Persistent hot flushes in older postmenopausal women

Prospective early adulthood risk factors for vasomotor symptoms in the Coronary Artery Risk Development in Young Adults study

OBJECTIVE

Previous studies have assessed potential risk factors for vasomotor symptoms (VMS) beginning in midlife. We examined whether early adulthood risk factors predict VMS trajectories over time.

METHODS

We performed a secondary data analysis of the Coronary Artery Risk Development in Young Adults (CARDIA) study, a population-based cohort. We included women who answered questions about VMS at three or more examinations (n = 1,966). We examined whether risk factors at baseline (when participants were aged 18-30 y; average age, 25 y) and the year 15 (Y15) exam (at ages 33-45 y; average age, 40 y) were associated with VMS trajectories from Y15 through Y35. Logistic regression models were used to evaluate the associations with VMS trajectories.

RESULTS

We identified three trajectories of VMS presence: minimal (40%), increasing over time (27%), and persistent (33%). Baseline factors associated with persistent VMS over time included Black race, less than a high school education, depressive symptoms, migraines, cigarette use, and at Y15 hysterectomy. Baseline factors associated with increasing VMS over time included Black race and lower body mass index. Risk factors for bothersome VMS were similar and also included thyroid disease, although thyroid disease was not associated with persistence of VMS over time. Associations were similar among women who had not undergone hysterectomy and in Black and White women.

CONCLUSIONS

Risk factors for VMS may be identified in early adulthood. Further examination of risk factors such as migraines and depressive symptoms in early adulthood may be helpful in identifying therapies for VMS.

Efficacy of Continuous Transdermal Nitroglycerin for Treating Hot Flashes by Inducing Nitrate Cross-tolerance in Perimenopausal and Postmenopausal Women: A Randomized Clinical Trial

Importance

Due to the potential risks of long-term systemic estrogen therapy, many menopausal women are interested in nonhormonal treatments for vasomotor symptoms. Physiologic studies indicate that nitric oxide plays a key role in mediating hot flash-related vasodilation, suggesting that nonhormonal medications that induce nitrate tolerance in the vasculature may offer therapeutic benefit for vasomotor symptoms.

Objective

To determine whether uninterrupted administration of transdermal nitroglycerin (NTG) to induce nitrate cross-tolerance decreased the frequency or severity of menopause-related hot flashes.

Design, Setting, and Participants

This randomized, double-blinded, placebo-controlled clinical trial included perimenopausal or postmenopausal women reporting 7 or more hot flashes per day who were recruited from northern California by study personnel at a single academic center. Patients were randomized between July 2017 and December 2021, and the trial ended in April 2022 when the last randomized participant completed follow-up.

Interventions

Uninterrupted daily use of transdermal NTG (participant-directed dose titration from 0.2-0.6 mg/h) or identical placebo patches.

Main Outcome Measures

Validated symptom diaries assessing changes in any hot flash frequency (primary outcome) and moderate-to-severe hot flash frequency over 5 and 12 weeks.

Results

Among the 141 randomized participants (70 NTG [49.6%], 71 placebo [50.4%]; 12 [85.8%] Asian, 16 [11.3%] Black or African American, 15 [10.6%] Hispanic or Latina, 3 [2.1%] multiracial, 1 [0.7%] Native Hawaiian or Pacific Islander, and 100 [70.9%] White or Caucasian individuals), a mean (SD) of 10.8 (3.5) hot flashes and 8.4 (3.6) moderate-to-severe hot flashes daily was reported at baseline. Sixty-five participants assigned to NTG (92.9%) and 69 assigned to placebo (97.2%) completed 12-week follow-up (P = .27). Over 5 weeks, the estimated change in any hot flash frequency associated with NTG vs placebo was -0.9 (95% CI, -2.1 to 0.3) episodes per day (P = .10), and change in moderate-to-severe hot flash frequency with NTG vs placebo was -1.1 (95% CI, -2.2 to 0) episodes per day (P = .05). At 12 weeks, treatment with NTG did not significantly decrease the frequency of any hot flashes (-0.1 episodes per day; 95% CI, -1.2 to 0.4) or moderate-to-severe hot flashes (-0.5 episodes per day; 95% CI, -1.6 to 0.7) relative to placebo. In analyses combining 5-week and 12-week data, no significant differences in change in the frequency of any hot flashes (-0.5 episodes per day; 95% CI, -1.6 to 0.6; P = .25) or moderate-to-severe hot flashes (-0.8 episodes per day; 95% CI, -1.9 to 0.2; P = .12) were detected with NTG vs placebo. At 1 week, 47 NTG (67.1%) and 4 placebo participants (5.6%) reported headache (P < .001), but only 1 participant in each group reported headache at 12 weeks.

Conclusions and Relevance

This randomized clinical trial found that continuous use of NTG did not result in sustained improvements in hot flash frequency or severity relative to placebo and was associated with more early but not persistent headache.

Trial Registration

Clinicaltrials.gov Identifier: NCT02714205.

Cost-Effectiveness Analysis of Ultra-Hypofractionated Whole Breast Radiation Therapy Alone Versus Hormone Therapy Alone or Combined Treatment for Low-Risk ER-Positive Early Stage Breast Cancer in Women Aged 65 Years and Older

PURPOSE

The optimal management of early-stage, low-risk, hormone-positive breast cancer in older women remains controversial. Recent trials have shown that 5-fraction ultrahypofractionated whole-breast irradiation (U-WBI) has similar outcomes to longer courses, reducing the cost and inconvenience of treatment. We performed a cost-utility analysis to compare U-WBI to hormone therapy alone or their combination.

METHODS AND MATERIALS

We simulated 3 different treatment approaches for women age 65 years or older with pT1-2N0 ER-positive invasive ductal carcinoma treated with lumpectomy with negative margins using a Markov microsimulation model. The strategies were U-WBI performed with a 3-dimensional conformal technique over 5 fractions without a boost ("radiation therapy [RT] alone"), adjuvant hormone therapy (anastrozole for 5 years) without RT ("aromatase-inhibitor [AI] alone"), or the combination of the 2. The combination strategy was calibrated to match trial results, and the relative effectiveness of the RT alone and AI alone strategies were inferred from previous randomized trials. The primary endpoint was the cost-effectiveness of the 3 strategies over a lifetime horizon as measured by the incremental cost-effectiveness ratio (ICER), with a value of $100,000/quality-adjusted life-year deemed "cost-effective."

RESULTS

The model results compared with the prespecified target outcomes. On average, RT alone was the least expensive strategy ($14,775), with AI alone slightly more ($14,998), and combination therapy the costliest ($19,802). RT alone dominated AI alone (the incremental cost-effectiveness ratio [ICER] -$5089). Combination therapy, compared with RT alone, was slightly more expensive than our definition of cost-effective (ICER $113,468) but was cost-effective compared with AI alone (ICER $54,451). Probabilistic sensitivity analysis demonstrated RT alone to be cost-effective in 50% of trials, with combination therapy in 36% and AI alone in 14%.

CONCLUSIONS

U-WBI alone appears the more cost-effective de-escalation strategy for these low-risk patients, compared with AI alone. Combining U-WBI and AI appears more costly but may be preferred by some patients.

