Menopausal hot flashes and white matter hyperintensities

Interactions between menopause and high-fat diet on cognition and pathology in a mouse model of Alzheimer's disease

INTRODUCTION

Post-menopausal women constitute about two-thirds of those with Alzheimer's disease (AD). Menopause increases dementia risk by heightening the likelihood of metabolic disease, a well-known risk factor for dementia. We aimed to determine the effects of menopause and high-fat diet (HF) on cognitive and pathological outcomes in an AD mouse model.

METHODS

At 3 months old, AppNL-F mice received 4-vinylcyclohexene diepoxide (menopause model) or vehicle and were placed on a control (10% fat) or an HF diet (60% fat) until 10 months old.

RESULTS

An interaction between HF diet and menopause led to impaired recognition memory. No effects of menopause were observed on amyloid pathology. However, menopause induced alterations in microglial response, white matter, and hippocampal neurogenesis.

DISCUSSION

This work highlights the need to model endocrine aging in animal models of dementia and contributes to further understanding of the interaction between menopause and metabolic health in the context of AD.

HIGHLIGHTS

The combination of menopause and HF diet led to early onset of cognitive impairment. HF diet increased amyloid pathology in the hippocampus. Menopause led to an increase in microglia density and a decrease in myelin in the corpus callosum. Menopause altered hippocampal neurogenesis in a diet-dependent manner.

Evolutionary Perspectives, Comparative Approaches, and the Lived Experience of Menopause

The purpose of this synthesis is to review age at menopause, symptom experience at midlife, and the evolution of menopause in a way that is helpful for biological anthropologists who are interested in the study of this challenging time of life. The synthesis begins with the biology of menopause, then shifts to the evolution of menopause with an emphasis on phylogenetic and adaptationist perspectives. Discussion of the biology and evolution of menopause incorporates a cross-species perspective, with particular attention to whales and primates. The synthesis continues with a cross-population review of variation in age at menopause. The final section is about symptom experience across populations with attention to the medical context of midlife, a focus on hot flashes, and consideration of the strengths and limitations of ethnographic and questionnaire-based research. The review ends with suggestions for where biological anthropology can make important contributions to the research of midlife and menopause.

Evolutionary Perspectives, Comparative Approaches, and the Lived Experience of Menopause

The purpose of this synthesis is to review age at menopause, symptom experience at midlife, and the evolution of menopause in a way that is helpful for biological anthropologists who are interested in the study of this challenging time of life. The synthesis begins with the biology of menopause, then shifts to the evolution of menopause with an emphasis on phylogenetic and adaptationist perspectives. Discussion of the biology and evolution of menopause incorporates a cross-species perspective, with particular attention to whales and primates. The synthesis continues with a cross-population review of variation in age at menopause. The final section is about symptom experience across populations with attention to the medical context of midlife, a focus on hot flashes, and consideration of the strengths and limitations of ethnographic and questionnaire-based research. The review ends with suggestions for where biological anthropology can make important contributions to the research of midlife and menopause.

Premenopausal bilateral oophorectomy and brain white matter brain integrity in later-life

INTRODUCTION

Premenopausal bilateral oophorectomy (PBO) is associated with later-life cognition, but the underlying brain changes remain unclear. We assessed the impact of PBO and PBO age on white matter integrity.

METHODS

Female participants with regional diffusion tensor imaging (DTI) metrics of fractional anisotropy (FA) and mean diffusivity (MD) were included (22 with PBO < 40 years; 43 with PBO 40-45 years; 39 with PBO 46-49 years; 907 referents without PBO < 50 years). Linear regression models adjusted for age and apolipoprotein E (APOE) genotype.

RESULTS

Females with PBO < 40 years, compared to referents, had lower FA and higher MD in the anterior corona radiata, genu of the corpus collosum, inferior fronto-occipital fasciculus, superior occipital, and superior temporal white matter. Females who underwent PBO between 45 and 49 also had some changes in white matter integrity.

DISCUSSION

Females who underwent PBO < 40 years had reduced white matter integrity across multiple regions in later-life. These results are important for females considering PBO for noncancerous conditions.

HIGHLIGHTS

Females with premenopausal bilateral oophorectomy (PBO) < 40 years had lower FA versus referents. Females with PBO < 40 years had higher MD in many regions versus referents. Adjusting for estrogen replacement therapy use did not attenuate results. Females with PBO 45-49 years also had some white matter changes versus referents.

The influence of habitual physical activity and sedentary behavior on objective and subjective hot flashes at midlife

OBJECTIVE

The purpose of this study was to evaluate relationships between physical activity, sedentary time, and hot flashes during both waking and sleeping periods using concurrent objective and subjective measures of hot flashes in midlife women.

METHODS

Women aged 45 to 55 years (n = 196) provided self-reported data on physical activity and underwent 24 hours of hot flash monitoring using sternal skin conductance. Participants used event marking and logs to indicate when hot flashes were perceived. Wake and sleep periods were defined by actigraphy. Mean ambient temperature and humidity were recorded during the study period. Generalized linear regression modeling was used to evaluate the effect of physical activity types and sedentary time on hot flash outcomes. Isotemporal substitution modeling was used to study the effect of replacing sedentary time with activity variables on hot flash frequency.

RESULTS

Modeled results indicated that increasing sitting by 1 hour was associated with a 7% increase in the rate of objectively measured but not subjectively reported hot flashes during sleep. Replacing 1 hour of sitting with 1 hour of vigorous activity was associated with a 100% increase in subjectively reported but not objectively measured waking hot flashes. There was little evidence for an effect of temperature or humidity on any hot flash outcome.

CONCLUSIONS

These data provide support for relations between sedentary time, physical activity, and hot flashes and highlight the importance of using objective and subjective assessments to better understand the 24-hour hot flash experience.

Menopausal vasomotor symptoms and plasma Alzheimer disease biomarkers

BACKGROUND

Identifying risk factors for Alzheimer disease in women is important as women compose two-thirds of individuals with Alzheimer disease. Previous work links vasomotor symptoms, the cardinal menopausal symptom, with poor memory performance and alterations in brain structure, function, and connectivity. These associations are evident when vasomotor symptoms are monitored objectively with ambulatory skin conductance monitors.

