Reproductive history and cardiovascular disease risk in postmenopausal women: a review of the literature

Child rearing or childbearing? Risk of cardiovascular diseases associated to parity and number of children

BACKGROUND

An increased risk of cardiovascular diseases (CVD) has been associated with women's parity, but whether or not this association reflects a direct pregnancy effect, or exposure to factors related to childrearing, still appears unclear. We assessed the CVD risk associated with number of children separately by gender and tested effect modification by socioeconomic position (SEP) and employment status, in order to elucidate the possible mechanisms underlying this association.

METHODS

The study population was composed of 20,904 men and 25,246 women who were interviewed in one of two National Health Surveys conducted in 2000 and 2005 in Italy. These subjects were followed for CVD incidence up to 2014 through record-linkage with national archives of mortality and hospitalisations. CVD risk was estimated by Cox regression models that were adjusted for socio-demographics, perceived health, lifestyles, biological CVD risk factors and for other potential confounders.

RESULTS

CVD incidence was significantly increased among men with 3 or more children (HR = 1.26, 95% CI: 1.02-1.56) and among women with 2 and with 3 or more children (HR = 1.42, 95% CI: 1.10-1.83; and HR = 1.39, 95% CI: 1.03-1.87, respectively) compared to subjects without children and no significant gender differences were observed. Subjects with lower SEP displayed stronger associations with parity and a higher number of children for both genders; by contrast, no modifying effect of employment status was observed.

CONCLUSIONS

Taken together, the significant association between higher parity and CVD risk in both genders, and the higher risk of CVD associated with higher parity among lower SEP parents, suggests that childrearing has a potential effect on the development of CVD that is more pronounced among disadvantaged families, although a concurrent effect of childbearing cannot be completely excluded.

Reproductive health factors in relation to risk of hypertension in postmenopausal women: Results from NHANES 2011-2014

Few studies have systematically assessed the relationship between multiple reproductive factors and hypertension, and these limited studies paid more attention to age at menarche and menopause, abortion, or the number of live births, and yielded controversial results. This study aimed to explore the relationship between reproductive health factors and hypertension from 5 aspects: history of menstruation, pregnancy, delivery, gynecological surgery, and reproductive-related medication use. We analyzed data from the National Health and Nutrition Examination Survey 2011 to 2014. Data on reproductive factors were collected using a questionnaire survey. The associations between multiple reproductive factors and the risk of hypertension were assessed using multivariable logistic regression models. There were significant inverse associations between age at menopause (odds ratio [OR] = 0.984, 95% confidence interval [CI]: 0.971-0.998, P = .0234 per 1-year increase), age at first live birth (OR = 0.970, 95% CI: 0.944-0.998, P = .0346 per 1-year increase), age at last live birth (OR = 0.982, 95% CI: 0.964-0.999, P = .0488 per 1-year increase), and the risk of hypertension. In contrast, a positive association was found between the risk of hypertension and a history of gestational diabetes (OR = 1.693, 95% CI: 1.042-2.751, P = .0333), hysterectomy (OR = 1.398, 95% CI: 1.139-1.717, P = .0014), ovariectomy (OR = 1.374, 95% CI: 1.074-1.758, P = .0115), and birth control pill use (OR = 1.293, 95% CI: 1.035-1.616, P = .0236). Age at menopause but not menarche, is inversely associated with hypertension. A history of gestational diabetes, hysterectomy, ovariectomy, or birth control pills was associated with a higher risk of hypertension.

Age at Menarche and Menopause, Reproductive Lifespan, and Risk of Cardiovascular Events Among Chinese Postmenopausal Women: Results From a Large National Representative Cohort Study

Background

At present, the association between age at menarche and menopause, reproductive lifespan, and cardiovascular disease (CVD) risk among Chinese postmenopausal women is not clear, and some related researches are contradictory.

Methods

A total of 6,198 Chinese postmenopausal women with a mean age of 63.6 years were enrolled at baseline in 2012-2015 and followed up for 5 years. A standardized questionnaire was used to collect relevant information by well-trained interviewers. Physical examination of the participants was performed by trained medical staff. CVD events were observed during follow-up. Cox proportional hazards models were used to estimate hazard ratios between reproductive characteristics and CVD events.

Results

Age at menarche was positively associated with CVD events (HR, 1.106; 95%CI, 1.047-1.167). There was a negative association between age at menopause and CVD risk in postmenopausal women with comorbidity (HR, 0.952; 95%CI, 0.909-0.996). Reproductive lifespan was negatively associated with CVD events (HR, 0.938; 95%CI, 0.880-0.999). The CVD risk increased by 10.6% for every 1-year increase in age at menarche. The CVD risk reduced by 6.2% for every 1-year increase in age at menopause in women with comorbidity. The CVD risk reduced by 3.8% for every 1-year increase in reproductive lifespan.

Conclusions

Based on the large prospective study with a nationally representative sample, Chinese postmenopausal women with late age at menarche and shorter reproductive lifespan have higher risk of CVD events.

Parity and Risk of Cardiovascular Disease in Women over 45 Years in the United States: National Health and Nutrition Examination Survey 2007-2018

Objective: Current research results on the association between parity and cardiovascular disease (CVD) risk are inconclusive. The purpose of this study was to examine the relationship between parity and risk of CVD in women over 45 years of age. Materials and Methods: Data were from the National Health and Nutrition Examination Survey for 2007-2018. A total of 8,882 women ≥45 years of age were included. The exposure of parity referred to the number of live births, and the outcome variable was the occurrence of CVD events, including stroke, heart attack, coronary heart disease (CHD), heart failure, and angina. We performed logistic regression to calculate the unadjusted and adjusted odds ratios (ORs; 95% confidence intervals [CIs]) controlling for confounding factors. Results: Among 8,882 women, the mean age was 62.4 ± 10.8 years, with a range of 45 to 80 years. The weighted prevalence of CVD, stroke, heart attack, CHD, heart failure, and angina in parous women were significantly higher than those of nulliparous women (p < 0.05). After adjusting for demographic factors, CVD risk factors, reproductive factors, the ORs of CVD with parity 1-2, 3-4, and 5+ were 1.85 (95% CI: 1.29-2.64), 1.70 (95% CI: 1.15-2.50), and 1.92 (95% CI: 1.28-2.88), respectively. The odds of stroke and heart attack were also significantly positively related to increasing parity compared with nulliparity. However, compared with nulliparity, parity of 3 was associated with a slightly lower risk of CVD. Conclusions: Our findings indicated that parity was significantly positively associated with CVD, giving birth to three children associated with a slightly lower risk compared with nulliparity. Further cohort studies are warranted to confirm the findings.

Patterns of menstrual cycle length over the menopause transition are associated with subclinical atherosclerosis after menopause

OBJECTIVE

Longer menstrual cycles have been associated with greater risk of cardiovascular disease, supporting a contribution of abnormal ovarian function. We aimed to characterize trajectories of menstrual cycle length over the menopause transition (MT) and test whether these trajectories are associated with postmenopausal markers of subclinical atherosclerosis.

METHODS

Women from the Study of Women's Health Across the Nation Daily Hormone Study were included if they had an observed date of the final menstrual period (FMP), recorded cycle lengths from ≥2 annual menstrual cycles (mean±SD: 4.22 ± 1.91 cycles), and had measurements of postmenopausal carotid intima-media thickness (cIMT) and/or brachial-ankle pulse wave velocity (baPWV). Trajectories of cycle length over the MT were identified using group-based trajectory modeling and linked with cIMT and baPWV using linear regression.

RESULTS

We studied 428 women who had 1,808 cycles over the MT (45.1 ± 2.3 y old at baseline visit), and of whom 263 had cIMT, and 213 had baPWV measured postmenopausally (after 13.88 ± 0.42 and 15.25 ± 0.70 y since baseline visit, respectively). Three distinct trajectories of cycle length were identified: stable (no changes in cycle length over the MT among 62.1% of women), late increase (a late increase 2 y before the FMP among 21.8%), and early-increase (an early increase 5 y before the FMP among 16.2%). Women with the late-increase pattern had significantly lower postmenopausal cIMT (0.72 mm) and baPWV (1392 cm/s) levels than the stable group (0.77 mm and 1508 cm/s, respectively) adjusting for race, concurrent age, socioeconomic status, physical activity level, and premenopausal cardiovascular risk profile.