Prevalence of menopausal hot flashes in Lebanon: A cross-sectional study

Background

Menopausal hot flashes or vasomotor symptoms are prevalent and could be debilitating in postmenopausal women. There is controversy regarding the risk factors for hot flashes, some of which may vary from one country or culture to another.

Objective

To shed light on this matter by assessing the prevalence of hot flashes, their effect on quality of life, and their association with certain factors such as physical exercise, caffeine, spicy food consumption, dietary intake, smoking, alcohol, etc.

Materials and Methods

A large cross-sectional study was conducted among 627 Lebanese women, aged 45-67 yr using a well-developed and comprehensive questionnaire, in order to better assess the prevalence of hot flashes, focusing on their characteristics, association with various factors, severity, and effect on the women's quality of life.

Results

62.5% of participants experienced hot flashes. A statistically significant difference was noted between women who experience hot flashes and their counterparts with respect to smoking, body mass index, spicy food consumption, education level, age, menstrual status, and parity. An association was not found with physical activity or other dietary factors.

Conclusion

As an alternative for hormone therapy, clinicians should consider lifestyle changes to help manage hot flashes, which impose a tremendous physical and social toll on the women experiencing them.

Cost-Effectiveness Analysis of No Adjuvant Therapy Versus Partial Breast Irradiation Alone Versus Combined Treatment for Treatment of Low-Risk DCIS: A Microsimulation

PURPOSE

Adjuvant therapy in patients with ductal carcinoma in situ who undergo partial mastectomy remains controversial, particularly for low-risk patients (60 years or older, estrogen-positive, tumor extent < 2.5 cm, grade 1 or 2, and margins ≥ 3 mm). We performed a cost-effectiveness analysis comparing three strategies: no adjuvant treatment after surgery, a five-fraction course of accelerated partial breast irradiation using intensity-modulated radiation therapy (accelerated partial breast irradiation [APBI]-alone), or APBI plus an aromatase inhibitor for 5 years.

MATERIALS AND METHODS

Outcomes including local recurrence, distant metastases, and survival as well as toxicity data were modeled by a patient-level Markov microsimulation model, which were validated against trial data. Costs of treatment and possible adverse events were included from the societal perspective over a lifetime horizon, adjusted to 2019 US dollars and extracted from Medicare reimbursement data. Quality-adjusted life-years (QALYs) were calculated based on utilities extracted from the literature.

RESULTS

No adjuvant therapy was the least costly approach ($5,744), followed by APBI-alone ($11,070); combined therapy was costliest ($16,052). Adjuvant therapy resulted in slightly higher QALYs (no adjuvant, 11.320; APBI-alone, 11.343; and combination, 11.381). In the base case, no treatment was the cost-effective strategy, with an incremental cost-effectiveness ratio of $239,109/QALY for APBI-alone and $171,718/QALY for combined therapy. The incremental cost-effectiveness ratio for combined therapy compared with APBI-alone was $131,949. Probabilistic sensitivity analyses found that no therapy was cost effective (defined as $100,000/QALY of lower) in 63% of trials, APBI-alone in 19%, and the combination in 18%.

CONCLUSION

No adjuvant therapy represents the most cost-effective approach for postmenopausal women 60 years or older who receive partial mastectomy for low-risk ductal carcinoma in situ.

Managing menopausal vasomotor symptoms in older women

This review considers the persistent vasomotor symptoms (VMS) of menopause-hot flashes-from the perspective of older women. Although these symptoms are most prevalent in younger women during the menopause transition and recent postmenopausal years, emerging data, corroborated by clinical experience, support the observation that for some women, VMS can remain bothersome into advanced age. Most clinical guidance focuses on treating VMS in younger women because of the concerns of increasing cardiovascular disease (CVD) risks and possibly dementia when menopausal hormone therapies (MHT) are initiated at more advanced ages. Furthermore, recent studies into the physiology of VMS suggest a potential link with endothelial dysfunction and evidence of increased subclinical CVD and CVD events. Clinical trials have reported that older women with VMS have markedly increased CVD risk in response to oral MHT initiation compared with asymptomatic women. Nonhormonal treatment options are available for those who elect not to use, or are advised not to use, menopausal hormone therapies. As the global population ages, more research is needed to clarify the physiology of VMS in older women, suggest optimal approaches to enhance awareness of potential health risks of VMS, and recommend strategic management of VMS in older women, with the goal of promoting health and maintaining quality of life.

Cost-effectiveness analysis of endocrine therapy alone versus partial-breast irradiation alone versus combined treatment for low-risk hormone-positive early-stage breast cancer in women aged 70 years or older

PURPOSE

We performed a cost-effectiveness analysis of three strategies for the adjuvant treatment of early breast cancer in women age 70 years or older: an aromatase inhibitor (AI-alone) for 5 years, a 5-fraction course of accelerated partial-breast irradiation using intensity-modulated radiation therapy (APBI-alone), or their combination.

METHODS

We constructed a patient-level Markov microsimulation from the societal perspective. Effectiveness data (local recurrence, distant metastases, survival), and toxicity data were obtained from randomized trials when possible. Costs of side effects were included. Costs were adjusted to 2019 US dollars and extracted from Medicare reimbursement data. Quality-adjusted life-years (QALY) were calculated using utilities extracted from the literature.

RESULTS

The strategy of AI-alone ($12,637) was cheaper than both APBI-alone ($13,799) and combination therapy ($18,012) in the base case. All approaches resulted in similar QALY outcomes (AI-alone 7.775; APBI-alone 7.768; combination 7.807). In the base case, AI-alone was the cost-effective strategy and dominated APBI-alone, while combined therapy was not cost-effective when compared to AI-alone ($171,451/QALY) or APBI-alone ($107,932/QALY). In probabilistic sensitivity analyses, AI-alone was cost-effective at $100,000/QALY in 50% of trials, APBI-alone in 28% and the combination in 22%. Scenario analysis demonstrated that APBI-alone was more effective than AI-alone when AI compliance was lower than 26% at 5 years.

CONCLUSIONS

Based on a Markov microsimulation analysis, both AI-alone and APBI-alone are appropriate options for patients 70 years or older with early breast cancer with small cost differences noted. A prospective trial comparing the approaches is warranted.

Symptomatic menopausal transition and risk of subsequent stroke

Objective

To examine the long-term risk of stroke in women who have experienced symptomatic menopausal transition.

Methods

In this nationwide, population-based cohort study conducted from January 1, 2000 to December 31, 2013, we identified 22,058 women with no prior history of stroke, who experienced symptomatic menopausal transition at ≥45 years of age. Moreover, 22,058 women without symptomatic menopause were matched by propensity scores and enrolled as a comparison group. The propensity score was calculated by using all characteristic variables of each subject, including demographics (age and monthly income), comorbidities (hypertension, hyperlipidemia, diabetes mellitus, obesity, chronic kidney disease, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, dysrhythmia, peripheral artery occlusive disease), Charlson’s comorbidity index score, clinic visit frequency, and long-term medications (antihypertensives, antidiabetic agents, statins, antiplatelets, aspirin, warfarin, and hormone replacement therapy). The primary endpoint was the development of stroke after the onset of symptomatic menopausal transition. The Fine and Gray’s proportional subhazards model was performed to assess the association between symptomatic menopausal transition and subsequent stroke. All subjects were followed up until December 31, 2013.

