Hot Flash Frequency and Blood Pressure: Data from the Study of Women's Health Across the Nation

A Systematic Review of Anxiety and Depressive Symptoms Among Women Experiencing Vasomotor Symptoms Across Reproductive Stages in the US

Purpose

Vasomotor symptoms (VMS) due to menopause affect up to 80% of women and are associated with fatigue, depressive symptoms, and anxiety although the exact nature of these associations is not fully understood. This systematic review aimed to examine the existing evidence on the relationship between VMS, fatigue, depressive symptoms, and anxiety among women in any stage of reproductive aging in the United States.

Methods

A comprehensive search of MEDLINE and Embase databases was performed to identify observational studies (2010-2022) that reported on the target population. Exposure of interest was VMS; data related to the outcomes of interest (measures of fatigue, depressive symptoms, and/or anxiety) were extracted and analyzed descriptively.

Results

Twenty-six studies met the inclusion criteria, with 19 reporting on depressive symptom outcomes, 16 on anxiety outcomes, and none on fatigue. The mean age of women with VMS ranged from 41.3 to 62.0 years; 34.8% to 91.1% of women were premenopausal or in the late stage of reproductive aging, 0.6% to 61% were perimenopausal or in menopause transition, and 0% to 49% were postmenopausal. The most frequent comorbidities were hypertension and diabetes. Baseline depressive symptom rates ranged from 1.4% to 58%, with higher rates and more severe symptoms among women with more frequent and severe VMS. Anxiety rates at baseline ranged from 2.2% to 52%, with higher rates reported among women with frequent VMS. Anxiety levels varied, with the highest levels observed among women with sleep disturbances and severe hot flashes. In regression model analyses, VMS were associated with increased risk, duration, frequency, and severity of both depressive symptoms and anxiety.

Conclusion

VMS are strongly and consistently associated with depressive symptoms and anxiety, negatively affecting a woman's health beyond physical discomfort. There is a need to reduce this burden and improve quality of life for women with VMS.

Health care concerns in women at midlife: differences by race, ethnicity, and neighborhood socioeconomic status

OBJECTIVES

The aims of the study were to identify conditions diagnosed in at least 10% of midlife women living in the US upper midwest and to assess prevalence by age, race, ethnicity, and sociodemographic status.

METHODS

The Rochester Epidemiology Project was used to conduct a cross-sectional prevalence study of 86,946 women between 40 and 59 years residing in a 27-county region of the United States on January 1, 2020. Diagnostic billing codes were extracted and grouped into broader condition categories using the Clinical Classification System Refined. The prevalence of 424 conditions was calculated by age, race, ethnicity, and area deprivation index quartiles. Logistic regression was used to examine associations between participant characteristics and conditions that affected 10% or more of the study population.

RESULTS

Twenty-eight conditions affected ≥10% of women, and eight conditions increased by ≥45% between the ages of 40 and 59 (disorders of lipid metabolism, hypertension, sleep/wake disorders, thyroid disorders, esophageal disorders, osteoarthritis, tendon and synovial disorders, and menopausal disorders; all test for trend P < 0.01). Black women had a significantly higher prevalence of hypertension and esophageal disorders at all ages (adjusted P values <0.05). Women living in more deprived areas had a significantly higher prevalence of hyperlipidemia, hypertension, sleep/wake disorders, and esophageal disorders (adjusted P values <0.05). Women living in less deprived areas had a significantly higher prevalence of thyroid disorders at age 40 to 44 and menopausal disorders at ages 50 to 59 (adjusted P values <0.05).

CONCLUSIONS

These data suggest that additional attention should focus on Black women and women with a lower socioeconomic status to ensure that common midlife conditions are diagnosed and treated.

Epidemiology and clinical outcomes of vasomotor symptoms among perimenopausal women and women aged 65 years or older in the US: a systematic review

Vasomotor symptoms (VMS) are the hallmark of menopause and negatively affect a large proportion of women over many years. However, studies evaluating the overall impact of VMS are limited. This systematic review (SR) aimed to examine epidemiological, clinical, humanistic, and economic outcomes of VMS among perimenopausal women and among women aged ≥65 years in the US. A systematic search of the MEDLINE and Embase databases was conducted to identify observational studies (2010-2022) reporting on these populations. Data reporting outcomes of interest were extracted and analyzed descriptively. Of 7,613 studies identified, 34 met inclusion criteria, of which 30 reported on perimenopausal women and 4 reported on VMS in women aged ≥ 65 years. VMS and severe/moderate-to-severe VMS were reported by 48.4-70.6 percent and 13.0-63.1 percent, respectively, of perimenopausal women. Mean VMS duration was 2.6 years, and median duration ranged from 7.4 to 10.1 years among women with onset in early perimenopause and from 3.8 to 6.1 years among those with onset in late perimenopause. Among women aged ≥65 years, 20.9-45.1 percent reported VMS; 2.0 percent reported severe symptoms, and 17.6 percent reported moderate symptoms. No studies reported VMS frequency and duration or the economic or humanistic burden among women aged ≥65 years. In conclusion, high VMS frequency and severity were observed among perimenopausal women and women aged ≥65 years in the US in this SR, highlighting the need for (1) better management of VMS to reduce frequency and severity and (2) further research to clarify the impact of VMS on disease burden, quality of life, and economic impact.

Study on blood pressure rhythm in hypertensive patients withdeficiency syndrome and a random forest model for predicting hypertension withdeficiency syndrome

OBJECTIVE

To investigate blood pressure rhythm (BPR) in Yin deficiency syndrome of hypertension (YDSH) patients and develop a random forest model for predicting YDSH.

METHODS

Our study was consistent with technical processes and specification for developing guidelines of Evidence-based Chinese medicine clinical practice (T/CACM 1032-2017). We enrolled 234 patients who had been diagnosed with primary hypertension without antihypertensive medications prior to the enrollment. All participants were divided into Yin deficiency group (YX, n = 74) and non-Yin deficiency group (NYX, n = 160). Participants were professionally grouped by three experienced chief Traditional Chinese Medicine (TCM) physicians according to four examinations (i.e., inspection, listening and smelling, inquiry and palpation). We collected data on 24 h ambulatory blood pressure monitoring (ABPM) and YDSH rating scale. We divided 24 h of a day into 12 two-hour periods [Chen-Shi (7:00-9:00), Si-Shi (9:00-11:00), Wu-Shi (11:00-13:00), Wei-Shi (13:00-15:00), Shen-Shi (15:00-17:00), You-Shi (17:00-19:00), Xu-Shi (19:00-21:00), Hai-Shi (21:00-23:00), Zi-Shi (23:00-1:00), Chou-Shi (1:00-3:00), Yin-Shi (3:00-5:00), Mao-Shi (5:00-7:00)] according to the theory of "midnight-midday ebb flow". We used random forest to build the diagnostic model of YDSH, with whether it was Yin deficiency syndrome as the outcome.

