The relationship between the endocrine characteristics and the regularity of menstrual cycles in the approach to menopause

The role of estradiol fluctuation in the pathophysiology of perimenopausal depression: A hypothesis paper

The menopause transition, which constitutes the five or so years surrounding the final menstrual period, has been established as a time of increased risk for depressive symptoms. While mounting research suggests that exposure to more extreme and fluctuating levels of estradiol (E2) plays a role, it remains unclear which specific trigger is most strongly implicated in the development of depressive mood: acute E2 withdrawal or extreme increases in E2. The current review summarises the literature supporting the role of each, considering research pertaining to perimenopausal depression as well as other reproductive mood disorders in which ovarian hormone change is believed to play a key role, namely premenstrual dysphoric disorder and postpartum depression. Taking together the available research pertaining to the various reproductive mood disorders, we propose that women may exhibit one of four E2 sensitivity profiles, each of which may have important implications for the expected timing and severity of depressive mood during the menopause transition: the E2-increase sensitive profile, developing depressive mood in response to elevations in E2, the E2-decrease sensitive profile, for whom E2 withdrawal triggers negative mood, the E2-change sensitive profile, characterised by mood sensitivity to E2 change in either direction, and the E2 insensitive profile for whom changes in E2 have negligible psychological effects. The evidence supporting the existence of such profiles are summarised, potential biological mechanisms are briefly highlighted, and implications for future research are discussed.

Expression of Sex Hormone Receptor and Immune Response Genes in Peripheral Blood Mononuclear Cells During the Menstrual Cycle

Sex hormones are known to interact with the immune system on multiple levels but information on the types of sex hormone receptors (SHR) and their expression levels in immune cells is scarce. Estrogen, testosterone and progesterone are all considered to interact with the immune system through their respective cell receptors (ERα and ERβ including the splice variant ERβ2, AR and PGR). In this study expression levels of SHR genes in peripheral blood mononuclear cells (PBMCs) and cell subsets (CD4⁺ and CD8⁺ T-cells, CD56⁺ NK-cells, CD14⁺ monocytes and CD19⁺ B-cells) were analyzed using standard manual qPCR or a qPCR array (TLDA). Nine healthy individuals including men (n = 2), premenopausal (Pre-MP, n = 5) and postmenopausal (post-MP, n = 2) women were sampled for PBMCs which were separated to cell subsets using FACS. Ten Pre-MP women were longitudinally sampled for total PBMCs at different phases of the menstrual cycle. We found that ERα was most abundant and, unexpectedly, that ERβ2 was the dominant ERβ variant in several FACS sorted cell subsets. In total PBMCs, SHR (ERα, ERβ1, ERβ2, and AR) expression did not fluctuate according to the phase of the menstrual cycle and PGR was not expressed. However, several immune response genes (GATA3, IFNG, IL1B, LTA, NFKB1, PDCD1, STAT3, STAT5A, TBX21, TGFB1, TNFA) were more expressed during the ovulatory and mid-luteal phases. Sex hormone levels did not correlate significantly with gene expression of SHR or immune response genes, but sex hormone-binding globulin (SHBG), a steroid hormone transporting protein, was positively correlated to expression of ERβ1 gene. This study provides new insights in the distribution of ERs in immune cells. Furthermore, expression patterns of several immune response genes differ significantly between phases of the menstrual cycle, supporting a role for sex hormones in the immune response.

Describing the status of reproductive ageing simply and precisely: A reproductive ageing score based on three questions and validated with hormone levels

OBJECTIVE

Most women live to experience menopause and will spend 4-8 years transitioning from fertile age to full menstrual stop. Biologically, reproductive ageing is a continuous process, but by convention, it is defined categorically as pre-, peri- and postmenopause; categories that are sometimes supported by measurements of sex hormones in blood samples. We aimed to develop and validate a new tool, a reproductive ageing score (RAS), that could give a simple and yet precise description of the status of reproductive ageing, without hormone measurements, to be used by health professionals and researchers.

METHODS

Questionnaire data on age, menstrual regularity and menstrual frequency was provided by the large multicentre population-based RHINE cohort. A continuous reproductive ageing score was developed from these variables, using techniques of fuzzy mathematics, to generate a decimal number ranging from 0.00 (nonmenopausal) to 1.00 (postmenopausal). The RAS was then validated with sex hormone measurements (follicle stimulating hormone and 17β-estradiol) and interview-data provided by the large population-based ECRHS cohort, using receiver-operating characteristics (ROC).

RESULTS

The RAS, developed from questionnaire data of the RHINE cohort, defined with high precision and accuracy the menopausal status as confirmed by interview and hormone data in the ECRHS cohort. The area under the ROC curve was 0.91 (95% Confidence interval (CI): 0.90-0.93) to distinguish nonmenopausal women from peri- and postmenopausal women, and 0.85 (95% CI: 0.83-0.88) to distinguish postmenopausal women from nonmenopausal and perimenopausal women.

CONCLUSIONS

The RAS provides a useful and valid tool for describing the status of reproductive ageing accurately, on a continuous scale from 0.00 to 1.00, based on simple questions and without requiring blood sampling. The score allows for a more precise differentiation than the conventional categorisation in pre-, peri- and postmenopause. This is useful for epidemiological research and clinical trials.

