Duration of the menopausal transition is longer in women with young age at onset: the multiethnic Study of Women's Health Across the Nation

An economic evaluation of eptinezumab for the preventive treatment of migraine in the UK, with consideration for natural history and work productivity

BACKGROUND

Migraine is a highly prevalent neurological disease with a substantial societal burden due to lost productivity. From a societal perspective, we assessed the cost-effectiveness of eptinezumab for the preventive treatment of migraine.

METHODS

An individual patient simulation of discrete competing events was developed to evaluate eptinezumab cost-effectiveness compared to best supportive care for adults in the United Kingdom with ≥ 4 migraine days per month and prior failure of ≥ 3 preventive migraine treatments. Individuals with sampled baseline characteristics were created to represent this population, which comprised dedicated episodic and chronic migraine subpopulations. Clinical efficacy, utility, and work productivity inputs were based on results from the DELIVER randomised controlled trial (NCT04418765). Timing of natural history events and treatment holidays-informed by the literature-were simulated to unmask any natural improvement of the disease unrelated to treatment. The primary outcomes were monthly migraine days, migraine-associated costs, quality-adjusted life years (QALYs), incremental cost-effectiveness ratio, and net monetary benefit, each evaluated over a 5-year time horizon from 2020. Secondary analyses explored a lifetime horizon and an alternative treatment stopping rule.

RESULTS

Treatment with eptinezumab resulted in an average of 0.231 QALYs gained at a saving of £4,894 over 5 years, making eptinezumab dominant over best supportive care (i.e., better health outcomes and less costly). This result was confirmed by the probabilistic analysis and all alternative assumption scenarios under the same societal perspective. Univariate testing of inputs showed net monetary benefit was most sensitive to the number of days of productivity loss, and monthly salary.

CONCLUSIONS

This economic evaluation shows that from a societal perspective, eptinezumab is a cost-effective treatment in patients with ≥ 4 migraine days per month and for whom ≥ 3 other preventive migraine treatments have failed.

TRIAL REGISTRATION

N/A.

An empowerment model for managing menopause

Menopause eventually happens to all people with typically functioning ovaries, and almost one billion women worldwide are postmenopausal. Although the biology of typical menopause is ubiquitous, the experience varies substantially. Factors contributing to the experience include not only individual factors, such as the nature and severity of symptoms, but also psychological, social, and contextual considerations, many of which are modifiable. In this first paper in the Lancet Series on menopause, we argue for a new approach that goes beyond the treatment of specific symptoms, to encompass a broad model to support women transitioning this life stage, using the model of empowerment. WHO defines empowerment as an active process of gaining knowledge, confidence, and self-determination to self-manage health and make informed decisions about care. Rather than focusing on menopause as an endocrine deficiency, we propose an empowerment model that recognises factors modifying the experience, in which the patient is an expert in their own condition and the health-care worker supports the patient to become an equal and active partner in managing their own care.

How do women feel cold water swimming affects their menstrual and perimenopausal symptoms?

OBJECTIVE

This study aimed to determine how women felt cold water swimming affected their menstrual and perimenopausal symptoms.

STUDY DESIGN

An online survey that asked women who regularly swim in cold water about their experiences. The survey was advertised for 2 months on social media. Questions related to cold water swimming habits and menstrual and perimenopausal symptoms were analysed.

MAIN OUTCOME MEASURES

Quantitative and qualitative data including; frequency of menstrual and menopause symptoms, the effect of cold water swimming on these symptoms.

RESULTS

1114 women completed the survey. Women reported that cold water swimming reduced their menstrual symptoms, notably psychological symptoms such as anxiety (46.7%), mood swings (37.7%) and irritability (37.6%). Perimenopausal women reported a significant improvement in anxiety (46.9%), mood swings (34.5%), low mood (31.1%) and hot flushes (30.3%). The majority of women with symptoms swam specifically to reduce these symptoms (56.4% for period and 63.3% for perimenopause symptoms). Women said they felt it was the physical and mental effects of the cold water that helped their symptoms. For the free text question, five themes were identified: the calming and mood-boosting effect of the water, companionship and community, period improvements, an improvement in hot flushes and an overall health improvement.

CONCLUSION

Women felt that cold water swimming had a positive overall effect on menstrual and perimenopause symptoms. Studies on other forms of exercise to relieve menstrual and perimenopause symptoms may show similar findings.

Challenges and Implications for Menopausal Health and Help-Seeking Behaviors in Midlife Women From the United States and China in Light of the COVID-19 Pandemic: Web-Based Panel Surveys

BACKGROUND

The global population of women of menopausal age is quickly increasing. The COVID-19 pandemic has led to an accelerated increase in the use of telehealth services, especially technological solutions targeting women's health. Understanding the factors behind midlife women's help-seeking behaviors amidst the pandemic will assist in the development of person-centered holistic telehealth solutions targeting menopausal and postreproductive health.

OBJECTIVE

This study aimed to compare the factors underlying help-seeking for menopausal distress among midlife women in the United States and China.