RESULTS

Compared with NYX group, YX group had more female participants with older age, lower waist circumference, body mass index (BMI), diastolic blood pressure (DBP), and smoking and drinking rate (all P ＜ 0.05). The YDSH rating scores of YX group [28.5 (21.0-36.0)] were significantly higher than NYX group [13.0 (8.0-22.0)] (P < 0.001), and the typical symptoms of YX group included vexing heat in the chest, palms and soles, dizziness, dry eyes, string-like and fine pulse, soreness and weakness of lumbus and knees, palpitations, reddened cheeks, and tinnitus (all P < 0.05). The ratio of non-dipper hypertension in YX group was higher than in NYX group (56.9% vs 44.4%, P = 0.004). Compared with NYX group, 24 h DBP standard deviation (SD), nighttime DBP SD, Si-Shi DBP, Si-Shi mean arterial pressure (MAP), Hi-Shi systolic blood pressure (SBP), Hi-Shi DBP, Hi-Shi MAP, Zi-Shi SBP, Zi-Shi DBP, Zi-Shi MAP, Chou-Shi SBP SD, Chou-Shi DBP SD, Chou-Shi SBP coefficient of variation (CV) were lower in YX group (all P ＜ 0.05). Binary Logistic Regression analysis showed that the diagnosis of YDSH was positively correlated with age, heart rate, YDSH rating scores, and four TCM symptoms including vexing heat in the chest, palms and soles, string-like and fine pulse, soreness and weakness of lumbus and knees, and reddened cheeks (all P ＜ 0.05), but was negatively correlated with smoking (P﹥0.05). In addition, the diagnosis of YDSH was positively correlated with daytime SBP SD, nighttime SBP SD, nighttime SBP CV, and Hi-Shi SBP CV, but was negatively correlated with 24 h SBP CV, daytime DBP SD, nighttime DBP SD, and Hi-Shi DBP (all P ＜ 0.05). Hi-Shi SBP CV had independent and positive correlation with the diagnosis of YDSH after adjusting the variables of age, gender, course of hypertension, BMI, waist circumference, SBP, DBP, heart rate, smoking and drinking (P = 0.029). Diagnostic model of YDSH was established and verified based on the random forest. The results showed that the calculation accuracy, specificity and sensitivity were 77.3%, 77.8% and 76.9%, respectively.

CONCLUSION

The BPR was significantly attenuated in YDSH patients, including lower 24 h DBP SD and nighttime DBP SD, and Hi-Shi SBP CV is independently correlated with the diagnosis of YDSH. The prediction accuracy of diagnosis model of YDSH based on the random forest was good, which could be valuable for clinicians to differentiate YDSH and non-Yin deficiency patients for more effective hypertensive treatment of TCM.

Reproductive risk factors across the female lifecourse and later metabolic health

Metabolic health is characterized by optimal blood glucose, lipids, cholesterol, blood pressure, and adiposity. Alterations in these characteristics may lead to the development of type 2 diabetes mellitus or dyslipidemia. Recent evidence suggests that female reproductive characteristics may be overlooked as risk factors that contribute to later metabolic dysfunction. These reproductive traits include the age at menarche, menstrual irregularity, the development of polycystic ovary syndrome, gestational weight change, gestational dysglycemia and dyslipidemia, and the severity and timing of menopausal symptoms. These risk factors may themselves be markers of future dysfunction or may be explained by shared underlying etiologies that promote long-term disease development. Disentangling underlying relationships and identifying potentially modifiable characteristics have an important bearing on therapeutic lifestyle modifications that could ease long-term metabolic burden. Further research that better characterizes associations between reproductive characteristics and metabolic health, clarifies underlying etiologies, and identifies indicators for clinical application is warranted in the prevention and management of metabolic dysfunction.

Midlife symptoms and household stress are associated with fingernail cortisol

OBJECTIVE

This study investigates menopausal symptoms, household stressors, and ethnopolitical problems in relation to stress markers, including chronic stress measured by fingernail cortisol, perceived stress measured by the Perceived Stress Scale, and acute stress measured by blood pressure.

METHODS

Data from 151 women aged 40 to 55 years were collected from four regions in Nagaland, India, using opportunity sampling. A structured questionnaire was used to collect sociodemographic and lifestyle variables. Symptoms were grouped into emotional instability, vasosomatic symptoms, mood disturbances, and aches and pains using principal component analysis in a previous study, and stress markers included fingernail cortisol, perceived stress, and blood pressure. Community-level, household-level, and midlife symptoms were included to ascertain stressors from different sources.

RESULTS

Our results revealed a significant positive association between a composite measure of emotional instability and stress assessed by fingernail cortisol ( β = 0.46, P < 0.001). In addition, there was a positive association between mood disturbances and fingernail cortisol ( β = 0.24, P < 0.05). This relationship persisted after controlling for body mass index, socioeconomic status, and menopausal status. In addition, household problems were positively associated with fingernail cortisol ( β = 0.25, P = 0.01).

CONCLUSIONS

These findings highlight the potential health impacts of the psychosocial stress response associated with domestic stressors such as financial strain and concerns about children and health.

Vasomotor symptoms and cardiovascular health: findings from the SWAN and the MsHeart/MsBrain studies

Vasomotor symptoms (VMS) are often considered the classic menopausal symptom and are experienced by most women during the menopause transition. VMS are well established to be associated with decrements in quality of life during the menopause. More recent research also links VMS to poorer cardiovascular health. This review summarizes key insights about links between VMS and cardiovascular disease (CVD) risk that come from the Study of Women's Health Across the Nation (SWAN), a longitudinal epidemiologic cohort study of the menopause transition, as well as from the MsHeart/MsBrain studies, clinical studies that leverage vascular imaging and brain imaging as well as wearable technologies that provide objective indicators of VMS. Using a range of methodologies and extensive consideration of confounders, these studies have shown that frequent and/or persistent VMS are associated with adverse CVD risk factor profiles, poorer underlying peripheral vascular and cerebrovascular health, and elevated risk for clinical CVD events. Collectively, the SWAN and MsHeart/MsBrain studies form complementary epidemiologic and clinical studies that point to the importance of VMS to women's cardiovascular health during the menopause transition and beyond.

Estrogen-mediated mechanisms in hypertension and other cardiovascular diseases

Cardiovascular disease (CVD) is the leading cause of death globally for men and women. Premenopausal women have a lower incidence of hypertension and other cardiovascular events than men of the same age, but diminished sex differences after menopause implicates 17-beta-estradiol (E2) as a protective agent. The cardioprotective effects of E2 are mediated by nuclear estrogen receptors (ERα and ERβ) and a G protein-coupled estrogen receptor (GPER). This review summarizes both established as well as emerging estrogen-mediated mechanisms that underlie sex differences in the vasculature during hypertension and CVD. In addition, remaining knowledge gaps inherent in the association of sex differences and E2 are identified, which may guide future clinical trials and experimental studies in this field.

Vasomotor symptoms and their links to cardiovascular disease risk

Hot flashes and night sweats, also known as vasomotor symptoms (VMS), are common and bothersome symptoms of the menopause transition. In addition to negatively impacting quality of life, VMS have been associated with multiple indicators of cardiovascular disease (CVD) risk, including an unfavorable CVD risk factor profile, increased subclinical CVD, and elevated risk of CVD events. Several facets of VMS have been associated with CVD risk, including the frequency, timing, duration, and severity of VMS. VMS may signify poor or degrading cardiovascular health among midlife women and indicate women who warrant focused CVD prevention efforts.

Menopausal symptoms and cardiometabolic risk factors in middle-aged women: A cross-sectional and longitudinal study with 4-year follow-up

OBJECTIVE

To study associations of menopausal symptoms with cardiometabolic risk factors.

