Childhood abuse and vasomotor symptoms among midlife women

Trauma history and persistent poor objective and subjective sleep quality among midlife women

OBJECTIVES

Whereas some work links trauma exposure to poor subjective sleep quality, studies largely rely upon limited trauma measures and self-reported sleep at one time point. It is unknown whether trauma is related to persistent poor sleep, whether associations differ based on childhood versus adulthood trauma, and whether trauma exposure is related to poorer objectively assessed sleep. We tested whether childhood or adult trauma associated with persistent poor objectively and subjectively measured sleep at two time points in midlife women.

METHODS

One hundred sixty-seven women aged 40-60 at baseline were assessed twice 5 years apart. At baseline, women reported childhood trauma (Child Trauma Questionnaire), adult trauma (Brief Trauma Questionnaire), demographics, depressive symptoms, apnea symptoms, and medical history, and provided physical measures. At both visits, women completed 3 days of actigraphy (total sleep time [TST], wake after sleep onset [WASO]) and reported sleep quality (Pittsburgh Sleep Quality Index). Relations of childhood and adult trauma exposure, respectively, with persistent poor sleep at both baseline and follow-up visits (TST [<6 hours], WASO [>30 minutes], Pittsburgh Sleep Quality Index [>5]) were assessed in logistic regression models, adjusted for age, race/ethnicity, education, body mass index, sleep medications, nightshift work, apnea, depressive symptoms, vasomotor symptoms, and alcohol use.

RESULTS

Childhood trauma was related to persistent high WASO (odds ratio [95% confidence interval] = 2.16 [1.04-4.50], P = 0.039, multivariable). Adult trauma was related to persistent poor sleep quality (odds ratio [95% confidence interval] = 2.29 [1.07-4.93], P = 0.034, multivariable). Trauma was unrelated to persistent short TST.

CONCLUSIONS

Childhood and adult trauma, respectively, were related to persistent poor objective sleep continuity and subjective sleep quality in midlife women, independent of risk factors.

Diverse experiences of menopause

Although the biologic underpinnings of menopause remain consistent across populations, the experience of this phase can vary. This Practice Pearl summarizes key sociocultural, behavioral, environmental, and healthcare-system factors that contribute to the menopause journey. In addition to obtaining an accurate health history, screening for social determinants of health can enhance individualized menopause care with the potential to significantly improve overall health outcomes.

A systematic review on the bidirectional relationship between trauma-related psychopathology and reproductive aging

Objective

Natural variation in ovarian steroid hormones across the female lifespan contributes to an increased risk for depressive and posttraumatic stress disorder (PTSD) symptoms in women. However, minimal work has focused on understanding the impacts of reproductive aging on the brain and behavioral health of trauma-exposed women. This systematic review examines the bidirectional relationship between trauma-related psychopathology and reproductive aging.

Method

Following PRISMA guidelines, a systematic review of PubMed, PsychInfo, and Medline databases was undertaken to identify controlled studies on how trauma history impacts psychopathology and menopause symptoms during reproductive aging.

Results

Twenty-one studies met the eligibility criteria, with only four utilizing the gold standard STRAW+ 10 criteria for defining reproductive aging stages. The peri and postmenopausal periods appear to be particularly vulnerable phases for individuals with trauma exposure. Menopause symptoms and trauma-related psychopathology symptom severity increase during reproductive aging with increases in the degree of trauma exposure. However, mechanistic insights that may explain this interaction are currently neglected in this area of research.

Conclusion

There is a significant lack of understanding regarding how reproductive aging and its related neuroendocrine changes impact the brain to influence PTSD and depression symptoms related to trauma exposure. This lack of basic understanding impedes the ability to identify, assess, and treat PTSD and depressive symptoms in trauma-exposed women most effectively, and mitigate the long-term consequences of these behavioral health symptoms on morbidity and mortality in aging women.

Brown Adipose Tissue Activity and Childhood Exposure to Cold Are Associated With Hot Flashes at Menopause

OBJECTIVE

Hot flashes (HFs) are experienced as sudden sensations of heat. We hypothesized that brown adipose tissue (BAT) activation could increase the likelihood of HFs in winter. The aim of this study was to test whether women with more BAT activity were more likely to experience self-reported or biometrically measured HFs.