CONCLUSIONS

Patterns of cycle length over the MT seem to be a marker of future vascular health that may help identify groups at greater or lesser risk of atherosclerosis after menopause.

History of Pregnancy Loss as a Risk Factor for Myocardial Infarction

Introduction

There are few cardiovascular risk factors that are unique to females, such as after menopause, lipid profiles change unfavorably. Another risk factor that might be associated with an increased risk of cardiovascular diseases in women is the incidence of miscarriages and abortions. In this study, we will determine the association between the previous history of pregnancy loss and myocardial infarction (MI).

Methods

This case-control study was conducted from December 2019 to January 2021. We enrolled 600 female patients with a confirmed diagnosis of MI from the outpatient department (OPD) of the cardiology and internal medicine unit of a tertiary care hospital in Pakistan. Another 600 female participants without the diagnosis of MI were enrolled from the OPD as the control group. Participants were asked about the history of pregnancy, including the number of miscarriages, abortions, and stillbirths.

Results

Participants with myocardial infarction had experienced greater than one miscarriage compared to participants without MI (25.1% vs. 13.6%; p-value: <0.0001). Similarly, participants with MI had significantly more participants with stillbirth compared to participants without MI (12.0% vs. 6.66%; p-value: 0.0017).

Conclusion

Pregnancy loss is associated with MI in the future. Women with a history of pregnancy loss must undergo regular cardiovascular screening to protect themselves from cardiovascular events.

Natural menopausal age and cardiovascular disease risk factors in older Chinese women: Guangzhou Biobank Cohort Study

OBJECTIVE

To examine the associations of natural menopausal age with cardiovascular disease risk factors and whether the associations varied by parity in older Chinese women.

METHODS

Information of demographic characteristics, lifestyles, and reproductive factors was collected by face-to-face interview. Framingham Risk Score was used as an indicator of cardiovascular disease risk, with a score ≥ 10% considered as high cardiovascular disease risk (vs low, dichotomous). Multivariable logistic and linear regressions were used to examine the associations of menopausal age with cardiovascular disease risk factors.

RESULTS

Of 18,339 women aged 50+ years, the average (standard deviation) age was 61.8 (6.9) years. Compared with women with menopausal age of 45 to 54 years, after adjustment for multiple potential confounders, women with menopausal age <45 years or ≥55 years had higher Framingham Risk Score (0.93%, 95% confidence interval: 0.40-1.46, and 0.69%, 95% confidence interval: 0.18-1.20, respectively). Women with menopausal age <45 or ≥55 years had higher odds of high cardiovascular disease risk (vs low) (odds ratio [95% confidence interval]:1.26 (1.10-1.44) and 1.17 (1.02-1.33), respectively). The associations of menopausal age with the Framingham Risk Score varied by parity (P for interaction ≤0.001). The Framingham Risk Score was higher in those with one to three parity (<45 y: 1.01 [0.43-1.59]; ≥55 y: 1.14 [0.60-1.68]) and lower for parity ≥4 (<45 y: -0.33 [-1.84 to 1.18]; ≥55 y: -2.02 [-3.82 to -0.22]). In nulliparous women, the Framingham Risk Score was highest in menopausal age <45 years (3.97 [1.67-6.26]), but the differences were nonsignificant in menopausal age ≥55 years (0.66 [-1.38 to 2.71]).

CONCLUSIONS

Both early and late natural menopausal ages were associated with a higher cardiovascular disease risk, and the associations were stronger in those with lower parity.

Age at menarche and risk of hypertension in Chinese adult women: Results from a large representative nationwide population

This study explored the association between age at menarche and the risk of hypertension in Chinese women. A total of 234 867 women aged ≥18 years from the China Hypertension Survey were included in this study. Participants were required to complete a standard questionnaire. Blood pressure and physical examination of the participants were performed by trained medical staff. Spearman correlation analysis was used to explore the correlation between age at menarche and other individual characteristics. Logistic regression was used to estimate the odds ratios for hypertension by age in years at menarche. The average age at menarche in Chinese women was 14.8 years. Women who were older at menarche were more likely to have a higher body mass index, larger waist circumference, smoke, and have a primary education (p < .05). After adjustments, odds ratios (95% confidence interval) for hypertension across age at menarche groups were 0.912 (0.877-0.948), 0.927 (0.893-0.963), 1.00 (reference), 1.061 (1.020-1.102), and 1.129 (1.090-1.169) for those aged ≤13, 14, 15 (reference), 16, and ≥17 years at menarche, respectively. Each 1-year delay in menarche was associated with a 6.2% increase in the prevalence of hypertension (odds ratio, 1.062; 95% confidence interval, 1.053-1.071). The positive association between age at menarche and hypertension was evident among age at recruitment groups, BMI categories, and education levels. This association was stronger in urban women and postmenopausal women. Our findings suggest that late menarche is related to a higher risk of hypertension among Chinese adult women, and this association appeared similar among different subgroups.

Association between Age at Menarche and Hypertension among Females in Southern China: A Cross-Sectional Study

Background

Association between age at menarche (AAM) and hypertension remains a controversial topic, and data in China were sparse. Therefore, we aimed to investigate the association between AAM and hypertension in Chinese female population.

Methods

In this cross-sectional study, 5,102 females aged ≥15 years were enrolled. Self-reported AAM was assessed by the questionnaire. Multiple linear regression analysis was used to evaluate the association between systolic blood pressure (SBP), diastolic blood pressure (DBP), and AAM. Logistic regression analysis was performed to evaluate the association between hypertension and AAM. Generalized additive model (GAM) and smooth curve fitting (penalized spline method) were conducted to explore the exact shape of curve between them.

Results

The overall mean of AAM was 15.5 years. Each additional year of AAM was associated with a 15% higher risk of hypertension (odds ratio (OR) = 1.15, 95% confidence interval (CI): 1.11-1.19). Among females with hypertension, there was a significant positive association between AAM and SBP (β = 0.88, 95% CI: 0.29-1.46) and DBP (β = 0.80, 95% CI: 0.47-1.13). A significantly higher risk of hypertension was found in younger subjects (15-44 y: OR = 1.37, 95% CI: 1.21-1.55; P for interaction = 0.009) compared with those aged between 62 and 97 y.

Conclusions

AAM was positively associated with hypertension and blood pressure, especially among females in early adulthood from southern China.

Early menarche is associated with an increased risk of type 2 diabetes in rural Chinese women and is partially mediated by BMI: the Henan Rural Cohort Study

OBJECTIVE

The aim of the study was to determine if early menarche is associated with an increased risk of type 2 diabetes mellitus (T2DM) in rural Chinese women and to estimate the proportion that can be attributed to adiposity.

METHODS

A total of 15,346 postmenopausal women were enrolled in this study. Logistic regression and restricted cubic spline analysis were performed to estimate the relationship between age at menarche and T2DM. Mediation analysis was used to investigate whether the association was mediated by body mass index (BMI).

RESULTS

After adjusting for multiple confounders, the early menarche group (≤14 y) had a higher risk of T2DM (odds ratio [OR] = 1.21; 95% CI = 1.06-1.38; P = 0.004) compared with the reference group (16-17 y), whereas the late onset group (≥19 y) had a lower risk of T2DM (OR = 0.78; 95% CI = 0.66-0.92; P = 0.003). BMI partially mediated the association between age at menarche and T2DM, and the proportion of the effect was 28%.

CONCLUSIONS

Early menarche increases the risk of T2DM, whereas later menarche decreases the risk. The association seems to be partially mediated by BMI.

Prevalence of cardiovascular risk factors in non-menopausal and postmenopausal inpatients with type 2 diabetes mellitus in China

BACKGROUND

To investigate the prevalence of cardiovascular disease (CVD) risk factors and assess the 10-year risk of CVD in non-menopausal and postmenopausal women with type 2 diabetes mellitus (T2DM).

METHODS

A total of 569 patients with T2DM at a Chinese tertiary hospital were investigated using the Framingham Risk Score (FRS). We evaluated the 10-year risk of CVD, clinical and menopause characteristics in all subjects.