OBJECTIVE

This study aimed to determine whether vasomotor symptoms are associated with Alzheimer disease biomarkers.

STUDY DESIGN

Between 2017 and 2020, the MsBrain study enrolled 274 community-dwelling women aged 45 to 67 years who had a uterus and at least 1 ovary and were late perimenopausal or postmenopausal status. The key exclusion criteria included neurologic disorder, surgical menopause, and recent use of hormonal or nonhormonal vasomotor symptom treatment. Women underwent 24 hours of ambulatory skin conductance monitoring to assess vasomotor symptoms. Plasma concentrations of Alzheimer disease biomarkers, including amyloid β 42-to-amyloid β 40 ratio, phosphorylated tau (181 and 231), glial fibrillary acidic protein, and neurofilament light, were measured using a single-molecule array (Simoa) technology. Associations between vasomotor symptoms and Alzheimer disease biomarkers were assessed via linear regression models adjusted for age, race and ethnicity, education, body mass index, and apolipoprotein E4 status. Additional models adjusted for estradiol and sleep.

RESULTS

A total of 248 (mean age, 59.06 years; 81% White; 99% postmenopausal status) of enrolled MsBrain participants contributed data. Objectively assessed vasomotor symptoms occurring during sleep were associated with significantly lower amyloid β 42/amyloid β 40, (beta, -.0010 [standard error, .0004]; P=.018; multivariable), suggestive of greater brain amyloid β pathology. The findings remained significant after additional adjustments for estradiol and sleep.

CONCLUSION

Nighttime vasomotor symptoms may be a marker of women at risk of Alzheimer disease. It is yet unknown if these associations are causal.

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.

Assessment of Microvascular Disease in Heart and Brain by MRI: Application in Heart Failure with Preserved Ejection Fraction and Cerebral Small Vessel Disease

The objective of this review is to investigate the commonalities of microvascular (small vessel) disease in heart failure with preserved ejection fraction (HFpEF) and cerebral small vessel disease (CSVD). Furthermore, the review aims to evaluate the current magnetic resonance imaging (MRI) diagnostic techniques for both conditions. By comparing the two conditions, this review seeks to identify potential opportunities to improve the understanding of both HFpEF and CSVD.

Identifying sex-specific risk architectures for predicting amyloid deposition using neural networks

In older adults without dementia, White Matter Hyperintensities (WMH) in MRI have been shown to be highly associated with cerebral amyloid deposition, measured by the Pittsburgh compound B (PiB) PET. However, the relation to age, sex, and education in explaining this association is not well understood. We use the voxel counts of regional WMH, age, one-hot encoded sex, and education to predict the regional PiB using a multilayer perceptron with only rectilinear activations using mean squared error. We then develop a novel, robust metric to understand the relevance of each input variable for prediction. Our observations indicate that sex is the most relevant predictor of PiB and that WMH is not relevant for prediction. These results indicate that there is a sex-specific risk architecture for Aβ deposition.

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.

Menopause causes metabolic and cognitive impairments in a chronic cerebral hypoperfusion model of vascular contributions to cognitive impairment and dementia

BACKGROUND

The vast majority of women with dementia are post-menopausal. Despite clinical relevance, menopause is underrepresented in rodent models of dementia. Before menopause, women are less likely than men to experience strokes, obesity, and diabetes-known risk factors for vascular contributions to cognitive impairment and dementia (VCID). During menopause, ovarian estrogen production stops and the risk of developing these dementia risk factors spikes. Here, we aimed to determine if menopause worsens cognitive impairment in VCID. We hypothesized that menopause would cause metabolic dysfunction and increase cognitive impairment in a mouse model of VCID.

METHODS

We performed a unilateral common carotid artery occlusion surgery to produce chronic cerebral hypoperfusion and model VCID in mice. We used 4-vinylcyclohexene diepoxide to induce accelerated ovarian failure and model menopause. We evaluated cognitive impairment using behavioral tests including novel object recognition, Barnes maze, and nest building. To assess metabolic changes, we measured weight, adiposity, and glucose tolerance. We explored multiple aspects of brain pathology including cerebral hypoperfusion and white matter changes (commonly observed in VCID) as well as changes to estrogen receptor expression (which may mediate altered sensitivity to VCID pathology post-menopause).

RESULTS

Menopause increased weight gain, glucose intolerance, and visceral adiposity. VCID caused deficits in spatial memory regardless of menopausal status. Post-menopausal VCID specifically led to additional deficits in episodic-like memory and activities of daily living. Menopause did not alter resting cerebral blood flow on the cortical surface (assessed by laser speckle contrast imaging). In the white matter, menopause decreased myelin basic protein gene expression in the corpus callosum but did not lead to overt white matter damage (assessed by Luxol fast blue). Menopause did not significantly alter estrogen receptor expression (ERα, ERβ, or GPER1) in the cortex or hippocampus.

CONCLUSIONS

Overall, we have found that the accelerated ovarian failure model of menopause caused metabolic impairment and cognitive deficits in a mouse model of VCID. Further studies are needed to identify the underlying mechanism. Importantly, the post-menopausal brain still expressed estrogen receptors at normal (pre-menopausal) levels. This is encouraging for any future studies attempting to reverse the effects of estrogen loss by activating brain estrogen receptors.

Do correlates of white matter features differ between older men and women living with human immunodeficiency virus?

OBJECTIVE

Given estrogen's role in human immunodeficiency virus (HIV) disease progression and the higher rates of neurocognitive decline in affected women, the purpose of this study was to assess whether the relationship of white matter features and reproductive hormone levels differed between men versus women (sex as a moderator), controlling for selected cardiometabolic risk factors, HIV-related health indicators, and demographics in an aging population of persons living with HIV (PLWH).

