Menopause: A Global Perspective and Clinical Guide for Practice

Is air pollution a risk factor for early menopause?

BACKGROUND

Ambient air pollution is a serious public health issue that may influence reproductive health, including fertility and menopause onset in women worldwide. Thus, understanding the risk factors associated with early menopause is crucial to inform women about potential health risks and guide public health interventions.

METHODS

We collected data from KHANES (The Korea National Health and Nutrition Examination Survey) at the Korean Center for Disease Control and Prevention, Ministry of Health and Welfare between 2010 and 2020. These data were linked with summary pollution data from AiMS-CREATE (AI-Machine Learning and Statistics Collaborative Research Ensemble for Air Pollution, Temperature, and All Types of Environmental Exposures) from 2002 to 2020. These summary data encapsulate the monthly average air pollution predictions for 226 si-gun-gu (cities, counties, and districts) in Korea. A total of 8506 participants who had experienced menopause (early menopause: 40-44 years, N = 341; normal menopause: ≥ 45 years, N = 8165) between 2002 and 2020 were included in the analysis. We employed survey logistic regression analyses to determine the associations between ambient air pollution and menopause after adjusting for covariates.

RESULTS

An association was observed between particulate matter 2.5 (PM2.5) and early menopause (adjusted survey logistic regression (aOR): 1.26, 95% confidence interval (CI): 1.21-1.31), between particulate matter 10 (PM10) and early menopause (aOR: 1.17, 95% CI: 1.14-1.20).

CONCLUSION

Our findings suggest that exposure to ambient air pollution may contribute to the onset of menopause, emphasizing the importance of addressing air quality as a public health priority. This study highlights the need for further research to explore the underlying mechanisms and long-term health impacts of environmental factors associated with early menopause.

Recommendations of the Spanish Society of Endocrinology and Nutrition (SEEN) on "what not to do" in clinical practice

Quality healthcare should be grounded on clinical practice with the highest benefit-risk ratio and cost-effectiveness according to the available scientific evidence. The overuse of unproven diagnostic or therapeutic procedures is common in our setting and leads to increased healthcare spending and even iatrogenic harm. Previous cost-effectiveness initiatives have proposed identifying diagnostic and therapeutic measures that are better 'not done' in certain clinical contexts under the lens of the available scientific evidence. In this regard, the Spanish Society of Endocrinology and Nutrition (SEEN) has compiled a series of 'not-to-do' recommendations from its various working groups. These recommendations cover common clinical situations classified into the following thematic areas: diabetes, nutrition, pituitary gland, neuroendocrine tumors, thyroid, and hormone replacement therapy in postmenopausal women.

Safety of Fezolinetant for Treatment of Moderate to Severe Vasomotor Symptoms Due to Menopause: Pooled Analysis of Three Randomized Phase 3 Studies

INTRODUCTION

This study evaluated the safety and tolerability of fezolinetant in women with vasomotor symptoms (VMS) due to menopause in a pooled analysis of data from three 52-week phase 3 studies (SKYLIGHT 1, 2, and 4).

METHODS

SKYLIGHT 1 and 2 were double-blind, placebo-controlled studies where women (≥ 40 to ≤ 65 years), with moderate to severe VMS (minimum average ≥ 7 hot flashes/day) were randomized to once-daily placebo, fezolinetant 30 mg or 45 mg. After 12 weeks, those on placebo were re-randomized to fezolinetant 30 mg or 45 mg, while those on fezolinetant continued on their assigned dose for 40 weeks. SKYLIGHT 4 was a placebo-controlled, double-blind, 52-week safety study. Safety was assessed by frequency of treatment-emergent adverse events (TEAEs) and endometrial events. TEAEs of special interest included liver test elevations and endometrial hyperplasia or cancer or disordered proliferative endometrium.