RESULTS

Among the 569 diabetic patients, the incidence of smoking, dyslipidemia, hypertension, overweight or obesity, and nonalcoholic fatty liver disease (NAFLD) was 0.7, 36.2, 38.1 56.6 and 58.2%, respectively. The usage rate of hypoglycemic agents, antihypertensive agents, lipid modulators and antithrombotic drugs was 88.6, 78.3, 50.0 and 27.1%, respectively. However, only 1.2% of inpatients achieved the three target goals for the control of blood glucose (HbA_1c < 7%), blood pressure (systolic blood pressure < 130 mmHg, diastolic blood pressure < 80 mmHg), and blood lipids (total cholesterol < 174 mg/dL). The 10-year risk of CVD was (1.6 ± 1.5%) and tended to increase along with age (F = 27.726, P <  0.001). For all subjects (n = 569), multiple linear regression analysis showed that menopause (β = 0.275, P <  0.001), low-density lipoprotein cholesterol (LDL-C) (β = 0.212, P <  0.001), fasting plasma glucose (FPG) (β = 0.093, P = 0.018) and waist-to-hip-ratio (β = - 0.078, P = 0.047) were risk factors of 10-year risk of CVD, which may explain the variance of 14.3%. In the postmenopausal group (n = 397), LDL-C (β = 0.227, P <  0.001), FPG (β = 0.139, P = 0.003) and time since menopause (β = 0.230, P <  0.001) were found to be associated with CVD, which may explain the variance of 14.6%.

CONCLUSION

The incidence of dyslipidmia, hypertension, overweight or obesity and NAFLD is high. The level of control of blood glucose, blood pressure, and blood lipids was found to be extremely low and the treatment status was not ideal. Besides menopause, LDL-C, FPG and time since menopause were found to be independent risk factors for the 10-year risk of CVD. Therefore, it is necessary to focus on comprehensive control of multiple risk factors, such as plasma glucose, blood pressure and serum lipid.

Association between parity and persistent weight gain at age 40-60 years: a longitudinal prospective cohort study

OBJECTIVES

Physiological metabolic adaptations occur in the pregnant woman. These may persist postpartum and thereby contribute to an unfavourable cardiovascular disease (CVD) risk profile in parous women. The aim of the current study is to assess time-dependent changes of cardiometabolic health in parous women compared with nulliparous women.

DESIGN AND SETTING

We studied data of 2459 women who participated in the Prevention of Renal and Vascular End-stage Disease study, a population-based prospective longitudinal cohort for assessment of CVD and renal disease in the general population.

PARTICIPANTS

We selected women ≥40 years at the first visit, who reported no new pregnancies during the four follow-up visits. All women were categorised in parity groups, and stratified for age.

OUTCOME MEASURES

We compared body mass index (BMI), high-density lipoprotein (HDL) cholesterol, blood pressure as continuous measurements and as clinical relevant CVD risk factors among parity groups over the course of 6 years using generalised estimating equation models adjusted for age.

RESULTS

The BMI was significantly higher in women para 2 or more in all age categories: per child, the BMI was 0.6 kg/m² higher. corresponding with 1.5-2.0 kg weight gain per child. HDL cholesterol was significantly lower in women para 2 or more aged 40-49 and 50-59 years: per child, the HDL cholesterol was up to 0.09 mmol/L lower. Blood pressure did not differ among parity groups in any of the age categories.

CONCLUSIONS

Higher parity is associated with higher BMI, lower HDL cholesterol and a higher prevalence of cardiovascular risk factors, which is constant over time. These findings warrant for prospective research assessing determinants of cardiometabolic health at earlier age to understand the role of pregnancy in the development of CVD in women.

Association between duration of endogenous estrogen exposure and cardiovascular outcomes: A population - based cohort study

AIMS

Duration of endogenous estrogen exposure is apparently associated with risk of cardiovascular disease, the longer durations being more cardiovascular disease protective in women. We aimed to investigate the association of cumulative duration of endogenous estrogen exposure over women's reproductive lifespans with cardiovascular disease outcomes.

MAIN METHODS

For the purpose of the present study, of 10,192 female participants, after excluding those using HRT (n = 84), 3656 women, aged ≥30 years, who met eligibility criteria were selected and divided into three groups based on tertiles (T1, T2, T3) of exposure durations to endogenous estrogen. Cox proportional hazards regression model was used to estimate associations between exposure durations and cardiovascular disease outcomes.

KEY FINDINGS

Cardiovascular events occurred in 352 participants over a median follow-up of 14.2 (13.5, 14.6) years (7.7 per 1000 person years; 95% CI: 6.9-8.5). Incidence of outcome was 10.9 per 1000 person years (CI, 9.4-12.8) in T₁, 7.2 per 1000 person years (CI, 6.0-8.7) in T₂, and 5.1 per 1000 person years (CI, 4.1-6.4) in T₃. The hazard ratio of cardiovascular events in T₁ was significantly higher than that inT₃, before and after adjustment for confounding variables. Before adjustment, women in T₂ had a 40% higher risk of CVD, compared to T₃; after adjustment however the risk was similar to that of women in T₃.

SIGNIFICANCE

Shorter durations of exposure to endogenous estrogen may increase the risk of cardiovascular diseases among these women later in life. Future studies should target women with short duration of exposure for timely screening and implementation of preventative interventions.

Association of Parenthood With Incident Heart Disease in United States' Older Men and Women: A Longitudinal Analysis of Health and Retirement Study Data

Objective: To examine the association of number of children birthed/fathered with incident heart disease, accounting for socioeconomic and lifestyle characteristics. Methods: We analyzed data from 24,923 adults 50 and older (55% women) in the Health and Retirement Study. Participants self-reported number of children and doctor-diagnosed incident heart disease. Cox proportional hazards models estimated heart disease risk. Results: Compared to women with one to two children, those with five or more had increased risk of heart disease (hazard ratio [HR] = 1.13, 95% confidence interval [CI] = [1.03, 1.25]). Compared to men with one to two children, those with five or more had a marginally increased risk of heart disease (HR = 1.11, 95% CI = [0.99, 1.25]), but this association attenuated in models adjusting for socioeconomic and lifestyle variables. Compared to men with no children, those with five or more retained a borderline significant association in the fully adjusted model (HR = 1.15, 95% CI = [0.99, 1.35]). Discussion: Social and lifestyle pathways appear to link parenthood to cardiovascular health.

Early or late pregnancy loss and development of clinical cardiovascular disease risk factors: a prospective cohort study

OBJECTIVE

To assess the association between the outcome of a woman's first pregnancy and risk of clinical cardiovascular disease risk factors.

DESIGN

Prospective cohort study.

SETTING AND POPULATION

Nurses' Health Study II.

METHODS

Multivariable-adjusted Cox proportional hazards models were used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) for the associations between first pregnancy outcome and hypertension, type 2 diabetes, and hypercholesterolemia.

MAIN OUTCOME MEASURES

Hypertension, type 2 diabetes, and hypercholesterolemia.

RESULTS

Compared to women who reported a singleton live first birth, women with early spontaneous abortion (<12 weeks) had a greater rate of type 2 diabetes (HR: 1.20; 95% CI: 1.07-1.34) and hypercholesterolemia (HR: 1.06; 95% CI: 1.02-1.10), and a marginally increased rate of hypertension (HR: 1.05, 95% CI: 1.00-1.11). Late spontaneous abortion (12-19 weeks) was associated with an increased rate of type 2 diabetes (HR: 1.38; 95% CI: 1.14-1.65), hypercholesterolemia (HR: 1.11; 95% CI: 1.03-1.19), and hypertension (HR: 1.15; 95% CI: 1.05-1.25). The rates of type 2 diabetes (HR: 1.45; 95% CI: 1.13-1.87) and hypertension (HR: 1.15; 95% CI: 1.01-1.30) were higher in women who delivered stillbirth. In contrast, women whose first pregnancy ended in an induced abortion had lower rates of hypertension (HR: 0.87; 95% CI: 0.84-0.91) and type 2 diabetes (HR: 0.89; 95% CI: 0.79-0.99) than women with a singleton live birth.

CONCLUSIONS

Several types of pregnancy loss were associated with an increased rate of hypertension, type 2 diabetes, and hypercholesterolemia, which may provide novel insight into the pathways through which pregnancy outcomes and CVD are linked.

TWEETABLE ABSTRACT

Pregnancy loss is associated with later maternal risk of hypertension, type 2 diabetes, and hypercholesterolemia.

Menopause Characteristics, Total Reproductive Years, and Risk of Cardiovascular Disease Among Chinese Women

Supplemental Digital Content is available in the text.