METHODS

We conducted 2 web-based panel surveys in the United States using Amazon Mechanical Turk and in China using Credamo between July and October 2022. A total of 1002 American and 860 Chinese women aged between 40 and 65 years took part in the survey. The survey was designed based on the Health Belief Model with questions related to their menopausal knowledge, perceived severity of menopausal symptoms, perceived susceptibility to menopausal distress, perceived benefits of help-seeking, perceived COVID-19- and non-COVID-19-related barriers against help-seeking, self-efficacy, and motivation to seek help. Structural equations models were fitted for the data using full information maximum likelihood to manage missing data.

RESULTS

Knowledge was not directly related to help-seeking motivation in both samples. Among the Chinese sample, knowledge was negatively related to perceived severity but positively related to COVID-19-related barriers; in turn, higher perceived severity, benefits, COVID-19-related barriers, and self-efficacy and lower non-COVID-19-related barriers were related to more motivation to seek help. In the US sample, knowledge was negatively related to perceived severity, susceptibility, benefits, barriers (COVID-19- and non-COVID-19-related), and self-efficacy; in turn, higher self-efficacy, COVID-19-related barriers, and benefits were associated with more help-seeking motivation. The factors explained 53% and 45.3% of the variance of help-seeking motivation among the American and Chinese participants, respectively.

CONCLUSIONS

This study revealed disparate pathways between knowledge, health beliefs, and the motivation for help-seeking among American and Chinese midlife women with respect to menopausal distress. Our findings show that knowledge may not directly influence help-seeking motivation. Instead, perceived benefits and self-efficacy consistently predicted help-seeking motivation. Interestingly, concern over COVID-19 infection was related to higher help-seeking motivation in both samples. Hence, our findings recommend the further development of telehealth services to (1) develop content beyond health education and symptom management that serves to enhance the perceived benefits of addressing women's multidimensional menopausal health needs, (2) facilitate patient-care provider communication with a focus on self-efficacy and a propensity to engage in help-seeking behaviors, and (3) target women who have greater midlife health concerns in the postpandemic era.

Mathematical recapitulation of the end stages of human ovarian aging

Ovarian aging in women can be described as highly unpredictable within individuals but predictable across large populations. We showed previously that modeling an individual woman's ovarian reserve of primordial follicles using mathematical random walks replicates the natural pattern of growing follicles exiting the reserve. Compiling many simulations yields the observed population distribution of the age at natural menopause (ANM). Here, we have probed how stochastic control of primordial follicle loss might relate to the distribution of the preceding menopausal transition (MT), when women begin to experience menstrual cycle irregularity. We show that identical random walk model conditions produce both the reported MT distribution and the ANM distribution when thresholds are set for growing follicle availability. The MT and ANM are shown to correspond to gaps when primordial follicles fail to grow for 7 and 12 days, respectively. Modeling growing follicle supply is shown to precisely recapitulate epidemiological data and provides quantitative criteria for the MT and ANM in humans.

Hormonal Injustice: Environmental Toxicants as Drivers of Endocrine Health Disparities

The toll of multiple endocrine disorders has increased substantially in recent decades, and marginalized populations bear a disproportionate burden of disease. Because of the significant individual and societal impact of these conditions, it is essential to identify and address all modifiable risk factors contributing to these disparities. Abundant evidence now links endocrine dysfunction with exposure to endocrine-disrupting chemicals (EDCs), with greater exposures to multiple EDCs occurring among vulnerable groups, such as racial/ethnic minorities, those with low incomes, and others with high endocrine disease burdens. Identifying and eliminating EDC exposures is an essential step in achieving endocrine health equity.

[Russian eligibility criteria prescribing menopausal hormonal hormones therapy for patients with cardiovascular and metabolic diseases. Consensus document of the Russian Cardiological Society, Russian Society of Obstetricians and Gynecologists, Russian Association of Endocrinologists, Eurasian Association of Therapists, Association of Phlebologists of Russia]

Menopausal symptoms can disrupt the life course of women at the peak of their career and family life. Currently, the most effective treatment for these manifestations is menopausal hormone therapy (MHT). The presence of cardiovascular and metabolic diseases in itself does not exclude the possibility of prescribing MHT to relieve menopausal symptoms and improve quality of life. However, often an obstacle to the use of this type of hormonal therapy is the fear of doctors who are afraid of doing more harm to patients than good. Caution is especially important when it comes to women with underlying health conditions. Moreover, it should be recognized that there is a lack of high-quality research regarding the safety of MHT for major chronic non-infectious diseases and common comorbid conditions. The presented consensus document analyzed all currently available data obtained from clinical trials of various designs and created a set of criteria for the acceptability of prescribing MHT to women with concomitant cardiovascular and metabolic diseases. Based on the presented document, doctors of various specialties who advise women in menopause will receive an accessible algorithm that will allow them to avoid potentially dangerous situations and reasonably prescribe MHT in real practice.

