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Reeves AN, Lewis TT, Hood MM, Thurston RC, Avis NE, Burnett-Bowie SAM, Cortés YI, Neal-Perry G, Harlow SD. Does everyday discrimination account for the increased risk of vasomotor symptoms in Black women?: the Study of Women's Health Across the Nation (SWAN). Menopause 2024:00042192-990000000-00313. [PMID: 38595299 DOI: 10.1097/gme.0000000000002357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
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.
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Affiliation(s)
| | - Tené T Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Michelle M Hood
- From the Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI
| | | | - Nancy E Avis
- Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Sherri-Ann M Burnett-Bowie
- Endocrine Division, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Yamnia I Cortés
- School of Nursing, University of North Carolina - Chapel Hill, Chapel Hill, NC
| | - Genevieve Neal-Perry
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina - Chapel Hill, NC, Chapel Hill, NC
| | - Siobán D Harlow
- From the Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI
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Mitro SD, Wise LA, Waetjen LE, Lee C, Zaritsky E, Harlow SD, Solomon DH, Thurston RC, El Khoudary SR, Santoro N, Hedderson MM. Hypertension, Cardiovascular Risk Factors, and Uterine Fibroid Diagnosis in Midlife. JAMA Netw Open 2024; 7:e246832. [PMID: 38625699 PMCID: PMC11022113 DOI: 10.1001/jamanetworkopen.2024.6832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 02/18/2024] [Indexed: 04/17/2024] Open
Abstract
Importance Fibroids are benign neoplasms associated with severe gynecologic morbidity. There are no strategies to prevent fibroid development. Objective To examine associations of hypertension, antihypertensive treatment, anthropometry, and blood biomarkers with incidence of reported fibroid diagnosis in midlife. Design, Setting, and Participants The Study of Women's Health Across the Nation is a prospective, multisite cohort study in the US. Participants were followed-up from enrollment (1996-1997) through 13 semiannual visits (1998-2013). Participants had a menstrual period in the last 3 months, were not pregnant or lactating, were aged 42 to 52 years, were not using hormones, and had a uterus and at least 1 ovary. Participants with prior fibroid diagnoses were excluded. Data analysis was performed from November 2022 to February 2024. Exposures Blood pressure, anthropometry, biomarkers (cholesterol, triglycerides, and C-reactive protein), and self-reported antihypertensive treatment at baseline and follow-up visits were measured. Hypertension status (new-onset, preexisting, or never [reference]) and hypertension treatment (untreated, treated, or no hypertension [reference]) were categorized. Main Outcomes and Measures Participants reported fibroid diagnosis at each visit. Discrete-time survival models estimated hazard ratios (HRs) and 95% CIs for associations of time-varying hypertension status, antihypertensive treatment, anthropometry, and biomarkers with incident reported fibroid diagnoses. Results Among 2570 participants without a history of diagnosed fibroids (median [IQR] age at screening, 45 [43-48] years; 1079 [42.1%] college educated), 526 (20%) reported a new fibroid diagnosis during follow-up. Risk varied by category of hypertension treatment: compared with those with no hypertension, participants with untreated hypertension had a 19% greater risk of newly diagnosed fibroids (HR, 1.19; 95% CI, 0.91-1.57), whereas those with treated hypertension had a 20% lower risk (HR, 0.80; 95% CI, 0.56-1.15). Among eligible participants with hypertension, those taking antihypertensive treatment had a 37% lower risk of newly diagnosed fibroids (HR, 0.63; 95% CI, 0.38-1.05). Risk also varied by hypertension status: compared with never-hypertensive participants, participants with new-onset hypertension had 45% greater risk of newly diagnosed fibroids (HR, 1.45; 95% CI, 0.96-2.20). Anthropometric factors and blood biomarkers were not associated with fibroid risk. Conclusions and Relevance Participants with untreated and new-onset hypertension had increased risk of newly diagnosed fibroids, whereas those taking antihypertensive treatment had lower risk, suggesting that blood pressure control may provide new strategies for fibroid prevention.