Background—

Previous studies, mostly of Western women, have reported inconsistent findings on the association of menopause characteristics (status, age, and time since menopause) and total reproductive years with risk of cardiovascular disease (CVD).

Methods and Results—

The China Kadoorie Biobank recruited 302 632 women in 2004 to 2008 from 10 regions across China. During 9-year follow-up, 19 393 incident cases of stroke, 18 611 of ischemic heart disease, and 4978 CVD deaths occurred. Cox regression yielded adjusted hazard ratios relating each menopause characteristic and total reproductive years to CVD risk. Among 274 233 women with no prior CVD at baseline, 134 010 were naturally postmenopausal women (mean [SD] age at menopause of 48.6 [4.0] years and total reproductive years 32.7 [4.4]). Compared with premenopausal women, naturally peri- or postmenopausal women were at a higher risk of either fatal or nonfatal CVD. Among women who had had menopause, inverse associations were observed between age at menopause and risks of CVD mortality, incident ischemic heart disease, stroke, and subtypes of stroke, with 1.5% higher risk of CVD death (P<0.001), 0.7% for incident ischemic heart disease (P=0.002), and 0.5% for incident stroke (P=0.02) for every 1 year lower age at menopause. Compared with women who had menopause at age 48 to 50 years, lower age at menopause (ie, <43 years) was associated with 14% higher risk of CVD death and 6% higher risks of both incident ischemic heart disease and stroke. Higher risks of both fatal and nonfatal CVD were also found in women with 5 to 10, 10 to 15, 15 to 20, or >20 years since menopause compared with <5 years since menopause. Total reproductive years were inversely associated with risks of both fatal and nonfatal CVD, with 1.4% lower risk of CVD death per additional reproductive year (P<0.001).

Conclusions—

Women with younger age at menopause, longer time since menopause, or fewer total reproductive years had a higher risk of CVD.

Is in utero exposure to maternal socioeconomic disadvantage related to offspring ovarian reserve in adulthood?

BACKGROUND

Because the ovarian follicle pool is established in utero, adverse exposures during this period may be especially impactful on the size and health of the initial follicle endowment, potentially shaping trajectories of ovarian follicle loss and the eventual onset of menopause. Building on a robust literature linking socioeconomic status (SES) and menopausal timing, the current study examined adverse prenatal exposures related to maternal SES, hypothesizing that greater maternal socioeconomic disadvantage would be associated with lower ovarian reserve in the adult offspring.

METHODS

In a healthy, community-based sub-sample (n = 350) of reproductive age participants in the OVA Study (2006-2011), prenatal maternal SES was examined in relation to two biomarkers of ovarian reserve, antimullerian hormone (AMH) and antral follicle count (AFC). Prenatal maternal SES was assessed indirectly using maternal addresses abstracted from participant birth certificates, geocoded, and linked to US Census-derived variables, including neighborhood-level characteristics: education (% of individuals with a HS diploma); poverty (% of families below the poverty line); unemployment (% of individuals > 16 years who are unemployed); and income (median family income).

RESULTS

In separate covariate-adjusted linear regression models (following the backward elimination of main effects with P > .10), greater maternal neighborhood education was related to higher ovarian reserve as marked by higher levels of offspring AMH (beta = .142, P < .001) and AFC (beta = .092, P < .10) with models accounting for 19.6% and 21.5% of the variance in AMH and AFC, respectively. In addition, greater maternal neighborhood poverty was related to lower ovarian reserve as marked by lower offspring AMH (beta = -.144, P < .01), with the model accounting for 19.5% of the variance in AMH.

CONCLUSIONS

Maternal socioeconomic disadvantage measured indirectly at the neighborhood level was associated with lower ovarian reserve among the adult offspring, independently of offspring SES and other potential confounding factors. This suggests SES-related adversity exposures may have a detrimental impact on the size or health of the initial follicle endowment, leading to accelerated follicle loss over time.

Association Between Duration of Reproductive Years and Metabolic Syndrome

BACKGROUND

The incidence of metabolic syndrome (MetS) has gradually increased in recent years. MetS has been associated with age at menarche and menopause; however, the association between MetS and the reproductive span remains unclear.

MATERIALS AND METHODS

This study examined MetS and the reproductive span among 1,214 participants of the 2014 Korea National Health and Nutrition Examination Surveys, a stratified, complex, multistage, probability cluster survey conducted by the Division of Chronic Disease Surveillance of the Korea Center for Disease Control and Prevention since 1998. MetS was defined by using the joint interim statement of the International Diabetes Federation; National Heart, Lung, and Blood Institute; and American Heart Association. The reproductive span or duration of reproductive years was calculated from age at menarche to age at menopause for postmenopausal women.

RESULTS

The prevalence of MetS in this study was 36% (437 of 1,214). In multivariate analysis adjusted for age, longer reproductive years were associated with a higher prevalence of MetS (odds ratio [OR] 1.059, 95% confidence interval [CI] 1.055-1.063). However, after adjusting for covariates (age, residential area, income, dyslipidemia medication, education, current smoking, regular exercise, alcohol consumption, body mass index, years after menopause, aspartate aminotransferase, alanine aminotransferase, and white and red blood cell counts), longer reproductive years were associated with a lower prevalence of MetS (OR 0.751, 95% CI 0.745-0.747).

CONCLUSION

Longer reproductive years were significantly associated with a decreased prevalence of MetS.

Adolescent Childbirth Is Associated With Greater Framingham Risk Scores for Cardiovascular Disease Among Participants of the IMIAS (International Mobility in Aging Study)

BACKGROUND

Previous studies observe associations between lifetime parity and cardiovascular disease, but relatively fewer investigate age at first childbirth (AFB). Herein, we examine the association of AFB with a summary cardiovascular risk measure (Framingham Risk Score [FRS]).

METHODS AND RESULTS

As part of the IMIAS (International Mobility in Aging Study), data were collected in 2012 among 1047 women, aged 65 to 74 years, from Canada, Albania, Colombia, and Brazil. FRSs were calculated to describe cardiovascular risk profiles, and linear regression analyses were performed, adjusting for early life and socioeconomic variables. Women with an AFB of <20 years were compared with women with an AFB of 20 to 24, 25 to 29, and ≥30 years, as well as nulliparous women. We also compared FRS between combinations of AFB and parity categories: nulliparous women, parity 1 to 3 combined with AFB <20 years, parity ≥4 with AFB <20 years, parity 1 to 3 with AFB ≥20 years, and parity ≥4 with AFB ≥20 years. Women with an AFB of <20 years had a higher mean FRS compared with all other AFB groups. Compared with the lowest AFB risk group (25-29 years), women with an AFB of <20 years had a 5.8-point higher mean FRS (95% confidence interval, 3.4-8.3 points). Nulliparous women presented the lowest mean FRS in all analyses. The analysis comparing combinations of AFB and parity categories showed no meaningful differences in FRS between women who had 1 to 3 childbirths and those who had ≥4 childbirths within the stratum of AFB <20 years, and in the stratum of AFB ≥20 years.

CONCLUSIONS

Our analyses suggest that nulliparity and AFB, rather than increasing parity, drive the association with cardiovascular disease risk.

Age at first birth and risk of later-life cardiovascular disease: a systematic review of the literature, its limitation, and recommendations for future research

Background

Cardiovascular disease (CVD) is the principal contributor to the burden of disease and mortality worldwide. Previous studies observed associations between early age at first birth (AFB) and all-cause mortality. AFB may be associated with CVD both through physiological and sociobiological pathways. In this paper, we review the literature on AFB and CVD events and mortality. Additionally, we provide an overview of limitations of the current research and recommendations for future research.

Methods

PubMed and Web of Science databases were searched for observational studies published between 1980-June 2016, investigating associations between AFB and CVD events and mortality. Data were extracted using a pre-defined list.

Results

A total of 20 publications, reporting on 33 associations, were included in the review. Ten studies observed a positive association between early AFB and CVD while two studies observed a positive association between later AFB and CVD. Substantial methodological limitations were observed related to: operationalization of exposure categories, choice of reference category, sample size, follow-up time and possibly over adjustment.

Conclusions

Early AFB is possibly related to CVD. More work, in particular from large cohort studies starting before reproductive age is reached, is needed to better investigate this relationship, and to ascertain causal pathways that may explain observed associations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4519-x) contains supplementary material, which is available to authorized users.