STUDY DESIGN

A cross-sectional and longitudinal study of a representative population sample of 1393 women aged 47-55 years with a sub-sample of 298 followed for four years. The numbers of vasomotor, psychological, somatic or pain, and urogenital menopausal symptoms were ascertained at baseline through self-report. Their associations with cardiometabolic risk factors were studied using linear regression and linear mixed-effect models. Models were adjusted for age, menopausal status, body mass index, the use of hormonal preparations, education, smoking, and alcohol consumption.

MAIN OUTCOME MEASURES

Cardiometabolic risk factors included total cholesterol, low-density and high-density lipoprotein cholesterol, blood pressure, glucose, triglycerides, total and android fat mass, and physical activity.

RESULTS

All cholesterol and fat mass measures had modest positive associations with menopausal symptoms. The number of vasomotor symptoms, in particular, was associated with total cholesterol (B = 0.13 mmol/l, 95 % CI [0.07, 0.20]; 0.15 mmol/l [0.02, 0.28]) and low-density lipoprotein cholesterol (0.08 mmol/l [0.03, 0.14]; 0.12 mmol/l [0.01, 0.09]) in cross-sectional and longitudinal analyses, respectively. However, these associations disappeared after adjusting for confounders. The number of symptoms was not associated with blood pressure, glucose, triglycerides, and physical activity. Menopausal symptoms at baseline did not predict the changes in the risk factors during the follow-up.

CONCLUSIONS

Menopausal symptoms may not be independently associated with cardiometabolic risk, and they do not seem to predict the changes in risk factors during the menopausal transition.

Association of Migraine and Vasomotor Symptoms

OBJECTIVE

To further examine a potential link between migraine and vasomotor symptoms as well as hypertension as a cardiovascular disease risk factor, potentially explaining the association in midlife women.

PATIENTS AND METHODS

We conducted a cross-sectional analysis from the Data Registry on Experiences of Aging, Menopause, and Sexuality using questionnaire data from women aged 45 to 60 years seen in women's clinics at a tertiary care center from May 15, 2015, through January 31, 2022. A history of migraine was self-reported; menopause symptoms were assessed with the Menopause Rating Scale. Associations between migraine and vasomotor symptoms were evaluated utilizing multivariable logistic regression models adjusting for multiple factors.

RESULTS

Of 5708 women included in the analysis, 1354 (23.7%) reported a migraine history. The total cohort had a mean age of 52.8 years, most (5184 [90.8%]) were White, and 3348 (58.7%) were postmenopausal. In adjusted analysis, women with migraine were significantly more likely to have severe/very severe hot flashes vs no hot flashes compared with women without migraine (odds ratio, 1.34; 95% CI, 1.08 to 1.66; P=.007). Migraine was associated with a diagnosis of hypertension in adjusted analysis (odds ratio, 1.31; 95% CI, 1.11 to 1.55; P=.002).

CONCLUSION

This large cross-sectional study confirms an association between migraine and vasomotor symptoms. Migraine also was associated with hypertension, potentially providing a link with cardiovascular disease risk. Given the high prevalence of migraine in women, this association may help identify those at risk for more severe menopause symptoms.

Symptom experiences in hypertension: a mixed methods systematic review

AIM

Understanding patients' hypertension (HTN) symptoms can assist healthcare professionals' awareness of individual, cultural, and behavioral responses and improve diagnostic accuracy to optimize treatment. The purpose of this review was to evaluate and synthesize current literature exploring HTN symptoms.

METHODS

Databases searched included MEDLINE (PubMed), CINAHL (EBSCO), Scopus, and Web of Science from January 2010 to January 2022. The search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The McMaster critical review forms were used to determine the quality of both qualitative and quantitative articles. Synthesis of the data was guided by the Joanna Briggs Institute Convergent Integrated Approach to Mixed Study Systematic Reviews.

RESULTS

In total, 41 articles were included, nine qualitative studies and 32 quantitative. The quality of the articles varied. Symptoms included commonly reported symptoms and some less prevalent, including some reporting absence of symptoms. Factors that affected symptoms included culture, beliefs, psychosocial factors, and knowledge. We also found that there may be a bidirectional relationship between symptoms and behaviors that may lead to self-management.

CONCLUSION

HTN is common and symptoms are frequently reported. HTN management is related to multiple factors. Symptoms continue in a number of individuals after initial diagnosis. Evaluating symptoms after initial diagnosis may help to optimally manage and meet blood pressure guidelines.

Vasomotor symptoms of menopause, autonomic dysfunction, and cardiovascular disease

Cardiovascular disease (CVD), the leading cause of death among US adults, is more prevalent in menopausal females compared with age-matched males. Vasomotor symptoms of menopause (VMS; hot flashes/flushes and night sweats) are common among females undergoing menopausal transition and have been associated with elevated blood pressure (BP) and increased CVD risk. Autonomic dysregulation of BP has been posited as a contributing factor to the elevated CVD risk in menopausal females with VMS. This review includes 1) a brief overview of the relationship between VMS and CVD, 2) mechanisms of hot flushes and their potential impact on short- and long-term BP regulation, and 3) how the disruption of autonomic function associated with VMS might provide a mechanistic pathway to CVD development. Finally, this review will highlight knowledge gaps and future directions toward better understanding of hot flush physiology and VMS contributions to CVD.

Ideal Cardiovascular Health Metrics and Risk of Incident Early-Onset Vasomotor Symptoms Among Premenopausal Women

CONTEXT

The relationship of ideal cardiovascular health (CVH) behaviors with preventing early-onset vasomotor symptoms (VMSs) is unknown.

OBJECTIVE

We investigated the association between CVH metrics and the development of early-onset VMSs in premenopausal women.

METHODS

This cohort study included 2541 premenopausal women aged 42 to 52 years without VMSs at baseline. CVH metrics were defined according to the American Heart Association Life Simple 7 metrics. Owing to limited availability of dietary information, CVH metrics were scored from 0 (unhealthy) to 6 (healthy) and classified into 3 groups: poor (0-2), intermediate (3-4), and ideal (5-6) CVH. VMSs, including hot flashes and night sweats, were assessed using the Menopause-Specific Quality of Life questionnaire. Moderate/severe VMSs was defined as a score of 3 or more points (range, 0 to 6; 6 being most bothersome).

RESULTS

During a median follow-up of 4.5 years, 1241 women developed VMSs before menopause. After adjustment for age, parity, education level, and alcohol consumption, the hazard ratio (HR) (95% CI) for developing early-onset VMSs comparing poor CVH group to the ideal group was 1.41 (1.07-1.86). CVH scores were also inversely associated with moderate/severe VMSs in a dose-response manner (P for trend = .004); specifically, multivariable-adjusted HRs comparing intermediate and poor CVH groups to the ideal group were 1.20 (95% CI, 1.02-1.43) and 1.57 (95% CI, 1.08-2.29), respectively.

CONCLUSION

Unfavorable CVH metrics were significantly associated with an increased risk of early-onset VMSs and its more severe forms among premenopausal women.

The association of vasomotor symptoms during the menopausal transition and cognition in later life

OBJECTIVE

The majority of women experience vasomotor symptoms (VMS) during the menopausal transition. Whether self-reported VMS are associated with cognitive test performance later in life remains unclear. The goal of this study was to determine whether a greater burden of VMS is associated with poor later-life cognition.