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Affiliation(s)
- Susanna D. Mitro
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Lauren A. Wise
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts
| | - L. Elaine Waetjen
- Department of Obstetrics and Gynecology, University of California Davis School of Medicine, Davis
| | - Catherine Lee
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Eve Zaritsky
- Department of Obstetrics and Gynecology, Kaiser Permanente Northern California, Oakland
| | - Siobán D. Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor
| | | | - Rebecca C. Thurston
- Department of Psychology and Psychiatry, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Samar R. El Khoudary
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora
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Ding N, Wang X, Harlow SD, Randolph JF, Gold EB, Park SK. Heavy Metals and Trajectories of Anti-Müllerian Hormone During the Menopausal Transition. J Clin Endocrinol Metab 2024:dgad756. [PMID: 38271266 DOI: 10.1210/clinem/dgad756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Experimental and epidemiological studies have linked metals with women's reproductive aging, but the mechanisms are not well understood. Disrupted ovarian folliculogenesis and diminished ovarian reserve could be a pathway through which metals impact reproductive hormones and outcomes. OBJECTIVE The study aimed to evaluate the associations of heavy metals with anti-Müllerian hormone (AMH), a marker of ovarian reserve. METHODS The study included 549 women from the Study of Women's Health Across the Nation with 2252 repeated AMH measurements from 10 to 0 years before the final menstrual period (FMP). Serum AMH concentrations were measured using picoAMH ELISA. Urinary concentrations of arsenic, cadmium, mercury, and lead were measured using high-resolution inductively coupled plasma mass spectrometry. Multivariable linear mixed regressions modeled AMH as a function of time before the FMP interaction terms between metals and time to the FMP were also included. RESULTS Adjusting for confounders, compared with those in the lowest tertile, women in the highest tertile of urinary arsenic or mercury concentrations had lower AMH concentrations at the FMP (percent change: -32.1%; 95% CI, -52.9 to -2.2, P-trend = .03 for arsenic; percent change: -40.7%; 95% CI, -58.9 to -14.5, P-trend = .005 for mercury). Higher cadmium and mercury were also associated with accelerated rates of decline in AMH over time (percent change per year: -9.0%; 95% CI, -15.5 to -1.9, P-trend = .01 for cadmium; -7.3%; 95% CI, -14.0 to -0.1, P-trend = .04 for mercury). CONCLUSION Heavy metals including arsenic, cadmium, and mercury may act as ovarian toxicants by diminishing ovarian reserve in women approaching the FMP.
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Affiliation(s)
- Ning Ding
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - Xin Wang
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - John F Randolph
- Department of Obstetrics and Gynecology, School of Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Ellen B Gold
- Department of Public Health Sciences, University of California, Davis, School of Medicine, Davis, CA 95616, USA
| | - Sung Kyun Park
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
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Wang X, Ding N, Harlow SD, Randolph JF, Gold EB, Derby C, Kravitz HM, Greendale G, Wu X, Ebisu K, Schwartz J, Park SK. Associations between exposure to air pollution and sex hormones during the menopausal transition. Sci Total Environ 2024; 908:168317. [PMID: 37949144 DOI: 10.1016/j.scitotenv.2023.168317] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/01/2023] [Accepted: 11/01/2023] [Indexed: 11/12/2023]
Abstract
Menopause is a significant milestone in a woman's life, characterized by decreasing estradiol (E2) and increasing follicle-stimulating hormone (FSH) levels. Growing evidence suggests that air pollution may affect reproductive health and disrupt hormone profiles, yet the associations in women undergoing menopausal transition (MT) remains underexplored. We examined the associations between annual air pollutant exposures and repeated measures of E2 and FSH in 1365 women with known final menstrual period (FMP) date from the Study of Women's Health Across the Nation. Air pollution was calculated as the annual averages of 24-h average PM2.5 levels, daily one-hour maximum NO2 levels, and daily 8-h maximum O3 levels. Linear mixed models with piece-wise linear splines were used to model non-linear trajectories of E2 and FSH in three distinct time periods: up to 2 years before the FMP (early MT), within 2 years before and 2 years after FMP (transmenopause), and >2 years post-FMP (postmenopause). In the transmenopausal period, an interquartile (5 μg/m3) increase in PM2.5 was associated with a significant decrease in E2 levels (-15.7 %, 95 % CI: -23.7, -6.8), and a 10 ppb increase in NO2 was associated with a significant decrease in E2 levels (-9.2 %, 95 % CI: -16.2, -1.7). A higher PM2.5 was also associated with an accelerated rate of decline in E2. Regarding FSH, a 10 ppb increase in NO2 was associated with decline in FSH levels (-11.7 %, 95 % CI: -21.8, -0.1) in the early MT and accelerated rates of decline in the postmenopause (-1.1 % per year, 95 % CI: -2.1, -0.1). Additionally, inverse associations between O3 and FSH were observed in the transmenopause and postmenopause. Our study suggests that increases in PM2.5, NO2, and O3 exposures are linked to significant declines in E2 and FSH levels across menopausal stages, suggesting the detrimental impact of air pollutants on women's reproductive hormones.