Australians' understanding of the decline in fertility with increasing age and attitudes towards ovarian reserve screening

The aim of this study is to determine Australians' understanding of the decline in fertility with age, social determinants that influence their decision to start a family and attitudes towards ovarian reserve screening as a tool allowing personalised reproductive life planning. An online survey of 383 childless Australian men and women, aged 18-45 years, was conducted. Both sexes overestimated natural and in vitro fertilization (IVF)-assisted fertility potential with increasing age, with the magnitude of overestimation being more pronounced for men and IVF treatment compared with natural conception. The primary determinants for starting a family were a stable relationship, followed by establishment of career; availability of accessible child care and paid parental leave were considered less important. Finally, the majority of women (74%) would alter their reproductive life planning if they were identified as having low ovarian reserve on screening. Despite increased education, Australians continue to have a poor understanding of age-related decline in natural and IVF-assisted conception, potentially explaining why many delay starting a family. Ovarian reserve screening may help identify individuals at increased risk of premature diminished fertility, giving these women the ability to bring forward their plans for natural conception or undertake fertility preservation (oocyte freezing).

A pooled analysis of the efficacy of desvenlafaxine for the treatment of major depressive disorder in perimenopausal and postmenopausal women

BACKGROUND

Few studies in the literature have examined the efficacy of antidepressant drugs in perimenopausal and postmenopausal women. The objective of the current study was to assess the efficacy of desvenlafaxine (administered as desvenlafaxine succinate) separately in perimenopausal and postmenopausal women with major depressive disorder (MDD).

METHODS

Data were pooled from two double-blind, placebo-controlled clinical trials enrolling perimenopausal and postmenopausal women (40-70 years old) diagnosed with MDD. Patients were randomly assigned to receive desvenlafaxine 100 to 200 mg/day or placebo (8 weeks) or desvenlafaxine 50 mg/day or placebo (10 weeks). The primary efficacy end point for each trial was change from baseline in Hamilton Rating Scale for Depression (HAM-D17) total score at week 8. Secondary end points included change from baseline in Sheehan Disability Scale (SDS) and Menopause Rating Scale (MRS) scores. Changes from baseline in continuous variables were analyzed using analysis of covariance with treatment, region, and baseline in the model. All treatment comparisons were carried out separately in perimenopausal or postmenopausal women, in individual studies, and in the pooled population, adjusting for menopausal status and study.

RESULTS

A total of 798 patients were included in the full analysis set (perimenopausal, n=252; postmenopausal, n=546). Desvenlafaxine significantly reduced HAM-D17 total scores versus placebo at week 8 in both perimenopausal (-10.3 vs. -6.5; p<0.001) and postmenopausal women (-10.1 vs. -7.6; p<0.001). Significant improvements in SDS and MRS total scores were also observed for desvenlafaxine versus placebo in perimenopausal (p ≤ 0.024) and postmenopausal women (p ≤ 0.009). A significant treatment by menopausal status interaction was observed for SDS only (p=0.036).

CONCLUSIONS

Desvenlafaxine demonstrated antidepressant efficacy in both perimenopausal and postmenopausal subgroups of women with MDD.

DISCLAIMER

In September 2011, Pfizer received a Complete Response Letter from the United States Food and Drug Administration on its application for approval to market desvenlafaxine for the treatment of moderate to severe vasomotor symptoms associated with menopause. The Complete Response Letter states that the data included in the application are not sufficient to establish an acceptable risk/benefit profile for the treatment of vasomotor symptoms in the general population of postmenopausal women, and therefore desvenlafaxine is not approved for the treatment of vasomotor symptoms in the United States at this time. This decision does not impact desvenlafaxine's approval for the treatment of MDD in adults.

Developmental programming: prenatal BPA treatment disrupts timing of LH surge and ovarian follicular wave dynamics in adult sheep

Developmental exposure to BPA adversely affects reproductive function. In sheep, prenatal BPA treatment induces reproductive neuroendocrine defects, manifested as LH excess and dampened LH surge and perturbs early ovarian gene expression. In this study we hypothesized that prenatal BPA treatment will also disrupt ovarian follicular dynamics. Pregnant sheep were treated from days 30 to 90 of gestation with 3 different BPA doses (0.05, 0.5, or 5mg/kgBW/day). All female offspring were estrus synchronized and transrectal ultrasonography was performed daily for 22days to monitor ovarian follicular and corpora lutea dynamics. Blood samples were collected to assess preovulatory hormonal changes and luteal progesterone dynamics. Statistical analysis revealed that the time interval between the estradiol rise and the preovulatory LH surge was shortened in the BPA-treated females. None of the three BPA doses had an effect on corpora lutea, progestogenic cycles, and mean number or duration of ovulatory and non-ovulatory follicles. However, differences in follicular count trajectories were evident in all three follicular size classes (2-3mm, 4-5mm, and ≥6mm) of prenatal BPA-treated animals compared to controls. Number of follicular waves tended also to be more variable in the prenatal BPA-treated groups ranging from 2 to 5 follicular waves per cycle, while this was restricted to 3 to 4 waves in control females. These changes in ovarian follicular dynamics coupled with defects in time interval between estradiol rise and preovulatory LH release are likely to lead to subfertility in prenatal BPA-treated females.

[Low circulating anti-Müllerian hormone and normal follicle stimulating hormone levels: which prognosis in an IVF program?]

OBJECTIVE

To evaluate the results of controlled ovarian hyperstimulation (COH) for IVF in patients with low anti-Müllerian hormone (AMH) and normal basal follicle stimulating hormone (FSH) and Estradiol levels (≤50 pg/mL).

PATIENTS AND METHODS

A retrospective cohort study including 704 patients for whom AMH and FSH levels (measured between days 3 and 5 of the menstrual cycle) were available, is performed in the IVF center at the Sèvres Hospital (France). Three groups are designed and analyzed: group 1 with AMH less or equal to 2 ng/mL and FSH less or equal to 10 mUI/mL (study group), Group 2 with AMH greater than 2 ng/mL and FSH less or equal to 10 mUI/mL (control group) and Group 3 with AMH less or equal to 2 ng/mL and FSH greater than 10 mUI/mL (group with decreased ovarian reserve).