Results

During a mean follow-up of 8.5 years (standard deviation 4.7 years, maximum 14 years), 2,274 (10.31%) women with symptomatic menopausal transition, and 1,184 (5.37%) matched comparison participants developed stroke. The incidence rates were 11.17 per 1,000 person-years in the symptomatic menopausal transition group compared with 8.57 per 1,000 person-years in the comparison group. The risk of developing stroke was significantly higher in women with symptomatic menopausal transition (crude subhazard ratio, 1.31; 95% confidence interval (CI) [1.22–1.41]; P < 0.001). After adjusting for demographics, comorbidities, clinic visit frequency, and long-term medications, the risk of stroke remained statistically significant (adjusted subhazard ratio, 1.30; 95% CI [1.21–1.40]; P < 0.001). Moreover, subgroup analyses revealed no evidence for inconsistent effects for symptomatic menopausal transition on subsequent risk of stroke across all subgroups except age, comorbidities, hypertension, and use of antihypertensives. Women with early menopausal transition (before age 50), without comorbid condition, without hypertension, or without use of antihypertensives are at a higher risk of stroke. The longer duration of symptomatic menopausal transition was associated with higher risk of stroke (P for trend < 0.001).

Conclusion

In this large-scale retrospective cohort study, symptomatic menopausal transition was statistically significantly associated with a 30% increased risk of stroke. Further prospective studies are required to confirm our findings.

History of hot flashes and aortic calcification among postmenopausal women

OBJECTIVE

Menopausal hot flashes are considered largely a quality-of-life issue. However, emerging research also links hot flashes to cardiovascular risk. In some investigations, this risk is particularly apparent among women using hormone therapy. The aim of this study was to determine whether a longer history of reported hot flashes over the study period was associated with greater aortic and coronary artery calcification. Interactions with hormone therapy use were examined in an exploratory fashion.

METHODS

Participants included 302 women participating in the Healthy Women Study, a longitudinal study of cardiovascular risk during perimenopause and postmenopause, which was initiated in 1983. Hot flashes (any/none) were assessed when women were 1, 2, 5, and 8 years postmenopausal. Electron beam tomography measures of coronary artery calcification and aortic calcification were completed in 1997-2004. Associations between the number of visits with report of hot flashes, divided by the number of visits attended, and aortic or coronary artery calcification (transformed) were examined in linear regression models. Interactions by hormone therapy use were evaluated.

RESULTS

Among women using hormone therapy, a longer history of reported hot flashes was associated with increased aortic calcification, controlling for traditional cardiovascular risk factors (b = 2.87, SE = 1.21, P < 0.05). There were no significant associations between history of hot flashes and coronary artery calcification.

CONCLUSIONS

Among postmenopausal women using hormone therapy, a longer history of reported hot flashes measured prospectively was associated with increased aortic calcification, controlling for traditional cardiovascular risk factors. Hot flashes may signal adverse cardiovascular changes among certain postmenopausal women.

Hot flushes, coronary heart disease, and hormone therapy in postmenopausal women

OBJECTIVE

The aim of this study was to examine interactions between hot flushes, estrogen plus progestogen therapy (EPT), and coronary heart disease (CHD) events in postmenopausal women with CHD.

METHODS

We analyzed data from the Heart and Estrogen/Progestin Replacement Study, a randomized, placebo-controlled trial of 0.625 mg conjugated equine estrogens plus 2.5 mg medroxyprogesterone acetate in 2,763 postmenopausal women with CHD. Hot flushes were assessed at baseline using self-administered questionnaires; women reporting bothersome hot flushes "some" to "all" of the time were considered to have clinically significant flushing. Cox regression models were used to examine the effect of EPT on risk of CHD events among women with and without significant flushing at baseline.

RESULTS

The mean age of participants was 66.7 ± 6.8 years, and 89% (n = 2,448) were white. Sixteen percent (n = 434) of participants reported clinically significant hot flushes at baseline. Among women with baseline flushing, EPT increased risk of CHD events nine-fold in the first year compared with placebo (hazard ratio = 9.01; 95% CI, 1.15-70.35); among women without baseline flushing, treatment did not significantly affect CHD event risk in the first year (hazard ratio = 1.32; 95% CI, 0.86-2.03; P = 0.07 for interaction of hot flushes with treatment). The trend toward differential effects of EPT on risk for CHD among women with and without baseline flushing did not persist after the first year of treatment.

CONCLUSIONS

Among older postmenopausal women with CHD, EPT may increase risk of CHD events substantially in the first year of treatment among women with clinically significant hot flushes but not among those without hot flushes.

Extended Use of Systemic Menopausal Hormone Therapy

Because clinical trial data assessing more than 10 years of hormone therapy (HT) use are not available, providing guidance to menopausal women regarding duration of systemic HT is controversial. However, clinicians routinely encounter this issue in practice. Using available evidence and clinical experience, this chapter provides guidance for clinicians who care for patients who may be candidates for extended use of systemic HT.

Female Sexual Health: Barriers to Optimal Outcomes and a Roadmap for Improved Patient-Clinician Communications

BACKGROUND

Although sexual health can be considered a vital sign for overall health, several barriers prevent women from receiving proper medical counseling, support, and/or care for their sexual health needs and concerns.

METHODS

Experts in sexual health compiled research and experience on the impediments to women receiving adequate assessment and treatment for their sexual health. Specific solutions and a roadmap for overcoming such barriers and improving patient-clinician communication are presented.

RESULTS

Social stigma around female sexuality remains in Western culture and as a result, women often avoid and/or are embarrassed to discuss their sexual health with their health care professionals (HCPs). Moreover, midlife women are typically unaware or have misconceptions about conditions that may adversely impact their sexual life, such as genitourinary syndrome of menopause and hypoactive sexual desire disorder. Without understanding there may be underlying medical conditions, there is also a lack of awareness that safe and effective treatments are available. Lack of training, tools, time, and limited treatment options impede HCPs from providing women with necessary sexual health support. Educating women, training HCPs, and providing communication tools to HCPs can facilitate effective dialog between patients and HCPs. More specifically, HCPs can be trained to initiate and maintain a sexual health conversation in a manner that is comfortable for women to convey sexual health needs and concerns, and for HCPs to correctly identify, diagnose, and treat the sexual problems of their female patients.

CONCLUSIONS

Solutions exist to address the barriers currently impeding patient-clinician interactions around sexual health.

Menopausal Hot Flashes: A Concise Review

Hot flashes (HFs), defined as transient sensations of heat, sweating, flushing, anxiety, and chills lasting for 1-5 min, constitute one of the most common symptoms of menopause among women though only a few seek treatment for these. The basis of HFs lies in abnormal hypothalamic thermoregulatory control resulting in abnormal vasodilatory response to minor elevations of core body temperature. Recent data suggest an important role for calcitonin gene-related peptide, hypothalamic kisspeptin, neurokinin B and dynorphin signal system, serotonin, norepinephrine in causation of HFs in addition to estrogen deficiency which plays a cardinal role. The mainstay of treatment includes hormonal replacement therapy, selective serotonin, and norepinephrine reuptake inhibitors in addition to lifestyle modification. In this review, we address common issues related to menopause HFs and suggest a stepwise approach to their management.

