ferritin was almost 3-fold greater (p < 0.0001) but was still within normal limits, except for the 38.5% of postmenopausal women who exhibited values above the 80 mug/l limit that has been associated with sharp increases in the rate of heart disease in either gender. Serum ferritin was low in one third of the postmenopausal group (as low as in the premenopausal control group, whose dietary iron intake was slightly below the nutritional recommendation). The mean plasma tHcy of the postmenopausal group was almost twice as elevated (p < 0.0001). Both ferritin and tHcy were found to be linked to serum cholesterol. The correlation between tHcy and triglycerides was also significant.

CONCLUSION

Early menopause is not associated with blood iron overload and CVD risk factor in an important proportion of women.

The increase in cholesterol with menopause is associated with the apolipoprotein E genotype. A population-based longitudinal study

During menopause, a sharp increase in cholesterol concentration occurs with an unexplained wide variation in change. Possibly, this is attributable to genetic variation. The authors prospectively studied the effect of the apolipoprotein E (APOE) genotype on the change in cholesterol level with menopause among 1116 Dutch women. Women with the APOE3E3 genotype were regarded as the reference category and changes were adjusted for age at baseline, years of follow-up, years since menopause, and body mass index. At baseline, the women were on average 50.4 years. After 5.9 years of follow-up, the women were on average 4.3 years (S.D. 1.5 years) postmenopausal. The mean increase in cholesterol with menopause in women with the APOE3E3 genotype was 0.67 mmol/L (95% CI, 0.61-0.72 mmol/L). In women with the APOE2E3 genotype the increase in cholesterol was 0.44 mmol/L (CI, 0.32-0.56 mmol/L). The increase in cholesterol in women with the APOE3E4 genotype did not differ from the increase in women with the APOE3E3 genotype. These results show that the increase in cholesterol level with menopause is 30% lower in women with the APOE2E3 genotype when compared with women with the APOE3E3 genotype, indicating that the APOE genotype contributes to the variation in cholesterol increase with menopause.

The importance of plasma apolipoprotein E concentration in addition to its common polymorphism on inter-individual variation in lipid levels: results from Apo Europe

Interindividual variation in the concentration of plasma lipids which are associated with coronary artery disease (CAD) risk is determined by a combination of genetic and environmental factors. This study investigates the effects of apoE genotype and plasma concentration on cholesterol and triglycerides (TG) levels in subjects from five countries: Finland, France, Northern Ireland, Portugal, and Spain. Age and sex significantly influenced serum cholesterol, TG and apoE concentrations. The age effect differs in males and females. The allele frequencies of the apoE gene, one of the most widely studied CAD susceptibility genes, were determined: the epsilon2 allele frequency and the apoE concentration showed a north-south increasing gradient while the epsilon4 allele frequency showed the reverse. ApoE plays an important role in lipid metabolism. Total cholesterol and TG concentrations were significantly dependent on apoE genotype in both sexes. These differences in lipids between genotypes were more pronounced when plasma apoE concentrations were taken into account.

Weight change in relation to natural menopause and other reproductive and behavioral factors in Japanese women

PURPOSE

To evaluate the effect of menopause on weight change in Japanese women.

METHODS

Community-based sample of 828 Japanese women who were premenopausal and aged 40 to 54 years completed a self-administered questionnaire asking information on demographic factors, body size, reproductive history and dietary and behavioral factors in 1992. They responded to a follow-up questionnaire asking weight and menopausal status in 1998.

RESULTS

Women gained weight modestly, on average, 0.17 kg during the 6-year study period. Weight gain was significantly higher in women who remained premenopausal at follow-up than those who had natural menopause during the study period. Weight gain was significantly associated with early menarche in women who had natural menopause and with high parity in women remained premenopausal.

CONCLUSION

Reproductive factors rather than sociodemographic and behavioral factors appeared to be associated with weight change during the perimenopausal period. Onset of menopause may diminish weight gain. In contrast, early menarche and high parity showed relationships with weight gain.