RESULTS

IVF outcome for patients from the study group is significantly worse than that of the second but not than that of the third group. In the first group, the number of retrieved oocytes, the number of total obtained embryos, the clinical pregnancy rate and the live birth rate are significantly lower than in the second group; moreover, there are more cancelled cycles because of poor response in the first group. There is no difference with the third group.

DISCUSSION AND CONCLUSIONS

This study shows that women with a low baseline AMH have a similar response to COH to the poor responders patients with a decreased ovarian reserve revealed by an elevated FSH level. Thus, when a woman undergoing IVF cycle presents a low AMH, she might be considered as a poor responder patient regardless of the FSH level and, although the clinical pregnancy rate is not so disappointing (18%), the couple should be informed of a higher risk of cycle cancellation.

Neuroendocrinology and ovarian aging

The ovarian aging, a dynamic process that precedes the clinical manifestations of menopause, can be assessed using ovarian reserve biomarkers. It is well-known that reproduction during the later years of reproductive life has known limitations that challenge the success of assisted reproduction. Therefore, a review of the neuroendocrine modifications during this critical period of reproductive life may help to elucidate the ovarian aging process and its impact on reproduction. In this review, we aim to further the discussion of neuroendocrine changes taking place during the ovarian aging process that may impact reproductive function.

Unpredictable endocrinology of the menopause transition: clinical, diagnostic and management implications

The approach to menopause can be divided into the early (E) and late (L) menopausal transitions (MT) on the basis of menstrual irregularity (EMT) and subsequent observation of at least one episode of 60 or more days amenorrhoea (LMT). In total, 40-60% of cycles in the LMT are anovulatory, often with low oestradiol (E2) and high follicle-stimulating hormone concentrations. The ovulatory cycles have variable endocrine characteristics, none of which is specific to EMT or LMT. Hormonal measurements of FSH and E2 are thus of little diagnostic value because of their unpredictable variability. Symptoms during the transitions may result from high or low E2 and can often be satisfactorily managed with low-dose oral contraceptives, which suppress pituitary-ovarian function.

Differential effects of aging on estrogen negative and positive feedback

Recent studies have demonstrated an age-related decline in gonadotropins and a decrease in pituitary responsiveness to GnRH, indicating that aging influences the neuroendocrine components of the female reproductive axis independently of changes in ovarian function. To determine whether aging might also affect the luteinizing hormone (LH) negative and positive feedback responses to gonadal steroids, we administered a controlled, graded sex steroid infusion to 11 younger (45-56 yr) and nine older (70-80 yr) postmenopausal women (PMW) in whom endogenous ovarian steroids and peptides are uniformly low. The doses of estradiol (E(2)) and progesterone (P) were chosen to mimic levels across the normal follicular phase and have been shown previously to induce negative followed by positive feedback on LH. Similar E(2) and P levels were achieved in younger and older PMW (P = 0.4 and 0.3, respectively) and produced a biphasic LH response in all subjects. The early decline in LH to 53% of baseline was not different in older vs. younger PMW. However, the positive feedback effect was attenuated in older compared with younger PMW (peak LH 144.4 ± 19.5 vs. 226.8 ± 22.3 IU/l, respectively, P = 0.01). In conclusion, these studies in PMW demonstrate preservation of short-term steroid negative and positive feedback in response to exogenous E(2) and P with aging. Attenuation of positive feedback in older compared with younger PMW is consistent with previous reports of declining GnRH responsiveness with aging.

Depression or menopause? Presentation and management of major depressive disorder in perimenopausal and postmenopausal women

OBJECTIVE

The purpose of this review was to examine the risk of depression onset in perimenopausal and postmenopausal women, discuss the importance and rationale for screening for major depressive disorder (MDD) in women in the menopausal transition, and review therapeutic options for management of MDD in perimenopausal and postmenopausal women.

DATA SOURCES

PubMed was searched (1970 to 2008) using combinations of the following terms: major depressive disorder, perimenopause, postmenopause, mood disorder, risk factors, reproductive period, family practice, differential diagnosis, hormone, estrogen replacement therapy, reuptake inhibitors, and neurotransmitter.

STUDY SELECTION

All relevant articles identified via the search terms reporting original data and published in English were considered for inclusion. Twenty-two cross-sectional and longitudinal studies were utilized to evaluate the relationship between the menopausal transition and risk of mood disorders and to formulate recommendations for screening and management of MDD in perimenopausal and postmenopausal women.

DATA EXTRACTION

RESEARCH STUDIES UTILIZED THE FOLLOWING MEASURES: postal questionnaires, Women's Health Questionnaire, Beck Depression Inventory, Center for Epidemiologic Studies-Depression scale, Modified Menopause Symptom Inventory, 12-item symptom questionnaire, or Structured Clinical Interview for DSM-IV.

DATA SYNTHESIS

Menopause is a normal, and for most women largely uneventful, part of life. For some women, however, the menopausal transition is a period of biologic vulnerability with noticeable physiologic, psychological, and somatic symptoms. The perimenopausal period is associated with a higher vulnerability for depression, with risk rising from early to late perimenopause and decreasing during postmenopause. Women with a history of depression are up to 5 times more likely to have a MDD diagnosis during this time period.

CONCLUSIONS

Routine screening of this at-risk population followed by careful assessment for depressive symptoms can help identify the presence of MDD in the menopausal transition. Recognition of menopausal symptoms, with or without depression, is important given their potential impact on quality of life.