METHODS

The Wisconsin Longitudinal Study is a prospective study of randomly selected Wisconsin high school graduates of the class of 1957. At ages 65 and 72, a random subset of participants completed six cognitive tests, including similarities, letter and category fluency, immediate and delayed word recall, and digit ordering. Nested regression models were used to examine the association between extent of VMS, assessed at age 54, and baseline cognition at 65, adjusting for early-life socioeconomic status, women's reproductive health variables, intelligence quotient, and midlife income. This series of models was also used to examine the association between VMS and change in cognition score from age 65 to 72. In sensitivity analyses, models were repeated in a sample using multiple imputation for missing covariates.

RESULTS

Of the 5,326 women enrolled, 874 had data onVMS, covariates, and all cognitive tests. In an unadjusted model, higher VMS were associated with a lower similarities score (b = -0.09 95% CI -0.16 to -0.02) at age 65 but no other cognitive tests. In adjusted models, VMS were not related to cognition at age 65 or change in cognition. Results remained similar with multiple imputation.

CONCLUSIONS

Our study does not support a relationship between self-reported VMS and cognition later in life.

Menopause: a cardiometabolic transition

Menopause is often a turning point for women's health worldwide. Increasing knowledge from experimental data and clinical studies indicates that cardiometabolic changes can manifest at the menopausal transition, superimposing the effect of ageing onto the risk of cardiovascular disease. The menopausal transition is associated with an increase in fat mass (predominantly in the truncal region), an increase in insulin resistance, dyslipidaemia, and endothelial dysfunction. Exposure to endogenous oestrogen during the reproductive years provides women with protection against cardiovascular disease, which is lost around 10 years after the onset of menopause. In particular, women with vasomotor symptoms during menopause seem to have an unfavourable cardiometabolic profile. Early management of the traditional risk factors of cardiovascular disease (ie, hypertension, obesity, diabetes, dyslipidaemia, and smoking) is essential; however, it is important to recognise in the reproductive history the female-specific conditions (ie, gestational hypertension or diabetes, premature ovarian insufficiency, some gynaecological diseases such as functional hypothalamic amenorrhoea, and probably others) that could enhance the risk of cardiovascular disease during and after the menopausal transition. In this Review, the first of a Series of two papers, we provide an overview of the literature for understanding cardiometabolic changes and the management of women at midlife (40-65 years) who are at higher risk, focusing on the identification of factors that can predict the occurrence of cardiovascular disease. We also summarise evidence about preventive non-hormonal strategies in the context of cardiometabolic health.

Increased Risk of Cardio-Cerebrovascular Diseases in Migraine Patients: A Nationwide Population-Based, Longitudinal Follow-Up Study in South Korea

Background and Purpose

Migraine is reportedly associated with several cardio-cerebrovascular diseases (CCDs), but some of these diseases have not received sufficient attention. We thus attempted to determine the associations of migraine with peripheral arterial disease (PAD), ischemic heart disease (IHD), atrial fibrillation/flutter (AF), ischemic stroke (IS), and hemorrhagic stroke (HS).

Methods

The study population was recruited by applying International Classification of Diseases, Tenth Revision (ICD-10) codes to the database of the Korean National Health Insurance Service from 2002 to 2018. Cumulative incidence curves were plotted to compare the incidence rates of CCDs between the migraine (ICD-10 code G43; n=130,050) and nonmigraine (n=130,050) groups determined using 1:1 propensity-score matching. Cox proportional-hazards regression models were used to obtain adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for CCDs in patients with any migraine, migraine with aura (n=99,751), and migraine without aura (n=19,562) compared with nonmigraine controls.

Results

For all CCDs, the cumulative incidence rates were higher in the migraine group than the nonmigraine group (p<0.001 in log-rank test). Any migraine, irrespective of the presence of aura, was associated with PAD (aHR 2.29, 95% CI 2.06–2.53), IHD (aHR 2.17, 95% CI 2.12–2.23), AF (aHR 1.84, 95% CI 1.70–1.99), IS (aHR 2.91, 95% CI 2.67–3.16), and HS (aHR 2.46, 95% CI 2.23–2.71). aHR was higher in female than in male migraineurs for all of the CCDs.

Conclusions

Associations of migraine with CCDs have been demonstrated, which are stronger in females than in males.

Pregnancy and Reproductive Risk Factors for Cardiovascular Disease in Women

Beyond conventional risk factors for cardiovascular disease, women face an additional burden of sex-specific risk factors. Key stages of a woman's reproductive history may influence or reveal short- and long-term cardiometabolic and cardiovascular trajectories. Early and late menarche, polycystic ovary syndrome, infertility, adverse pregnancy outcomes (eg, hypertensive disorders of pregnancy, gestational diabetes, preterm delivery, and intrauterine growth restriction), and absence of breastfeeding are all associated with increased future cardiovascular disease risk. The menopause transition additionally represents a period of accelerated cardiovascular disease risk, with timing (eg, premature menopause), mechanism, and symptoms of menopause, as well as treatment of menopause symptoms, each contributing to this risk. Differences in conventional cardiovascular disease risk factors appear to explain some, but not all, of the observed associations between reproductive history and later-life cardiovascular disease; further research is needed to elucidate hormonal effects and unique sex-specific disease mechanisms. A history of reproductive risk factors represents an opportunity for comprehensive risk factor screening, refinement of cardiovascular disease risk assessment, and implementation of primordial and primary prevention to optimize long-term cardiometabolic health in women.

Trajectories of Blood Pressure in Midlife Women: Does Menopause Matter?

BACKGROUND

Whether changes in blood pressure (BP) over women's midlife are more driven by chronological aging or the menopause transition has been debated. We sought to determine whether women can be classified into distinct trajectory groups based on pattern and level of systolic BP (SBP), diastolic BP, pulse pressure (PP), and mean arterial pressure (MAP) over the menopause transition, and to assess whether menopause-related factors predict the group and level of BP measures.

METHODS

Participants were from the SWAN (Study of Women's Health Across the Nation). Group-based trajectory modeling was used to identify women who shared distinct BP trajectories over time relative to menopause onset and to assess associations of menopause-related factors with trajectory group and level of BP measures. An accelerated rise relative to menopause onset suggests a menopause contribution.

RESULTS

The study included 3302 multiracial and multiethnic women with BP measures over 17 follow-up visits (baseline age [SD]: 46.3 [2.7]). Women were classified into either low, medium, or high trajectory group in each BP measure. The low SBP, PP, and MAP trajectories (in 35%, 53%, and 28% of the cohort, respectively) were rising slowly before menopause but showed a significant accelerated rise 1 year after menopause, indicating a menopause contribution. The remaining BP trajectories were rising up until menopause and either continued with the same rise or declined after menopause. A younger menopause age predicted the low SBP, PP, and MAP trajectories. A greater follicle-stimulating hormone level predicted lower SBP and PP levels, while vasomotor symptoms occurrence predicted higher SBP, PP, and MAP levels over time. Estradiol did not predict trajectory or level of any BP measure.

CONCLUSIONS

Distinct BP trajectories over the menopause transition exist that revealed a group of women whose SBP, PP, and MAP trajectories are consistent with a menopause contribution. Our findings support frequent monitoring of BP during the menopause transition.

Menopause is more than Hot Flashes: What is Missing in Homeopathic Research? A Narrative Review

BACKGROUND

 Menopausal complaints are frequently treated with homeopathy in daily practice worldwide. Recently, vasomotor symptoms have been understood to have implications as predictors of other important and long-term outcomes, causing increased risk of mortality and/or disability.

METHODS

 A comprehensive search of the literature was conducted to investigate whether homeopathic treatments for menopausal women with vasomotor symptoms have a positive effect on other important health outcomes associated with menopause, such as cardiovascular disease, neurocognitive impairment, metabolic and mood disorders, or osteoporosis.