RESULTS

Totals of 952 participants receiving placebo, 1100 receiving fezolinetant 45 mg, and 1103 receiving fezolinetant 30 mg took ≥ 1 dose of study medication. TEAEs occurred in 55.3%, 62.9%, and 65.4%, respectively; exposure-adjusted results were consistent with these results. Most frequent TEAEs in fezolinetant-treated participants included upper respiratory tract infection (7.7-8.3%), headache (6.8-8.2%), coronavirus disease 2019 (5.8-6.1%), back pain (3.1-3.7%), arthralgia (2.9-3.2%), diarrhea (2.3-3.2%), urinary tract infection (2.9-3.4%), and insomnia (2.0-3.0%). The incidence of drug-related serious TEAEs and associated treatment withdrawals was low. Elevations in liver transaminases occurred in 1.5-2.3% of fezolinetant-treated participants, were typically asymptomatic and transient, resolved on treatment or discontinuation, with no evidence of severe drug-induced liver injury (Hy's law). Endometrial safety results were well within US Food and Drug Administration criteria. Analysis of benign and non-benign neoplasm controlled for exposure demonstrated no increased risk versus placebo.

CONCLUSION

Pooled data confirm the safety and tolerability of fezolinetant over 52 weeks.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers, NCT04003155, NCT04003142, and NCT04003389. Graphical abstract available for this article.

Cultural Determinants of Body Image: What About the Menopausal Transition?

Body image is an important aspect of psychological well-being that is influenced by several biological and psychosocial risk factors. Cultural determinants of body image include the patterns of shared beliefs, values, practices, and social norms within a group that can act as a lens through which a person perceives, compares, and evaluates their body. Women tend to experience higher rates of body dissatisfaction than men, with reproductive milestones such as puberty, pregnancy, and postpartum being windows of vulnerability for body image concerns. The menopausal transition is another reproductive stage of women's lives that involves major physical changes, psychological challenges, and social pressures that can impact body image negatively. However, the literature on the influence of cultural determinants on the body image of menopausal women is limited. Therefore, this perspective review paper aims to discuss the potential role of cultural determinants in influencing body image satisfaction in women undergoing the menopausal transition. To this end, the relationships between different cultural perspectives and body image around the world are first discussed. Sociocultural influences on body image throughout women's lifespan and reproductive stages are then presented. Finally, cultural perspectives on menopause and aging and their potential influence on the body image of menopausal women are explored. This paper underscores the importance of considering culture and sociocultural factors when studying body image and highlights the need for further research on the cultural determinants of body image during the menopausal transition.

Rural residence and health-related quality of life in a sample of Spain perimenopausal women

BACKGROUND

The prevalence and severity of perimenopausal symptoms are typically associated with multiple factors, including demographic characteristics. The sociodemographic characteristics of women living in rural areas differ from those residing in urban areas, and it has been suggested that these differences could potentially influence the prevalence of symptoms experienced during perimenopause.

OBJECTIVES

To evaluate if perimenopausal women living in Spanish rural areas have a higher prevalence of perimenopausal symptoms and assess their influence on health-related quality of life.

METHODS

A cross-sectional study was conducted in a sample of 270 perimenopausal women residing in rural and urban areas. The participants completed the Cervantes Scale Short Version and Beck Depression Inventory 2.

RESULTS

Perimenopausal women in rural areas reported a higher incidence of perimenopausal symptoms and a lower perception of health-related quality of life compared to those in urban areas, as evidenced by higher scores on the total Cervantes Scale Short Version scale (33.2 (±16.2) vs. 26.4 (±18.1), p = .001). No differences in the Beck Depression Inventory 2 score were detected.

CONCLUSIONS

Perimenopausal women residing in rural areas of Spain reported a higher prevalence of perimenopausal symptoms and experienced a poorer Health-Related Quality of Life compared to those living in urban areas of Spain.