Population frequency distributions of HDL, HDL(2), and HDL(3) cholesterol and apolipoproteins A-I and B in healthy men and women and associations with age, gender, hormonal status, and sex hormone use: the Stanford Five City Project

BACKGROUND

The purpose of this study is to present population-based frequency distribution data for several lipoprotein-related variables and to examine their associations with gender, age, menopausal status, and sex hormone use.

METHODS

High-density lipoprotein cholesterol (HDL-C), HDL(2)-C, HDL(3)-C, apolipoprotein (Apo) A-I, and Apo B were measured in a population-based sample of 1, 027 healthy adults from four California cities who participated in the 1989-1990 survey of the Stanford Five City Project. These data were examined cross-sectionally with sociodemographic and other related variables.

RESULTS

Relative to men, all of the HDL-related parameters-HDL-C, HDL(2)-C, HDL(3)-C, Apo A-I-were significantly higher and Apo B levels were significantly lower among women (P < 0. 001). Menopausal status was not associated with HDL-related parameters, but Apo B levels were higher in post- versus premenopausal women (P < 0.001). Among women, HDL-C and Apo A-I levels were higher in oral contraceptive and estrogen replacement therapy users (P = 0.003). Most of the significant findings remained statistically significant after adjusting for age, body mass index, smoking, energy expenditure, and alcohol intake.

CONCLUSIONS

These population-based data indicate that gender, menopausal status, and the use of sex hormones among women are associated with differential levels of one or more of HDL-C, HDL(2)-C, HDL(3)-C, Apo A-I, and Apo B, independent of age and a broad set of lifestyle factors.

Menopause and risk of non-fatal acute myocardial infarction: an Italian case-control study and a review of the literature

The relationship between menopause and non-fatal acute myocardial infarction (AMI) was considered by analysing data from a case-control study conducted in Italy between 1983 and 1992. Cases were 429 women, below age 75 years, with a first episode of non-fatal AMI, admitted to 30 coronary care units; controls were 863 women admitted to the same network of hospitals for acute diseases other than cardiovascular, neoplastic, or hormone-related. Postmenopausal women were not at higher risk of AMI than pre/perimenopausal women, after adjustment for age and other selected covariates [multivariate odds ratio (OR) 0.99]. With reference to age at menopause, compared with women reporting menopause when <45 years, the multivariate OR were 1.54 for those aged 45-49 at menopause, 1.36 for those aged 50-52 years, and 0.97 for those aged >/=53, in the absence of any trend in risk. No meaningful relationship emerged with time since menopause (OR 0.85 for <10 years since menopause). The results were similar in women aged <60 and >/=60 years at AMI. Although the present study does not support a substantial relationship between menopause and non-fatal AMI, the overall epidemiological evidence is compatible with a moderate association.

Menopausal status and risk factors for cardiovascular disease

OBJECTIVES

Changes in cardiovascular risk factors with menopausal status are difficult to study, owing to the high correlation of menopausal status with age. Therefore we examined cardiovascular risk factors in a meticulously selected population in which the contrast in oestrogen status between pre- and postmenopausal women of the same age was maximized.

DESIGN

Risk factors were compared in 93 premenopausal and 93 postmenopausal women who were matched on age (range 43-55 years).

SETTING

The women were selected from respondents to a mailed questionnaire about the menopause, which was sent to all women aged 40-60 years in the Dutch town of Zoetermeer (n = 12 675; response 54%).

SUBJECTS

Postmenopausal women who were at least 3 years after menopause or whose menses had stopped naturally before age 48 were age-matched with premenopausal women with regular menses and without menopausal complaints.

RESULTS

Compared to premenopausal women, postmenopausal women had significantly increased levels of total cholesterol (10.0%, 95% confidence interval 5.1-14.0), low density lipoprotein (LDL) cholesterol (14.0%, 6.9-19.9), and apolipoprotein B (8.2%, 0.6-15.5). The difference was present within 3 years after onset of menopause and did not show a trend towards an increase with the number of postmenopausal years. No differences were found in high density lipoprotein (HDL) cholesterol, triglycerides, apolipoprotein A1, blood glucose, insulin, body mass index, waist-to-hip ratio, and systolic and diastolic blood pressure.