METHODS

Women aged 45-55 years (n = 270) participated in face-to-face interviews and anthropometric and ambulatory measures. Level of BAT activity was estimated from the difference in supraclavicular skin temperature measured by infrared thermography before and after cooling. Logistic regressions were applied to examine whether bothersome HFs (yes/no) during the past 2 weeks were associated with BAT activity, adjusting for menopausal status, childhood exposure to cold, waist/hip ratio, and self-reported health. Linear regressions were used to examine the frequency of self-reported and biometrically measured HFs during the study period and BAT activity, adjusting for potential confounders.

RESULTS

Menopausal status, childhood exposure to cold, waist-to-hip ratio (WHR), and self-reported health were associated with both BAT activity and HFs. After adjusting for potential confounders, an increase in BAT activity almost tripled the likelihood of bothersome HFs (OR 2.84, 95% CI 1.26-6.43). In linear regressions, BAT activity was not associated with frequency of subjective or objective HFs during the study period, but childhood exposure to cold was associated with subjective HF report (β = 0.163, p = 0.010).

CONCLUSION

To our knowledge, this is the first study of BAT activation and HFs. Our results support a role for BAT activity in HF experience. Therefore, we encourage further examination of the role of BAT, as well as childhood exposure to cold, in HFs.

Biopsychosocial factors intersecting with weekly sleep difficulties in the menopause transition

OBJECTIVES

Sleep difficulties are common in the menopause transition and increase risk for a variety of physical and psychological problems. The current study investigated potential interactions between psychosocial variables and within-person changes in ovarian hormones in predicting perimenopausal sleep problems as well as the potential interactions between poor sleep and psychosocial factors in predicting worsened mood, affect, and attention.

STUDY DESIGN

The sample included 101 perimenopausal individuals. Participants completed 12 weekly assessments of self-reported sleep outcomes, depressive mood and affect, and attention function, and of estrone glucuronide (E1G) and pregnanediol glucuronide (PdG) levels (urinary metabolites of estradiol and progesterone, respectively); they also had 24-h tracking of vasomotor symptoms. Other psychosocial variables such as trauma history and stressful life events were assessed at baseline.

RESULTS

A history of depression, baseline depressive symptoms, trait anxiety, and more severe and bothersome vasomotor symptoms predicted worsened sleep outcomes. Recent stressful life events, trauma history, and person-centred E1G and PdG changes did not predict sleep outcomes. However, there was an interaction whereby person-centred E1G decreases predicted lower sleep efficiency in those with higher baseline depressive symptoms. Higher baseline depression and trauma history also amplified the effect of vasomotor symptoms on sleep outcomes. In evaluating the effect of poor sleep on psychological and cognitive outcomes, stressful life events emerged as a moderating factor. Finally, trauma history and poor sleep interacted to predict worsened attention function.

CONCLUSIONS

The current study suggests that certain individuals may be at greater risk of perimenopausal sleep problems and the resulting negative effects on mood and cognition.

Dimensions of posttraumatic stress disorder and menopause-related health in midlife women veterans

OBJECTIVE

Posttraumatic stress disorder (PTSD) has been linked with menopause symptoms (eg, vasomotor, urinary) and their sequelae (eg, sexual difficulties). However, PTSD is a heterogeneous disorder, and less is known about which aspects may be most associated with menopause-related health.

METHODS

Using confirmatory factor analyses, we evaluated five structural models of PTSD symptoms in 208 predominately postmenopausal women veterans (aged 45-64 years). We investigated associations between PTSD-operationalized as a probable diagnosis and symptom dimensions of the best-fitting model-and common menopause-related health concerns, including (1) vasomotor, urinary, and vaginal symptoms; (2) vasomotor symptom interference; and (3) sexual functioning.

RESULTS

A six-factor anhedonia model-comprising re-experiencing, avoidance, negative affect, anhedonia, anxious arousal, and dysphoric arousal-provided optimal fit. Both probable PTSD and greater symptoms across all dimensions were linked with presence of urinary and vasomotor, but not vaginal, symptoms. Comparing dimensions revealed that negative affect and dysphoric arousal were particularly associated with urinary symptoms, whereas dysphoric arousal was the factor most strongly related to vasomotor symptom interference. Associations between PTSD and sexual dysfunction were mixed; whereas there was no relation with probable diagnosis, all dimensions were linked with adverse sexual sequelae.