RESULTS

 Though observational studies have shown encouraging results in reducing the severity and frequency of hot flashes in women treated with homeopathy, few randomized controlled trials have shown positive results. In most of the studies using homeopathy, the primary outcome is reduction in the frequency and severity of hot flashes, and other menopausal complaints are assessed secondarily as a part of the symptoms evaluated in the menopausal scales. Quality of life improves with homeopathic treatments for hot flashes, but there is scarce evidence of the effect of homeopathy on other health outcomes associated with menopause. Limited evidence exists in the case of menopausal women treated with individualized homeopathy for depression and metabolic disorders.

CONCLUSION

 A more comprehensive approach for treating menopause in routine homeopathic practice constitutes a valuable opportunity to increase knowledge and high-quality research in this field. Future homeopathic research for menopause should be focused on well-designed, double-blind, placebo-controlled, randomized trials as well as on pragmatic trials to show whether homeopathic treatments for vasomotor symptoms can also improve outcomes that are well-known to increase the risk of mortality and/or disability.

Menopausal symptoms and risk of heart failure: a retrospective analysis from Taiwan National Health Insurance Database

Aims

Women with menopausal symptoms show evidence of accelerated epigenetic ageing, vascular aging and low‐grade systemic inflammation status. However, data are limited regarding menopausal symptoms and risk of heart failure (HF). We aimed to explore the impact of menopausal symptoms on risk of HF.

Methods

We included 14 340 symptomatic menopausal women without a history of coronary heart disease (CHD) or HF from the Taiwan National Health Insurance Research Database as the experimental cohort. We included 14 340 asymptomatic women matched for age and comorbidities as controls. We surveyed possible comorbidity‐attributable risks of HF and assessed whether menopausal symptoms play a role in risk of HF. Additional analyses were conducted to ascertain the association of CHD and HF in different risk factor burdens categories in both cohorts and CHD was applied as a sensitivity analysis.

Results

The incidence of HF was not significantly lower in the experimental than in the control cohort (4.87 vs. 5.06 per 1000 person‐years, P = 0.336). Participants with a higher comorbidity burden had a proportionally increased risk of HF and CHD in both cohorts. The burden of risk factors had a greater impact on risk of HF in the control than in the experimental cohort (≥five risk factors, adjusted hazard ratio 25.69 vs. 14.75). Participants undergoing hormone therapy had no significant effect on the risk of HF, regardless of the presence or absence of menopausal symptoms. Subgroup analysis revealed that compared with the control cohort, the risk of HF in the experimental cohort did not increase significantly in all subgroups.

Conclusions

Menopausal symptoms were associated with CHD risk but not with risk of HF. Traditional risk factors rather than menopausal symptoms play important roles in the HF risk among middle‐aged women.

Identification of Symptom Clusters Among Midlife Menopausal Women with Metabolic Syndrome

The aim of this study was to identify and compare symptom clusters in midlife menopausal women with and without metabolic syndrome based on symptom occurrence and severity dimension through secondary data analysis of the Study of Women's Health Across the Nation. Exploratory factor analysis was used to group symptoms that are highly correlated with each other and verified by confirmatory factor analysis. Midlife menopausal women with metabolic syndrome (n = 424) experienced mental health, vasomotor, and somatic cluster across both symptom dimensions. In contrast, midlife menopausal women without metabolic syndrome (n = 1022) experienced mental health/sleep/urinary, vasomotor, and somatic cluster for symptom occurrence dimension and mental health/sleep, vasomotor/genital, and somatic cluster for symptom severity dimension. This is the first study to identify symptom clusters in midlife menopausal women with metabolic syndrome, who are at risk for experiencing complex symptoms associated with menopause transition and metabolic syndrome, and to compare symptom clusters to those without metabolic syndrome.

Are vitamin D deficiency and VDR gene polymorphisms associated with high blood pressure as defined by the ACC/AHA 2017 criteria in postmenopausal women?

OBJECTIVES

To assess the vitamin D levels, prevalence of vitamin D deficiency and genotypes of Fok-I, Bsm-I, Apa-I and Taq-I polymorphisms in the VDR gene and to determine whether vitamin D deficiency and VDR gene variants are associated with blood pressure levels and systemic arterial hypertension as defined by the 2017 ACC/AHA criteria.

STUDY DESIGN

A cross-sectional study of biobanked blood samples from 339 postmenopausal women.

MAIN OUTCOME MEASURES

Blood pressure strata were defined according to the 2017 ACC/AHA cutoffs. Circulating 25(OH)D levels were considered deficient if <20 ng/mL.

RESULTS

Mean serum total 25(OH)D levels were 22.99 ± 8.54 ng/mL, and 40.1% of participants were deficient in vitamin D. Overall, 7.7% had elevated blood pressure, 36.6% had stage 1 and 37.8% had stage 2 hypertension. Mean total (p = 0.014) and free 25(OH)D levels (p = 0.029) were lower in women with stage 2 hypertension than in those with normal blood pressure. A higher prevalence rate of stage 2 hypertension was associated with age (PR 1.058; 95%CI 1.033-1.083; p < 0.001), BMI (PR 1.046; 95%CI 1.025-1.068; p < 0.001), vitamin D deficiency (PR 1.333; 95%CI 1.016-1.749; p = 0.038) and Taq-I polymorphism (PR 1.764; 95%CI 1.030-3.019; p = 0.039). Women with vitamin D deficiency and the AA+AG genotype of Taq-I polymorphism were 33% and 76% more likely to have stage 2 hypertension, respectively, but these associations lost significance when adjusted for age and BMI.

CONCLUSION

The results suggest that vitamin D deficiency and Taq-I polymorphism are associated with stage 2 hypertension, depending on age and BMI, in postmenopausal women.

Blood pressure and adiposity in midlife Singaporean women

Hypertension is a major risk factor for cardiac events and stroke. Visceral adipose tissue (VAT) is known to increase the risk of incident hypertension in adults. Although adiposity has been linked to markers of inflammation, few studies have examined these markers as potential mediators of the association between visceral adiposity and elevated blood pressure. We evaluated sociodemographic, reproductive, and lifestyle risk factors for elevated blood pressure among midlife Singaporean women. A total of 1189 women, with a mean age of 56.3 ± 6.2 years, from the Integrated Women's Health Program (IWHP) at National University Hospital, Singapore were studied. Hypothesized risk factors and levels of inflammatory markers were examined in relation to systolic blood pressure (SBP) and diastolic blood pressure (DBP) using multivariable linear regression models. Prehypertension (SBP 120-139 mmHg and/or DBP 80-89 mmHg) and hypertension (SBP ≥140 mmHg and/or DBP ≥90 mmHg) were observed in 518 (43.6%) and 313 (26.3%) women, respectively. Compared to women in the lowest tertiles, women in the middle and upper tertiles of VAT had 7.1 (95% CI, 4.4, 9.8) mmHg and 10.2 (95% CI, 6.7, 13.7) mmHg higher adjusted SBP, respectively. Nulliparous older women with a lower education level and those with no or mild hot flashes also had a significantly higher adjusted SBP. No significant independent risk factors were observed for DBP. Adjustments for IL-6, TNF-α, and hs-CRP did not attenuate the association between VAT and SBP. In summary, we found an independent positive association between VAT and SBP. Elevated levels of inflammatory markers did not mediate the increase in SBP in women with high VAT.