The Effects and Action Mechanisms of Phytoestrogens on Vasomotor Symptoms During Menopausal Transition: Thermoregulatory Mechanism

Background:

Phytoestrogens have recently been claimed to positively influence menopausal discomforts, including hot flashes. However, little is known about the influence of phytoestrogens on core body temperature during oestrogen fluctuation at menopause.

Objective:

Previously published findings showed that phytoestrogens could relieve menopausal complaints, thus, the present review was aimed at assessing the effects of phytoestrogens on thermoregulatory mechanism during menopausal transition.

Results:

The molecular mechanisms underlying hot flashes are complex. Oestrogen fluctuations cause hypothalamic thermoregulatory centre dysfunction, which leads to hot flashes during menopause. The phytoestrogens of interest, in relation to human health, include isoflavones, lignans, coumestans, and stilbenes, which are widely distributed in nature. The phytoestrogens are capable of reducing hot flashes via their oestrogen-like hormone actions. The potential effects of phytoestrogens on hot flashes and their molecular mechanisms of action on thermoregulatory centre are discussed in this review.

Conclusion:

The effects of phytoestrogens on these mechanisms may help explain their beneficial effects in alleviating hot flashes and other menopausal discomforts.

Randomized, Double-Blind, Placebo-Controlled Study of Modified Erzhi Granules in the Treatment of Menopause-Related Vulvovaginal Atrophy

Objective

To evaluate the clinical therapeutic efficacy and safety of modified Erzhi granules (MEG) in patients with menopause-related vulvovaginal atrophy (VVA).

Methods

This randomized, double-blind, placebo-controlled study comprised two groups, including the treatment and control groups. Patients receive MEG and placebo for 12 weeks, respectively. Vaginal health score (VHS), vaginitis score, vaginal maturation index (VMI), female sexual function index (FSFI), and modified Kupperman Index (modified KI) were used as efficacy endpoints and assessed at baseline, 4, 8, and 12 weeks during administration, and 4 weeks after drug withdrawal. At baseline and 12 weeks, serum estradiol (E₂), follicle stimulating hormone (FSH), pelvic ultrasound, breast ultrasound, and other safety parameters were measured, recording adverse events.

Results

At 12 weeks, VHS, percentage of superficial cells in the vaginal epithelium and FSFI were significantly increased, while vaginitis score, percentage of basal cells in the vaginal epithelium, and modified KI were significantly decreased in comparison with baseline and control group (all P<0.05); these differences persisted for up to 4 weeks after drug withdrawal. The placebo group showed no significant change during treatment compared with baseline values (p>0.05). Serum E₂ and FSH levels, endometrial thickness, and breast thickness in all patients were within the normal ranges before and after treatment, with no serious adverse reactions observed.

Conclusion

MEG significantly alleviates menopause-related vulvovaginal atrophy, with no overt adverse effects on the endometrium, breast, hepatic, and renal functions.

Predictors of vasomotor symptoms among breast cancer survivors

PURPOSE

Vasomotor symptoms (VMS) are a common side effect of breast cancer treatment, yet modifiable factors that may predict VMS among breast cancer survivors are unknown.

METHODS

We estimated multivariable-adjusted odds ratios and 95% confidence intervals (aOR, 95% CI) for predictors of VMS among 3595 breast cancer survivors enrolled in the Life and Longevity after Cancer (LILAC) study, an ancillary study of the Women's Health Initiative (WHI).

RESULTS

VMS post-diagnosis were reported by 790 (22.0%) participants. Risk of VMS after diagnosis was positively associated with prior chemotherapy (aOR 1.80, 95% CI 1.21-2.68) and adjuvant hormone therapy (aOR 2.73, 95% CI 2.08-3.58), postmenopausal hormone therapy use (aOR 1.67, 95% CI 1.30-2.13), prior VMS (aOR 2.20, 95% CI 1.73-2.80), bilateral oophorectomy (aOR 1.77, 95% CI 1.37-2.27), and baseline antidepressant use (aOR 1.49, 1.06-2.09). VMS post-diagnosis were less likely among younger women (aOR 0.94, 95% CI 0.93-0.96), women younger at menopause (aOR 0.98, 95% CI 0.97-1.00), women with more time since diagnosis (aOR 0.92, 95% CI 0.90-0.94), and diabetics (aOR 0.45, 95% CI 0.21-0.95). Metabolic syndrome was not associated with post-diagnosis VMS (aOR 0.76, 95% CI 0.45-1.28).

CONCLUSIONS

VMS following breast cancer diagnosis was related to a number of modifiable factors, but was unrelated to metabolic syndrome.

IMPLICATIONS FOR CANCER SURVIVORS

Identification of factors that predispose women to VMS following a breast cancer diagnosis may allow clinicians to recognize and address VMS in the subset of women who are most likely to experience such symptoms.

Cortisol dysregulation is associated with daily diary-reported hot flashes among midlife women

OBJECTIVE

Hot flashes are reported by 70-80% of women during the menopause transition. It has been proposed that cortisol dysregulation is involved in hot flashes, but the relationship between cortisol and hot flashes has received little empirical attention. This study examined the relationship between cortisol and daily self-reported hot flashes.

DESIGN

For 7 days, participants used electronic diaries to report their hot flash frequency, severity and bothersomeness, along with mood and health behaviours, multiple times each day. Participants also provided hair samples for cortisol assays at baseline and morning and bedtime saliva samples for salivary cortisol collection over 3 days during the observation period. Hierarchical linear regression was used to examine the relationships between cortisol and hot flashes.

PARTICIPANTS

Forty-four women (41% African American, 39% non-Hispanic White) who reported daily hot flashes were enrolled.

MEASUREMENTS

Salivary cortisol, hair cortisol and the frequency, severity and bothersomeness of daily diary-reported hot flashes were measured in this study.

RESULTS

Controlling for health and demographic variables, higher hair cortisol was associated with a higher frequency of hot flashes (β = 0·05, P = 0·01). A flatter diurnal cortisol slope was associated with greater hot flash severity (β = 0·09, P = 0·03) and bother (β = 0·10, P = 0·01). Hair cortisol was no longer significant after adjusting for depression or disturbed sleep; all other associations persisted.

CONCLUSION

Cortisol dysregulation was related to more frequent, severe and bothersome daily self-reported hot flashes. These findings support a potential role of the HPA axis in the aetiology and phenomenology of these common menopause symptoms.

Relationship between sociodemographic, reproductive, and lifestyle factors and the severity of menopausal symptoms among Egyptian women in Alexandria

OBJECTIVE

During menopause, women often experience some symptoms which may affect their daily activities. Information about menopausal experiences among different racial and ethnic groups is important for healthcare personnel to provide appropriate and specific interventions. The aim of the present study was thus to determine the frequency and determinants of severity of menopausal symptoms among Egyptian women using the Menopause Rating Scale as a screening tool for identification of menopausal symptoms.

METHODS

A total of 540 women (aged 40-65 y) were recruited in this cross-sectional study. Demographic information was collected, and the Menopause Rating Scale questionnaire was administered.