Pregnancy: An Underutilized Window of Opportunity to Improve Long-term Maternal and Infant Health-An Appeal for Continuous Family Care and Interdisciplinary Communication

Physiologic adaptations during pregnancy unmask a woman's predisposition to diseases. Complications are increasingly predicted by first-trimester algorithms, amplify a pre-existing maternal phenotype and accelerate risks for chronic diseases in the offspring up to adulthood (Barker hypothesis). Recent evidence suggests that vice versa, pregnancy diseases also indicate maternal and even grandparent's risks for chronic diseases (reverse Barker hypothesis). Pub-Med and Embase were reviewed for Mesh terms "fetal programming" and "pregnancy complications combined with maternal disease" until January 2017. Studies linking pregnancy complications to future cardiovascular, metabolic, and thrombotic risks for mother and offspring were reviewed. Women with a history of miscarriage, fetal growth restriction, preeclampsia, preterm delivery, obesity, excessive gestational weight gain, gestational diabetes, subfertility, and thrombophilia more frequently demonstrate with echocardiographic abnormalities, higher fasting insulin, deviating lipids or clotting factors and show defective endothelial function. Thrombophilia hints to thrombotic risks in later life. Pregnancy abnormalities correlate with future cardiovascular and metabolic complications and earlier mortality. Conversely, women with a normal pregnancy have lower rates of subsequent diseases than the general female population creating the term: "Pregnancy as a window for future health." Although the placenta works as a gatekeeper, many pregnancy complications may lead to sickness and earlier death in later life when the child becomes an adult. The epigenetic mechanisms and the mismatch between pre- and postnatal life have created the term "fetal origin of adult disease." Up to now, the impact of cardiovascular, metabolic, or thrombotic risk profiles has been investigated separately for mother and child. In this manuscript, we strive to illustrate the consequences for both, fetus and mother within a cohesive perspective and thus try to demonstrate the complex interrelationship of genetics and epigenetics for long-term health of societies and future generations. Maternal-fetal medicine specialists should have a key role in the prevention of non-communicable diseases by implementing a framework for patient consultation and interdisciplinary networks. Health-care providers and policy makers should increasingly invest in a stratified primary prevention and follow-up to reduce the increasing number of manifest cardiovascular and metabolic diseases and to prevent waste of health-care resources.

Signatures of reproductive events on blood counts and biomarkers of inflammation: Implications for chronic disease risk

Whether inflammation mediates how reproductive events affect chronic-disease risk is unclear. We studied inflammatory biomarkers in the context of reproductive events using National Health and Nutrition Examination Survey (NHANES) data. From 15,986 eligible women from the 1999–2011 data cycles, we accessed information on reproductive events, blood counts, C-reactive protein (CRP), and total homocysteine (tHCY). We calculated blood-count ratios including: platelet-lymphocyte (PLR), lymphocyte-monocyte (LMR), platelet-monocyte (PMR), and neutrophil-monocyte (NMR). Using sampling weights per NHANES guidelines, means for counts, ratios, or biomarkers by reproductive events were compared using linear regression. We performed trend tests and calculated p-values with partial sum of squares F-tests. Higher PLR and lower LMR were associated with nulliparity. In postmenopausal women, lower PMR was associated with early age at first birth and higher NMR with later age at and shorter interval since last birth. Lower PNR and higher neutrophils and tHCY were associated with early natural menopause. In all women, the neutrophil count correlated positively with CRP; but, in premenopausal women, correlated inversely with tHCY. Reproductive events leave residual signatures on blood counts and inflammatory biomarkers that could underlie their links to chronic disease risk.

Association of Female Reproductive Factors with Hypertension, Diabetes and LQTc in Chinese Women

The association of female reproductive factors (FRFs) with cardiovascular risk factors among different population was variable and inconsistent. The objective of this study was to examine the association between FRFs and hypertension, type 2 diabetes mellitus (DM), and long heart-rate-corrected QT interval (LQTc) in Chinese post-menopausal women (Post-MW). A total of 8046 Post-MW from the China Chaoshan Biobank Cohort Study were included for analysis. Logistic regression and general linear regression models were used to estimate the association between FRFs and hypertension, DM, and LQTc. Compared with women with 0 or 1 live birth, increasing risk of hypertension (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.16-1.96), DM (OR, 1.65; 95% CI, 1.22-2.22), and LQTc (OR, 1.45; 95% CI, 1.01-2.09) were observed in women who had five or more live births. Further analysis demonstrated that the association between parity and hypertension, DM, and LQTc was mediated by lifestyle and dyslipidemia. Women with more live births had increased body mass index and waist circumstance, and were inclined to consume more salty food, animal fat, and alcohol, but less meat, vegetable, fish, plant oil, and tea, compared with that had fewer live births (all P < 0.05).

Age at menarche and risk of major cardiovascular diseases: Evidence of birth cohort effects from a prospective study of 300,000 Chinese women

Background

Previous studies of mostly Western women have reported inconsistent findings on the association between age at menarche and risk of cardiovascular disease (CVD). Little is known about the association in China where there has been a large intergenerational decrease in women's mean age at menarche.

Methods

The China Kadoorie Biobank recruited 302,632 women aged 30–79 (mean 50.5) years in 2004–8 from 10 diverse regional sites across China. During 7 years follow-up, 14,111 incident cases of stroke, 14,093 of coronary heart disease (CHD), and 3200 CVD deaths were reported among 281,491 women who had no prior history of CVD at baseline. Cox regression yielded adjusted hazard ratios (HRs) relating age at menarche to CVD risks.

Results

The mean (SD) age of menarche was 15.4 (1.9) years, decreasing from 16.2 (2.0) among women born before 1940 to 14.7 (1.6) for those born during the 1960s–1970s. The patterns of association between age at menarche and CVD risk appeared to differ between different birth cohorts, with null associations in older generations but U-shaped or weak positive associations in younger women, especially those born after the 1960s. After minimizing the potential confounding effects from major CVD risk factors, both early and late menarche, compared with menarche at age 13 years, were associated with increased risk of CVD morbidity and mortality, which was more pronounced in younger generations.

Conclusion

Among Chinese women the associations between age at menarche and risk of CVD differed by birth cohort, suggesting other factors may underpin the association.

Duration of reproductive lifespan and age at menarche in relation to metabolic syndrome in postmenopausal Chinese women

AIM

This study aimed to assess the associations between menstrual characteristics and the prevalence of metabolic syndrome (MetS) and non-alcoholic fatty liver disease.

METHODS

A cross-sectional study was conducted with a sample of 1625 postmenopausal women in China. Subjects were classified into three groups according to the tertiles of some variables related to the reproductive life. We assessed associations in multivariable-adjusted analyses, using logistic regressions.

RESULTS

After adjustments for confounding factors, the odds ratios (OR) for predicting the presence of MetS increased gradually: as the years of menstruation increased (18-34 years vs 35-37 years vs 38-46 years: OR [95% confidence interval (CI)] = 1 vs 1.231 [0.942-1.610] vs 1.309 [0.985-1.740], respectively); as age at menopause increased (31-48 years vs 49-51 years vs 52-59 years: OR [95%CI] = 1 vs 1.115 [0.846-1.469] vs 1.315 [0.986-1.753], respectively); and as age at menarche decrease (11-13 years vs 14-15 years vs 16-20 years: OR [95%CI] = 1 vs 0.950 [0.728-1.240] vs 0.862 [0.610-1.119], respectively). Among the components of MetS, the highest tertile of years of menstruation was significantly associated with elevated waist circumference (OR =1.401 [95%CI = 1.092-1.798]), and elevated triglyceride (OR =1.220 [95%CI = 0.934-1.593]). Nevertheless, the association between these reproductive factors and non-alcoholic fatty liver disease was not significant.

CONCLUSION

Longer duration of menstruation and earlier age at menarche were significantly associated with a higher risk of central obesity and MetS in postmenopausal Chinese women.

Association between Age at Menarche and Cardiovascular Disease Risk Factors in China: A Large Population-Based Investigation

BACKGROUND

The association between age at menarche (AAM) and cardiovascular disease (CVD) has previously been investigated with controversial results. The relationship between the psychological characteristic of AAM and many cardiovascular risk factors remains unclear.

PURPOSE

To assess the association between AAM and CVD risk factors in a large population.