Cardiovascular health after menopause transition, pregnancy disorders, and other gynaecologic conditions: a consensus document from European cardiologists, gynaecologists, and endocrinologists

Women undergo important changes in sex hormones throughout their lifetime that can impact cardiovascular disease risk. Whereas the traditional cardiovascular risk factors dominate in older age, there are several female-specific risk factors and inflammatory risk variables that influence a woman's risk at younger and middle age. Hypertensive pregnancy disorders and gestational diabetes are associated with a higher risk in younger women. Menopause transition has an additional adverse effect to ageing that may demand specific attention to ensure optimal cardiovascular risk profile and quality of life. In this position paper, we provide an update of gynaecological and obstetric conditions that interact with cardiovascular risk in women. Practice points for clinical use are given according to the latest standards from various related disciplines (Figure 1).

Menopausal Vasomotor Symptoms and Risk of Incident Cardiovascular Disease Events in SWAN

Background

Cardiovascular disease (CVD) in women has unique features, including associations with reproductive factors that are incompletely understood. Vasomotor symptoms (VMS), the classic menopausal symptom, are linked to CVD risk factors and subclinical CVD. Evidence linking VMS to CVD events is limited. We tested whether frequent and/or persistent VMS were associated with increased risk for fatal and nonfatal CVD events in SWAN (Study of Women’s Health Across the Nation).

Methods and Results

A total of 3083 women, aged 42 to 52 years at baseline, underwent up to 16 in‐person visits over 22 years. Assessments included questionnaires on VMS frequency (0, 1–5, or ≥6 days/2 weeks), physical measures, phlebotomy, and reported CVD events (myocardial infarction, stroke, heart failure, and revascularization). A subset of events was adjudicated via medical record. Death certificates were obtained. Relationships between baseline VMS or persistent VMS over the follow‐up (proportion of visits with frequent VMS) with combined incident nonfatal and fatal CVD were tested in Cox proportional hazards models adjusted for demographics, medication use, and CVD risk factors. Participants experienced 231 CVD events over the follow‐up. Women with frequent baseline VMS had an elevated risk of subsequent CVD events (relative to no VMS; ≥6 days: hazard ratio [HR] [95% CI], 1.51 [1.05–2.17], P=0.03; 1–5 days: HR [95% CI], 1.02 [0.75–1.39], P=0.89, multivariable). Women with frequent VMS that persisted over time also had an increased CVD event risk (>33% versus ≤33% of visits: HR [95% CI], 1.77 [1.33–2.35], P<0.0001, multivariable).

Conclusions

Frequent and persistent VMS were associated with increased risk of later CVD events. VMS may represent a novel female‐specific CVD risk factor.

Prevalence of hot flashes in women of 40 to 65 years of age with metabolic syndrome

SUMMARY OBJECTIVE: Hot flashes have a negative impact on the quality of life of women during the menopausal transition and thereafter. The progressive reduction in gonadal estrogen levels associated with aging promotes an accumulation of abdominal fat, dyslipidemia, and arterial hypertension, all of which are components of metabolic syndrome (MetS). The objective of the present study was to estimate the prevalence of hot flashes and evaluate their relationship with MetS in women ≥ 40 years of age. METHODS: This was a cross-sectional study involving women aged between 40 and 65 years. We used the Kupperman index to quantify the climacteric symptoms and the National Cholesterol Education Program Adult Treatment Panel III criteria for the diagnosis of MetS. RESULTS: 1,435 women were initially selected, and we obtained information from 647. The mean age at menopause was 45.99 years (SD 6.61 years) and the prevalence of hot flashes and MetS were 55.83% (95% CI: 52.35-59.25%) and 46.29% (95% CI: 44.75-52.53%), respectively. We identified a positive association between MetS and hot flashes (OR 1.16; 95% CI: 1.01-1.33). CONCLUSIONS: In women ≥ 40 years of age, hot flashes are highly prevalent and appear to be associated with MetS.

The midlife transition and the risk of cardiovascular disease and cancer Part II: strategies to maximize quality of life and limit dysfunction and disease

Chronic dysfunction, disabilities, and complex diseases such as cardiovascular disease, diabetes mellitus type 2, osteoporosis and certain cancers, among other burdens, emerge and accelerate in midlife women. Previously in part l, we described the clinical and laboratory research findings that more readily explain and clarify the underlying pathogenetic mechanisms driving these clinical burdens, including new findings on how in particular visceral obesity and the emergence and acceleration of various components of metabolic syndrome-glucotoxicity and lipotoxicity-and a chronic systemic inflammatory state abetted by the loss of ovarian production of estradiol and the inevitable inroads of aging generate this spectrum of clinical problems. These research insights translate into opportunities for effective care strategies leading to prevention, amelioration, possible correction, and enhanced quality of life. To achieve these goals, updated detailed diagnostic, management, and therapeutic guidelines implemented by a reprogrammed and repurposed "menopause" office visit are described. A triage mechanism-when to refer to other specialists for further care-is emphasized. The previously polarized views of menopausal hormone therapy have narrowed significantly, leading to the construction of a more confident, unified, and wider clinical application. Accordingly, a menopausal hormone therapy program providing maximum benefit and minimum risk, accompanied by an algorithm for enhanced shared decision making, is included.

The severity of vasomotor symptoms and number of menopausal symptoms in postmenopausal women and select clinical health outcomes in the Women's Health Initiative Calcium and Vitamin D randomized clinical trial

OBJECTIVE

This study evaluated whether vasomotor symptom (VMS) severity and number of moderate/severe menopausal symptoms (nMS) were associated with health outcomes, and whether calcium and vitamin D (CaD) modified the risks.

METHODS

The Women's Health Initiative CaD study was a double blind, randomized, placebo-controlled trial, which tested 400 IU of 25-hydroxyvitamin-D and 1,000 mg of calcium per day in women aged 50 to 79 years. This study included 20,050 women (median follow-up of 7 y). The outcomes included hip fracture, colorectal cancer, invasive breast cancer, all-cause mortality, coronary heart disease, stroke, cardiovascular death, and total cardiovascular disease (CVD). MS included: hot flashes, night sweats, dizziness, heart racing, tremors, feeling restless, feeling tired, difficulty concentrating, forgetfulness, mood swings, vaginal dryness, breast tenderness, migraine, and waking up several times at night. Associations between VMS severity and nMS with outcomes were tested.

RESULTS

No association between VMS severity and any outcome were found. In contrast, nMS was associated with higher stroke (hazard ratio [HR] 1.40 95% confidence interval [CI] 1.04-1.89 for ≥ 2 MS vs none; HR 1.20 95% CI 0.89-1.63 for 1 MS vs none, P trend = 0.03) and total CVD (HR 1.35, 95% CI, 1.18-1.54 for ≥ 2 MS vs none; HR 0.99, 95% CI, 0.87-1.14 for 1 MS vs none P trend < 0.001). CaD did not modify any association.

CONCLUSION

Severity of VMS was not associated with any outcome. Having ≥2 moderate or severe MS was associated with an increased risk for CVD. The number of moderate/severe MS may be a marker for higher CVD risk. : Video Summary:http://links.lww.com/MENO/A669.