Disordered eating behaviours during the menopausal transition: a systematic review

Disordered eating refers to a range of eating behaviours and attitudes towards weight and food that can negatively influence physical and psychosocial well-being. The menopausal transition could be a vulnerable period for disordered eating due to major hormonal fluctuations, menopausal symptoms, common body composition shifts, and an increased risk of psychological challenges. This systematic review aimed to summarize evidence on the associations between the menopausal transition and disordered eating. Records published before October 2023 were identified through MEDLINE, PsycINFO, Scopus, Embase, and CINAHL. Studies investigating associations between menopausal status, menopausal symptoms, or reproductive hormone levels, and disordered eating during the menopausal transition were sought. A total of 1301 non-duplicate records were screened, with 10 studies deemed eligible for inclusion. Most included studies used a cross-sectional design (n = 9). Findings include potentially higher levels of binge eating during the perimenopausal stage, whereas restrictive eating behaviours appeared more common during postmenopause compared to premenopause. Both studies investigating menopausal symptoms found strong positive associations with disordered eating. Nonetheless, findings are equivocal with contrasting results and limited methodological quality across studies. Further research is needed to verify these findings and better assist health professionals in supporting healthy eating behaviours in menopausal women during this complex transition. (PROSPERO ID: CRD42021290736).

Does the Fear of COVID-19 Impact on Menopausal Symptoms in Women? A Research Investigation

Objectives: This study aimed to determine the relationship between the fear of COVID-19 and menopausal symptoms in women during the menopausal period. Methods: This study is a descriptive cross-sectional study. This study was completed with a total of 161 women who met the inclusion criteria. Data were collected face-to-face using the Personnel Information Form, Menopause Symptom Assessment Scale, and Coronavirus 19 Phobia Scale. Results: There is a slightly positive relationship between the social subscale of the COVID-19 fear scale and the somatic subscale of the menopause symptoms scale. There is a slightly positive relationship between the economic subscale of the COVID-19 scale and the psychological subscale of the menopausal symptoms scale. There is a slightly positive correlation between the total score of the total COVID-19 phobia scale and the somatic and psychological subscales of the menopause symptoms assessment scale. However, there is no significant relationship between the total score of the COVID-19 phobia scale and the total score and urological subscale of the menopause symptoms assessment scale. Conclusions: It has been determined that fear of COVID-19 is slightly positively associated with somatic and psychological complaints in menopausal women.

Sharing the multidisciplinary clinical approach to peri- and postmenopausal women: A Delphi consensus among Italian gynecologists, endocrinologists, and cardiologists for an integrated and optimal approach to clinical practice

OBJECTIVE

The critical phase of perimenopausal period is marked by a reduction in estrogen levels, leading to various clinical issues (vasomotor and neurodegenerative symptoms, increased osteoporosis risk and cardiovascular risk). These complex clinical scenarios pose challenges to clinicians in providing the right support for diagnosis and treatment. A group of Italian cardiologists, endocrinologists, and gynecologists conducted a survey among expert colleagues to assess consensus on controversial issues and best practices for screening and treating peri- and postmenopausal women.

METHODS

The Delphi methodology was used to analyze responses from a qualitative expert panel comprising 25 cardiologists, 25 endocrinologists, and 25 gynecologists, selected nationwide. Two consecutive questionnaires were proposed between February and May 2023. Agreement among experts was assessed following the Delphi method as developed by the RAND Corporation.

RESULTS

The results of this Delphi Consensus have been shared by the leading scientific societies: Italian Society of Cardiology, Italian Society of Endocrinology, Italian Society of Gynecology and Obstetrics, and Italian Hospital Obstetricians Gynecologists Association.

CONCLUSIONS

The experts highlighted comorbidities and hormone deprivation as crucial clinical problems to be evaluated in perimenopausal women, requiring investigation from cardiovascular and endocrinologic perspectives to assess cardiovascular risk, involving the use of BMI, standard blood samples, endocrine-metabolic tests, and lifestyle assessment, particularly in women with higher cardiovascular and metabolic risks candidates for hormone replacement therapy (HRT). The experts also agreed on the benefits of HRT in improving lipid metabolism and reducing insulin resistance, thereby mitigating the metabolic risks associated with menopause. However, this therapy should be tailored considering individual women's comorbidities and thrombotic risk.

Effects of hormone replacement therapy on mood and sleep quality in menopausal women

BACKGROUND

Hormone replacement therapy is an effective treatment strategy for the management of symptoms in naturally menopausal women. However, some patients report experiencing adverse effects.

AIM

To analyze the effects of hormone replacement therapy in menopausal female patients.