METHODS

Older PLWH (50 y and older; 44 women and 35 men; mean ± SD age, 59.8 ± 0.6 y; 55.7% women; 72.2% non-Hispanic Black) participated in a cross-sectional study involving a fasting blood draw and a demographic survey (visit 1) and a magnetic resonance imaging scan (visit 2) to determine white matter volume and white matter hyperintensity (WMH) volume. Associations between reproductive hormones (follicle-stimulating hormone [FSH], estradiol, testosterone, dehydroepiandrosterone sulfate [DHEA-S]) and white matter features were assessed in linear regression models. Covariates were age, body mass index, hypertension, diabetes, dyslipidemia, current smoking status, CD4 count, and cranial size.

RESULTS

For white matter volume, a sexually dimorphic interaction was seen for DHEA-S (B = 21.23; P = 0.012) and observed for FSH (B = -22.97, P = 0.08) with a trend for significance after controlling for risk factors. In women, higher white matter volume was associated with higher DHEA-S (B = 13.89, P = 0.017) and lower FSH (B = 23.58, P = 0.01). No hormone associations were shown in men for white matter volume. For WMH volume, no significant interaction effects between sex and reproductive hormones were identified. For WMH, sex did not predict associations with reproductive hormones after controlling for risk factors.

CONCLUSIONS

Although sexually dimorphic interactions of reproductive hormones and total white matter volume were demonstrated, our study findings do not support a role for sex-based differences in reproductive hormones as predictive correlates of WMH in a small sample of older PLWH.

Role of estrogen in women's Alzheimer's disease risk as modified by APOE

Alzheimer's disease (AD) is characterized by numerous sexual dimorphisms that impact the development, progression, and probably the strategies to prevent and treat the most common form of dementia. In this review, we consider this topic from a female perspective with a specific focus on how women's vulnerability to the disease is affected by the individual and interactive effects of estrogens and apolipoprotein E (APOE) genotype. Importantly, APOE appears to modulate systemic and neural outcomes of both menopause and estrogen-based hormone therapy. In the brain, dementia risk is greater in APOE4 carriers, and the impacts of hormone therapy on cognitive decline and dementia risk vary according to both outcome measure and APOE genotype. Beyond the CNS, estrogen and APOE genotype affect vulnerability to menopause-associated bone loss, dyslipidemia and cardiovascular disease risk. An emerging concept that may link these relationships is the possibility that the effects of APOE in women interact with estrogen status by mechanisms that may include modulation of estrogen responsiveness. This review highlights the need to consider the key AD risk factors of advancing age in a sex-specific manner to optimize development of therapeutic approaches for AD, a view aligned with the principle of personalized medicine.

Menopausal Vasomotor Symptoms and White Matter Hyperintensities in Midlife Women

BACKGROUND AND OBJECTIVES

The menopause transition is increasingly recognized as a time of importance for women's brain health. A growing body of work indicates that the classic menopausal symptom, vasomotor symptom (VMS), may be associated with poorer cardiovascular health. Other work links VMS to poorer cognition. We investigate whether VMS, when rigorously assessed using physiologic measures, are associated with greater white matter hyperintensity volume (WMHV) among midlife women. We consider a range of potential explanatory factors in these associations and explore whether VMS are associated with the spatial distribution of WMHV.

METHODS

Women aged 45-67 years and free of hormone therapy underwent 24 hours of physiologic VMS monitoring (sternal skin conductance), actigraphy assessment of sleep, physical measures, phlebotomy, and 3 Tesla neuroimaging. Associations between VMS (24-hour, wake, and sleep VMS, with wake and sleep intervals defined by actigraphy) and whole brain WMHV were considered in linear regression models adjusted for age, race, education, smoking, body mass index, blood pressure, insulin resistance, and lipids. Secondary models considered WMHV in specific brain regions (deep, periventricular, frontal, temporal, parietal, and occipital) and additional covariates including sleep.

RESULTS

The study sample included 226 women. Physiologically assessed VMS were associated with greater whole brain WMHV in multivariable models, with the strongest associations observed for sleep VMS (24-hour VMS, B[SE] = 0.095 [0.045], p = 0.032; Wake VMS, B[SE] = 0.078 [0.046], p = 0.089, Sleep VMS, B[SE] = 0.173 [0.060], p = 0.004). Associations were not accounted for by additional covariates including actigraphy-assessed sleep (wake after sleep onset). When considering the spatial distribution of WMHV, sleep VMS were associated with both deep WMHV, periventricular WMHV, and frontal lobe WMHV.

DISCUSSION

VMS, particularly VMS occurring during sleep, were associated with greater WMHV. Identification of female-specific midlife markers of poor brain health later in life is critical to identify women who warrant early intervention and prevention. VMS have the potential to serve as female-specific midlife markers of brain health in women.

Higher perceived stress during the COVID-19 pandemic increased menstrual dysregulation and menopause symptoms

BACKGROUND

The increased stress the world experienced with the coronavirus disease (COVID-19) pandemic affected mental health, disproportionately affecting females. However, how perceived stress in the first year affected menstrual and menopausal symptoms has not yet been investigated.

OBJECTIVES

This study evaluates the effect that the first year of the COVID-19 pandemic had on female reproductive and mental health.

METHODS

Residents in British Columbia, Canada, were surveyed online as part of the COVID-19 Rapid Evidence Study of a Provincial Population-Based Cohort for Gender and Sex. A subgroup of participants (n = 4171), who were assigned female sex at birth (age 25-69 years) and were surveyed within the first 6-12 months of the pandemic (August 2020-February 2021), prior to the widespread rollout of vaccines, was retrospectively asked if they noticed changes in their menstrual or menopausal symptoms, and completing validated measures of stress, depression and anxiety.

DESIGN

This is a population-based online retrospective survey.

RESULTS

We found that 27.8% reported menstrual cycle disturbances and 6.7% reported increased menopause symptoms. Those who scored higher on perceived stress, depression and anxiety scales were more likely to report reproductive cycle disturbances. Free-text responses revealed that reasons for disturbances were perceived to be related to the pandemic.

CONCLUSION

The COVID-19 pandemic has highlighted the need to research female-specific health issues, such as menstruation. Our data indicate that in the first year of the pandemic, almost one-third of the menstruating population reported disturbances in their cycle, which was related to percieved stress, depression and anxiety scores.