Hypertensive disorders of pregnancy and menopausal symptoms: a cross-sectional study from the data registry on experiences of aging, menopause, and sexuality

OBJECTIVE

Hypertensive disorders of pregnancy and menopausal symptoms, specifically vasomotor symptoms, have both been associated with cardiovascular disease risk in women. However, data are sparse on the association between these two female-specific cardiovascular risk factors. This study was conducted to investigate the association between a history of a hypertensive disorder of pregnancy and menopausal symptoms.

METHODS

This was a cross-sectional study of women aged 40 to 65 years seen for specialty consultation in women's health clinics at Mayo Clinic Rochester, MN and Scottsdale, AZ, between May, 2015 and September, 2019. A self-reported history of hypertensive disorders of pregnancy served as the independent variable, and menopause symptoms as assessed by the Menopause Rating Scale were the primary outcome measure.

RESULTS

Of 2,684 women included in the analysis, 180 had a self-reported history of a hypertensive disorder of pregnancy. The total menopausal symptom scores as well as somatic and psychological domain scores were higher in women with a history of a hypertensive disorder of pregnancy compared to women without a history of a hypertensive disorder of pregnancy or to women without a pregnancy. On multivariable analysis, women with a hypertensive disorder of pregnancy using hormone therapy had significantly higher total menopause symptom scores than women with no such history.

CONCLUSIONS

In this large cross-sectional study, a history of hypertensive disorders of pregnancy was associated with more bothersome menopausal symptoms. Additional study is needed to determine the strength of this association, underlying mechanisms of the association, and clinical implications for cardiovascular risk prediction in women.

Life-Course Reproductive History and Cardiovascular Risk Profile in Late Mid-Life: The CARDIA Study

Background Reproductive events, that is, a preterm birth (PTB), small-for-gestational-age infant (SGA), and vasomotor symptoms of menopause, are associated with subclinical atherosclerotic cardiovascular disease (ASCVD). We evaluated whether women with a past PTB and/or SGA (henceforth PTB/SGA) were more likely to have severe vasomotor symptoms of menopause and whether the estimated 10-year ASCVD risk was higher in women with PTB/SGA and vasomotor exposures. Methods and Results We assigned 1866 women (mean age=55±1 years) in the CARDIA (Coronary Artery Risk Development in Young Adults) study to the following categories of reproductive exposures: none, PTB/SGA only, vasomotor symptoms only, or both PTB/SGA and vasomotor symptoms. We used Kruskal-Wallis tests to evaluate the differences in pooled cohort equation ASCVD risk scores by category and linear regression to evaluate the associations of categories with ASCVD risk scores adjusted for study center, body mass index, education, current hormone replacement therapy use, parity, and hysterectomy. Women with PTB/SGA were more likely to have severe vasomotor symptoms, 36% versus 30%, P<0.02. ASCVD risk score was higher in women with both PTB/SGA and vasomotor symptoms (4.6%; 95% CI, 4.1%-5.1%) versus women with no exposures (3.3%; 95% CI, 2.9%-3.7%) or vasomotor symptoms only (3.8%; 95% CI, 3.5%-4.0%). ASCVD risk score was higher in women PTB/SGA (4.8%; 95% CI, 3.6%-5.9%) versus no exposures. PTB/SGA and vasomotor symptoms was associated with ASCVD risk score in white women versus no exposures (β=0.40; 95% CI, 0.02-0.78). Conclusions Women with prior PTB/SGA were more likely to have severe vasomotor symptoms of menopause. Reproductive exposures were associated with an estimated 10-year ASCVD risk in white women.

Vasomotor Symptoms and Accelerated Epigenetic Aging in the Women's Health Initiative (WHI)

PURPOSE

The hallmark menopausal symptom, vasomotor symptoms (VMS), has been linked to adverse health indicators. However, the relationship between VMS and biological aging has not been tested. We examined associations between menopausal VMS and biological aging as assessed by 2 DNA methylation-based epigenetic aging indicators previously linked to poor health outcomes.

METHODS

Participants were members of the Women's Health Initiative Observational Study integrative genomics substudy (N = 1206) who had both ovaries and were not taking hormone therapy. Relationships between VMS at enrollment (presence, severity) or VMS timing groups (no VMS: not at menopause onset nor at study enrollment; early VMS: at menopause onset but not at enrollment; persistent VMS: at menopause onset and study enrollment; and late VMS: at enrollment but not at menopause onset) and epigenetic clock indicators predictive of physical aging and early death (DNAm PhenoAge, DNAm GrimAge) were tested in linear regression models adjusting for age, race/ethnicity, hysterectomy, education, body mass index, smoking, and, in additional models, sleep disturbance.

RESULTS

Women were on average 65 years of age at enrollment. Severe hot flashes at enrollment were associated with higher DNAm PhenoAge [relative to no hot flashes: B (SE) = 2.79 (1.27), P = 0.028, multivariable]. Further, late-occurring VMS were associated with both higher DNAm PhenoAge [B (SE) = 2.15 (0.84), P = 0.011] and DNAm GrimAge [B (SE) = 1.09 (0.42), P = 0.010, multivariable] relative to no VMS.

MAIN CONCLUSIONS

Among postmenopausal women, severe or late-occurring VMS were associated with accelerated epigenetic age, controlling for chronological age. Postmenopausal women with severe or late-occurring VMS may have greater underlying epigenetic aging.

Changes in heart rate and blood pressure during nocturnal hot flashes associated with and without awakenings

Hot flashes (HFs) are a hallmark of menopause in midlife women. They are beyond bothersome symptoms, having a profound impact on quality of life and wellbeing, and are a potential marker of cardiovascular (CV) disease risk. Here, we investigated the impact on CV functioning of single nocturnal HFs, considering whether or not they were accompanied by arousals or awakenings. We investigated changes in heart rate (HR, 542 HFs), blood pressure (BP, 261 HFs), and pre-ejection period (PEP, 168 HFs) across individual nocturnal physiological HF events in women in the menopausal transition or post-menopause (age: 50.7 ± 3.6 years) (n = 86 for HR, 45 for BP, 27 for PEP). HFs associated with arousals/awakenings (51.1%), were accompanied by an increase in systolic (SBP; ~6 mmHg) and diastolic (DBP; ~5 mmHg) BP and HR (~20% increase), sustained for several minutes. In contrast, HFs occurring in undisturbed sleep (28.6%) were accompanied by a drop in SBP and a marginal increase in HR, likely components of the heat dissipation response. All HFs were accompanied by decreased PEP, suggesting increased cardiac sympathetic activity, with a prolonged increase for HFs associated with sleep disruption. Older age predicted greater likelihood of HF-related sleep disturbance. HFs were less likely to wake a woman in rapid-eye-movement and slow-wave sleep. Findings show that HFs associated with sleep disruption, which are in the majority and more likely in older women, lead to increases in HR and BP, which could have long-term impact on nocturnal CV restoration in women with multiple HFs.

The menopause transition and women's health at midlife: a progress report from the Study of Women's Health Across the Nation (SWAN)

OBJECTIVE

Our initial understanding of the menopause transition (MT) has been framed by clinical samples of women seeking treatment rather than by population-based studies. The Study of Women's Health Across the Nation (SWAN) initiated in 1996 with an overall goal to define the MT, to characterize its biological and psychosocial antecedents and sequelae in an ethnically and racially diverse sample of midlife women.

METHODS

This review summarizes the central findings of SWAN to date that can inform women and their healthcare providers about the impact of the MT and midlife aging on overall health and well-being.