RESULTS

Most frequently reported symptoms were joint and muscular discomfort (501, 92.8%) followed by urogenital symptoms (460, 85.2%). A significant association was found between the number of menopausal symptoms and working status of participants (r = 0.504, P = 0.005), number of children (r = 0.474, P = 0.042), and body mass index (r = 0.544, P = 0.006). Women who reported urogenital symptoms and self-perceived general health as poor were more frequently referred to a gynecologist for moderate-to-severe menopausal symptoms.

CONCLUSIONS

Participant-related information such as working status, which was shown to increase the frequency of psychological symptoms in our ethnic group, should be noted by the physician, and a suitable approach should be adopted to achieve better therapy outcomes. Counseling about the importance of maintaining an ideal body weight and exercise should be emphasized to reduce menopausal symptoms. Appropriate advice and support in improving the overall state of the postmenopausal women is essential.

Continuous transdermal nitroglycerin therapy for menopausal hot flashes: a single-arm, dose-escalation trial

OBJECTIVE

To describe the efficacy and tolerability of continuous nitroglycerin for treatment of hot flashes.

METHODS

Perimenopausal and postmenopausal women reporting at least seven hot flashes per day were recruited into a single-arm, dose-escalation trial of continuous transdermal nitroglycerin. Participants were started on a generic 0.1 mg/hour nitroglycerin patch applied daily without patch-free periods. During 4 weeks, participants escalated dosage weekly to 0.2, 0.4, or 0.6 mg/hour as tolerated, then discontinued nitroglycerin during the final week. Changes in hot flash frequency and severity were assessed using symptom diaries. Paired t tests examined change in outcomes between baseline and maximal-dose therapy and after discontinuation of nitroglycerin.

RESULTS

Of the 19 participants, mean age was 51.4 (±4.3) years. Women reported an average 10.6 (±3.0) hot flashes and 7.1 (±3.8) moderate-to-severe hot flashes per day at baseline. Eleven women escalated to 0.6 mg/hour, three to 0.4 mg/hour, two to 0.2 mg/hour, and one remained on 0.1 mg/hour nitroglycerin. Two discontinued nitroglycerin before the first outcomes assessment. Among the remaining 17 women, the average daily frequency of hot flashes decreased by 54% and the average frequency of moderate-to-severe hot flashes decreased by 69% from baseline to maximum-dose therapy (P < 0.001 for both). After discontinuing nitroglycerin, participants reported an average 23% increase in frequency of any hot flashes (P = 0.041) and 96% increase in moderate-to-severe hot flashes (P < 0.001).

CONCLUSIONS

Continuous nitroglycerin may substantially and reversibly decrease hot flash frequency and severity. If confirmed in a randomized blinded trial, it may offer a novel nonhormonal hot flash treatment.

Day-to-Day Impact of Vaginal Aging questionnaire: a multidimensional measure of the impact of vaginal symptoms on functioning and well-being in postmenopausal women

OBJECTIVE

This study aims to develop a self-report questionnaire assessing the impact of vaginal dryness, soreness, itching, irritation, and pain on functioning and well-being in postmenopausal women.

METHODS

Structured self-report items were developed to address the impact of vaginal symptoms on functioning and well-being based on findings from focus groups with racially/ethnically diverse, symptomatic postmenopausal women. Items were refined after cognitive interview pretesting and field-tested among symptomatic postmenopausal women enrolled in a multiethnic cohort study in California. Exploratory factor analysis (SAS PROC VARCLUS) and confirmatory factor analysis evaluated factor structure and eliminated poorly fitting items. Additional evidence of construct validity was obtained via examination of correlations with other measures of related constructs. Internal consistency and test-retest reliability were assessed using Cronbach α and correlation coefficients, respectively.

RESULTS

For the 745 postmenopausal women who completed the draft questionnaire, the mean (SD) age was 56.2 (8.5) years, and 66% of the respondents were racial/ethnic minorities. The refined questionnaire included four multi-item scales addressing symptom impact on (1) activities of daily living, (2) emotional well-being, (3) sexual functioning, and (4) self-concept and body image. The four-factor model provided good approximate fit (comparative fit index, 0.987; standardized root-mean-square residual, 0.038). Correlations with other measures of symptom bothersomeness, sexual function, depression, and anxiety conformed to hypotheses. Cronbach α values ranged from 0.82 to 0.93. Intraclass coefficients ranged from 0.47 to 0.72.

CONCLUSIONS

The Day-to-Day Impact of Vaginal Aging questionnaire is a new multidimensional self-report measure designed to facilitate evaluation of the impact of vaginal symptoms on postmenopausal women of diverse backgrounds.

Device-guided slow-paced respiration for menopausal hot flushes: a randomized controlled trial

OBJECTIVE

To evaluate the efficacy of device-guided slow-paced respiration for reducing the frequency and severity of menopausal hot flushes.

METHODS

Perimenopausal or postmenopausal women reporting four or more hot flushes per day were recruited into a parallel-group, randomized trial of slow-paced respiration using a portable guided-breathing device. Women were randomly assigned to use a standard device to practice slowing their resting breathing rate to less than 10 breaths per minute for at least 15 minutes everyday or use an identical-appearing control device programmed to play relaxing nonrhythmic music while monitoring spontaneous breathing. The primary outcome, change in hot flush frequency over 12 weeks, was assessed using data from validated 7-day diaries abstracted by blinded analysts.

RESULTS

Among the 123 participants, mean age was 53.4 (±3.4) years. Women reported an average of 8.5 (±3.5) hot flushes per day at baseline. After 12 weeks, women randomized to paced respiration (n=61) reported an average reduction of 1.8 (95% confidence interval [CI] 0.9-2.6) hot flushes per day (-21%) compared with 3.0 (95% CI 2.1-3.8) hot flushes per day (-35%) in the music-listening group (n=62) (P=.048). Paced respiration was associated with a 19% decrease in frequency of moderate-to-severe hot flushes compared with a 44% decrease with music listening (P=.02).

CONCLUSION

In this randomized trial, women assigned to device-guided slow-paced respiration reported modest improvements in the frequency and severity of their hot flushes, but the paced respiration intervention was significantly less effective than a music-listening intervention in decreasing the frequency and severity of these symptoms.

LEVEL OF EVIDENCE

I.

Association between use of self-prescribed complementary and alternative medicine and menopause-related symptoms: a cross-sectional study

OBJECTIVES

To examine the association between self-prescribed complementary and alternative medicine use and menopause-related symptoms, stratified by menopausal status.

METHODS

Data were obtained from a cross-sectional survey of a nationally representative sample of 10,011 menopausal women from the Australian Longitudinal Study on Women's Health, conducted in 2010. Multivariable logistic regression models were applied to identify if the use of selected self-prescribed complementary and alternative medicine was significantly associated with a range of menopause-related symptoms.

RESULTS

Vitamins/minerals were more likely to be used by natural menopausal women experiencing anxiety (adjusted OR=1.20) and/or stiff/painful joints (adjusted OR=1.16). Yoga/meditation was more likely to be used by women with hysterectomy (adjusted OR=1.76) or natural menopausal women (adjusted OR=1.38) experiencing anxiety. Herbal medicines were more likely to be used by natural menopausal women experiencing anxiety (adjusted OR=1.22), tiredness (adjusted OR=1.20), and/or stiff/painful joints (adjusted OR=1.17), and by women with oophorectomy experiencing tiredness (adjusted OR=1.45). Aromatherapy oils were more likely to be used by natural menopausal women experiencing night sweats (adjusted OR=1.25) and by women with hysterectomy experiencing anxiety (adjusted OR=2.02). Chinese medicines were more likely to be used by women with oophorectomy experiencing stiff/painful joints (adjusted OR=4.06) and/or palpitations (adjusted OR=3.06).