The reproductive endocrinology of the menopausal transition

The menopause transition is a dynamic process that begins with the first appearance of menstrual irregularity and ends with a woman's final menstrual period. As ovarian follicle numbers dwindle, the hypothalamic-pituitary-ovarian axis enters a state of compensated failure. In this state, elevated FSH is capable of maintaining relatively regular folliculogenesis and ovulation, but fertility is reduced. Eventually, this state of compensated failure cannot be sustained, and the ovary becomes unable to produce functioning follicles. Recent multicenter studies from several countries have addressed the pattern of change in hormones and a model form reproductive aging has been developed that helps explain the changes in hormone patterns and fertility that accompany menopause. Perhaps more important, the hormonal changes of the menopausal transition may be predictive of future disease risk. This review will undertake an explanation of the current literature on this topic.

Progesterone and ovulation across stages of the transition to menopause

OBJECTIVE

Detailed characterization of progesterone and ovulation across the menopausal transition provides insight into conception risk and mechanisms of reproductive aging.

METHODS

Participants (n = 108, aged 25-58 y) collected daily urine specimens for 6-month intervals in each of 5 consecutive years. Specimens were assayed for pregnanediol glucuronide (PDG), luteinizing hormone (LH), follicle-stimulating hormone (FSH), and estrone glucuronide (E1G). Reproductive stage was determined using cycle length variance. A hierarchical algorithm was used to identify ovulation. Linear mixed-effects models estimated (1) the frequency and day of ovulation by age and stage; (2) differences in FSH, LH, and E1G levels between ovulatory (O) and anovulatory (AO) cycles; and (3) total PDG levels and PDG levels in O cycles by age and stage.

RESULTS

The probability of AO cycles increased across the perimenopause (P < 0.0001); reproductive stage was a stronger predictor than age of the probability of anovulation. Most cycles in late perimenopause were AO (>60%), but one quarter of cycles longer than 60 days were O. Average day of ovulation was later in the late perimenopause (mean [SD] cycle day, 27 [25] d) compared with the premenopause. FSH and LH levels were higher and E1G levels were lower in AO than O cycles (P < 0.0001 for each). Total PDG decreased in the late perimenopause, but 95th percentile PDG in O cycles declined steadily across the transition.

CONCLUSIONS

Exposure to the risk of conception in women experiencing cycles long enough to classify them as late perimenopausal is far from negligible. Reproductive stage is more informative than age about PDG levels and the likelihood of anovulation.

Vitex agnus-castus (Chaste-Tree/Berry) in the treatment of menopause-related complaints

BACKGROUND

The origin of the current practice of administering Vitex agnus-castus in menopause-related complaints is uncertain, but appears to be relatively recent. Here we review the evidence for this application of Vitex based on evidence from pharmacological studies and clinical research.

METHODS

The mechanisms of potential relevance in the context of menopause are explored with reference to the current understanding of the endocrinology and neuroendocrinology of menopause and associated symptoms.

CONCLUSIONS

We conclude that, while evidence from rigorous randomized controlled trials is lacking for the individual herb in this context, emerging pharmacological evidence supports a role for V. agnus-castus in the alleviation of menopausal symptoms and suggests that further investigation may be appropriate.

Carbohydrate complexity and proportion of serum FSH isoforms reflect pituitary-ovarian activity in perimenopausal women and depot medroxyprogesterone acetate users

BACKGROUND

FSH is synthesized and secreted in multiple glycosylation variants with different oligosaccharide structures; the endocrine milieu regulates the composition of FSH carbohydrate moiety.

OBJECTIVES

To characterize serum FSH isoforms according to their sialic acid content and oligosaccharide complexity in regularly menstruating women and in depot medroxyprogesterone acetate (DMPA) users during the menopausal transition. Subjects and methods Ten regularly menstruating perimenopausal women aged 45-52, with mid-follicular phase FSH levels < or =10 IU/l and 10 regularly menstruating women, aged 20-39, were included. Blood samples were collected on the ninth day of the menstrual cycle. Twenty DMPA users were divided into two groups (n = 10) according to age: DMPA(1), age range 20-39 and DMPA(2), age range 45-52. Blood samples were collected 90 +/- 5 days after the last injection of DMPA. Oestradiol (E(2)), inhibin B (Inh B), Pro-alphaC levels and the relative abundance of FSH isoforms on the basis of charge (preparative isoelectric focusing) and carbohydrate complexity (Concanavalin A chromatography) were determined.

RESULTS

Decreased Inh B and moderately elevated E(2) levels were observed in perimenopausal women associated with an increase in FSH sialylation and a decrease in its oligosaccharide complexity. DMPA induced changes in the hormonal profile and FSH molecular microheterogeneity; the secreted hormone was more heterogeneous and its oligosaccharides were less complex under this condition.

CONCLUSION

Serum FSH glycoforms with increased sialylation and decreased oligosaccharide complexity reflect the decline of the gonadal activity induced either by age or by the use of a DMPA as a contraceptive.

Menopause and post-polio symptoms as predictors of subjective sleep disturbance in poliomyelitis survivors

OBJECTIVES

Sleep disturbance in polio survivors is a common complaint, yet little is known about the effects of the interaction of physical disability and menopause on sleep. The purpose of this study was to understand the relative contribution of menopause factors and disability to subjective sleep disturbance.

METHODS

Participants were 465 women aged 50-65 years who had physical disabilities due to poliomyelitis. Hierarchical regression modeling was used to examine menopause (symptoms, status, hormone replacement use, ovarectomy status) and disability factors (post-polio symptoms) in sleep disturbance.

RESULTS

In the final model, 19% (frequency) and 17% (severity) of sleep disturbance variance was explained. Psychological symptoms exerted the most influence (for both outcomes) followed by post-polio symptoms, vasomotor symptoms, an interaction of vasomotor and post-polio symptoms and estrogen use. For women with fewer post-polio symptoms, vasomotor symptoms exerted greater influence on sleep disturbance than for women with greater post-polio symptoms.