[Russian Eligibility Criteria for Prescribing Menopausal Hormone Therapy to Patients With Cardiovascular and Metabolic Diseases. Consensus Document of RSC, RSOG, RAE, EUAT, RAP]

Menopausal symptoms can impair the life of women at the peak of their career and family life. At the present time, the most effective treatment for these manifestations is menopausal hormone therapy (MHT). The presence of cardiovascular and metabolic diseases in itself does not exclude the possibility of prescribing MHT to relieve menopausal symptoms and improve quality of life. However, often an obstacle to the use of this type of hormone therapy is the fear of physicians to do more harm to patients than good. Caution is especially important when it comes to women with concurrent diseases. Moreover, it should be recognized that there is a shortage of high-quality research on the safety of MHT for underlying chronic non-infectious diseases and common comorbidities. The presented consensus analyzed all currently available data from clinical trials of various designs and created a set of criteria for the appropriateness of prescribing MHT to women with concomitant cardiovascular and metabolic diseases. Based on the presented document, physicians of various specialties who advise menopausal women will receive an accessible algorithm that will allow them to avoid potentially dangerous situations and reasonably prescribe MHT in real-life practice.

Systematic exclusion at study commencement masks earlier menopause for Black women in the Study of Women's Health Across the Nation (SWAN)

BACKGROUND

Shorter average lifespans for minoritized populations are hypothesized to stem from 'weathering' or accelerated health declines among minoritized individuals due to systemic marginalization. However, evidence is mixed on whether racial/ethnic differences exist in reproductive ageing, potentially due to selection biases in cohort studies that may systematically exclude 'weathered' participants. This study examines racial/ethnic disparities in the age of menopause after accounting for differential selection 'into' (left truncation) and 'out of' (right censoring) a cohort of midlife women.

METHODS

Using data from the Study of Women's Health Across the Nation (SWAN) cross-sectional screener (N = 15 695) and accompanying ∼20-year longitudinal cohort (N = 3302) (1995-2016), we adjusted for potential selection bias using inverse probability weighting (left truncation) to account for socio-demographic/health differences between the screening and cohort study, and multiple imputation (right censoring) to estimate racial/ethnic differences in age at menopause (natural and surgical).

RESULTS

Unadjusted for selection, no Black/White differences in menopausal timing [hazard ratio (HR)=0.98 (0.86, 1.11)] were observed. After adjustment, Black women had an earlier natural [HR = 1.13 (1.00, 1.26)] and surgical [HR= 3.21 (2.80, 3.62)] menopause than White women with natural menopause-corresponding to a 1.2-year Black/White difference in menopause timing overall.

CONCLUSIONS

Failure to account for multiple forms of selection bias masked racial/ethnic disparities in the timing of menopause in SWAN. Results suggest that there may be racial differences in age at menopause and that selection particularly affected the estimated menopausal age for women who experienced earlier menopause. Cohorts should consider incorporating methods to account for all selection biases, including left truncation, as they impact our understanding of health in 'weathered' populations.

Impact of menopausal symptoms on work and careers: a cross-sectional study

BACKGROUND

Women over 50 years are one of the fastest-growing employment groups. Menopausal symptoms can adversely impact quality of life, work performance and attendance; however, few studies look at the impact of individual menopausal symptoms on work and career development.

AIMS

To measure the prevalence of menopausal symptoms in employees in a healthcare setting, to assess the impact of individual symptoms on work, attendance and career development and to explore perceptions about workplace supports.

METHODS

In this cross-sectional study of Irish hospital workers, menopausal employees were asked about the frequency of 10 menopausal symptoms and the extent to which each symptom impacted them at work. Impacts on performance, attendance and career development were assessed, along with the benefits of workplace support.

RESULTS

Responses from 407 women showed that the most common menopausal symptoms affecting employees greater than 50% of the time while at work were fatigue (54%), difficulty sleeping (47%), poor concentration (44%) and poor memory (40%). Work performance was impacted for 65% of respondents and 18% had taken sick leave. There was a significant association between symptom severity at work and reduced work performance, career development decisions and attendance. Manager awareness about menopause (29%) and flexible working times (29%) were selected as the most important workplace supports.

CONCLUSIONS

Female employees are negatively impacted by menopausal symptoms while at work, particularly by psychological and neurocognitive symptoms which were associated with reduced work performance, attendance and career decisions. Manager awareness and flexible schedules were considered the most beneficial workplace supports.

Menopause-Biology, consequences, supportive care, and therapeutic options

Menopause is the cessation of ovarian function, with loss of reproductive hormone production and irreversible loss of fertility. It is a natural part of reproductive aging. The physiology of the menopause is complex and incompletely understood. Globally, menopause occurs around the age of 49 years, with geographic and ethnic variation. The hormonal changes of the menopause transition may result in both symptoms and long-term systemic effects, predominantly adverse effects on cardiometabolic and musculoskeletal health. The most effective treatment for bothersome menopausal symptoms is evidence-based, menopausal hormone therapy (MHT), which reduces bone loss and may have cardiometabolic benefits. Evidence-based non-hormonal interventions are also available for symptom relief. Treatment should be individualized with shared decision-making. Most MHT regimens are not regulator approved for perimenopausal women. Studies that include perimenopausal women are needed to determine the efficacy and safety of treatment options. Further research is crucial to improve menopause care, along with research to guide policy and clinical practice.