DESIGN AND SETTING

13,242 women aged 24-79 years were recruited from China mainland during 2009-2013 for a cross-sectional, population-based study to investigate the association between AAM and CVD risk factors. Information on AAM was obtained from self-report and information on CVD risk factors from physical examination.

RESULTS

In age-, body-mass-index- and height-adjusted analyses, AAM was positively associated with hypertension and 'college or above' educational level and incident CVD events. The adjusted odds ratios (ORs) and 95% confidence intervals for hypertension across AAM categories (≤12, 13-14, 15-16, and ≥17 years) were 0.820 (0.70-0.96), 0.82 (0.70-0.96), 0.88 (0.79-0.99) and 1 (referent), respectively; adjusted ORs for high educational level ('college or above') were 0.29 (0.24-0.34), 0.60 (0.41-0.51), 0.69 (0.62-0.76), and 1 (referent), respectively; adjusted ORs for incident CVD events were 0.18 (0.08-0.41), 0.18 (0.08-0.41), 0.62 (0.41-0.93), 1 (referent), respectively.

CONCLUSIONS

Earlier AAM were positively associated with incident CVD events, hypertension and 'college or above' educational level.

Reproductive History in Women with Lower Limb Ischemia

The purpose of this study was to identify reproductive factors that may contribute to the development of arteriosclerosis in the leg arteries by comparing the reproductive history of women with lower limb ischemia to a reference group of women. All 173 female patients treated for chronic lower limb ischemia with surgical or endovascular procedures performed from 1994 to 1996 at a university clinic received a validated questionnaire to which 116 (67%) responded. The reference group, 348 women, 197 (57%) of whom responded, was recruited randomly from the hospital catchment area. The 2 groups were similar regarding age at menopause and menarche, pregnancies, salpingo-oophorectomies, and hormone replacement therapy. There was a higher number of women who had used oral contraceptives in the reference group than in the patient group (53% vs 16%, p<0.001). The same results were found when comparing the subgroup of patients younger than 55 years to the references. No association between reproductive history and development of lower limb ischemia could be found. Our results support that use of oral contraceptives early in life is not associated with an increased risk for lower limb ischemia.

Associations Between Parity, Obesity, and Cardiovascular Risk Factors Among Middle-Aged Women

BACKGROUND

Several studies have demonstrated an association between parity and the risk of developing cardiovascular disease (CVD) in middle-aged women; however, some inconsistencies still remain in the literature after accounting for obesity. The purpose of this study was to examine the association between parity and the risk factors of CVD while accounting for current obesity status in middle-aged women.

METHOD

Data for this study came from the National Health and Nutrition Examination Survey 2007-2012. The final analytic sample included 2024 middle-aged women (40-60 years old). General linear models predicting CVD risk factors based on parity (nulliparous, 1, 2, 3, and ≥4) were established after controlling for study covariates. Least square adjusted means of CVD risk factors and associated 95% confidence intervals were estimated across parity and body mass index (BMI) levels.

RESULTS

Women with ≥4 parity (8.34%; standard error [SE] = 0.84) showed significantly distinct demographic characteristics and health conditions, including obesity (49.08%; SE = 3.55). There were no significant associations between parity and CVD risk factors after controlling for covariates. Follow-up analyses showed consistent results across parity; however, CVD risk factors were significantly increased with higher BMI levels, regardless of parity status.

CONCLUSIONS

Our results suggest that parity is not a significant predictor of CVD risk factors in middle-aged women, whereas current overweight or obesity status is more important when explaining the risk of the development of CVD.

Climacteric symptoms in middle-aged women with chronic somatic diseases

OBJECTIVES

Chronic diseases may aggravate or simulate climacteric symptoms. Although acknowledged in clinical practice, there is a lack of research systematically analysing the association between chronic diseases and climacteric symptoms.

STUDY DESIGN AND MAIN OUTCOME MEASURES

Our study was a cross-sectional population-based study, which included 3421 women, aged 41-54 years. Climacteric symptoms were evaluated using the Women's Health Questionnaire (WHQ), of which we included seven symptom domains (vasomotor, sleep, depressive, anxiety/fears, cognitive, sexual, and menstrual) and a question concerning whether the women were worried about growing old. The occurrence of various diseases (cardiovascular, neurological, sensory organ, bronchopulmonary, musculoskeletal, gastrointestinal, urological, dermatological, and thyroid disease, diabetes, and cancer) was recorded. The associations between the diseases and symptoms were defined with multivariable analyses, adjusting for various confounding factors.

RESULTS

The women with the diseases had more symptoms. Vasomotor symptoms and sleep problems were associated only with gastrointestinal diseases, and lower sexual functioning only with diabetes. The remaining symptoms were associated with several diseases, except being worried about growing old, which was not associated with any.

CONCLUSIONS

Many symptoms connected to the climacteric may manifest also due to chronic diseases. Thus, health-care professionals should consider the origin of the symptoms when treating middle-aged women with chronic diseases.

Cumulative effect of reproductive factors on ideal cardiovascular health in postmenopausal women: a cross-sectional study in central south China

Background

The American Heart Association developed the Life’s Simple 7 metric for defining cardiovascular health. Little is known, however, whether co-occurring reproductive factors, which affects endogenous oestrogen levels during a woman’s life, also influences ideal cardiovascular health in postmenopausal women.

Methods

Using data on a cross-sectional study with a convenience sample of 1,625 postmenopausal women (median age, 60.0 years) in a medical health checkup program at a general hospital in central south China 2013–2014, we examined the association between cumulative reproductive risk and ideal cardiovascular health in postmenopausal women. A cumulative risk score (range 0 to 4) was created by summing four reproductive risk factors (age at menarche, age at menopause, number of children, and pregnancy losses) present in each individual from binary variables in which 0 stands for favorable and 1 for less-than-favorable level. Ideal levels for each component in Life’s Simple 7 (blood pressure, cholesterol, glucose, BMI, smoking, physical activity, and diet) were used to create an ideal Life’s Simple 7 score [0–1 (low), 2, 3, 4, 5 and 6–7 (high)].

Results

Participants with earlier age at menarche (odds ratio [OR] =0.42 [95 % CI 0.26-0.48]), earlier age at menopause [0.46 (0.32-0.58)], who have more than three children (0.42 [0.38-0.56]) and have history of pregnancy losses [0.76 (0.66-0.92)] were more likely to attain low (0–1) ideal Life’s Simple 7 after adjustment for age. Participants were more likely to attain low (0–1) ideal Life’s Simple 7 as exposure to the number of reproductive risk factors increased [OR (95 % CI) of 0.52 (0.42-0.66), 0.22 (0.16-0.26), and 0.16 (0.12-0.22) for cumulative reproductive risk scores of 1, 2, and 3 or 4, respectively, each versus 0].

Conclusions

The postmenopausal Chinese women with an increasing number of reproductive risk factors were progressively less likely to attain ideal levels of cardiovascular health factors.

MENSTRUAL AND REPRODUCTIVE FUNCTION IN WOMEN WITH TYPE 1 DIABETES

OBJECTIVE

Menstrual irregularities, reproductive abnormalities, and androgen excess are reported to be more prevalent in women with type 1 diabetes (T1D). The objective of this study was to investigate the prevalence of menstrual irregularities, reproductive abnormalities, and androgen excess among women with T1D and their age-matched controls.

METHODS

A survey requesting information regarding menstrual and reproductive histories was administered to all participants. Results were stratified according to age (18 to 40, 40 to 50, and >50 years).

RESULTS

There were no significant differences between women with and without diabetes in age at menarche, cycle length, or androgen excess in any group. Women who self-reported difficulty with glycemic control were more likely to report irregular menses than controls (P = .04). Among women who reported ever being pregnant, there were fewer pregnancies (P = .02) and live births (P = .002) in women with T1D. Women with T1D reported a lower frequency of oral contraceptive use (P = .003), despite being less likely to smoke (P = .016).

CONCLUSION

Menstrual and reproductive abnormalities were not observed more frequently in women with T1D in this study. Subtle but measurable differences in menstrual and reproductive function were confined to the subgroup of women who perceived poor control of their diabetes. Additional prospective studies of T1D and menstrual and reproductive function would be useful.