CONCLUSIONS

Psychological symptoms had the strongest association with sleep disturbance in these women. Controlling for the influence of various menopause factors, our findings show that vasomotor symptoms were only one of several influences on sleep disturbance.

Abnormal uterine bleeding: a focus on polycystic ovary syndrome

Abnormal uterine bleeding imposes major medical, social and financial problems for women, their families and the health services. Abnormal uterine bleeding refers to the regularity, frequency, duration and volume of bleeding. Irregular menstrual bleeding is most common at the extremes of reproductive life, in the initial 12-18 months after menarche and 5-6 years before the menopause begins. In Australia, the estimated cost of investigating and managing heavy menstrual bleeding alone is approximately AUS $6 million per annum. This article addresses the common causes of irregular bleeding in pre- and peri-menopausal women and presents an investigational approach.

Atypical estradiol secretion and ovulation patterns caused by luteal out-of-phase (LOOP) events underlying irregular ovulatory menstrual cycles in the menopausal transition

OBJECTIVE

The menopausal transition is characterized by irregular menstrual cycles and unpredictable hormone levels, including dramatic swings in estradiol (E2). An increasing number of studies have found variable high E2 and low luteal phase progesterone occur with progression of Stages of Reproductive Aging Workshop (STRAW)stage, but the cause remains unclear. To explore the causes of the erratic changes in E2, individual within-cycle secretion patterns of E2, progesterone, follicle-stimulating hormone, luteinizing hormone, inhibin A, and inhibin B were explored in detail.

DESIGN

Blood samples taken three times per week over 1 1/3 menstrual cycles from 77 women aged 21 to 55 classified as mid-reproductive age (STRAW stages 5 and 4; n = 21), late-reproductive age (STRAW stages 4 and 3; n = 16), early menopausal transition (STRAW stage 2; n = 17), and late menopausal transition (STRAW stage 1; n = 23) were analyzed.

RESULTS

Eleven of the 29 (37%) early and late menstrual transition ovulatory cycles exhibited a specific pattern of E2 secretion that was characterized by a second increase in E2 during the mid- and late luteal phases and that continued to a peak during the subsequent menstrual phase. This second rise and fall in E2 was typical in appearance of a normal follicular phase, except that it was superimposed on an existing ovulatory cycle(specifically during the luteal and menstrual phases). The pattern was therefore referred to as a luteal out-of-phase(LOOP) follicular event. In four of these LOOP cycles, a luteinizing hormone peak and ovulatory episode followed the second E2 peak early in the subsequent cycle. Compared with the typical ovulatory cycles, the cycles with LOOP events exhibited lower luteal phase progesterone, higher early cycle follicle-stimulating hormone, and lower early cycle inhibin B. They were also associated with abnormally short (<21 d) or long (>40 d) cycle length.

CONCLUSIONS

Many of the marked increases in ovulatory cycle E2 and cycle irregularities during the menopausal transition may be due to LOOP events and appear to be triggered by prolonged high follicular phase follicle-stimulating hormone levels.

Cycle and hormone changes during perimenopause: the key role of ovarian function

The menopausal transition is the stage in reproductive life commonly defined as commencing with the onset of menstrual irregularity. Classic studies of the endocrinology of the transition postulated the existence of inhibin in women to explain the observed increase in follicle-stimulating hormone (FSH) levels without a significant decrease in estradiol (E2). Descriptions were provided of cycle characteristics during the transition, emphasizing the unpredictability of the endocrine changes rather than the occurrence of an orderly and progressive decline in ovarian function. Women older than the age of 45 exhibited menstrual irregularity when the average number of primordial follicles per ovary decreased to approximately 100. Inhibin B is a major regulator of FSH secretion and a product of small antral follicles. Its levels respond to the early follicular phase increase and decrease in FSH. The age-related decrease in ovarian primordial follicle numbers, which is reflected in a decrease in the numbers of small antral follicles, leads to a decrease in inhibin B, which in turn leads to an increase in FSH, hypothesized to act as a stimulus to the maintenance of circulating E2 in the follicular phase until late in the transition. Concurrently, the concentrations of testosterone do not change significantly. Early follicular phase FSH levels in women reporting menstrual irregularity fluctuate markedly, with a more uniform increase in levels when no menses have occurred for at least 3 months. Anovulatory cycles occur at increased frequency in the last 30 months before final menses or menopause. In ovulatory cycles, FSH shows little, if any, increase, but anovulatory cycles are usually characterized by low levels of inhibin B, markedly increased levels of FSH, and low levels of E2. Thus, the heterogeneity of follicular phase FSH represents a mixture of ovulatory and anovulatory cycles. Longitudinal data indicate that both ovulatory and anovulatory cycles occur after entry into both the early and late menopausal transition and that ovulatory cycles occur even after final menses. There is no endocrine marker of menopause, which may be primarily an endometrial event. Using the hormonal concentrations in ovulatory cycles observed in women in mid-reproductive age as controls and comparing such concentrations in late reproductive age women older than 45 either continuing to cycle regularly or having entered the early or late menopausal transition, a gradual increase in follicular phase FSH and E2 and a decrease in inhibin B were observed in ovulatory cycles. Anovulatory cycles showed markedly increased FSH with low E2 and inhibin B. No specific endocrine change was characteristic of either the early or late menopausal transition, confirming the observations of previous studies regarding the unpredictability of cycle characteristics and hormone changes with the approach of menopause. Antimüllerian hormone correlates with follicle numbers and shows a large age-related decrease to reach undetectable levels at menopause. Thus, the marked decrease in follicle numbers during late reproductive age appears to predispose to erratic and unpredictable cycle characteristics, with normal ovulatory cycles continuing to occur episodically. There is no specific endocrine marker of the early or late transition, making measurements of FSH or E2 unreliable in attempting to stage an individual with regard to approaching menopause.