Substantial Lipid Increases During Menopausal Transition in Korean Middle-Aged Women

BACKGROUND

Adverse lipid profiles are observed in postmenopausal women. However, there is insufficient evidence of the association between lipids and reproductive aging in Korean women. We aimed to characterize lipid changes with respect to timing relative to menopause in Korean middle-aged women.

METHODS

This study included 1,436 premenopausal women who had a natural menopause during the follow-up period (median = 15.76 years) from the Korean Genome and Epidemiology Study (KoGES) Ansan and Anseong cohort. Lipid levels were measured every 2 years, and the magnitudes of annual lipid changes and differences in the changes by premenopausal body mass index were estimated using piecewise linear mixed-effects models.

RESULTS

All lipid levels increased greatly from 3 or 5 years before menopause to 1 year after menopause in all women, regardless of their premenopausal body mass index. During the period, high-density lipoprotein cholesterol (HDL-C) levels increased at 0.42 mg/dL per year (95% confidence interval [CI], 0.29 to 0.55 mg/dL). Nevertheless, non-HDL-C levels simultaneously increased at 3.42 mg/dL per year (95% CI, 3.11 to 3.72 mg/dL), and an annual change in the non-HDL-C to HDL-C ratio was 0.05 (95% CI, 0.04 to 0.06). One year after menopause, changes in all lipid parameters significantly slowed down, except for the non-HDL-C to HDL-C ratio (P < 0.001 for all). The ratio continued to increase until 3 years after menopause, but thereafter, the change leveled off.

CONCLUSION

Women experienced remarkable increases in lipid levels during menopausal transition, highlighting the need for early intervention strategies for cardiovascular disease prevention in women.

Perimenopause and/or menopause help-seeking among women from ethnic minorities: a qualitative study of primary care practitioners' experiences

BACKGROUND

Each woman's experience of the perimenopause and/or menopause is individual and unique. Research shows women from ethnic minorities often have different experiences from their White peers, and these are not being considered in conversations about the menopause. Women from ethnic minorities already face barriers to help-seeking in primary care, and clinicians have expressed challenges in cross cultural communication including the risk that women from ethnic minorities' perimenopause and/or menopause health needs are not being met.

AIM

To explore primary care practitioners' experiences of perimenopause and/or menopause help-seeking among women from ethnic minorities.

DESIGN AND SETTING

A qualitative study of 46 primary care practitioners from 35 practices across 5 regions of England, with patient and public involvement (PPI) consultations with 14 women from three ethnic minority groups.

METHOD

Primary care practitioners were surveyed using an exploratory approach. Online and telephone interviews were conducted and the data were analysed thematically. The findings were presented to three groups of women from ethnic minorities to inform interpretation of the data.

RESULTS

Practitioners described a lack of awareness of perimenopause and/or menopause among many women from ethnic minorities, which they felt impacted their help-seeking and communication of symptoms. Cultural expressions of embodied experiences could offer challenges to practitioners to 'join the dots' and interpret experiences through a holistic menopause care lens. Feedback from the women from ethnic minorities provided context to practitioner findings through examples from their individual experiences.

CONCLUSION

There is a need for increased awareness and trustworthy information resources to help women from ethnic minorities prepare for the menopause, and clinicians to recognise their experiences and offer support. This could improve women's immediate quality of life and potentially reduce future disease risk.

Studying the association between longitudinal mammographic density measurements and breast cancer risk: a joint modelling approach

BACKGROUND

Researchers have suggested that longitudinal trajectories of mammographic breast density (MD) can be used to understand changes in breast cancer (BC) risk over a woman's lifetime. Some have suggested, based on biological arguments, that the cumulative trajectory of MD encapsulates the risk of BC across time. Others have tried to connect changes in MD to the risk of BC.

METHODS

To summarize the MD-BC association, we jointly model longitudinal trajectories of MD and time to diagnosis using data from a large ([Formula: see text]) mammography cohort of Swedish women aged 40-80 years. Five hundred eighteen women were diagnosed with BC during follow-up. We fitted three joint models (JMs) with different association structures; Cumulative, current value and slope, and current value association structures.

RESULTS

All models showed evidence of an association between MD trajectory and BC risk ([Formula: see text] for current value of MD, [Formula: see text] and [Formula: see text] for current value and slope of MD respectively, and [Formula: see text] for cumulative value of MD). Models with cumulative association structure and with current value and slope association structure had better goodness of fit than a model based only on current value. The JM with current value and slope structure suggested that a decrease in MD may be associated with an increased (instantaneous) BC risk. It is possible that this is because of increased screening sensitivity rather than being related to biology.

CONCLUSION

We argue that a JM with a cumulative association structure may be the most appropriate/biologically relevant model in this context.