RESULTS

SWAN characterized changes in reproductive axis and menstrual cycle patterns that informed the development of the reproductive aging staging system Staging of Reproductive Aging Workshop+10; MT-related symptoms and mental health (vasomotor symptoms, sleep complaints, psychological symptoms, cognitive performance, and urogenital and sexual health); and physiological systems and functions (cardiovascular and cardiometabolic health, bone health, physical function performance) that are influenced by the MT. SWAN demonstrated substantial interrelations among these changes and significant racial/ethnic differences in the rate and magnitude of change in multiple health indictors in midlife women. The findings point to midlife as a critical stage for adopting healthy behavior and preventive strategies.

CONCLUSIONS

Over the past 23 years, SWAN has advanced our understanding of the impact of the MT and midlife aging on health and well-being in women. SWAN will be instrumental to determine whether MT-related changes during midlife are related to unfavorable health and well-being in early old age.

Sex-Specific Physiology and Cardiovascular Disease

Sex differences in cardiovascular diseases can be classified as those which are specific to one sex and those that differ in incidence, prevalence, etiology, symptomatology, response to treatment, morbidity, and mortality in one sex compared to the other. All sex differences in cardiovascular conditions have their basis in the combined expression of genetic and hormonal differences between women and men. This chapter addresses how understanding basic mechanisms of hormone responses, imaging diagnostics, and integration of genomics and proteomics has advanced diagnosis and improved outcomes for cardiovascular conditions, apart from those related to pregnancy that are more prevalent in women. These conditions include obstructive coronary artery disease, coronary microvascular dysfunction, spontaneous coronary artery dissection, diseases of the cardiac muscle including heart failure and takotsubo cardiomyopathy, and conditions related to neurovascular dysregulation including hot flashes and night sweats associated with menopause and effects of exogenous hormones on vascular function. Improvement in technologies allowing for noninvasive assessment of neuronally mediated vascular reactivity will further improve our understanding of the basic etiology of the neurovascular disorders. Consideration of sex, hormonal status, and pregnancy history in diagnosis and treatment protocols will improve prevention and outcomes of cardiovascular disease in women as they age.

Cardiovascular Implications of the Menopause Transition: Endogenous Sex Hormones and Vasomotor Symptoms

The menopause transition (MT) is a critical period of women's lives marked by several physiologic changes and menopause-related symptoms that have implications for health. Risk for cardiovascular disease, the leading cause of death in women, increases after menopause, suggesting a contribution of the MT to its development. This article focuses on the relationship between 2 main features of the MT and women's cardiovascular health: (1) dynamic alterations of sex hormones, particularly endogenous estradiol and follicle-stimulating hormone, and (2) vasomotor symptoms, the cardinal symptom of the menopause. Limitations and future directions are discussed.

Neighborhood disorder, exposure to violence, and perceived discrimination in relation to symptoms in midlife women

BACKGROUND

Some symptoms at midlife are associated with stress, such as hot flashes, trouble sleeping, headaches, or depressed mood. Hot flashes have been studied in relation to laboratory stressors, physiological biomarkers, and self-reported stress, but less is known about hot flashes in relation to the larger context of women's lives. This study examined the risk of symptoms in relation to neighborhood disorder, exposure to neighborhood violence, social cohesion and perceived discrimination. We hypothesized that women exposed to more negative neighborhood characteristics and discrimination would be more likely to report hot flashes and other midlife symptoms.

METHODS

Participants were black and white women, aged 40 to 60, drawn from a cross-sectional investigation of race/ethnicity, socioeconomic status, and blood pressure in New York City (n = 139). Demographic information, medical history, menopausal status, and symptoms were measured by questionnaire. Likert scales were used to measure neighborhood characteristics, specifically, the Neighborhood Disorder Scale, the Exposure to Violence Scale, the Perceived Violence Subscale, the Neighborhood Social Cohesion and Trust Scale, and the Everyday Discrimination Scale. Ten symptoms were included in analyses: lack of energy, feeling blue/depressed, backaches, headaches, aches/stiffness in joints, shortness of breath, hot flashes, trouble sleeping, nervous tension, and pins/needles in hands/feet. Each scale with each symptom outcome was examined using logistic regression analyses adjusting for significant covariates.

RESULTS

Black women reported higher scores on all negative neighborhood characteristics and discrimination, and a lower score on the positive Neighborhood Social Cohesion and Trust. Neighborhood Disorder was associated with feeling blue/depressed, aches/stiffness in joints, and hot flashes, and Perceived Violence was associated with aches/stiffness in joints, after controlling for model-specific covariates. There was a lower risk of backaches with increasing Neighborhood Social Cohesion and Trust score. The Everyday Discrimination Scale was associated with lack of energy. Lack of energy, feeling blue/depressed, aches/stiffness in joints, and hot flashes appeared to be most vulnerable to negative neighborhood context and discrimination.

CONCLUSIONS

This study adds to the literature linking neighborhood environments to health outcomes. The associations between negative neighborhood contexts and discrimination with diverse symptoms, and the association between social cohesion and back pain, point to the need to expand analyses of stress to multiple physiological systems.

Vasomotor symptoms: natural history, physiology, and links with cardiovascular health

Vasomotor symptoms (VMS), or hot flushes and night sweats, are the classic symptom of menopause. Recent years have brought key advances in the knowledge about VMS. VMS last longer than previously thought, on average 7-10 years for frequent or moderate to severe VMS. Although VMS have long been understood to be important to women's quality of life, research has also linked VMS to indicators of cardiovascular disease (CVD) risk, such as an adverse CVD risk factor profile, greater subclinical CVD and, in emerging work, CVD events. Relations between VMS and CVD are not typically accounted for by CVD risk factors. In newer work, VMS-CVD risk relations are demonstrated with state-of-the-art subjective and objective measures of VMS. Some research indicates that VMS-CVD risk relations may be sensitive to the timing or duration of VMS. Thus, research collectively supports relations between VMS and CVD risk independent of known CVD risk factors. Next steps include identifying the mechanisms linking VMS and CVD risk indicators, understanding any timing effects, and clarifying the precise nature of relations between VMS and CVD risk. Clinical implications are discussed.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Data Registry on Experiences of Aging, Menopause, and Sexuality (DREAMS): A cohort profile

The Women's Health Clinic (WHC) at Mayo Clinic in Rochester, Minnesota, has provided consultative care to women with menopausal and sexual health concerns since 2005. Clinical information on the 8688 women seen in the WHC through May 2017 who gave consent for the use of their medical records in research is contained in the Data Registry on Experiences of Aging, Menopause, and Sexuality (DREAMS). Initially, DREAMS was created to improve the clinical care of women, but it has become a valuable research tool. About 25% of the DREAMS women have been seen in the WHC 2 or more times, allowing for passive longitudinal follow-up. Additionally, about 25% of the DREAMS women live in the 27-county region included in the expanded Rochester Epidemiology Project medical records linkage system, providing additional information on those women. The cohort has been used to investigate associations between: caffeine intake and vasomotor symptom bother; recent abuse (physical, sexual, verbal, and emotional) and menopausal symptoms; specific menopausal symptoms and self-reported view of menopause; and obstructive sleep apnea risk and vasomotor symptom severity and the experience of vasomotor symptoms in women older than 60 years. A study nearing completion describes a clinical series of over 3500 women presenting for sexual health consultation by sexual function domain and by decade of life. Other studies under way are determining correlates with sexual health and dysfunction. Planned studies will investigate associations between the experience with menopause and the risk of disease.