Risk of cardiovascular disease among postmenopausal women with prior pregnancy loss: the women's health initiative

PURPOSE

Metabolic, hormonal, and hemostatic changes associated with pregnancy loss (stillbirth and miscarriage) may contribute to the development of cardiovascular disease (CVD) in adulthood. This study evaluated prospectively the association between a history of pregnancy loss and CVD in a cohort of postmenopausal women.

METHODS

Postmenopausal women (77,701) were evaluated from 1993-1998. Information on baseline reproductive history, sociodemographic, and CVD risk factors were collected. The associations between 1 or 2 or more miscarriages and 1 or more stillbirths with occurrence of CVD were evaluated using multiple logistic regression.

RESULTS

Among 77,701 women in the study sample, 23,538 (30.3%) reported a history of miscarriage; 1,670 (2.2%) reported a history of stillbirth; and 1,673 (2.2%) reported a history of both miscarriage and stillbirth. Multivariable-adjusted odds ratio (OR) for coronary heart disease (CHD) for 1 or more stillbirths was 1.27 (95% CI, 1.07-1.51) compared with no stillbirth; for women with a history of 1 miscarriage, the OR=1.19 (95% CI, 1.08-1.32); and for 2 or more miscarriages the OR=1.18 (95% CI, 1.04-1.34) compared with no miscarriage. For ischemic stroke, the multivariable odds ratio for stillbirths and miscarriages was not significant.

CONCLUSIONS

Pregnancy loss was associated with CHD but not ischemic stroke. Women with a history of 1 or more stillbirths or 1 or more miscarriages appear to be at increased risk of future CVD and should be considered candidates for closer surveillance and/or early intervention; research is needed into better understanding the pathophysiologic mechanisms behind the increased risk of CVD associated with pregnancy loss.

Does accelerated reproductive aging underlie premenopausal risk for cardiovascular disease?

OBJECTIVE

The menopausal transition is associated with an increase in risk for cardiovascular disease; however, whether variability in reproductive aging relates to cardiovascular risk factors in the premenopausal period has not been studied.

METHODS

In a multiethnic sample of 951 healthy, regularly cycling women aged 25 to 45 years (mean [SD] age, 35.2 [5.5] y), we examined antimüllerian hormone (AMH), a validated marker of ovarian reserve, in relation to the overall number of cardiometabolic risk factors, calculated as the sum of the five components of metabolic syndrome (triglycerides ≥150 mg/dL; high-density lipoprotein <50 mg/dL; homeostasis model assessment of insulin resistance ≥2.6; waist circumference equal to or higher than race-specific cutoff; and hypertensive [vs normotensive] status), and in relation to each of these risk factors individually.

RESULTS

In age-adjusted models, results showed that the number of cardiometabolic risk factors was 52.1% higher among women with low versus high AMH levels and 46.0% higher among women with mid versus high AMH levels. In addition, results showed that low and mid levels of AMH (vs high) were associated with an increase in risk with respect to high-density lipoprotein (odds ratio [OR], 1.814; 95% CI, 1.211-2.718 and OR, 1.568; 95% CI, 1.083-2.269, respectively), waist circumference (OR, 2.012; 95% CI, 1.380-2.934 and OR, 1.881; 95% CI, 1.333-2.654, respectively), and hypertensive status (OR, 2.373; 95% CI, 1.095-5.143 and OR, 2.052; 95% CI, 0.976-4.314, respectively) outcomes. Associations, however, attenuated when body mass index was covaried (Ps > 0.05).

CONCLUSIONS

Cross-sectional evidence suggests that having a greater ovarian reserve is associated with having a healthier cardiometabolic risk factor profile. Future longitudinal studies are needed to determine whether this association may be mediated by body mass index.

Recognizing pregnancy-associated cardiovascular risk factors

Preeclampsia, gestational diabetes, or pregnancy-induced hypertension identify a woman at risk for cardiovascular disease. This information should be incorporated into the routine cardiovascular risk assessment for women, as a basis for appropriate risk factor screening, counseling, and preventive interventions. There is need for development and validation of a clinometric tool to assess cardiovascular risk and guide management.

Disruptions in ovarian function are related to depression and cardiometabolic risk during premenopause

OBJECTIVE

The aim of this study was to evaluate the extent to which mild disruptions in ovarian function, indexed by changes in menstrual cycle length, may relate to cardiometabolic and psychological health in premenopausal women.

METHODS

Among 804 healthy, regularly cycling women (aged 25-45 y; mean [SD] age, 35.5 [5.5] y), patterns of any change (shortening, lengthening, or increased variability) versus no change in menstrual cycle length were examined in relation to a composite of cardiometabolic risk and individual risk factors (high-density lipoprotein, triglycerides, waist circumference, glucose, and hypertensive status), as well as in relation to depression indicators (Center for Epidemiological Studies Depression Scale score ≥16 [yes/no], lifetime depression diagnosis [yes/no], and lifetime antidepressant medication use [yes/no]). Models were also explored to test whether changes in menstrual cycle length mediated relations between depression history and cardiometabolic risk.

RESULTS

In covariate-adjusted models compared with no change, any change in menstrual cycle length was associated with higher cardiometabolic risk composite scores and lower high-density lipoprotein (P < 0.05). In addition, compared with no change, any change in menstrual cycle length was associated with a Center for Epidemiological Studies Depression Scale score of 16 or higher, having received a depression diagnosis, and having used antidepressant medications (P < 0.05). In exploratory analyses, any change in menstrual cycle length partially mediated the relation between depression history and cardiometabolic risk (b = 0.152, P = 0.040), which attenuated (b = 0.129, P = 0.083) when any change in menstrual cycle length was covaried.

CONCLUSIONS

Findings suggest that disruptions in ovarian function, marked by subtle changes in menstrual cycle length, may relate to aspects of cardiometabolic and psychological health among healthy, premenopausal women.

Do differences in risk factors explain the lower rates of coronary heart disease in Japanese versus U.S. women?

BACKGROUND

Mortality from coronary heart disease (CHD) in women in Japan is one of the lowest in developed countries. In an attempt to shed some light on possible reasons of lower CHD in women in Japan compared with the United States, we extensively reviewed and analyzed existing national data and recent literature.

METHODS

We searched recent epidemiological studies that reported incidence of acute myocardial infarction (AMI) and examined risk factors for CHD in women in Japan. Then, we compared trends in risk factors between women currently aged 50-69 years in Japan and the United States, using national statistics and other available resources.

RESULTS

Recent epidemiological studies have clearly shown that AMI incidence in women in Japan is lower than that reported from other countries, and that lipids, blood pressure (BP), diabetes, smoking, and early menopause are independent risk factors. Comparing trends in risk factors between women in Japan and the United States, current levels of serum total cholesterol are higher in women in Japan and levels have been similar at least since 1990. Levels of BP have been higher in in Japan for the past 3 decades. Prevalence of type 2 diabetes has been similar in Japanese and white women currently aged 60-69 for the past 2 decades. In contrast, rates of cigarette smoking, although low in women in both countries, have been lower in women in Japan.

CONCLUSIONS

Differences in risk factors and their trends are unlikely to explain the difference in CHD rates in women in Japan and the United States. Determining the currently unknown factors responsible for low CHD mortality in women in Japan may lead to new strategy for CHD prevention.

Race/ethnic disparities in reproductive age: an examination of ovarian reserve estimates across four race/ethnic groups of healthy, regularly cycling women

OBJECTIVE

To determine whether reproductive age, as indexed by a validated marker of ovarian reserve (antimüllerian hormone [AMH]), varies among women of different race/ethnic backgrounds.

DESIGN

Cross-sectional study.

SETTING

Community-based sample.

PATIENT(S)

Multiethnic sample of 947 (277 white, 237 African American, 220 Latina, and 213 Chinese) healthy and regularly cycling premenopausal women, ages 25-45.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

AMH level.

RESULT(S)

A multivariate model was fit examining race/ethnicity, covariates, nonlinear terms for age (age(2), age(3)), and body mass index (BMI(2), BMI(3)), and two-way interactions between race/ethnicity and each of the other predictor variables in relation to AMH. After backward elimination, significant effects included race/ethnicity (F = 8.45), age (F = 349.94), race/ethnicity-by-linear age interaction (F = 4.67), age(2) (F = 31.61), and BMI (F = 10.69). Inspection of the significant race/ethnicity-by-linear age interaction showed AMH levels were consistently lower among Latina women compared with white women across all ages, whereas AMH levels were lower among African American and Chinese women compared with the white women at younger and middle ages, respectively. The AMH levels were higher among African American compared with Latina and Chinese women at older ages.