Obesity and menopause

The global obesity pandemic continues to rise, with figures from the World Health Organization showing that 13% of the world's adult population was obese in 2016. Obesity has significant implications, with an increased risk of cardiovascular diseases, diabetes mellitus, metabolic syndrome, and several malignancies. The menopausal transition is associated with increased obesity, a transition from a gynecoid to an android body shape, and increased abdominal and visceral fat, which further worsens the associated cardiometabolic risks. Whether this increased obesity is a consequence of menopause, age, genetics, or environmental factors has long been debated. Increasing life expectancy means women spend a significant part of their lives in the menopause. As such, understanding this complex interplay of obesity and menopause is important to providing the right advice/management. We review the current evidence on obesity and menopause, focusing on the implications of increased obesity during menopause, the impact of menopause on obesity, and the effect of available treatments on associated morbidities.

An overview of menopause, and why this should feature within pre-registration education

BACKGROUND

Over half the population (51%) of England and Wales is female, most of whom will experience menopause, either as a result of endocrine ageing or medical treatment.

AIM

The project aimed to undertake a review of the literature to determine the level of knowledge about menopause that healthcare students are exposed to, and to highlight why it is important for them to have an understanding of this subject both for their own clinical practice and for supporting colleagues in the workplace.

METHOD

A literature review was conducted by the project team.

FINDINGS

There is a lack of education for healthcare students, who will go on to care for those affected by menopause, and will also work with colleagues experiencing menopause.

CONCLUSION

Educational programmes should include menopause as a component, which will allow for a breaking down of barriers on a subject that is still generally considered taboo.

RECOMMENDATIONS

A national audit should be conducted on menopause coverage in UK pre-registration nursing. The addition of menopause to the Liverpool John Moores University pre-registration nursing curriculum is also recommended based on agreed competencies.

Perceptions, Benefits, and Use of Complementary and Integrative Therapies to Treat Menopausal Symptoms: A Pilot Study

Background

Menopause symptoms can be debilitating, and the use of menopausal hormone therapy (MHT) has declined significantly since the Women's Health Initiative.

Materials and Methods

We surveyed 508 peri- and postmenopausal females to determine (1) the use of complementary and integrative therapies (CIT), MHT; and pharmacotherapies; (2) the perceptions, perceived benefits/risks of CIT, MHT; and pharmacotherapy use; and (3) factors associated with CIT and MHT use for menopause symptom treatment.

Results

The majority of respondents used CIT to treat menopause symptoms based on physician recommendation and research studies. Treatments that were perceived as most beneficial included exercise, mind-body therapies, diet, and spiritual practices, with exercise and mind-body therapies chosen to treat the most common symptoms of sleep disturbances, depressive mood, and anxiety. Higher education level was the main predictive variable for choosing exercise (odds ratio [OR] = 1.27, p = 0.02) and mind-body therapies (OR = 1.57, p = 0.02) to treat menopausal symptoms. Perceptions, beliefs, and use of different CIT by primarily white, affluent, and educated peri- and postmenopausal females to treat menopause symptoms, including sleep disturbances, depression, and anxiety, are driven by conversations with physicians and evidence-based research.

Conclusion

These findings reinforce the necessity for both additional research in more diverse populations, as well as comprehensive, individualized personalized care from an interdisciplinary team that considers the best options available for all female patients.

Symptom monitoring improves physical and emotional outcomes during menopause: a randomized controlled trial

ABSTRACT

Objectives: A recent systematic review suggested that symptom monitoring can result in reductions in menopausal symptoms and improvements in health-related behaviors. To date, no studies have experimentally investigated whether symptom monitoring could be a beneficial intervention during the menopause transition.Methods: One hundred perimenopausal and postmenopausal women (mean age, 46 y; SD, 8 y) were randomized into either a monitoring-intervention or control group. A mixed between/within design was used, with group membership (ie, monitoring-intervention or control) as the between-subjects component and time (ie, baseline and 2-wk follow-up) as the within-subjects component. Dependent variables included symptom reductions and emotional reactions as measured via the Daily Record Keeping form. Secondary outcomes included help-seeking, communication, medical decision making, health awareness, self-efficacy, and health anxiety.Results: A linear mixed-effects model demonstrated that the monitoring-intervention group reported a 42% reduction in physical symptoms at follow-up versus a 12% reduction in the control group: ρ = 0.009, β = 6.3, 95% CI (1.5-11). Negative emotions also significantly reduced in the monitoring-intervention group but did not alter in the control group: ρ < 0.001, β = 3.4, and 95% CI (1.6-5.2). These effects remained significant after controlling for potential moderator variables such as trait neuroticism and coping preferences and potential confounders such as medical and demographic characteristics. Variances in other health outcomes were nonsignificant.Conclusions: Findings demonstrated that symptom monitoring reduced symptoms and negative emotions within a perimenopausal and postmenopausal sample, and these outcomes endured after controlling for key moderators and covariates. However, symptom monitoring was not related to improvements in health-related behavioral outcomes, which contrasts with previous findings. These findings show that symptom monitoring may be useful within healthcare settings by providing perimenopausal and postmenopausal women with a simple and accessible means of symptom alleviation while they await treatment or medical consultation.