METHODS

A total of 152 menopausal female patients admitted to the Gynecology Department of the Ganzhou Maternal and Child Health Hospital between January 2021 and December 2023 were divided into the observation group (n = 76, conventional treatment + hormone replacement therapy) and the control group (n = 76, conventional treatment only) via random casting. The improvement observed in the following items were compared between the groups: Kupperman menopausal index (KMI), emotional state [The Positive and Negative Affect Scale (PANAS)], sleep quality [Self-Rating Scale of Sleep (SRSS)], treatment effectiveness, and treatment safety.

RESULTS

The modified KMI and SRSS scores of the observation group were lower than those of the control group after three rounds of treatment. The improvement in the PANAS score observed in the observation group was greater than that observed in the control group (P < 0.05). The total treatment effectivity rate in the observation group was higher than that in the control group (86.84% vs 96.05%, χ 2 = 4.121, P = 0.042). The incidence rate of adverse reactions in the two groups was comparable (6.58% vs 9.21%, χ 2 = 0.361, P = 0.547).

CONCLUSION

Hormone replacement therapy effectively improved the clinical symptoms, actively channeled negative emotions, and improved the quality of sleep in menopausal patients, indicating its effectiveness and safety.

Integrating network pharmacology with experimental validation to investigate the mechanism of Wuwei Zishen formula in improving perimenopausal syndrome

OBJECTIVES

To investigate the role of the Wuwei Zishen formula (WWZSF) in treating and preventing perimenopausal syndrome (PMS) and to understand its mechanism.

METHODS

Network pharmacology and molecular docking was used to predict active compounds, potential targets, and pathways for PMS treatment using WWZSF. Female Sprague-Dawley (SD) rats were induced with D-galactose (D-gal) to establish a PMS model and treated with Kunbao pill (KBP) and WWZSF. Estrus cycles were observed using vaginal smears. Serum sex hormones were measured using the enzyme-linked immunosorbent assay (ELISA). Histological changes in the uterus and ovaries were evaluated using hematoxylin-eosin staining (HE). Western blot was used to assess the protein expression levels of Cleaved Caspase-3, p62, BAX/Bcl-2, p-PI3K/PI3K, p-AKT/AKT, and p-mTOR/mTOR in the uterus and ovaries.

RESULTS

A total of 70 active compounds and 440 potential targets were screened out. Important targets and pathways, including AKT1, Bcl-2, Caspase-3, mTOR, and the PI3K/AKT/mTOR pathways, and molecular docking verified their high affinities to key WWZSF components. In vivo experiments showed that WWZSF can ameliorate the morphological abnormalities of the uterus and ovaries, increase sex hormone levels and organ index, and restore the estrus cycles in PMS rats. Moreover, the western blot results showed decreased Cleaved Caspase-3 and BAX/Bcl-2 protein levels in the ovarian and uterine tissues after WWZSF therapy. Concurrently, there was an increase in the expression of p62 and the ratios of p-AKT/AKT, p-mTOR/mTOR, and p-PI3K/PI3K.

CONCLUSION

The PI3K/AKT/mTOR signaling pathway-mediated apoptosis and autophagy pathways may be how WWZSF efficiently reduces PMS.

Effectiveness of Tibolone in Relieving Postmenopausal Symptoms for a Short-Term Period in Indian Women

Background

Tibolone is an alternative to conventional estrogen and progesterone in relieving post-menopausal symptoms in Indian women.

Material and Methods

A prospective short-term observational study was done at a tertiary care teaching hospital in New Delhi from November 2019 to September 2021. Fifty-three women, less than 60 years of age, presenting with moderate to severe intensity of menopausal symptoms as assessed by measuring menopausal rating score (MRS > 8) were enrolled and given Tibolone 2.5 mg daily for 3 months. Improvements in symptoms were seen at 1 month and 3 months. Side effects were also noted.

Results

Marked improvement was seen as reduction in scores of psychological, somatic and genitourinary symptoms was noted. The psychological symptoms reduced from 8.92 ± 1.959 to 2.905 ± 1.042, the somatic symptoms decreased from 8.33 ± 2.299 to 3.4 ± 1.167, and genitourinary symptoms decreased from 3.64 ± 1.42 to 2.150 ± 0.948 after 3 months of treatment with Tibolone. Only 3 patients (5.6%) experienced vaginal spotting with no major side effects.