Hormonal factors moderate the associations between vascular risk factors and white matter hyperintensities

To examine the moderation effects of hormonal factors on the associations between vascular risk factors and white matter hyperintensities in men and women, separately. White matter hyperintensities were automatically segmented and quantified in the UK Biobank dataset (N = 18,294). Generalised linear models were applied to examine (1) the main effects of vascular and hormonal factors on white matter hyperintensities, and (2) the moderation effects of hormonal factors on the relationship between vascular risk factors and white matter hyperintensities volumes. In men with testosterone levels one standard deviation higher than the mean value, smoking was associated with 27.8% higher white matter hyperintensities volumes in the whole brain. In women with a shorter post-menopause duration (one standard deviation below the mean), diabetes and higher pulse wave velocity were associated with 28.8% and 2.0% more deep white matter hyperintensities, respectively. These findings highlighted the importance of considering hormonal risk factors in the prevention and management of white matter hyperintensities.

Brain fog in menopause: a health-care professional's guide for decision-making and counseling on cognition

Midlife women commonly experience changes in their cognitive function as they transition through menopause and express concern about whether these changes represent the initial stages of a more serious cognitive disorder. Health-care practitioners play an important role in counseling women on cognitive changes at midlife and normalizing women's experience. The aim of this commissioned International Menopause Society White Paper on cognition is to provide practitioners with an overview of data informing the clinical care of menopausal women and a framework for clinical counseling and decision-making. Among the topics presented are the specific cognitive changes occurring in menopause, the duration of such changes and their severity. The role of estrogen and menopause symptoms is reviewed. We present talking points for clinical counseling on the effects of hormone therapy on cognition and dementia risk in women, including discussion of absolute risk. Lastly, a brief review of modifiable risk factors for age-related cognitive decline and dementia is presented, with guidance for counseling patients on optimizing their brain health at midlife and beyond.

Childhood Maltreatment and Arterial Stiffness Among Midlife Women

Background Childhood maltreatment has been associated with arterial stiffness. This relationship has not been examined specifically among women at midlife, a time of increased arterial stiffness in women. This study tested whether childhood maltreatment is associated with arterial stiffness among a cohort of midlife women. Methods and Results A total of 162 nonsmoking perimenopausal and postmenopausal women free of clinical cardiovascular disease (mean age, 54 years; 72% White race, 23% Black race, and 5% Asian/Pacific Islander or Mixed race) completed the Child Trauma Questionnaire at baseline. At a follow-up visit 5 years later, blood pressure and carotid-femoral pulse wave velocity (a measure of arterial stiffness) were assessed. Relationships between childhood maltreatment and carotid-femoral pulse wave velocity were tested in linear regression models, adjusting for time between visits, age, race and ethnicity, education, body mass index, heart rate, hypertension medication, and diastolic blood pressure. Seventy-one women (44% of the sample) met criteria for a history of childhood maltreatment. Women with a history of childhood maltreatment had higher carotid-femoral pulse wave velocity (B [SE]=0.47 [0.21]; P=0.03) than women without this history, controlling for time between visits, age, race and ethnicity, education, body mass index, heart rate, hypertension medication, and diastolic blood pressure. Conclusions Among these midlife women, childhood maltreatment was associated with arterial stiffness, highlighting the potential long-term cardiovascular implications of childhood maltreatment.

Ovarian steroid hormones: A long overlooked but critical contributor to brain aging and Alzheimer's disease

Ovarian hormones, particularly 17β-estradiol, are involved in numerous neurophysiological and neurochemical processes, including those subserving cognitive function. Estradiol plays a key role in the neurobiology of aging, in part due to extensive interconnectivity of the neural and endocrine system. This aspect of aging is fundamental for women's brains as all women experience a drop in circulating estradiol levels in midlife, after menopause. Given the importance of estradiol for brain function, it is not surprising that up to 80% of peri-menopausal and post-menopausal women report neurological symptoms including changes in thermoregulation (vasomotor symptoms), mood, sleep, and cognitive performance. Preclinical evidence for neuroprotective effects of 17β-estradiol also indicate associations between menopause, cognitive aging, and Alzheimer's disease (AD), the most common cause of dementia affecting nearly twice more women than men. Brain imaging studies demonstrated that middle-aged women exhibit increased indicators of AD endophenotype as compared to men of the same age, with onset in perimenopause. Herein, we take a translational approach to illustrate the contribution of ovarian hormones in maintaining cognition in women, with evidence implicating menopause-related declines in 17β-estradiol in cognitive aging and AD risk. We will review research focused on the role of endogenous and exogenous estrogen exposure as a key underlying mechanism to neuropathological aging in women, with a focus on whether brain structure, function and neurochemistry respond to hormone treatment. While still in development, this research area offers a new sex-based perspective on brain aging and risk of AD, while also highlighting an urgent need for better integration between neurology, psychiatry, and women's health practices.

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.

Endogenous and Exogenous Estrogen Exposures: How Women's Reproductive Health Can Drive Brain Aging and Inform Alzheimer's Prevention

After advanced age, female sex is the major risk factor for late-onset Alzheimer's disease (AD), the most common cause of dementia affecting over 24 million people worldwide. The prevalence of AD is higher in women than in men, with postmenopausal women accounting for over 60% of all those affected. While most research has focused on gender-combined risk, emerging data indicate sex and gender differences in AD pathophysiology, onset, and progression, which may help account for the higher prevalence in women. Notably, AD-related brain changes develop during a 10-20 year prodromal phase originating in midlife, thus proximate with the hormonal transitions of endocrine aging characteristic of the menopause transition in women. Preclinical evidence for neuroprotective effects of gonadal sex steroid hormones, especially 17β-estradiol, strongly argue for associations between female fertility, reproductive history, and AD risk. The level of gonadal hormones to which the female brain is exposed changes considerably across the lifespan, with relevance to AD risk. However, the neurobiological consequences of hormonal fluctuations, as well as that of hormone therapies, are yet to be fully understood. Epidemiological studies have yielded contrasting results of protective, deleterious and null effects of estrogen exposure on dementia risk. In contrast, brain imaging studies provide encouraging evidence for positive associations between greater cumulative lifetime estrogen exposure and lower AD risk in women, whereas estrogen deprivation is associated with negative consequences on brain structure, function, and biochemistry. Herein, we review the existing literature and evaluate the strength of observed associations between female-specific reproductive health factors and AD risk in women, with a focus on the role of endogenous and exogenous estrogen exposures as a key underlying mechanism. Chief among these variables are reproductive lifespan, menopause status, type of menopause (spontaneous vs. induced), number of pregnancies, and exposure to hormonal therapy, including hormonal contraceptives, hormonal therapy for menopause, and anti-estrogen treatment. As aging is the greatest risk factor for AD followed by female sex, understanding sex-specific biological pathways through which reproductive history modulates brain aging is crucial to inform preventative and therapeutic strategies for AD.