CONCLUSIONS

PTSD-considered categorically and dimensionally-was relevant to menopause-related health in midlife women veterans. Further, symptoms of negative affect and dysphoric arousal were particularly related to urinary and vasomotor symptoms. These specific symptoms may drive associations between PTSD and these aspects of menopause-related health. Clinical interventions targeting these symptoms may promote midlife women's health.

Does everyday discrimination account for the increased risk of vasomotor symptoms in Black women?: the Study of Women's Health Across the Nation (SWAN)

OBJECTIVES

Vasomotor symptoms (VMS), including hot flashes and night sweats, are hallmark symptoms of the menopause transition. Previous research has documented greater frequency, duration, and severity of VMS in Black women compared with women from other racial/ethnic groups, even after accounting for other factors. This analysis examined the association between discrimination and VMS and the extent to which discrimination accounts for the disproportionate burden of VMS in Black women.

METHODS

Using available discrimination and VMS data from the SWAN cohort study (n = 2,377, 48% White, 32% Black, 6% Japanese, 4% Chinese, and 9% Hispanic women) followed approximately yearly in midlife from premenopause (42-52 y) through postmenopause (~20 y), we assessed concurrent associations between discrimination and VMS frequency in the past 2 weeks using weighted generalized mixed models. We also assessed associations between chronic discrimination across first four visits and VMS trajectories from premenopause to postmenopause using weighted multinomial logistic regression. Models were adjusted for known risk factors for VMS.

RESULTS

Higher levels of discrimination were associated with concurrent reporting of any (odds ratio [OR], 1.57 [1.31-1.89]) and frequent (≥6 d) VMS (OR, 1.55 [1.21-1.99]). After adjustment, associations remained significant for any (OR, 1.30 [1.09-1.54]) but not frequent VMS. For any VMS trajectories, chronic discrimination was associated with "continuously high" (OR, 1.69 [1.03-2.77]) and "high pre-FMP-decline post-FMP" (OR, 1.70 [1.01-2.88]) versus "FMP-onset low" trajectories. After adjusting for discrimination, odds of reporting any, frequent, and of being in the "continuously high" any VMS trajectory remained elevated for Black versus White women.

CONCLUSIONS

Discrimination is associated with greater concurrent risk of any (but not frequent) VMS, and chronic discrimination is associated with a continuously high reporting of any VMS over time, independent of known risk factors. Adjusting for discrimination attenuates but does not eliminate the increased risk of VMS for Black women.

Risks and benefits of hormone therapy after menopause for cognitive decline and dementia: A conceptual review

OBJECTIVE

The effects on the brain of hormone therapy after the onset of menopause remain uncertain. The effects may be beneficial, neutral, or harmful. We provide a conceptual review of the evidence.

METHODS

We 1) provide a brief history of the evidence, 2) discuss some of the interpretations of the evidence, 3) discuss the importance of age at menopause, type of menopause, and presence of vasomotor symptoms, and 4) provide some clinical recommendations.

RESULTS

The evidence and the beliefs about hormone therapy and dementia have changed over the last 30 years or more. Five recent observation studies suggested that hormone therapy is associated with an increased risk of dementia, and the association appears not to change with the timing of initiation of therapy. These harmful associations may be explained by a causal effect of hormone therapy on the brain or by several confounding mechanisms. We suggest that the use of hormone therapy should be customized for different subgroups of women. It may be important to subgroup women based on age at onset of menopause, type of menopause, and presence or absence of vasomotor symptoms. In addition, the effects may vary by type, dose, route, and duration of administration of estrogens and by the concurrent use of progestogens.

DISCUSSION

The relation of hormone therapy with the risk of dementia is complex. Hormone therapy may have beneficial, neutral, or harmful effects on the brain. Hormone therapy should be guided by the clinical characteristics of the women being treated.