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Affiliation(s)
- Xin Wang
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA.
| | - Ning Ding
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - John F Randolph
- Department of Obstetrics and Gynecology, School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Ellen B Gold
- Department of Public Health Sciences, University of California, Davis, School of Medicine, Davis, CA, USA
| | - Carol Derby
- Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Howard M Kravitz
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA; Department of Family and Preventive Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Gail Greendale
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Xiangmei Wu
- Air and Climate Epidemiology Section, Office of Environmental Health Hazard Assessment, California Environmental Protection Agency, Oakland, CA, USA
| | - Keita Ebisu
- Air and Climate Epidemiology Section, Office of Environmental Health Hazard Assessment, California Environmental Protection Agency, Oakland, CA, USA
| | - Joel Schwartz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Sung Kyun Park
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA; Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, USA
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Dugan SA, Crawford SL, Wente K, Waetjen LE, Karvonen-Gutierrez C, Harlow SD. The association of urinary incontinence and disability among a diverse sample of midlife Study of Women's Health Across the Nation women. Menopause 2024; 31:18-25. [PMID: 38016162 PMCID: PMC10766380 DOI: 10.1097/gme.0000000000002282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
OBJECTIVE The aim of the study is to examine whether urinary incontinence (UI) type, frequency, and amount are associated with self-reported disability in a racially/ethnically diverse cohort of community-dwelling midlife women. METHODS Data were from longitudinal analyses of questionnaires from the multicenter, prospective cohort Study of Women's Health Across the Nation (SWAN). We used multivariable ordinal logistic regression to examine whether urinary incontinence type, frequency, and amount at the 13th follow-up were associated with the World Health Organization Disability Assessment Schedule at the 15th follow-up controlling for other factors (menopause status, body mass index, lifestyle and psychosocial factors, and disability at follow-up 13). RESULTS Urinary incontinence was associated with subsequent reports of disability in participants, particularly in the World Health Organization Disability Assessment Schedule domains of mobility ( P < 0.0001), communication ( P = 0.0057), and life activities ( P = 0.0407). Associations were strongest for mixed UI type compared with stress UI or urgency UI (odds ratio [OR] = 1.66, 95% confidence interval [CI] = 1.26-2.17, P < 0.001), daily frequency of UI compared with monthly or less than weekly frequency of UI (OR = 1.61, 95% CI = 1.04-2.47, P < 0.001), and larger amounts of urine leakage compared with drops of leakage (OR = 2.98, 95% CI = 1.58-5.62, P < 0.0001) for mobility/getting around domain. CONCLUSIONS Urinary incontinence seems to have a strong association with multiple domains of disability, including mobility and interacting with others, after approximately 3.7 years. Thus, UI may be an important factor limiting social engagement among women. Screening for mixed UI and UI that occurs greater than weekly and in amounts requiring pads may yield better information regarding an individual's future disability risk and may preserve social interaction.