Assessment of Climacteric Symptoms and Its Impact on Daily Lives of Employed and Unemployed Perimenopausal Women in Selected Rural Villages in South India

Perimenopause is a transitional state which occurs in women in their mid-life. These women may experience climacteric symptoms that affect their day-to-day life. The aim of the study was to assess and compare climacteric symptoms and their impact on daily lives among employed and unemployed perimenopausal women. A cross-sectional survey was done on 160 rural south Indian women aged 40 to 55 years who were identified as symptomatic of perimenopause as per the Stages of Reproductive Aging Workshop 10+ (STRAW) staging criteria. The study participants were grouped as employed and unemployed. Climacteric symptoms were assessed using Greene Climacteric Scale and climacteric symptoms' impact on daily lives was measured using a structured self-administered questionnaire. Both descriptive and inferential statistics were used to compare the variables between the two groups. The total Greene Climacteric score for unemployed perimenopausal women were found to be significantly higher than the employed group of perimenopausal women (14.5 ± 7.23 versus 12.52 ± 4.9, p < 0.05). The majority (58.8%) of the employed group had minimum impact whereas; the majority (51.2%) of the unemployed group had an average impact score. There was a strong positive correlation between climacteric symptoms and their impact on the daily lives of perimenopausal women. Employment status is a significant factor in causing variation in the climacteric symptoms. Unemployed perimenopausal women suffered more climacteric symptoms than their employed counterparts.

AMPK-like proteins and their function in female reproduction and gynecologic cancer

Serine-threonine kinase (STK11), also known as liver kinase B1 (LKB1), is a regulator of cellular homeostasis through regulating the cellular ATP-to-ADP ratio. LKB1 is classified as a tumor suppressor and functions as the key activator of AMP-activated protein kinase (AMPK) and a family of serine-threonine kinases called AMPK-like proteins. These proteins include novel (nua) kinase family 1 (NUAK1 and 2), salt inducible kinase (SIK1), QIK (known as SIK2), QSK (known as SIK3 kinase), and maternal embryonic leuzine zipper kinase (MELK) on tightly controlled and specific residual sites. LKB1 also regulates brain selective kinases 1 and 2 (BRSK1 and 2), additional members of AMPK-like protein family, which functions are probably less studied. AMPK-like proteins play a role in variety of reproductive physiology functions such as follicular maturation, menopause, embryogenesis, oocyte maturation, and preimplantation development. In addition, dysfunctional activity of AMPK-like proteins contributes to apoptosis blockade in cancer cells and induction of the epithelial-mesenchymal transition required for metastasis. Dysregulation of these proteins occurs in ovarian, endometrial, and cervical cancers. AMPK-like proteins are still undergoing further classification and may represent novel targets for targeted gynecologic cancer therapies. In this chapter, we describe the AMPK-like family of proteins and their roles in reproductive physiology and gynecologic cancers.

Menopause transition: Physiology and symptoms

With life expectancy for women on the rise, most women will experience menopausal transition and spend a significant number of years of their life in the menopausal phase. Menopausal transition involves a myriad of physical, endocrine, and psychological changes which are influenced by ethnic, psychological, and socio-cultural factors. Every woman's experience of the menopausal transition is unique, and a one-size-fits-all approach to the management of symptoms does not work. An understanding of the pathophysiology and severity of menopausal symptoms and the benefits and risks associated with both hormonal and non-hormonal treatments is important when individualising treatment options for menopausal symptoms.

Influences of the menopause transition and adverse childhood experiences on peripheral basal inflammatory markers

Objective

To characterize the influence of early life stress on peripheral basal inflammatory markers across the menopause transition.

Methods

Participants from the longitudinal Penn Ovarian Aging study were assessed for childhood adversity at study end (14 years) using the Adverse Childhood Experiences (ACE) questionnaire. Responses were categorized as low (0-1) or high (≥2) ACE exposure. The stored blood sample catalogue was reviewed to exclude those samples collected during use of medications that could impact immune status or medications suggestive of infection or allergies. Remaining blood samples (n ​= ​640) from 167 participants were assayed for interleukin-6 (IL-6), interleukin 1-beta (IL-1β), high sensitivity C-reactive protein (hsCRP), and tumor necrosis factor alpha (TNF-α). Menopause staging (premenopause, early transition, late transition, and postmenopause) was determined by questionnaire and menstrual diaries at yearly assessments. Generalized linear models for repeated measures were used to quantify the association between outcomes of interest (i.e., IL-6, IL-1β, hsCRP, and TNF-α) and exposures (i.e., menopause stage, ACE status, their interaction) while controlling for relevant covariates (i.e., BMI, smoking, age at first blood sample, and race). Inflammatory marker levels were log-transformed for modeling.

Results

Log IL-6 levels were higher in the late perimenopause versus premenopause (p ​= ​0.035). Menopause stage ​× ​ACE interaction was observed for log IL-6, IL-1β, and TNF-α (p ​= ​0.042, p ​= ​0.054, p ​= ​0.053, respectively); for individuals with high (≥2) ACE exposure, IL-6 was higher in the late perimenopause (p ​= ​0.015) while IL-1β and TNF-α were lower in the postmenopause versus premenopause (p ​= ​0.019 and p ​= ​0.020).