Relation of daily urinary hormone patterns to vasomotor symptoms in a racially/ethnically diverse sample of midlife women: study of women's health across the nation

The associations of urinary pregnanediol-glucuronide (PdG) levels and menstrual bleeding and their modification of associations of other risk factors with vasomotor symptoms (VMS) are examined. Daily urine samples were collected for 1 menstrual cycle or 50 days if no bleeding occurred. Participants (n = 742) were aged 43 to 54 years, not using exogenous hormones, not pregnant, had an intact uterus and > 1 ovary, and menstruated in the prior 3 months. Multivariate analyses were performed of urinary hormone metabolites and within-woman proportion of days reporting VMS. VMS reporting was 4-fold greater (P = .0005) in women whose urine collections ended without bleeding. In collections with PdG levels suggestive of ovulatory activity according to the work of Kassam et al, VMS are significantly associated with obesity, early perimenopause, and increasing PdG levels. In collections with lower PdG concentrations, VMS are significantly increased with no bleeding, smoking, higher age, physical activity, follicle-stimulating hormone, and luteinizing hormone and are significantly reduced with increasing estrogen concentrations.

Changes in ultrasound morphology of the uterus and ovaries during the menopausal transition and early postmenopause: a 4-year longitudinal study

OBJECTIVES

To describe changes in uterine and ovarian size and morphology as determined by ultrasonography from 2 years before to 2 years after menopause.

METHODS

Twenty 50-year-old women with fairly regular vaginal bleeding at the start of the study underwent transvaginal ultrasound examination every 3 months until 12 months postmenopause, then every 6 months until 24 months postmenopause. The results are presented from 2 years before to 2 years after the menopause.

RESULTS

In the 2 years preceding menopause all the women were in menopausal transition. From 2 years before to 2 years after menopause uterine anteroposterior diameter decreased by 22% (mean) and left and right ovarian volumes by 45 and 20% (median), respectively. At 2 years before the menopause the total number of intraovarian follicle-like cystic structures varied from 0 to 5, at the menopause from 0 to 7, and at 1 and 2 years after the menopause from 0 to 4 and from 0 to 2, respectively. Premenopause, the most common finding was that of ovaries containing either no follicles or a few follicles with at least one measuring >/= 11 mm and simultaneously a hyperechogenic endometrium of varying thickness and not manifesting any midline echo or triple-layer appearance. Images compatible with the late follicular phase were found in 6% (9/150) of examinations ('cycle day' 8-196) and images compatible with the luteal phase in 7% (10/150) ('cycle day' 11-56). Intraovarian cystic structures (3-25 mm) were seen in 14 women after the menopause.

CONCLUSION

We have described sonographic changes in the uterus and ovaries occurring during the transition from premenopause to postmenopause.

Mass spectrometric and physiological validation of a sensitive, automated, direct immunoassay for serum estradiol using the Architect

BACKGROUND

Measurement of estradiol (E(2)) plays a critical role in the diagnosis and clinical management of reproductive disorders. The challenge for all currently available direct methods for measuring E(2) is to provide accuracy and precision across a wide dynamic range.

METHODS

We describe the development and multi-site performance evaluation of a direct E(2) assay on the Architect i2000. Assay performance and method comparisons were performed by testing specimens from men, healthy women with regular menstrual cycles, and post-menopausal women using the Architect assay and isotope dilution, gas chromatography-mass spectrometry (ID/GC-MS). Reference intervals were established by testing prospectively collected daily blood draws from 42 healthy women, 72 postmenopausal women and 101 males.

RESULTS

No unexpected cross-reactivity or interference was observed for over 40 compounds tested. Recovery was 100+/-10% in the presence of estrone and estriol. Functional sensitivity (%CV<20%) was <15 pg/ml.(1) The imprecision of the assay was <7.1% (total CV), <2.5%, and <2.3% for control sera containing 45, 190, and 600 pg/ml estradiol, respectively. The assay had a correlation of y=1.033 x+0.3156, r(2)=0.99, n=131 compared to ID/GC-MS. Reference intervals for the current Architect Estradiol assay are reported.

CONCLUSIONS

Format changes resulted in dramatic improvement in the performance and accuracy of this direct, fully automated assay. The assay is standardized by ID/GC-MS. The assay is clinically useful for serum concentrations from 15 to >4000 pg/ml.

The ReSTAGE Collaboration: defining optimal bleeding criteria for onset of early menopausal transition

OBJECTIVE

Criteria for staging the menopausal transition are not established. This article evaluates five bleeding criteria for defining early transition and provides empirically based guidance regarding optimal criteria.

DESIGN/SETTING

Prospective menstrual calendar data from four population-based cohorts: TREMIN, Melbourne Women's Midlife Health Project (MWMHP), Seattle Midlife Women's Health Study (SMWHS), and Study of Women's Health Across the Nation (SWAN) with annual serum FSH from MWMHP and SWAN.

PARTICIPANTS

735 TREMIN, 279 SMWHS, 216 MWMHP, and 2270 SWAN women aged 35-57 at baseline who maintained menstrual calendars.

MAIN OUTCOME MEASURE(S)

Age at and time to menopause for: standard deviation >6 and >8 days, persistent difference in consecutive segments >6 days, irregularity, and >or=45 day segment. Serum FSH concentration.

RESULT(S)

Most women experienced each of the bleeding criteria. Except for a persistent >6 day difference that occurs earlier, the criteria occur at a similar age and at approximately the same age as late transition in a large proportion of women. FSH was associated with all proposed markers.

CONCLUSION(S)

The early transition may be best described by ovarian activity consistent with the persistent >6 day difference, but further study is needed, as other proposed criterion are consistent with later menstrual changes.