CONCLUSIONS

The results of this study add to the evidence that total cholesterol, LDL cholesterol and apolipoprotein B are the primary cardiovascular risk factors affected by menopause.

Associations of C-reactive protein with measures of obesity, insulin resistance, and subclinical atherosclerosis in healthy, middle-aged women

Obesity, the insulin resistance syndrome, and atherosclerosis are closely linked and may all be determinants of an increased acute-phase response. In this study, we examined the relationship of C-reactive protein (CRP) with measures of obesity, variables of the insulin resistance syndrome, and intima-media thickness of the common carotid arteries in 186 healthy, middle-aged women selected from the general population. Associations were assessed by regression analysis. CRP was strongly associated with body mass index (BMI) and waist circumference. CRP was also associated with other variables of the insulin resistance syndrome, including blood pressure, insulin, high density lipoprotein cholesterol, triglycerides, apolipoprotein A1 (inversely), plasminogen activator inhibitor-1 antigen, and tissue-type plasminogen activator antigen. Associations between CRP and the variables of the insulin resistance syndrome disappeared after controlling for BMI but remained significant for plasminogen activator inhibitor-1 antigen only. The association of CRP with common carotid artery intima-media thickness was weak and limited to ever-smokers. BMI explained 29.7% of the variance of CRP, whereas common carotid artery intima-media thickness explained only 3.7%. The results of this population-based study indicate that adiposity is strongly associated with CRP in healthy, middle-aged women. In this population, BMI accounted for the relationship between CRP and other variables of the insulin resistance syndrome. Further studies should determine whether losing weight ameliorates the inflammatory state.

The relationship between the female menopause and serum sialic acid, a known cardiovascular risk factor

Serum total sialic acid (SA) has recently been reported as a cardiovascular risk factor. The risk of cardiovascular disease increases after the menopause in females. However, there are little data looking at the relationship between serum SA and the menopause. Overall 92 females were studied. The women were divided into five groups: the first three groups were age-matched pre-menopausal (n = 20), peri-menopausal (n = 10) and post-menopausal women (n = 20). In order to study serum SA changes with adult female age we also studied 14 young pre-menopausal women and 28 elderly women. There was no significance difference between the serum SA concentration in the age-matched pre-, peri- or post-menopausal women (62.7 +/- 10.4 mg/dl, 61.7 +/- 4.5 mg/dl, 62.9 +/- 7.0 mg/dl respectively). Furthermore, there was no significant difference between the serum SA in the "young" women (64.7 +/- 9.8 mg/dl) and that of the peri-, pre- or post-menopausal women. However, in the elderly women the serum SA was elevated (75.6 +/- 16.6 mg/dl) with P < 0.05 for each comparison group. In conclusion, serum SA does not seem to change at the time of the female menopause although in elderly women (average age 75.6 +/- 16.6 years) it increases. The reason for this increase is not known and may merit further research.

Relationship of endogenous sex hormones to lipids and blood pressure in mid-aged women

PURPOSE

The relationship between endogenous sex hormones and blood lipids was examined in a representative sample of 438 Australian-born women 45 to 56 years of age taking part in a longitudinal study of the menopausal transition. Data from 363 women who were taking neither exogenous hormones nor lipid-altering medications, were not diabetic, and who had provided blood samples were available for analysis.

METHODS

Multiple linear regression was used to examine the relationship between sex hormones and high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides, and diastolic blood pressure (DBP), taking account of the effects of age, body mass index (BMI), smoking, alcohol intake, and exercise.

RESULTS

There was no significant relationship between estradiol and HDL, LDL, triglyceride, or DBP levels. Free androgen index was positively associated with LDL. However, BMI was an important predictor of all three lipid measures and DBP. HDL was positively associated with age and was highest among women with lowest BMI, high alcohol intake, and in nonsmokers. LDL increased with BMI, free androgen index, and age, but was lower amongst women who exercised more than two or three times per week. Triglyceride also increased with BMI, and was higher among smokers. DBP increased with BMI only.

CONCLUSIONS

The results do not support the view that endogenous sex hormones are strongly associated with cardiovascular risk factors around the time of menopause.