Conclusions

Results from this investigation indicate that the late perimenopause stage may be a window of risk for inflammation, particularly for individuals with greater childhood adversity. Prospective studies designed to address childhood stress and inflammation across the menopause transition are needed to confirm these findings. Heightened inflammation, even if transitory, may have negative impact on healthy aging.

Associations between polygenic risk score for age at menarche and menopause, reproductive timing, and serum hormone levels in multiple race/ethnic groups

OBJECTIVE

We assessed associations of genetic loci that contribute to age at menarche and menopause with sentinel menopausal traits in multiple race/ethnic groups.

METHODS

Genetic data from the Study of Women's Health Across the Nation include 738 White, 366 Black, 139 Chinese, and 145 Japanese women aged 42 to 52 at baseline. We constructed standardized polygenic risk scores (PRSs) using single nucleotide polymorphisms identified from large-scale genome-wide association studies meta-analyses of ages at menopause and menarche, evaluating associations with each trait within each race/ethnic group.

RESULTS

Menopause PRS was significantly associated with age at menopause in White women after Bonferroni correction (P < 0.004) and nominally associated in Chinese and Japanese women (P < 0.05) (7.4-8.5 mo delay for one standard deviation [SD] increase in PRS). Menarche PRS was significantly associated with age at menarche in White (P < 0.004) and nominally associated in Black and Japanese women (P < 0.05) (2.6-4.8 mo delay for one SD increase). In White women, menarche and menopause PRSs were significantly associated (P < 0.004) with shorter and longer (5.9 and 9.6 mo for one SD increase) reproductive lifespans, respectively, and menopause PRS with a longer menopausal transition (7.1 mo for one SD increase). We observed a significant positive association (P < 0.004) between menopause PRS and E2 level 2 years before menopause and a nominal association (P < 0.05) 2 years after menopause in Japanese women.

CONCLUSIONS

In addition to menopausal timing, PRSs associated with onset and ending of reproductive life were associated with reproductive lifespan, length of the menopausal transition, and E2 levels in different race/ethnic groups.

The Menopause Transition: Signs, Symptoms, and Management Options

CONTEXT

Menopause, the permanent cessation of menses, reflects oocyte depletion and loss of gonadal steroids. It is preceded by a transition state, the perimenopause, which is characterized by the gradual loss of oocytes, altered responsiveness to gonadal steroid feedback, wide hormonal fluctuations, and irregular menstrual patterns. The goal of this mini-review is to discuss the basic pathophysiology of the menopausal transition and the hormonal and nonhormonal management of clinicopathology attributed to it.

EVIDENCE ACQUISITION

A Medline search of epidemiologic, population-based studies, and studies of reproductive physiology was conducted. A total of 758 publications were screened.

EVIDENCE SYNTHESIS

The reproductive hormonal milieu of the menopausal transition precipitates bothersome vasomotor symptoms, mood disruption, temporary cognitive dysfunction, genitourinary symptoms, and other disease processes that reduce the quality of life of affected women. The endocrine tumult of the menopause transition also exposes racial and socioeconomic disparities in the onset, severity, and frequency of symptoms. Hormone therapy (HT) treatment can be effective for perimenopausal symptoms but its use has been stymied by concerns about health risks observed in postmenopausal HT users who are older than 60 and/or women who have been postmenopausal for greater than 10 years.

CONCLUSIONS

The menopause transition is a disruptive process that can last for over a decade and causes symptoms in a majority of women. It is important for clinicians to recognize early signs and symptoms of the transition and be prepared to offer treatment to mitigate these symptoms. Many safe and effective options, including HT, are available.

The evolutionary ecology of age at natural menopause: implications for public health

Evolutionary perspectives on menopause have focused on explaining why early reproductive cessation in females has emerged and why it is rare throughout the animal kingdom, but less attention has been given to exploring patterns of diversity in age at natural menopause. In this paper, we aim to generate new hypotheses for understanding human patterns of diversity in this trait, defined as age at final menstrual period. To do so, we develop a multilevel, interdisciplinary framework, combining proximate, physiological understandings of ovarian ageing with ultimate, evolutionary perspectives on ageing. We begin by reviewing known patterns of diversity in age at natural menopause in humans, and highlight issues in how menopause is currently defined and measured. Second, we consider together ultimate explanations of menopause timing and proximate understandings of ovarian ageing. We find that ovarian ageing is highly constrained by ageing of the follicle - the somatic structure containing the oocyte - suggesting that menopause timing might be best understood as a by-product of ageing rather than a facultative adaptation. Third, we investigate whether the determinants of somatic senescence also underpin menopause timing. We show that diversity in age at menopause can be, at least partly, explained by the genetic, ecological and life-history determinants of somatic ageing. The public health implications of rethinking menopause as the by-product rather than the catalyst of biological ageing are discussed.

Follicle stimulating hormone and estradiol trajectories from menopausal transition to late postmenopause in indigenous Chinese women

OBJECTIVE

The aim of this study was to examine follicle stimulating hormone (FSH) and estradiol (E2) trajectories in indigenous Chinese women through the ovarian aging process from 10 years before the final menstrual period (FMP) to 20 years after.