Trauma and its implications for women's cardiovascular health during the menopause transition: Lessons from MsHeart/MsBrain and SWAN studies

Trauma exposure, whether experienced during childhood or adulthood, is prevalent among women. While experiences of trauma are well known to impact mental health, emerging research also links them to women's physical health. The Study of Women's Health Across the Nation (SWAN) and the MsHeart/MsBrain studies, two separate studies devoted to studying midlife women's health, have contributed importantly to the understanding of the implications of trauma to women's health at midlife and beyond. Specifically, findings from these studies have revealed that both childhood and adult trauma exposure are associated with poorer cardiovascular and cerebrovascular health in women, including greater subclinical cardiovascular disease, indicators of cerebral small vessel disease, and increased risk for clinical cardiovascular disease events. When considering trauma types, findings have pointed to the particular importance of sexual and interpersonal violence, such as childhood sexual abuse, intimate-partner violence, sexual harassment, and sexual assault to women's vasculatures. Further, using a range of measures of menopausal vasomotor symptoms, the SWAN and the MsHeart/MsBrain studies have also shown that women with greater trauma exposure have more objectively assessed and self-reported vasomotor symptoms. Finally, although links between trauma exposure and health are not typically explained by post-traumatic stress disorder, work also points to the additional importance of post-traumatic stress disorder to women's cardiovascular and brain health. Collectively, these studies have underscored the importance of trauma to the occurrence of menopausal symptoms, to cardiovascular health, and to women's brain health at midlife and beyond. Future directions and implications for prevention and intervention are discussed.

Childhood adversity and accelerated reproductive events: a systematic review and meta-analysis

OBJECTIVE

Accelerated female reproductive events represent the early onset of reproductive events involving puberty, menarche, pregnancy loss, first sexual intercourse, first birth, parity, and menopause. This study aimed to explore the association between childhood adversity and accelerated female reproductive events.

DATA SOURCES

PubMed, Web of Science, and Embase were systematically searched from September 22, 2022 to September 23, 2022.

STUDY ELIGIBILITY CRITERIA

Observational cohort, cross-sectional, and case-control studies in human populations were included if they reported the time of reproductive events for female individuals with experience of childhood adversity and were published in English.

METHODS

Two reviewers independently screened studies, obtained data, and assessed study quality, and conflicts were resolved by a third reviewer. Dichotomous outcomes were evaluated using meta-analysis, and pooled odds ratios and 95% confidence intervals were generated using random-effects models. Moderation analysis and meta-regression were used to investigate heterogeneity.

RESULTS

In total, 21 cohort studies, 9 cross-sectional studies, and 3 case-control studies were identified. Overall, female individuals with childhood adversity were nearly 2 times more likely to report accelerated reproductive events than those with no adversity exposure (odds ratio, 1.91; 95% confidence interval, 1.33-2.76; I2=99.6%; P<.001). Moderation analysis indicated that effect sizes for the types of childhood adversity ranged from an odds ratio of 1.61 (95% confidence interval, 1.23-2.09) for low socioeconomic status to 2.13 (95% confidence interval, 1.14-3.99) for dysfunctional family dynamics. Among the 7 groups based on different reproductive events, including early onset of puberty, early menarche, early sexual initiation, teenage childbirth, preterm birth, pregnancy loss, and early menopause, early sexual initiation had a nonsignificant correlation with childhood adversity (odds ratio, 2.70; 95% confidence interval, 0.88-8.30; I2=99.9%; P<.001). Considerable heterogeneity (I2>75%) between estimates was observed for over half of the outcomes. Age, study type, and method of data collection could explain 35.9% of the variance.

CONCLUSION

The literature tentatively corroborates that female individuals who reported adverse events in childhood are more likely to experience accelerated reproductive events. This association is especially strong for exposure to abuse and dysfunctional family dynamics. However, the heterogeneity among studies was high, requiring caution in interpreting the findings and highlighting the need for further evaluation of the types and timing of childhood events that influence accelerated female reproductive events.

Impact of violence against women on quality of life and menopause-related disorders

Violence against women is a pressing global issue that poses a number of significant health risks. The influence of violence on women's health during the menopause has been underestimated, especially its impact on the early onset of menopause and on the exacerbation of symptoms that determine quality of life. The objectives of our study were to analyse whether experiencing any type of violence increases the risk of early menopause, worsens menopausal symptoms, and results in a lower quality of life. This cross-sectional observational study recruited 29 postmenopausal women who had experienced violence from a partner in their lifetimes. Additionally, 89 postmenopausal who had not suffered from violence were included as a control group. All the women who had experienced violence from a partner reported psychological and economic violence, 75 % reported physical violence, 57.1 % reported sexual violence, and 39.3 % reported all types of violence. Violence was found to be associated with menopausal symptoms and poorer quality of life. These associations persisted after adjustment for multiple factors, and women who had experienced any form of violence reported a worse quality of life during menopause. Moreover, violence-exposed women reached menopause approximately 20 months earlier (p < 0.05), and 20.7 % of these women developed premature ovarian insufficiency (p < 0.001).