A review of hormonal changes during the menopausal transition: focus on findings from the Melbourne Women's Midlife Health Project

The menopause, defined as the permanent cessation of menstruation resulting from the loss of ovarian follicular activity, marks the end of natural female reproductive life. It is preceded by a period of menstrual cycle irregularity, the menopausal transition, which usually begins in the mid-40s and is conventionally divided into early and late phases. The endocrine changes, which underlie the transition, are predominantly the consequence of a marked decline in ovarian follicle numbers. The most significant changes include a decrease in early cycle inhibin B and in anti-Mullerian hormone (AMH) levels. The decline in inhibin B results in an increase in FSH, which appears to be an important factor in the maintenance of estradiol (E2) concentrations until late in reproductive life. In the post-menopause, FSH levels are markedly raised, E2 levels are low, whereas inhibin B and AMH are undetectable. The menopausal transition is a time of marked hormonal instability. The Melbourne Women's Midlife Health Project has been an extremely productive study in which it has been possible to describe longitudinal changes in hormone levels throughout the menopause transition and to separate the effects of hormone change from the effects of ageing on a number of endpoints. This review provides the background for an accompanying manuscript in which a novel approach to modelling the hormonal changes during the transition is described.

Monitoring reproductive aging in a 5-year prospective study: aggregate and individual changes in luteinizing hormone and follicle-stimulating hormone with age

OBJECTIVE

This study describes age-related changes in luteinizing hormone (LH) and follicle-stimulating hormone (FSH) in a 5-year prospective study of reproductive aging.

DESIGN

Participants (n = 156 college-educated, white, US women; 25 to 58 y) were recruited from the TREMIN Research Program on Women's Health. They collected daily urine specimens for 6 months in each of 5 consecutive years. Specimens were assayed for LH and FSH. Aggregate changes were calculated in LH and FSH with age, and multilevel models were used to estimate individual hormone trajectories and within-woman and between-woman variances by age.

RESULTS

Aggregate LH levels increased beginning after age 45; FSH increased at all ages, accelerating after age 45. Individual-level patterns with age included the following: reproductive-age LH and FSH levels, with increasing FSH and increasing or decreasing LH (ages 20 to 49); rapidly increasing LH and FSH (ages 40 to 59); and increasing or steady postmenopausal LH and FSH (ages 46 to 62). FSH levels were consistently high in the latter category, but LH levels overlapped with levels found in younger women (<45 y). Individual LH patterns showed more variability (5% to 35% of total variance) than FSH (3% to 22% of total variance). Both hormones had relatively low variation within individuals compared with between-woman differences (65% to 97% of total variance).

CONCLUSIONS

Aggregate-level data do not reflect differences across women and oversimplify the age-related increases and variability in LH and FSH. Individual FSH levels are not distinguishable from reproductive-age levels until after rapid perimenopausal increases in FSH occur; individuals vary in whether their postmenopausal LH levels are distinguishable from reproductive-age levels.

Endometrial bleeding

Abnormal bleeding is a significant health problem, especially during adolescence and before menopause when anovulatory cycles are common. Curettage is rarely necessary to investigate or treat menstrual problems in adolescents, and its use should also be minimized in women younger than 40 years. In every age group, medical treatment is the initial choice, but surgical treatment by endometrial destruction or hysterectomy is sometimes required. Benign causes of bleeding include fibroids and possibly adenomyosis, but the indications for treatment in each case depend upon the extent of bleeding, not the extent of the lesion. Breakthrough bleeding (BTB) with combined oral contraceptives commonly leads to discontinuation of the method. As BTB tends to improve with time, in the first 3 months of pill use, unless there are obvious underlying causes, women should be reassured that it will likely settle. BTB is often the reason for discontinuing progestogen-only contraception, and there is a need for effective means of treating unscheduled bleeding. Bleeding occurs in approximately 3% of post-menopausal women, and the use of hormones increases the likelihood of bleeding by >5-fold. Knowledge of the underlying mechanisms of bleeding is essential to the development of effective treatment.

Menstrual cycle lengths and bone mineral density: a cross-sectional, population-based study in rural Chinese women ages 30-49 years

INTRODUCTION

The menstrual cycle involves periodic fluctuations in estrogen and progesterone levels. Longer cycles have been associated with longer follicular phase, delayed estrogen peak and a lower mean oestradiol level of the entire cycle.

METHODS

We hypothesized that prolonged menstrual cycle length is associated with decreased bone mineral density (BMD) in a population of pre- and perimenopausal women. This population-based cross-sectional study was conducted in rural Anhui province, China. It includes 4,771 women, aged 30 to 49 years, who did not smoke or drink alcohol, and did not use oral contraceptives or breastfeed during the previous year. Dual-energy X-ray absorptionometry (DEXA) BMD measurements were taken at four skeletal sites: whole body, total hip, femoral neck and lumbar spine. Menstrual cycle characteristics (polymenorrhea, short normal, long normal, oligomenorrhea, 90-day amenorrhea, irregular cycle) in the prior year were assessed by questionnaire.

RESULTS

Prolonged menstrual cycle was consistently associated with decreased BMD at whole body, total hip, and femoral neck in both age 30-39, and age 40-49 stratum (p(trend)<0.05). Prolonged menstrual cycle was also associated with decreased lumbar spine BMD for women aged 40-49 (p(trend)<0.05). Among women with normal cycles aged 30-39, menstrual cycle length in the previous year was inversely associated with whole-body BMD (p<0.05). Women with 90-day amenorrhea had significantly lower mean total hip and femoral neck BMD relative to women with short normal cycles in the 30-39 age group; and had significantly lower whole body and total hip BMD relative to short normal cycles in the 40-49 age group. BMD in polymenorrheic women did not differ from BMD in women with short normal cycles at any of the skeletal sites.