CONCLUSION(S)

Although the results must be considered preliminary, the findings are twofold: African American women may have lower AMH levels at younger ages but experience less of a reduction in AMH with advancing age, and Latina and Chinese women compared with white women may have lower AMH levels, marking a lower ovarian reserve and a possibly increased risk for earlier menopause.

Cardiovascular disease in menopause: Does the obstetric history have any bearing?

Cardiovascular disease remains a leading cause of morbidity and mortality in menopausal women in spite of the overall reduction in age-adjusted mortality from the disease in the last few years. It is now clear that mechanisms of cardiovascular disease in menopausal women are similar to men and rather than midlife acceleration of cardiovascular disease in women, the final impact of cardiovascular disease in later life may be a reflection of cardiovascular changes during reproductive years as a result of woman’s obstetric history. A decade after the Women’s Health Initiative trial, there is upcoming evidence to suggest that hormone replacement therapy in young recently menopausal women has a cardioprotective effect. Cardiovascular changes during normal pregnancy or pregnancy complications such as preeclampsia may affect a woman’s long-term cardiovascular health. Therefore, it is plausible that the cardioprotective benefit of hormone replacement therapy depends on occult pre-existing cardiovascular risks in women in relation to their previous obstetric history. In this review, we describe the cardiovascular changes during and after pregnancy in obstetric complications such as recurrent miscarriage, preeclampsia, intrauterine growth restriction, preterm labour and gestational diabetes; existing evidence regarding their association with cardiovascular disease later in life, and hypothesize possible mechanisms. Our aim is to improve the understanding and highlight the importance of including obstetric history in risk assessment in menopausal women and individualizing their risks before prescribing hormone replacement therapy. Future research in risk benefit assessment of hormone replacement therapy should also account for a woman’s background cardiovascular risk in the light of her obstetric history.

Associations between age at menarche and menopause with cardiovascular disease, diabetes, and osteoporosis in Chinese women

CONTEXT

Ages at menarche and menopause are associated with cardiovascular disease (CVD), diabetes, and osteoporosis in Caucasian women, but associations remain unexplored in Chinese women.

OBJECTIVE

The purpose of this study was to assess associations between age at menarche and menopause with CVD, diabetes, and osteoporosis in Chinese women.

DESIGN AND SETTING

A cross-sectional, population-based study was conducted in Fujian, China, from June 2011 to January 2012.

PARTICIPANTS

Among 6242 women aged 21 to 92 years, 3304 postmenopausal women were enrolled, excluding premenopausal women (n = 2527), those with unreported ages at menarche and menopause (n = 138), those with unrecorded physical measurements (n = 203), and those with menarche age <8 years or >20 years (n = 70).

MAIN OUTCOME MEASURES

An oral glucose tolerance test, a 12-lead resting electrocardiogram, and calcaneus quantitative ultrasound were performed.

RESULTS

No significant associations were found between menarche age, diabetes, and osteoporosis (both P > .05); later menarche (>18 years) was significantly associated with lower CVD risk (odds ratio = 0.71, 95% confidence interval, 0.57-0.89; P = .002). Menopause age was not associated with diabetes; higher menopause age was associated with decreasing CVD risk (P for trend = .020) and earlier menopause (≤46 years) with significantly higher osteoporosis risk (odds ratio = 1.59, 95% confidence interval, 1.07-2.36; P = .023).

CONCLUSIONS

In China, ages at menarche and menopause are not associated with diabetes. Later menarche and menopause are associated with decreasing CVD risk and earlier menopause with higher osteoporosis risk. Menarche and menopause history may help identify women with increased risk of developing CVD and osteoporosis.

Cardiovascular function in women with recurrent miscarriage, pre-eclampsia and/or intrauterine growth restriction

OBJECTIVE

To investigate prepregnancy cardiovascular function and risk factors in women with previous pregnancy complications.

METHODS

Thirty-four women with previous normal pregnancy (controls), 26 with unexplained recurrent miscarriage (RM) and 14 with pre-eclampsia (PE) and/or intrauterine growth restriction (IUGR), planning to conceive were recruited. Brachial and central blood pressures (BP), cardiac output (CO), peripheral vascular resistance (PVR), aortic stiffness, blood biochemistry and platelet aggregation were assessed.

RESULTS

Women with previous PE/IUGR had higher brachial diastolic BP (78 ± 9 vs 71 ± 7 mmHg; p = 0.03), central systolic BP (107 ± 10 vs 99 ± 8 mmHg; p = 0.03), mean arterial pressure (92 ± 10 vs 84 ± 8 mmHg; p = 0.01) and PVR (1499 ± 300 vs 1250 ± 220 dynes.s(-1) cm(-5); p = 0.005), than the controls. No differences were observed in either cardiovascular function or blood biochemistry in women with unexplained RM compared with the controls. Women with previous PE/IUGR though not with RM had a stronger family history of cardiovascular disease (CVD) than controls.

CONCLUSIONS

Women with previous PE and/or IUGR had higher BP and PVR compared with controls, which may predispose them to CVD later in life. However, in the absence of underlying vascular pathology, women with unexplained RM did not have abnormal cardiovascular function. Prepregnancy period provides an opportunity to identify cardiovascular risks in relation to previous obstetric history.

Early age at menarche associated with increased all-cause mortality

The objective was to examine the association between age at menarche and all-cause mortality. A population-based prospective study involving 55,128 Japanese women aged 40-79 years in 1988-1990 and followed up to December 2006 was used. A total of 6,967 deaths occurred during the follow-up. Hazard ratios (HR) and 95% confidence intervals (CI) adjusted for age, smoking and drinking status, exercise, sleeping hours, parity, menopausal status, and body mass index at baseline were calculated by Cox proportional hazards model. The HRs (95% CI) of all-cause mortality were 1.16 (1.01-1.32), 1.01 (0.92-1.11), 1.00, 0.97 (0.90-1.05), 0.98 (0.91-1.05), 0.92 (0.84-1.01), and 1.05 (0.96-1.14) for women with menarche aged 9-12, 13, 14 (referent), 15, 16, 17, 18-20 years, respectively, indicating an inverse J-shaped association (P for quadratic trend <.01). Moreover, women with menarche aged ≤12 years have a significantly high risk of all-cause mortality compared with those with menarche aged ≥13 years (HR 1.17, 95% CI 1.03-1.33). Comparing between women with menarche aged ≤13 years and ≥14 years, those with earlier age at menarche had borderline significantly high risk of all-cause mortality in both comparisons (HR 1.07, 95% CI 0.99-1.15, P = .082). Japanese women with early age at menarche of ≤12 years were associated with increased risk of all-cause mortality and those with late age at menarche of ≥18 years also had a slightly higher mortality risk. These associations were independent of lifestyle, anthropometric, and reproductive factors.

Age at menarche and its association with the metabolic syndrome and its components: results from the KORA F4 study

OBJECTIVE

The metabolic syndrome is a major public health challenge and identifies persons at risk for diabetes and cardiovascular disease. The aim of this study was to examine the association between age at menarche and the metabolic syndrome (IDF and NCEP ATP III classification) and its components.

DESIGN

1536 women aged 32 to 81 years of the German population based KORA F4 study were investigated. Data was collected by standardized interviews, physical examinations, and whole blood and serum measurements.

RESULTS

Young age at menarche was significantly associated with elevated body mass index (BMI), greater waist circumference, higher fasting glucose levels, and 2 hour glucose (oral glucose tolerance test), even after adjusting for the difference between current BMI and BMI at age 25. The significant effect on elevated triglycerides and systolic blood pressure was attenuated after adjustment for the BMI change. Age at menarche was inversely associated with the metabolic syndrome adjusting for age (p-values: <0.001 IDF, 0.003 NCEP classification) and additional potential confounders including lifestyle and reproductive history factors (p-values: 0.001, 0.005). Associations remain significant when additionally controlling for recollected BMI at age 25 (p-values: 0.008, 0.033) or the BMI change since age 25 (p-values: 0.005, 0.022).

CONCLUSION

Young age at menarche might play a role in the development of the metabolic syndrome. This association is only partially mediated by weight gain and increased BMI. A history of early menarche may help to identify women at risk for the metabolic syndrome.