Associations of adverse childhood and lifetime experiences with sleep quality and duration among women in midlife

OBJECTIVES

Many women experience sleep problems during midlife. Associations of adverse lifetime experiences-more common among women-with sleep outcomes are understudied.

METHODS

We studied 476 women enrolled in Project Viva 1999-2002. At enrollment, participants reported any lifetime history of abuse and/or financial hardship. At midlife follow-up ∼20 years later, they reported a history of up to 10 adverse childhood experiences (ACEs); 7-day sleep quality (patient-reported outcomes measurement information system sleep disturbance and sleep-related impairment T-scores); and past month average sleep duration. We examined associations of adverse experiences with sleep outcomes, adjusted for childhood sociodemographic variables. We also explored mediation by current depression and anxiety symptoms, hot flash severity, general health, and body mass index.

RESULTS

ACEs were common: 301 women (63%) reported one or more. Each additional ACE was associated with higher midlife sleep disturbance (adjusted β = 0.65 points, 95% confidence interval [CI]: 0.27, 1.02) and sleep-related impairment (0.98, 95% CI: 0.54, 1.41) T-scores, and with sleep duration <6 hour/night (odds ratio 1.19, 95% CI: 1.00, 1.42), but not with continuous sleep duration (-2 minutes, 95% CI: -5, 1). Adverse experiences in adulthood were less consistently associated with sleep quality but were associated with sleep duration, for example, financial hardship during the index pregnancy was associated with 75 minutes (95% CI: -120, -29) shorter sleep duration 2 decades later. Associations of ACEs with sleep disturbance and sleep-related impairment were mediated by midlife depression anxiety and physical health but not by hot flash severity or body mass index.

CONCLUSIONS

Adverse lifetime experiences have deleterious associations with sleep duration and quality in midlife women.

Longitudinal associations of psychosocial stressors with menopausal symptoms and well-being among women in midlife

OBJECTIVE

We examined longitudinal associations of psychosocial stressors with menopausal symptoms and well-being of women in midlife in a longitudinal cohort.

METHODS

This study is based on 682 women from Project Viva, a prospective cohort enrolled in 1999 to 2002 during pregnancy (median age = 33.3 y) and followed for almost two decades. In pregnancy, women self-reported psychosocial stressors (history of physical and sexual abuse and financial instability, from childhood to the current pregnancy). In 2017 to 2021 (median age, 51.6 y), they reported their menopausal symptoms (0-44 point scale) and well-being (general health [good/fair/poor vs excellent/very good], generalized anxiety symptoms, and depressive symptoms [both-more than minimal levels vs none/minimal]). We performed multivariable and logistic regression models to examine associations of psychosocial stressors with outcomes, adjusting for covariates.

RESULTS

History of physical abuse (reported by 37.3%) was associated with worse menopausal symptoms in the somatovegetative (odds ratio [OR], 0.46 points; 95% confidence interval [CI], 0.04-0.87 points) and psychological (OR, 0.52 points; 95% CI, 0.07-0.97 points) domains and with worse general health (OR, 1.73; 95% CI, 1.17-2.55) and greater depressive symptoms (OR, 1.74; 95% CI, 1.05-2.87). History of sexual abuse (7.7%) was associated with worse menopausal symptoms (OR, 2.81 points; 95% CI, 1.05-4.56) and worse general health (OR, 2.04; 95% CI, 1.04-4.03) but not with depressive symptoms. History of financial instability (10.8%) was associated with worse menopausal symptoms (1.92 points; 0.49 to 3.34), worse general health (OR, 2.16; 95% CI, 1.24-3.75), and greater depressive symptoms (OR, 2.68; 95% CI, 1.44-4.98). We observed no association between psychosocial stressors and generalized anxiety symptoms assessed at midlife.

CONCLUSIONS

Psychosocial stressors were associated with worse menopausal symptoms and well-being decades after initial report.