A tale of two systems: Lessons learned from female mid-life aging with implications for Alzheimer's prevention & treatment

Neurological aging is frequently viewed as a linear process of decline, whereas in reality, it is a dynamic non-linear process. The dynamic nature of neurological aging is exemplified during midlife in the female brain. To investigate fundamental mechanisms of midlife aging that underlie risk for development of Alzheimer's disease (AD) in late life, we investigated the brain at greatest risk for the disease, the aging female brain. Outcomes of our research indicate that mid-life aging in the female is characterized by the emergence of three phases: early chronological (pre-menopause), endocrinological (peri-menopause) and late chronological (post-menopause) aging. The endocrinological aging program is sandwiched between early and late chronological aging. Throughout the three stages of midlife aging, two systems of biology, metabolic and immune, are tightly integrated through a network of signaling cascades. The network of signaling between these two systems of biology underlie an orchestrated sequence of adaptative starvation responses that shift the brain from near exclusive dependence on a single fuel, glucose, to utilization of an auxiliary fuel derived from lipids, ketone bodies. The dismantling of the estrogen control of glucose metabolism during mid-life aging is a critical contributor to the shift in fuel systems and emergence of dynamic neuroimmune phenotype. The shift in fuel reliance, puts the largest reservoir of local fatty acids, white matter, at risk for catabolism as a source of lipids to generate ketone bodies through astrocytic beta oxidation. APOE4 genotype accelerates the tipping point for emergence of the bioenergetic crisis. While outcomes derived from research conducted in the female brain are not directly translatable to the male brain, the questions addressed in a female centric program of research are directly applicable to investigation of the male brain. Like females, males with AD exhibit deficits in the bioenergetic system of the brain, activation of the immune system and hallmark Alzheimer's pathologies. The drivers and trajectory of mechanisms underlying neurodegeneration in the male brain will undoubtedly share common aspects with the female in addition to factors unique to the male. Preclinical and clinical evidence indicate that midlife endocrine aging can also be a transitional bridge to autoimmune disorders. Collectively, the data indicate that endocrinological aging is a critical period "tipping point" in midlife which can initiate emergence of the prodromal stage of late-onset-Alzheimer's disease. Interventions that target both immune and metabolic shifts that occur during midlife aging have the potential to alter the trajectory of Alzheimer's risk in late life. Further, to achieve precision medicine for AD, chromosomal sex is a critical variable to consider along with APOE genotype, other genetic risk factors and stage of disease.

Associations between abdominal adipose tissue, reproductive span, and brain characteristics in post-menopausal women

The menopause transition involves changes in oestrogens and adipose tissue distribution, which may influence female brain health post-menopause. Although increased central fat accumulation is linked to risk of cardiometabolic diseases, adipose tissue also serves as the primary biosynthesis site of oestrogens post-menopause. It is unclear whether different types of adipose tissue play diverging roles in female brain health post-menopause, and whether this depends on lifetime oestrogen exposure, which can have lasting effects on the brain and body even after menopause. Using the UK Biobank sample, we investigated associations between brain characteristics and visceral adipose tissue (VAT) and abdominal subcutaneous adipose tissue (ASAT) in 10,251 post-menopausal females, and assessed whether the relationships varied depending on length of reproductive span (age at menarche to age at menopause). To parse the effects of common genetic variation, we computed polygenic scores for reproductive span. The results showed that higher VAT and ASAT were both associated with higher grey and white matter brain age, and greater white matter hyperintensity load. The associations varied positively with reproductive span, indicating more prominent associations between adipose tissue and brain measures in females with a longer reproductive span. The effects were in general small, but could not be fully explained by genetic variation or relevant confounders. Our findings indicate that associations between abdominal adipose tissue and brain health post-menopause may partly depend on individual differences in cumulative oestrogen exposure during reproductive years, emphasising the complexity of neural and endocrine ageing processes in females.

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.

A Lifecourse Perspective on Female Sex-Specific Risk Factors for Later Life Cognition

PURPOSE OF REVIEW

The prevalence of Alzheimer's disease and related dementias is greater in women compared to men. We provide a review of female sex-specific risk factors across the lifecourse for cognition in older adulthood, highlighting areas that need further study.

RECENT FINDINGS

Pregnancy may affect late-life cognition, with adverse pregnancy outcomes associated with an increased risk of cognitive decline but parity providing a protective effect. Cumulative estrogen exposure, influenced by age of menarche, menopause, and exogenous estrogen use, may modify a woman's risk for dementia. Menopause transition-associated symptoms may impact cognitive health at the time of the symptoms, but long-term effects remain unknown. As compared to natural menopause, surgical menopause seems to increase the risk for cognitive impairment. Studies that have assessed the association between women's reproductive health and cognition have produced conflicting results. Future studies that address these inconsistencies among diverse populations are needed to better care for women throughout their lives.

Physiologic vasomotor symptoms are associated with verbal memory dysfunction in breast cancer survivors

OBJECTIVE

Vasomotor symptoms (VMS), sleep disturbance, and cognitive complaints are common among women with a history of breast cancer and contribute to decreased quality of life. Studies in healthy women showed an association between verbal memory performance and physiologic VMS measured with ambulatory skin conductance monitors but not with VMS by self-report. We hypothesized that we would find a similar association in women with breast cancer.