METHODS

A prospective community-based longitudinal cohort study of 362 Chinese middle-aged women with a clearly determined FMP was performed.

RESULTS

FSH and E2 trajectories were identified according to years from FMP and the Stages of Reproductive Aging Workshop + 10 (STRAW + 10), and further classified by body mass index. E2 decreases relatively steadily from Stage -2 to +1c, while FSH stabilizes quickly from Stage -2 to +1a. Obese women have higher E2 levels and lower FSH levels during menopausal transition, which last for decades after the FMP. There was no obvious decline in FSH levels for at least 20 years after the FMP.

CONCLUSIONS

The FSH and E2 trajectories in this indigenous Chinese cohort appear similar to those discussed in the Study of Women's Health Across the Nation, with ethnic differences. STRAW + 10 criteria may be used to ascertain the ovarian aging process in Chinese women. Obese women may experience different levels of hormonal fluctuations during the menopause transition, while FSH levels in all women appear to remain high even at late postmenopause.

NAMS 2019 Pre-Meeting Symposium, September 2019, Chicago Illinois: The Perimenopause

The North American Menopause Society held the 2019 Pre-Meeting Symposium on September 25, 2019, in Chicago, Illinois, to review the current state of the science related to the physiology of the perimenopause and to address management of the most prevalent and pressing clinical issues. The perimenopause, as defined by the Stages of Reproductive Aging Workshop + 10, encompasses the menopause transition as well as the first year following menopause, the final menstrual period. This phase in the continuum of women's reproductive lives had been one of the least well understood. Fortunately, contributions from a number of prospective, longitudinal, decades-long studies have provided a better understanding of the perimenopause, whereas posing important new questions related to symptom interaction and linkages between symptoms and long-term health. There is now added clarity to distinguish the effects of reproductive hormonal changes from aging. The variation in symptoms, including vasomotor symptoms, among women over time including differences in experiences by ethnicity and race, provides paradigm shifts in clinical perspective. Refinements in understanding the character, timing, and potential predictive markers for menstrual cycles during the transition have emerged. From the perspective of myriad clinical management challenges, significant progress in recommendations for evaluation and therapeutic approaches has been achieved. Finally, recognizing the menopause transition as an opportunity to initiate positive lifestyle changes to enhance future health was emphasized.

Vasomotor symptoms in women over 60: results from the Data Registry on Experiences of Aging, Menopause, and Sexuality (DREAMS)

OBJECTIVE

Frequency of vasomotor symptoms (VMS) in older women and the contributing factors are largely undefined. We measured the frequency of moderate-to-severe vasomotor symptoms (msVMS) in women ≥60 years of age and examined their characteristics to determine factors that may associate with VMS in older women.

METHODS

A cross-sectional survey was completed using the Menopause Health Questionnaire from the Data Registry on Experiences of Aging, Menopause, and Sexuality. Data were collected from women presenting for menopause consultation to Mayo Clinic, Rochester, MN, from January 1, 2006 to October 7, 2014. We created a binary variable where women were classified as having msVMS bother if they reported "quite a bit" or "extremely" compared with women reporting "not at all" or "a little bit." Women with and without msVMS were evaluated by menopause type, self-rated heath, current tobacco, caffeine, and alcohol use, as well as pertinent medication use. Associations between participant characteristics and msVMS were evaluated using logistic regression and a multivariable model with age as a covariate. Interactions between participant characteristics and age were also assessed.

RESULTS

Of the 4,956 women presenting for menopause consultation, 921 (18%) were ≥60 years old. Of these, 379 (41.2%) reported msVMS bother. Women with msVMS were more likely to have a history of nonspontaneous menopause and report their health as fair, versus good or excellent. Women reporting current use of hormone therapy (HT) (21%) were less likely to report msVMS compared with those not taking HT (P < 0.001).

CONCLUSIONS

A substantial number of women seen in a specialty menopause clinic were over age 60 years and reported msVMS, highlighting that VMS may be disruptive in women over a decade past the natural age of menopause.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Management of the Perimenopause

Perimenopause, or the menopausal transition, represents a period of time during which newly arising symptoms can present complex management decisions for providers. Many women present to care with complaints of hot flashes, vaginal and sexual changes, altered mood and sleep, and changing bleeding patterns. The effect of these symptoms on quality of life, even before a woman enters menopause, can be significant. The appropriate evaluation and evidence-based management of women in this transition is reviewed in this article. Two case vignettes are used to highlight certain evaluation and treatment challenges.

Menstrual Cycle Changes as Women Approach the Final Menses: What Matters?

Increased variability in menstrual cycle length marks the onset of the menopausal transition, with the likelihood of long cycles increasing as women approach menopause. This article describes the STRAW+10 bleeding criteria for recognizing onset of the early and late menopausal transition, as well as the specific bleeding changes a woman may experience during this life stage, including how women's bleeding experiences differ. The high probability of episodes of excessive and prolonged bleeding as women approach their final menstrual period is documented, as is the continuing probability of ovulation as women reach their final menstrual period.