Association between intergenerational violence exposure and maternal age of menopause

OBJECTIVE

To investigate whether maternal violence exposure personally and through her child is associated with an earlier age of menopause, controlling for covariates.

METHODS

Analyses used merged data from two related sources. Although mothers (n = 1,466) were interviewed in 1995 and then 20 years later (2015-17), their children were interviewed in the National Longitudinal Study of Adolescent to Adult Health repeatedly (Waves 1-4, 1994/5 to 2008-2009). Mothers reported their own age of menopause, and mothers and adolescents each reported their own exposure to violence as children and adults.

RESULTS

A mother's own childhood physical abuse (b = -1.60, P < .05) and her child's sexual abuse (b = -1.39, P < .01) both were associated with an earlier age of menopause. Mothers who were physically abused in childhood and have a child who experienced regular sexual abuse reached menopause 8.78 years earlier than mothers without a history of personal abuse or abuse of their child.

CONCLUSIONS

Our study is the first to find that age of natural menopause is associated with intergenerational violence exposures.

Systematic review on the association between sleep-related hyperarousal and child maltreatment

BACKGROUND

Various outcomes like sleep deficiencies can endure into adulthood as consequences from child maltreatment (CM). Hyperarousal as an explanation for the development of insomnia can be applied on this association. However, research on this link is lacking.

METHOD

A PRISMA-guided systematic literature review was conducted by searching academic literature databases. Empirical studies with no restriction of publishing year were eligible. Search terms were predefined and related to CM.

RESULTS

Of 602 records, 13 studies met the inclusion criteria. Sample sizes ranged from 39 to 304, with a total of 1469 participants. The studies were heterogenous, therefore comparability was diminished. Yet tendencies for sleep-related hyperarousal in maltreated individuals were found especially for somatic hyperarousal. Cortical and cognitive hyperarousal was rarely examined.

CONCLUSION

Hyperarousal (heightened nighttime acticity and heart rate, diminished heart rate variability) was found in individuals with CM experiences in several studies. The insights into mechanisms of how CM and sleep problems are interrelated, can help to sensitize therapists to not oversee CM experiences when a patient reports sleep difficulties. Yet, more studies with more rigorous methods are needed to illuminate this topic. This gap in research regarding the consequences of CM is not acceptable.

Association of adverse childhood experiences with menopausal symptoms: Results from the Data Registry on Experiences of Aging, Menopause and Sexuality (DREAMS)

OBJECTIVE

To examine the association of adverse childhood experiences (ACEs) with overall menopausal symptom burden in midlife women.

STUDY DESIGN

This was a cross-sectional study of women between the ages of 40 and 65 years who were seen for specialty consultation in the Menopause and Women's Sexual Health Clinic, Mayo Clinic, Rochester, MN between May 1, 2015 and December 31, 2016.

MAIN OUTCOME MEASURES

Participants completed the ACE questionnaire to assess childhood abuse and neglect, the Menopause Rating Scale (MRS) to assess menopausal symptom burden, the Patient Health Questionnaire (PHQ-9) to assess depression, the Generalized Anxiety Disorder questionnaire (GAD-7) to assess anxiety, and provided information on current abuse (physical, sexual and verbal/emotional).

RESULTS

Women meeting inclusion criteria (N = 1670) had a median age of 53.7 years (interquartile range: 49.1, 58.0). Of these women, 977 (58.5 %) reported any ACE and 288 (17.2 %) reported ≥4 ACEs. As menopausal symptoms increased in severity from the first to fourth quartile, the odds ratio of ACE 1-3 (vs. 0) increased from 1 to 2.50 (trend p < 0.01), and the odds ratio of ACE ≥ 4 (vs. 0) increased from 1 to 9.61 (trend p < 0.01), a pattern that was consistent across all menopausal symptom domains. The association between severe menopausal symptoms and higher childhood adversity (ACE score 1-3 or ≥4 vs. ACE = 0) remained significant after adjusting for age, partner status, education, employment, depression, anxiety, and hormone therapy use (OR 1.84 and 4.51, p < 0.01).

CONCLUSION

In this large cross-sectional study, there was a significant association between childhood adversity and self-reported menopausal symptoms that persisted even after adjustment for multiple confounders. These associations highlight the importance of screening women with bothersome menopausal symptoms for childhood adversity, and of offering appropriate management and counseling for the adverse experiences, when indicated.