Effect of hormone replacement therapy on non-invasive cardiovascular haemodynamics

OBJECTIVE

To determine the detailed effects of hormone replacement therapy (HRT) on non-invasive haemodynamics, including an assessment of the effect on the pulsatile afterload assessed in terms of the augmentation index and pulse-wave velocity.

DESIGN

A cross-sectional study of healthy postmenopausal women using carotid and radial tonometry and pulse-wave velocity measurements.

SETTING

Community-based ambulatory women attending the menopause centre at a tertiary hospital.

PATIENTS

Seventy postmenopausal women divided into those not currently being administered HRT (n = 38, aged 46-72 years) and those who were being administered a variety of HRT (n = 32, aged 49-67 years).

METHODS

Central arterial pressure waveforms were measured using carotid applanation tonometry to derive the augmentation index and ejection duration. The arterial pulse-wave velocity was assessed using paired carotid, radial and dorsalis tonometry waveforms.

RESULTS

Women being administered HRT had a significantly lower augmentation index (20.4 +/- 8.6 versus 27.0 +/- 10.2%, P = 0.005) and shorter ejection times (320 +/- 17 versus 329 +/- 18 ms, P = 0.037). There was no significant difference in brachial blood pressure (131/76 versus 129/77 mmHg). Women being administered HRT exhibited a greater reversal in the age-related loss of amplification which occurs owing to arterial stiffening. This amplification between central and peripheral systolic blood pressures was greater among women being administered HRT (5.3 +/- 6.2 versus 2.2 +/- 4.0 mmHg, P = 0.014). There was no difference in pulse-wave velocity between the two groups.

CONCLUSIONS

HRT appears to improve the pulsatile vascular afterload by decreasing the augmentation of the late systolic blood pressure. This effect is not apparent from routine brachial cuff measurements, which, as a result, may underestimate haemodynamic benefits. Such effects may help to explain a portion of the improvement in cardiovascular morbidity found in other trials.

Changes over time in blood lipids and their correlates in Polish rural and urban populations: the Poland-United States Collaborative Study in cardiopulmonary disease epidemiology

PURPOSE

The purpose of this manuscript is to examine changes in blood lipid levels and related factors between 1983 and 1987 in two selected Polish populations, to evaluate these changes and their association with other coronary heart disease (CHD) risk factors, and to examine the nutrient intake changes for consistency with observed lipid changes.

METHODS

Men and women, aged 35-64 were screened from Warsaw and rural Tarnobrzeg province, Poland-the Pol-MONICA screening sites. An independent random sample of 5132 screened in 1983-84 and a second independent random sample of 2596 screened in 1987-88 were compared. A 25% cohort of the 1983-84 sample was also rescreened in 1987-88 (n = 1236) and 24-hour dietary recall information on this cohort was used to evaluate nutrient intake changes and their relationship to the lipid changes.

RESULTS

For the random samples, the total cholesterol increased by 5.1 mg/dL (rural) and by 7.9 mg/dL (urban) for women; there were no significant changes among men. Low-density lipoprotein cholesterol (LDL-C) increased for all site and gender subgroups by 5.4-8.7 mg/dL. Among rural men and women, high-density lipoprotein cholesterol (HDL-C) decreased by 3.4 and 3.3 mg/dL, respectively, whereas it increased by 3.3 mg/dL among urban women and did not change among urban men. Total triglycerides (TG) increased by 9.5 mg/dL for rural men, with no significant change for rural women. For urban men and women, TG decreased by 29.5 and 21.8 mg/dL respectively. In the cohort, changes in dietary intake (decreases in energy from fat, Keys index and increases in the polyunsaturated to saturated fats ratio) were related to a decrease in TC at both sites and to a decrease or smaller increase in LDL-C for rural men.

CONCLUSIONS

The observed changes were generally unfavorable, with a decrease in the proportion of persons with desirable lipid levels. At both sites nutritional changes were favorable, including a drop in total energy intake. Less pronounced were changes in percentages of total energy from fats, where the only significant decrease was for rural women; however, improvements in dietary fat composition and declines in cholesterol consumption were found. These favorable changes in diet were not strong enough or were not in effect long enough to counter the unfavorable changes in blood lipids.