Conclusions

Tibolone is a highly effective and well accepted drug to reduce moderate to severe menopausal symptoms, especially psychological symptoms including depression.

Associations between menopause and body image: A systematic review

BACKGROUND

The menopausal transition involves multiple biological and psychosocial challenges that may render middle-aged women vulnerable to body image concerns.

OBJECTIVE

The aim of this study was to summarize evidence on the associations between menopause and body image perception in healthy middle-aged women.

DESIGN

This study is a systematic review of observational studies.

DATA SOURCES AND METHODS

Menopause-related exposure measures included menopausal stages, menopausal symptoms, and reproductive hormone levels during the menopausal transition. Studies investigating body image as an outcome, including through a positive (e.g. body self-esteem) or negative (e.g. body dissatisfaction) lens, were considered eligible. Articles published before March 2023 were identified through MEDLINE, PsycINFO, and Embase and underwent double screening, extraction, and quality assessment by two independent investigators. Characteristics and results were summarized using narrative synthesis.

RESULTS

A total of 820 non-duplicate records were identified, with 18 observational studies deemed eligible for inclusion after full-text screening. All studies investigating menopausal symptoms and body image (n = 6) found some significant association between them, with a higher frequency, intensity, or number of symptoms being associated with greater body image concern. Differences in body image perception between menopausal stages were inconsistent across studies (n = 12), while evidence of potential associations between reproductive hormones and body image was minimal (n = 2). Findings should be interpreted with caution as 17 of the included studies used a cross-sectional design, and not all studies adjusted their analyses for relevant confounders.

CONCLUSION

Overall, menopausal symptoms showed relatively consistent associations with a more negative body image perception. Additional research is required to understand the potential role of menopausal stages and reproductive hormone levels in the body image perception of middle-aged women and to confirm the direction of reported associations.

REGISTRATION

PROSPERO-CRD42021241637.

Effects of nutritional interventions on the severity of depressive and anxiety symptoms of women in the menopausal transition and menopause: a systematic review, meta-analysis, and meta-regression

IMPORTANCE

Depression and anxiety may significantly affect women during the menopausal transition. In addition to traditional treatment strategies such as hormone therapy, antidepressants, and psychotherapy, nutritional interventions have been increasingly studied, but there is no consensus about their role in this patient population.

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the effect of nutritional interventions on the severity of depressive (DS) and anxiety (AS) symptoms in women during the menopausal transition or menopausal years.

EVIDENCE REVIEW

Electronic search using databases PubMed, Cochrane, and Embase to identify articles indexed until January 31, 2021, focusing on randomized placebo-controlled trials documenting the effect of diet, food supplements, and nutraceuticals on DS and AS.

FINDINGS

Thirty-two studies were included (DS, n = 15; AS, n = 1; DS and AS combined, n = 16). We found two studies that demonstrated data combined with other interventions: one with lifestyle interventions (vitamin D plus lifestyle-based weight-loss program) and another with exercise (omega 3 plus exercise). The pooled effect size favored the intervention group over placebo for both DS and AS (DS: standardized mean difference, -0.35 [95% confidence interval, -0.68 to -0.03; P = 0.0351]; AS: standardized mean difference, -0.74 [95% CI, -1.37 to -0.11; P = 0.0229]). There was significant heterogeneity in the pooled results, which can be attributed to differences in assessment tools for depression and anxiety as well as the variety of nutritional interventions studied. The subgroup analysis showed a statistically significant effect of menopausal status (perimenopausal or menopausal) but not the type or duration of nutritional intervention. Older age was the only significant predictor of the effect size of nutritional interventions in the meta-regression.

CONCLUSIONS AND RELEVANCE

Nutritional interventions are promising tools for the management of mood/anxiety symptoms in women during the menopausal transition and in postmenopausal years. Because of significant heterogeneity and risk of bias among studies, the actual effect of different approaches is still unclear.