CONCLUSIONS

Our study will help improve the patient-provider communication regarding complementary and alternative medicine use for menopause, and we conclude that menopausal status should be taken into account by providers for menopause care. The women's experience and motivations of such use warrant further research.

Extended duration use of menopausal hormone therapy

Although providing guidance to patients regarding duration of hormone therapy represents a topic surrounded by controversy, clinicians often encounter this issue in practice. As pointed out in the NAMS 2012 Hormone Therapy (HT) Position Statement, determining the optimal duration of HT is challenging both for clinicians and for patients. This Practice Pearl addresses clinical situations for which long-term HT might be appropriate and provides practical guidance regarding prudent therapeutic choices for women using HT for an extended duration.

Hot flushes and night sweats are associated with coronary heart disease risk in midlife: a longitudinal study

OBJECTIVE

The purpose of this study was to investigate associations between vasomotor menopausal symptoms (VMS), i.e. hot flushes and night sweats, and the incidence of coronary heart disease (CHD).

DESIGN

A prospective cohort study.

SETTING AND POPULATION

11 725 women, aged 45-50 years at baseline in 1996, were followed up at 3-year intervals for 14 years.

METHODS

Self-reported VMS and incident CHD were measured at each survey.

MAIN OUTCOME MEASURE

We determined the association between VMS and CHD at the subsequent survey, using generalised estimating equation analysis, adjusting for time-varying covariates.

RESULTS

At baseline, 14% reported rarely, 17% reported sometimes, and 7% reported often having night sweats. During follow-up, 187 CHD events occurred. In the age-adjusted analysis, women who reported their frequency of experiencing hot flushes and night sweats as 'often' had a greater than two-fold increased odds of CHD (OR hot flushes 2.18, 95% CI 1.49-3.18; OR night sweats 2.38, 95% CI 1.62-3.50) compared with women with no symptoms (P trend < 0.001 for frequency of symptoms). Adjustment for menopausal status, lifestyle factors, body mass index, diabetes, and hypertension attenuated the associations (OR hot flushes 1.70, 95% CI 1.16-2.51, P trend = 0.01; OR night sweats 1.84, 95% CI 1.24-2.73), P trend = 0.004).

CONCLUSIONS

Women who report having hot flushes or night sweats 'often' have an increased risk of developing CHD over a period of 14 years, even after taking the effects of age, menopause status, lifestyle, and other chronic disease risk factors into account.

Vasomotor symptoms and insulin resistance in the study of women's health across the nation

CONTEXT

Emerging research suggests links between menopausal hot flashes and cardiovascular disease risk. The mechanisms underlying these associations are unclear, due to the incomplete understanding of the physiology of hot flashes. OBJECTIVE AND MAIN OUTCOME MEASURES: We examined the associations between hot flashes/night sweats and glucose and insulin resistance over 8 yr, controlling for cardiovascular risk factors and reproductive hormones.

DESIGN, SETTING, AND PARTICIPANTS

Participants in the Study of Women's Health Across the Nation (SWAN) (n=3075), a longitudinal cohort study, were ages 42-52 yr at entry. Women completed questionnaires (hot flashes, night sweats: none, 1-5 d, ≥6 d, past 2 wk), physical measures (blood pressure, height, weight), and a fasting blood draw [serum glucose, insulin, estradiol (E2), FSH] annually for 8 yr. Hot flashes/night sweats were examined in relation to glucose and the homeostasis model assessment (HOMA) in mixed models, adjusting for demographics, cardiovascular risk factors, medications, and E2/FSH.

RESULTS

Compared to no flashes, hot flashes were associated with a higher HOMAlog index [vs. none; hot flashes, 1-5 d: % difference (95% confidence interval), 2.37 (0.36-4.43), P=0.02; and ≥6 d: 5.91 (3.17-8.72), P<0.0001] in multivariable models that included body mass index. Findings persisted adjusting for E2 or FSH, and were similar for night sweats. Findings were statistically significant, yet modest in magnitude, for the outcome glucose.

CONCLUSIONS

Hot flashes were associated with a higher HOMA index, an estimate of insulin resistance, and to a lesser extent higher glucose. Metabolic factors may be relevant to understanding the link between hot flashes and cardiovascular disease risk.

Factors associated with reporting classic menopausal symptoms differ

OBJECTIVES

To investigate how symptoms experienced in midlife cluster and to identify factors independently associated with hot flushes, night sweats, and vaginal dryness.

METHODS

A questionnaire was sent to 8206 women aged 45-54 years, recruited from family practices in north-east Scotland, UK. Using data collected about 23 symptoms, we conducted factor analysis for premenopausal, perimenopausal, postmenopausal and surgically menopausal women. Forward stepwise logistic regression was used to identify sociodemographic, lifestyle and psychological variables independently associated with the classic menopausal symptoms.

RESULTS

Overall, 4407 women responded. Hot flushes were experienced by 46.7% (95% confidence interval (CI) 45.2-48.2) of women, night sweats by 46.4% (95% CI 44.9-47.9) and vaginal dryness by 28.2% (95% CI 26.9-29.6). Seven factors including 20 symptoms emerged from factor analysis. Hot flushes were associated with: being perimenopausal or postmenopausal; low education; obesity; low social support; reporting night sweats, musculoskeletal, bloating, menstrual and sexual symptoms; using complementary alternative medicines, lifestyle (e.g. exercising) or psychological management strategies (e.g. talking to family or friends) for menopausal symptoms. Night sweats were associated with: lower body weight; smoking; possible depression; reporting sleep difficulties, hot flushes and sexual symptoms; using lifestyle strategies for menopausal symptoms. Vaginal dryness was associated with: being postmenopausal; high education; high social support; below average physical health, reporting hot flushes, somatic symptoms and decreased sexual interest; using psychological or lifestyle strategies for menopausal symptoms.

CONCLUSION

It is important to investigate each classic menopausal symptom separately. Combining menopausal symptoms into categories such as vasomotor symptoms may lead to inaccurate conclusions about variables associated with these symptoms.

Perceived control, lifestyle, health, socio-demographic factors and menopause: impact on hot flashes and night sweats

OBJECTIVE

To develop a model to predict the perceived severity of hot flashes (HF) and night sweats (NS) in symptomatic middle-aged women.

METHODS

This was a cross-sectional study of a community-based sample of 243 women with vasomotor symptoms. Menopausal status was ascertained using the 'Stages of Reproductive Aging Workshop' criteria. Women's 'perceived control' over their symptoms was measured by a validated Portuguese version of the Perceived Control over Hot Flushes Index. Structural equation modelling was employed to construct a causal model of self-reported severity of both HF and NS, using a set of 20 variables: age, marital status, parity, professional status, educational level, family annual income, recent diseases and psychological problems, medical help-seeking behaviour to manage menopausal symptoms, use of hormone therapy and herbal/soy products, menopause status, intake of alcohol, coffee and hot beverages, smoking, physical exercise, body mass index and perceived control.