METHODS

Participants included 30 female breast cancer survivors (mean age 52.7 y; 26.7% African-American) with moderate-to-severe VMS enrolled in a larger clinical trial of a nonhormonal intervention for VMS. At baseline, participants completed assessments of physiologic VMS, actigraphy-based assessments of sleep, questionnaires about mood, and two tests of verbal memory - Logical Memory (LM) and the California Verbal Learning Test (CVLT). Using baseline data, we conducted multivariate regression analyses to examine the association between VMS and memory, controlling for sleep and other factors.

RESULTS

On average, women reported 46% of total physiologic VMS. A higher frequency of physiologic VMS - but not reported VMS - was significantly associated with lower scores on the California Verbal Learning Test short-delay free recall (r[28] = -0.41, P = 0.03), long-delay free recall (r[28] = -0.42, P = 0.03), and total clustering, (r[28] = -0.39, P = 0.04). These associations were independent of sleep, mood, and other factors.

CONCLUSIONS

Independent of their effect on sleep, VMS may be a modifiable contributor to memory difficulties in women with breast cancer. These findings underscore the importance of objective measurement of VMS in cognitive studies. : Video Summary:http://links.lww.com/MENO/A623.

Sleep characteristics and white matter hyperintensities among midlife women

STUDY OBJECTIVES

Sleep disturbance is common among midlife women. Poor self-reported sleep characteristics have been linked to cerebrovascular disease and dementia risk. However, little work has considered the relation of objectively assessed sleep characteristics and white matter hyperintensities (WMHs), a marker of small vessel disease in the brain. Among 122 midlife women, we tested whether women with short or disrupted sleep would have greater WMH, adjusting for cardiovascular disease (CVD) risk factors, estradiol, and physiologically assessed sleep hot flashes.

METHODS

We recruited 122 women (mean age = 58 years) without a history of stroke or dementia who underwent 72 h of actigraphy to quantify sleep, 24 h of physiologic monitoring to quantify hot flashes; magnetic resonance imaging to assess WMH; phlebotomy, questionnaires, and physical measures (blood pressure, height, and weight). Associations between actigraphy-assessed sleep (wake after sleep onset and total sleep time) and WMH were tested in linear regression models. Covariates included demographics, CVD risk factors (blood pressure, lipids, and diabetes), estradiol, mood, and sleep hot flashes.

RESULTS

Greater actigraphy-assessed waking after sleep onset was associated with more WMH [B(SE) = .008 (.002), p = 0.002], adjusting for demographics, CVD risk factors, and sleep hot flashes. Findings persisted adjusting for estradiol and mood. Neither total sleep time nor subjective sleep quality was related to WMH.

CONCLUSIONS

Greater actigraphy-assessed waking after sleep onset but not subjective sleep was related to greater brain WMH among midlife women. Poor sleep may be associated with brain small vessel disease at midlife, which can increase the risk for brain disorders.

Hot flashes are associated with altered brain function during a memory task

OBJECTIVE

Vasomotor symptoms (VMS) are associated with decreased memory performance and alterations in brain function. We conducted a preliminary examination of VMS and patterns of brain activity during a verbal memory task to provide insights into the VMS-related brain mechanisms that can contribute to memory problems in midlife women.

METHODS

Fourteen postmenopausal women (mean age 53.5, 64% African-American) with moderate-to-severe VMS (>35/wk) and not taking hormone therapy completed functional magnetic resonance imaging (fMRI) assessments during word encoding and recognition, 24-hour physiologic VMS monitoring, symptom questionnaires, and two verbal memory tests.

RESULTS

In regression analyses, a higher number of physiologic VMS, but not reported VMS, was associated with worse verbal memory on immediate and delayed logical memory (r = 0.53 and r = 0.72, P < 0.05). On fMRI assessments, a higher number of physiologic VMS, but not subjective VMS, was associated with greater activation in the left orbitofrontal cortex, left medial and superior frontal gyrus, right superior frontal gyrus, and right parahippocampal gyrus during the encoding task (P < 0.005). During the recognition task, physiologic VMS were associated with greater activation in the left medial and superior frontal gyrus, left parahippocampal gyrus and hippocampus, right medial and superior frontal gyrus, right parahippocampal gyrus and hippocampus (P < 0.005), and with decreased activation in the ventral medial prefrontal cortex (P < 0.005). Those associations were independent of symptoms and hormone levels.

CONCLUSIONS

Preliminary data suggest that VMS may contribute to memory performance through effects on the hippocampus and prefrontal cortex. Larger studies are warranted to determine the robustness of these initial observations. : Video Summary:http://links.lww.com/MENO/A508.

Menopause and Brain Health: Hormonal Changes Are Only Part of the Story

Most studies of menopause and brain aging have focused on the role of the sex steroid hormone, estradiol, as a key mechanisms contributing to cognitive and brain aging in women. An emerging literature demonstrates that beyond endogenous estradiol levels, menopausal symptoms, particularly vasomotor symptoms (VMS), are also key determinants of menopause-related changes in cognition and brain function. Critically, that literature shows the importance of using objective techniques to identify associations of VMS with memory performance, brain structure, and brain function. While self-report measures are important patient-centered outcomes in women's health research, objective measures of VMS typically relate more strongly to indices of cognitive and brain health. Currently, it is premature to make a causal claim about VMS and memory dysfunction, but initial findings raise the possibility that women with VMS might experience an improvement in cognition with VMS treatment. More generally, these findings underscore the utility of investigating female-specific risk factors for cognitive decline.

Childhood abuse and vasomotor symptoms among midlife women

OBJECTIVE

Childhood maltreatment is related to adverse health outcomes. However, the relation of childhood maltreatment to the menopause transition-a universal transition for women often accompanied by troubling symptoms such as vasomotor symptoms-is relatively underexplored. This study tested whether childhood abuse and neglect are associated with menopausal vasomotor symptoms, utilizing both physiologic and prospective self-report measures of vasomotor symptoms.