CONCLUSIONS

We conclude that prolonged menstrual cycle length is associated with decreased BMD in pre- and perimenopausal women in this population.

Menopause characteristics of women with physical disabilities from poliomyelitis

OBJECTIVE

To describe menopause characteristics of women with physical disabilities from poliomyelitis.

METHODS

Nine hundred and nine women with a history of poliomyelitis completed a survey on health, physical functioning, emotional well being and menopause.

RESULTS

The majority of the sample was postmenopausal having had a natural menopause around the average age of 50.3 years; 34.7% of the sample had had hysterectomies. Thirty-nine percent were using some form of hormone replacement therapy (HRT). Menopause symptoms were clustered into psychological, somatic-sensory, somatic-sleep and vasomotor factors. Among never and past HRT users, there were significant differences in menopause factor severity by menopause status. Somatic/sleep symptoms were lowest in never users; past users had significantly higher vasomotor symptoms; desire for sexual activity and painful intercourse did not vary by HRT use. Compared to population estimates, post-polio women had similar rates of hysterectomies overall, but among some age cohorts they had significantly lower rates, contrary to expectations. However, they used HRT at significantly higher rates than expected.

CONCLUSIONS

This study suggests that basic menopause characteristics of women with polio are generally similar to those of their non-disabled peers. There were few substantial differences in severity of menopause symptoms by HRT use, which is critical in light of the dearth of studies examining its risk-benefit ratio among women with physical disabilities. Until such studies provide some evidence of the specific risks or benefits to women with physical disability, each woman should carefully weigh the known risks and benefits with her physician.

Effects of the menstrual cycle on looking preferences for faces in female rhesus monkeys

Fluctuations of ovarian hormones across the menstrual cycle influence a variety of social and cognitive behaviors in primates. For example, female rhesus monkeys exhibit heightened interest for males and increased agonistic interactions with other females during periods of high estrogen levels. In the present study, we hypothesized that females' preference for males during periods of high estrogen levels is also expressed at the level of face perception. We tested four intact females on two face-tasks involving neutral portraits of male and female rhesus monkeys, chimpanzees and humans. In the visual preference task (VP), monkeys had to touch a button to view a face image. The image remained on the screen as long as the button was touched, and the duration of pressing was taken as an index of the monkey's looking time for the face stimulus. In the Face-Delayed Recognition Span Test (Face-DRST), monkeys were rewarded for touching the new face in an increasing number of serially presented faces. Monkeys were tested 5 days a week across one menstrual cycle. Blood was collected every other day for analysis of estradiol and progesterone. Two of the four females were cycling at the time of testing. We did not find an influence of the cycle on Face-DRST, likely due to a floor effect. In the VP however, the two cycling individuals looked longer at conspecific male faces than female faces during the peri-ovulatory period of the cycle. Such effects were absent for human and chimpanzee faces and for the two noncycling subjects. These data suggest that ovarian hormones may influence females' preferences for specific faces, with heightened preference for male faces during the peri-ovulatory period of the cycle. Heightened interest for stimuli of significant reproductive relevance during periods of high conception risk may help guide social and sexual behavior in the rhesus monkey.

The length of perimenopausal menstrual cycles increases later and to a greater degree than previously reported

OBJECTIVE

To demonstrate that the perimenopausal increase in menstrual cycle length presented by Treloar et al. was biased by misidentified menopause dates, mean values classified by calendar year, and exclusion of menstrual cycles straddling two calendar years; and to use the revised data to investigate women's experiences of longer perimenopausal cycles.

DESIGN

Secondary analysis of prospectively collected menstrual cycle data.

SETTING

Center for Population and Health, Georgetown University.

PATIENT(S)

One hundred twenty white, college-educated, US women in the Tremin Research Program on Women's Health.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Mean cycle length and time spent in >40-day cycles, by year before menopause.

RESULT(S)

Mean estimates for each of the 4 years before menopause were 30.48, 35.02, 45.15, and 80.22 days, respectively, compared with the original analysis: 33.60, 43.91, 55.87, and 54.58 days. In the year before menopause, the majority of women spent >or=75% of their time in cycles >40 days long.

CONCLUSION(S)

Treloar's estimates of mean cycle length were biased. Long cycles occurred throughout perimenopause, but the largest increase in mean cycle length did not occur until the final year before menopause. New estimates of the time spent in cycles >40 days may be useful clinically as well as epidemiologically for assessing menopausal onset and symptomatology.

Ovulation detection methods for urinary hormones: precision, daily and intermittent sampling and a combined hierarchical method

BACKGROUND

We evaluate the performance of ovulation detection methods and present new approaches, including evaluation of methods for precision, combining multiple markers into a hierarchical system and using ovulation markers in intermittent sampling designs.

METHODS

With serum LH peak day as the 'gold standard' of ovulation, we estimated accuracy and precision of ovulation day algorithms using 30 ovulatory menstrual cycles with daily urinary and serum hormones and transvaginal ultrasound. Sensitivity and specificity for estimating the presence of ovulation were tested using visually assessed ovulatory (30) and anovulatory (22) cycles.

RESULTS

Sensitivity and specificity ranged from 70 to 100% for estimating presence of ovulation with twice-per-cycle, weekly, twice weekly, every-other-day and daily specimens. A combined hierarchical method estimated ovulation day using daily specimens within +/-2 days of the gold standard in 93% of cases. Accuracy of estimating ovulation day within +/-2 days using intermittent sampling ranged from 40% (weekly sampling) to 97% (every-other-day).

CONCLUSIONS

A combined hierarchical algorithm using precise and accurate markers allows maximal use of available data for efficient and objective identification of ovulation using daily specimens. In intermittent sampling designs, the presence and the timing of ovulation can be estimated with good sensitivity, specificity and accuracy.