RESULTS

Significant predictors of perceived severity were the use of hormone therapy for both HF (β=-.245; p=.022) and NS (β=-.298; p=.008), coffee intake for both HF (β=-.234; p=.039) and NS (β=-.258; p=.029) and perceived control for both HF (β=-1.0; p<.001) and NS (β=-1.0; p<.001). The variables explained respectively 67% and 72% of the variability in the perceived severity of HF and NS. Women with high perceived control had a significantly lower frequency (t(235)=2.022; p=.044) and intensity of HF (t(217)=3.582; p<.001); similarly, participants with high perceived control presented a lower frequency (t(235)=3.267; p<.001) and intensity (t(210)=3.376; p<.001) of NS.

CONCLUSION

Perceived control was the strongest predictor of the self-reported severity of both HF and NS. Other causal predictors were hormone therapy and caffeine intake. All three were associated with less severe vasomotor symptoms.

Vasomotor menopausal symptoms are associated with increased risk of coronary heart disease

OBJECTIVE

Emerging evidence suggests that women with vasomotor menopausal symptoms (VMS) may have an adverse cardiovascular disease (CVD) risk profile. We investigated whether VMS are related to an increased risk of future coronary heart disease (CHD) and whether possible associations can be explained by CVD risk factors.

METHODS

Data used were from a Dutch and Swedish population-based sample of 10,787 women enrolled between 1995 and 2000, aged 46 to 64 years, and free of CVD at baseline. Data on VMS were collected by questionnaires. Body mass index and blood pressure were measured in all women, and total cholesterol levels were measured in a subgroup of the population. Multivariable Cox regression models were used to analyze the data.

RESULTS

After a mean ± SD follow-up period of 10.3 ± 2.1 years, 303 women were diagnosed with CHD. Symptoms of flushing were not associated with risk of CHD. However, the presence of night sweats was associated with a significantly modest increased risk of CHD, with a multivariable-adjusted hazard ratio of 1.33 (95% CI, 1.05-1.69). This association was attenuated but not eliminated after correction for body mass index, blood pressure, and total cholesterol (hazard ratio, 1.25; 95% CI, 0.99-1.58).

CONCLUSIONS

Women with menopausal symptoms of night sweats have a significantly moderately increased risk of CHD, which cannot be totally explained by the levels of CVD risk factors.

Vasomotor symptoms and cardiovascular events in postmenopausal women

OBJECTIVE

Emerging evidence suggests that women with menopausal vasomotor symptoms (VMS) have increased cardiovascular disease (CVD) risk as measured by surrogate markers. We investigated the relationships between VMS and clinical CVD events and all-cause mortality in the Women's Health Initiative Observational Study (WHI-OS).

METHODS

We compared the risk of incident CVD events and all-cause mortality between four groups of women (total N = 60,027): (1) no VMS at menopause onset and no VMS at WHI-OS enrollment (no VMS [referent group]), (2) VMS at menopause onset but not at WHI-OS enrollment (early VMS), (3) VMS at both menopause onset and WHI-OS enrollment (persistent VMS [early and late]), and (4) VMS at WHI-OS enrollment but not at menopause onset (late VMS).

RESULTS

For women with early VMS (n = 24,753), compared with no VMS (n = 18,799), hazard ratios (95% CIs) in fully adjusted models were as follows: major coronary heart disease (CHD), 0.94 (0.84-1.06); stroke, 0.83 (0.72-0.96); total CVD, 0.89 (0.81-0.97); and all-cause mortality, 0.92 (0.85-0.99). For women with persistent VMS (n = 15,084), there was no significant association with clinical events. For women with late VMS (n = 1,391), compared with no VMS, hazard ratios (95% CIs) were as follows: major CHD, 1.32 (1.01-1.71); stroke, 1.14 (0.82-1.59); total CVD, 1.23 (1.00-1.52); and all-cause mortality, 1.29 (1.08-1.54).

CONCLUSIONS

Early VMS were not associated with increased CVD risk. Rather, early VMS were associated with decreased risk of stroke, total CVD events, and all-cause mortality. Late VMS were associated with increased CHD risk and all-cause mortality. The predictive value of VMS for clinical CVD events may vary with the onset of VMS at different stages of menopause. Further research examining the mechanisms underlying these associations is needed. Future studies will also be necessary to investigate whether VMS that develop for the first time in the later postmenopausal years represent a pathophysiologic process distinct from the classic perimenopausal VMS.

Menopausal hot flushes and vascular health

Hot flushes are complained of by approximately 75% of all postmenopausal women, and hormone therapy (HT) is the most effective way to alleviate them. Hot flushes are characterized by altered vascular function and sympathetic nervous system activity. Hot flushes occurred more often in women attending large, non-randomized observational studies (e.g. Nurses' Health Study), where HT use protected against cardiovascular disease (CVD). However, they were absent (or mild) in randomized HT trials where HT use was accompanied with an elevated risk for CVD. Hot flushes, if a factor for cardiovascular health, could partly explain the conflict between observational and randomized trials. Several cross-sectional studies imply that hot flushes are detrimental to the cardiovascular system. However, the data are not uniform, and hot flushes were recalled retrospectively or during HT use. In our prospective study hot flushes were accompanied with a vasodilatory effect during endothelial testing, and this was related to the severity of hot flushes. Night-time hot flushes were followed with transient rises in ambulatory blood pressure (BP). However, no effect of hot flushes on diurnal BP was detected. The use of estradiol showed no harmful effects on endothelial function in women with hot flushes, but in non-flushing women oral, but not transdermal, estradiol led to vasoconstrictive changes. Estradiol complemented with medroxyprogesterone acetate eliminated the vasoconstrictive effect of sole oral estradiol. Thus, both oral and transdermal estradiol are applicable in flushing women, whereas a transdermal route should be favored in non-flushing women if used e.g. for bone protection.

Impact of hot flashes and night sweats on carotid intima-media thickness and bone mineral density among postmenopausal women

OBJECTIVE

To determine whether postmenopausal women with vasomotor symptoms have a lower bone mineral density (BMD) and a higher carotid intima-media thickness (CIMT) than those without vasomotor symptoms.

METHODS

Postmenopausal women with (n=87) or without (n=117) vasomotor symptoms who did not receive hormone therapy were included. The CIMT and BMD were determined and the relationship with vasomotor symptoms evaluated.

RESULTS

The presence of both hot flashes and night sweats was associated with a CIMT of more than 0.80 mm after adjusting for age, time since menopause, and body mass index (adjusted odds ratio 3.2; 95% confidence interval [CI], 2.3-4.5; P<0.001). The adjusted odds ratio for a CIMT higher than 0.80 mm in women with night sweats was 3.6 (95% CI 1.5-8.9; P=0.006); the adjusted odds ratio in women with hot flashes was 23.1 (95% CI 9.1-58.4; P<0.001). The mean CIMT was 0.65±0.08 mm in the asymptomatic group and 0.81±0.06 mm in the symptomatic group (P<0.001). The mean lumbar (L1, L2, and L3) and total hip BMD values were lower in the symptomatic group (P<0.05).