METHODS

In all, 295 nonsmoking perimenopausal and postmenopausal women aged 40 to 60 years with and without vasomotor symptoms completed psychosocial measures, including the Child Trauma Questionnaire, ambulatory physiologic (sternal skin conductance) and self-report measurement of vasomotor symptoms during wake and sleep, and actigraphy measurement of sleep. Relationships between childhood abuse/neglect and vasomotor symptoms during wake and sleep were tested in linear regression models controlling for demographics, body mass index, and menopause stage.

RESULTS

44% of the sample reported abuse or neglect during childhood. Among women reporting vasomotor symptoms, childhood sexual or physical abuse was associated with more frequent physiologically-recorded vasomotor symptoms during sleep (sexual abuse: b [SE] = 1.45 [0.52], P = 0.006; physical abuse: b [SE] = 0.97 [0.47], P = 0.03) in multivariable models. Among these women, women with a physical or sexual abuse history had approximately 1.5 to 2-fold the number of sleep vasomotor symptoms than women without this history.

CONCLUSIONS

Childhood abuse is associated with more frequent physiologically-detected vasomotor symptoms during sleep.

Towards an understanding of women's brain aging: the immunology of pregnancy and menopause

Women are at significantly greater risk of developing Alzheimer's disease and show higher prevalence of autoimmune conditions relative to men. Women's brain health is historically understudied, and little is therefore known about the mechanisms underlying epidemiological sex differences in neurodegenerative diseases, and how female-specific factors may influence women's brain health across the lifespan. In this review, we summarize recent studies on the immunology of pregnancy and menopause, emphasizing that these major immunoendocrine transition phases may play a critical part in women's brain aging trajectories.

Safety and feasibility of estrogen receptor-β targeted phytoSERM formulation for menopausal symptoms: phase 1b/2a randomized clinical trial

OBJECTIVE

PhytoSERM is a formulation of genistein, daidzein, and S-equol that has an 83-fold selective affinity for estrogen receptor-β (ERβ); and may enhance neuron function and estrogenic mechanisms in the brain without having peripheral estrogenic activity.

METHODS

We conducted an overarching, two-stage, dose-ranging, double-blinded, randomized, placebo-controlled trial of 12 weeks duration comparing 50 and 100 mg/d of phytoSERM with placebo for noncognitively impaired, perimenopausal women aged 45 to 60, with intact uteri and ovaries, with at least one cognitive complaint, and one vasomotor-related symptom. Primary objectives were to assess safety and tolerability of a 50 and 100 mg daily dose; and, secondly, to evaluate potential indicators of efficacy on cognition and vasomotor symptoms over 4 and 12 weeks, and using an embedded, 4-week, 2-period, placebo-controlled crossover trial for a subset of participants.

RESULTS

Seventy-one women were randomized to treatment; 70 were evaluated at 4 weeks; 12 were entered into the crossover study; 5 did not complete 12 weeks. Reasons for discontinuation were withdrawal of consent (n = 1) and lost to follow-up (n = 4). Adverse events occurred in 16.7% (n = 4) placebo, 39.1% (n = 9) 50 mg/d, and 29.2% (n = 7) 100 mg/d treated participants; 85% were mild and none was severe. Vaginal bleeding occurred in 0, placebo; 1, 50 mg; and 3, 100 mg/d participants.

CONCLUSIONS

The phytoSERM formulation was well tolerated at 50 and 100 mg daily doses. Based on safety outcomes, vaginal bleeding at the 100 mg dose, and vasomotor symptoms and cognitive outcomes at 12 weeks, a daily dose of 50 mg was considered preferable for a phase 2 efficacy trial.

Postmenopausal health interventions: Time to move on from the Women's Health Initiative?

Menopause is a critical period during which, without timely interventions, increased risks of cardiovascular and metabolic diseases, osteoporosis, sexual dysfunction and premature cognitive decline will contribute to diminished quality-of-life in women. Hormone therapy (HT) used to be the standard of care for managing vasomotor symptoms and prevention of chronic diseases until publication of the Women's Health Initiative (WHI) in 2002. Concerned about risks highlighted in WHI publications, many symptomatic women promptly ceased HT which resulted in increased vasomotor symptoms, osteoporosis-related-fractures and insomnia. Data from post-hoc WHI analyses and newer clinical trials consistently show reductions in coronary heart disease and mortality when estrogen therapy is initiated soon after menopause, whereas administration in later years and/or in combination with progesterone carries increased risks. However, no validated primary preventive strategies are available for younger postmenopausal women (<60 years), highlighting the need to re-evaluate the use of estrogen alone for which the risk-benefit balance appears positive. In contrast, in older women (>60 years), risks associated with oral HT exceed benefits; however transdermal estrogen may offer a safer alternative and should be further evaluated. Alternative therapies such as phytoestrogens and non-hormonal prescriptions may be beneficial for older women or those who are unsuitable for HT. Long-term head-to-head comparisons of HT with alternative interventions are warranted to confirm their efficacy for chronic disease prevention.

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.

Impact of sex steroids and reproductive stage on sleep-dependent memory consolidation in women

Age and sex are two of the three major risk factors for Alzheimer's disease (ApoE-e4 allele is the third), with women having a twofold greater risk for Alzheimer's disease after the age of 75 years. Sex differences have been shown across a wide range of cognitive skills in young and older adults, and evidence supports a role for sex steroids, especially estradiol, in protecting against the development of cognitive decline in women. Sleep may also be a protective factor against age-related cognitive decline, since specific electrophysiological sleep events (e.g. sleep spindle/slow oscillation coupling) are critical for offline memory consolidation. Furthermore, studies in young women have shown fluctuations in sleep events and sleep-dependent memory consolidation during different phases of the menstrual cycle that are associated with the levels of sex steroids. An under-appreciated possibility is that there may be an important interaction between these two protective factors (sex steroids and sleep) that may play a role in daily fluctuations in cognitive processing, in particular memory, across a woman's lifespan. Here, we summarize the current knowledge of sex steroid-dependent influences on sleep and cognition across the lifespan in women, with special emphasis on sleep-dependent memory processing. We further indicate gaps in knowledge that require further experimental examination in order to fully appreciate the complex and changing landscape of sex steroids and cognition. Lastly, we propose a series of testable predictions for how sex steroids impact sleep events and sleep-dependent cognition across the three major reproductive stages in women (reproductive years, menopause transition, and post-menopause).