CONCLUSION

Hot flashes and night sweats in postmenopausal women are associated with a higher CIMT and a lower BMD.

Associations between tamoxifen, estrogens, and FSH serum levels during steady state tamoxifen treatment of postmenopausal women with breast cancer

Background

The cytochrome P450 (CYP) enzymes 2C19, 2D6, and 3A5 are responsible for converting the selective estrogen receptor modulator (SERM), tamoxifen to its active metabolites 4-hydroxy-tamoxifen (4OHtam) and 4-hydroxy-N-demethyltamoxifen (4OHNDtam, endoxifen). Inter-individual variations of the activity of these enzymes due to polymorphisms may be predictors of outcome of breast cancer patients during tamoxifen treatment. Since tamoxifen and estrogens are both partly metabolized by these enzymes we hypothesize that a correlation between serum tamoxifen and estrogen levels exists, which in turn may interact with tamoxifen on treatment outcome. Here we examined relationships between the serum levels of tamoxifen, estrogens, follicle-stimulating hormone (FSH), and also determined the genotypes of CYP2C19, 2D6, 3A5, and SULT1A1 in 90 postmenopausal breast cancer patients.

Methods

Tamoxifen and its metabolites were measured by liquid chromatography-tandem mass spectrometry. Estrogen and FSH levels were determined using a sensitive radio- and chemiluminescent immunoassay, respectively.

Results

We observed significant correlations between the serum concentrations of tamoxifen, N-dedimethyltamoxifen, and tamoxifen-N-oxide and estrogens (p < 0.05). The genotype predicted CYP2C19 activity influenced the levels of both tamoxifen metabolites and E1.

Conclusions

We have shown an association between tamoxifen and its metabolites and estrogen serum levels. An impact of CYP2C19 predicted activity on tamoxifen, as well as estrogen kinetics may partly explain the observed association between tamoxifen and its metabolites and estrogen serum levels. Since the role of estrogen levels during tamoxifen therapy is still a matter of debate further prospective studies to examine the effect of tamoxifen and estrogen kinetics on treatment outcome are warranted.

Vaginal symptoms in postmenopausal women: self-reported severity, natural history, and risk factors

OBJECTIVE

This study aimed to examine factors other than estrogen deficiency influencing the development and persistence of vaginal dryness, itching, and painful sexual intercourse after menopause.

METHODS

We analyzed data from a 2-year, population-based cohort of 1,017 postmenopausal women aged 55 to 75 years. Vaginal symptoms were assessed by interviewer-administered questionnaire, and vaginal swabs were performed to assess vaginal pH and microbial flora at baseline, 12 months, and 24 months. Generalized estimating equations were used to identify characteristics associated with symptoms.

RESULTS

Half of the women (n = 471) reported problematic vaginal dryness, a third (n = 316) reported itching, and 40% of sexually active women (n = 166) reported painful intercourse at baseline. Of women not taking estrogen, half of those reporting baseline symptoms were symptomatic after 24 months. Vaginal dryness was associated with younger age (odds ratio [OR], 0.81; 95% CI, 0.69-0.94, per 5-y increase), nonwhite race (ie, African American, Hispanic, Asian or Pacific Islander, or American Indian [OR, 1.53; 95% CI, 1.04-2.27]), diabetes (OR, 1.51; 95% CI, 1.07-2.12), lower 36-item Short-Form Health Survey physical functioning scores (OR, 0.90; 95% CI, 0.85-0.97, per 10-point increase), lower body mass index (OR, 0.81; 95% CI, 0.71-0.93, per 5 kg/m increase), recent sexual activity (OR, 1.14; 95% CI, 1.08-1.21), and vaginal colonization with enterococci (OR, 1.25; 95% CI, 1.04-1.51). Vaginal itching was also associated with lower physical functioning scores (OR, 0.86; 95% CI, 0.80-0.92, per 10-point increase). Risk factors for painful intercourse included younger age (OR, 0.72; 95% CI, 0.56-0.93, per 5-y increase), diabetes (OR, 3.48; 95% CI, 1.93-6.27), lower body mass index (OR, 0.76; 95% CI, 0.61-0.95, per 5 kg/m increase), and higher vaginal pH (OR, 1.10; 95% CI, 1.00-1.21, per 0.5 units).

CONCLUSIONS

Vaginal symptoms affect a large proportion of postmenopausal women, particularly those with diabetes and those with lower body mass index, but may resolve for up to half of women without estrogen therapy.

Vasomotor symptoms, estradiol levels and cardiovascular risk profile in women

OBJECTIVES

We investigated whether menopausal vasomotor symptoms (VMS) are related to an adverse cardiovascular risk profile. Furthermore, we examined the association between estradiol levels and VMS, and whether an association between VMS and cardiovascular risk factors can be explained by estradiol levels.

STUDY DESIGN

We used data from a Swedish population-based sample of 5857 women, aged 50-64 years. Data on VMS and potential confounders were collected by questionnaires.

MAIN OUTCOME MEASURES

Body mass index (BMI), waist hip ratio (WHR), glucose, blood pressure, lipid profile and estradiol levels were measured.

RESULTS

Symptoms of flushing/sweats were reported by 55% and sweats by 31% of all women. Estradiol concentrations were significantly lower in women with VMS. After multivariate adjustment, women with symptoms of sweats had a statistically significantly higher BMI, waist hip ratio, total cholesterol level, LDL level, triglycerides level, glucose level, systolic and diastolic blood pressure. These patterns did not change after correction for estradiol. The associations between flushing/sweats combined and cardiovascular risk factors were less pronounced.

CONCLUSIONS

Women with VMS have a less favorable cardiovascular risk profile. Although estradiol levels were significantly lower among women with VMS, the increased cardiovascular risk profile cannot be explained by circulating estradiol levels.

History of hot flashes and aortic calcification among postmenopausal women

OBJECTIVE

Menopausal hot flashes are considered largely a quality-of-life issue. However, emerging research also links hot flashes to cardiovascular risk. In some investigations, this risk is particularly apparent among women using hormone therapy. The aim of this study was to determine whether a longer history of reported hot flashes over the study period was associated with greater aortic and coronary artery calcification. Interactions with hormone therapy use were examined in an exploratory fashion.

METHODS

Participants included 302 women participating in the Healthy Women Study, a longitudinal study of cardiovascular risk during perimenopause and postmenopause, which was initiated in 1983. Hot flashes (any/none) were assessed when women were 1, 2, 5, and 8 years postmenopausal. Electron beam tomography measures of coronary artery calcification and aortic calcification were completed in 1997-2004. Associations between the number of visits with report of hot flashes, divided by the number of visits attended, and aortic or coronary artery calcification (transformed) were examined in linear regression models. Interactions by hormone therapy use were evaluated.

RESULTS

Among women using hormone therapy, a longer history of reported hot flashes was associated with increased aortic calcification, controlling for traditional cardiovascular risk factors (b = 2.87, SE = 1.21, P < 0.05). There were no significant associations between history of hot flashes and coronary artery calcification.

CONCLUSIONS

Among postmenopausal women using hormone therapy, a longer history of reported hot flashes measured prospectively was associated with increased aortic calcification, controlling for traditional cardiovascular risk factors. Hot flashes may signal adverse cardiovascular changes among certain postmenopausal women.