Hormone replacement therapy in young women with surgical primary ovarian insufficiency

Bilateral oophorectomy performed in women before they are menopausal induces surgical primary ovarian insufficiency, an acute and chronic deficiency of the hormones normally produced by the ovaries. Without hormone replacement therapy (HRT) most of these women develop severe symptoms of estrogen (E) deficiency and are at increased risk for osteoporosis, cardiovascular disease, cognitive decline, dementia, and the associated increases in morbidity and mortality. In cases in which a hysterectomy has been performed at the time of bilateral oophorectomy transdermal or transvaginal E2 replacement therapy without cyclic progestin replacement is the optimum hormonal management for these women. There is substantial evidence this approach even reduces the risk for breast cancer. Unfortunately, unwarranted fear of all menopausal HRTs has become widespread following the reports of the Women's Health Initiative studies. This fear has led to a steep decline in use of E therapy, even in women in whom HRT is clearly indicated. Discussion of possible ovarian conservation in women who are premenopausal is an integral part of the preoperative planning for any women undergoing hysterectomy. Timely and effective HRT for women who will experience surgical primary ovarian insufficiency is clearly indicated.

Menopausal Hot Flashes and Carotid Intima Media Thickness Among Midlife Women

BACKGROUND AND PURPOSE

There has been a longstanding interest in the role of menopause and its correlates in the development of cardiovascular disease (CVD) in women. Menopausal hot flashes are experienced by most midlife women; emerging data link hot flashes to CVD risk indicators. We tested whether hot flashes, measured via state-of-the-art physiologic methods, were associated with greater subclinical atherosclerosis as assessed by carotid ultrasound. We considered the role of CVD risk factors and estradiol concentrations in these associations.

METHODS

A total of 295 nonsmoking women free of clinical CVD underwent ambulatory physiologic hot flash assessments; a blood draw; and carotid ultrasound measurement of intima media thickness and plaque. Associations between hot flashes and subclinical atherosclerosis were tested in regression models controlling for CVD risk factors and estradiol.

RESULTS

More frequent physiologic hot flashes were associated with higher carotid intima media thickness (for each additional hot flash: β [SE]=0.004 [0.001]; P=0.0001; reported hot flash: β [SE]=0.008 [0.002]; P=0.002, multivariable) and plaque (eg, for each additional hot flash, odds ratio [95% confidence interval] plaque index ≥2=1.07 [1.003-1.14]; P=0.04, relative to no plaque, multivariable] among women reporting daily hot flashes; associations were not accounted for by CVD risk factors or by estradiol. Among women reporting hot flashes, hot flashes accounted for more variance in intima media thickness than most CVD risk factors.

CONCLUSIONS

Among women reporting daily hot flashes, frequent hot flashes may provide information about a woman's vascular status beyond standard CVD risk factors and estradiol. Frequent hot flashes may mark a vulnerable vascular phenotype among midlife women.

Stellate ganglion blockade and verbal memory in midlife women: Evidence from a randomized trial

OBJECTIVES

In a pilot randomized clinical trial of active stellate ganglion blockade (SGB) versus sham control, SGB significantly reduced the frequency of reported moderate to severe vasomotor symptoms (VMS) and the frequency of physiologic VMS measured using ambulatory skin conductance monitors. Here we examine secondary effects of SGB on verbal learning and memory.

STUDY DESIGN

In a randomized, sham-controlled study, 36 women met eligibility criteria for cognitive assessments, of whom 17 were randomized to receive fluoroscopy-guided SGB and 19 to sham control.

MAIN OUTCOME MEASURES

At baseline and three months post-treatment, women completed tests of verbal learning and memory (primary outcome) and other cognitive measures and also wore an ambulatory monitor for 24h to measure physiologic VMS and VMS reported in real time.

RESULTS

Verbal learning improved following active SGB (p<0.05) but not sham treatment; however, the interaction between group and time was not significant (p values 0.13-0.20). Two secondary cognitive measures improved only in the sham group. Improvements in physiologic VMS correlated significantly with improvements in verbal learning (r=0.51, p<0.05).

CONCLUSIONS

SGB might confer benefits to memory in relation to the magnitude of improvement in physiologic VMS. Broadly these findings suggest a possible link between physiologic VMS and memory problems in midlife women.

Perimenopause: From Research to Practice

The menopausal transition, or perimenopause, is associated with profound reproductive and hormonal changes. These changes have been well chronicled and matched with concomitant symptoms. The pattern of appearance of menopausal symptoms and their natural history have become increasingly clear thanks to the conduct of several long-term, longitudinal cohort studies that have examined many aspects of women's biology and psychology through this time of life. Menopausal symptoms are highly prevalent; they are sufficiently bothersome to drive almost 90% of women to seek out their healthcare provider for advice on how to cope. (1) The classic symptom of menopause is the hot flash, which is experienced by most women, and is moderately to severely problematic for about 1/3 of women. While most women will have an experience of hot flashes limited to just a year or two, others will experience them for a decade or more, and a small proportion of women will never be free of them. Poor sleep becomes more common in perimenopausal women not only in association with the menopausal transition but also in relation to aging. Depressed mood and increased anxiety also increase during the transition, with an abrupt rise in prevalence as women approach the later stages of the menopausal transition and have longer bouts of amenorrhea. These common symptoms often interact with one another such that depressed women tend to experience worse hot flashes along with worse sleep. As women enter the latter stages of the transition, vaginal dryness and dyspareunia also become more likely, affecting about 1/3 of the population. Unlike hot flashes, mood issues, and sleep, vaginal symptoms will not go away without treatment. Clinical approaches to these problems often involve hormone therapy, which can be safely given to most perimenopausal women on a short-term basis. Therapeutic strategies that are nonhormonal and behavioral can also be deployed.