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Affiliation(s)
- Sheila A. Dugan
- Department of Physical Medicine & Rehabilitation, Rush University Medical Center, Chicago, IL
- Department of Preventive Medicine, Rush University Medical Center, Chicago, IL
| | - Sybil L. Crawford
- UMass Chan Medical School, Tan Chingfen Graduate School of Nursing, Worcester, MA
| | - Karla Wente
- Department of Physical Medicine & Rehabilitation, Rush University Medical Center, Chicago, IL
- College of Health Sciences, Rush University, Chicago, IL
| | - L. Elaine Waetjen
- Department of Obstetrics and Gynecology, University of California Davis, Sacramento, CA
| | | | - Siobán D. Harlow
- Department of Epidemiology, University of Michigan, Ann Arbor, MI
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
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Reeves A, Elliott MR, Karvonen-Gutierrez CA, Harlow SD. Systematic exclusion at study commencement masks earlier menopause for Black women in the Study of Women's Health Across the Nation (SWAN). Int J Epidemiol 2023; 52:1612-1623. [PMID: 37382579 PMCID: PMC10555828 DOI: 10.1093/ije/dyad085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 05/30/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Shorter average lifespans for minoritized populations are hypothesized to stem from 'weathering' or accelerated health declines among minoritized individuals due to systemic marginalization. However, evidence is mixed on whether racial/ethnic differences exist in reproductive ageing, potentially due to selection biases in cohort studies that may systematically exclude 'weathered' participants. This study examines racial/ethnic disparities in the age of menopause after accounting for differential selection 'into' (left truncation) and 'out of' (right censoring) a cohort of midlife women. METHODS Using data from the Study of Women's Health Across the Nation (SWAN) cross-sectional screener (N = 15 695) and accompanying ∼20-year longitudinal cohort (N = 3302) (1995-2016), we adjusted for potential selection bias using inverse probability weighting (left truncation) to account for socio-demographic/health differences between the screening and cohort study, and multiple imputation (right censoring) to estimate racial/ethnic differences in age at menopause (natural and surgical). RESULTS Unadjusted for selection, no Black/White differences in menopausal timing [hazard ratio (HR)=0.98 (0.86, 1.11)] were observed. After adjustment, Black women had an earlier natural [HR = 1.13 (1.00, 1.26)] and surgical [HR= 3.21 (2.80, 3.62)] menopause than White women with natural menopause-corresponding to a 1.2-year Black/White difference in menopause timing overall. CONCLUSIONS Failure to account for multiple forms of selection bias masked racial/ethnic disparities in the timing of menopause in SWAN. Results suggest that there may be racial differences in age at menopause and that selection particularly affected the estimated menopausal age for women who experienced earlier menopause. Cohorts should consider incorporating methods to account for all selection biases, including left truncation, as they impact our understanding of health in 'weathered' populations.
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Affiliation(s)
- Alexis Reeves
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Michael R Elliott
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
- Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | | | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
- Obstetrics and Gynecology, School of Medicine, University of Michigan, Ann Arbor, MI, USA
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Ding N, Karvonen-Gutierrez CA, Zota AR, Mukherjee B, Harlow SD, Park SK. The role of exposure to per- and polyfluoroalkyl substances in racial/ethnic disparities in hypertension: Results from the study of Women's health across the nation. Environ Res 2023; 227:115813. [PMID: 37004857 PMCID: PMC10227830 DOI: 10.1016/j.envres.2023.115813] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 03/14/2023] [Accepted: 03/29/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Racial/ethnic disparities in hypertension are a pressing public health problem. The contribution of environmental pollutants including PFAS have not been explored, even though certain PFAS are higher in Black population and have been associated with hypertension. OBJECTIVES We examined the extent to which racial/ethnic disparities in incident hypertension are explained by racial/ethnic differences in serum PFAS concentrations. METHODS We included 1058 hypertension-free midlife women with serum PFAS concentrations in 1999-2000 from the multi-racial/ethnic Study of Women's Health Across the Nation with approximately annual follow-up visits through 2017. Causal mediation analysis was conducted using accelerated failure time models. Quantile-based g-computation was used to evaluate the joint effects of PFAS mixtures. RESULTS During 11,722 person-years of follow-up, 470 participants developed incident hypertension (40.1 cases per 1000 person-years). Black participants had higher risks of developing hypertension (relative survival: 0.58, 95% CI: 0.45-0.76) compared with White participants, which suggests racial/ethnic disparities in the timing of hypertension onset. The percent of this difference in timing that was mediated by PFAS was 8.2% (95% CI: 0.7-15.3) for PFOS, 6.9% (95% CI: 0.2-13.8) for EtFOSAA, 12.7% (95% CI: 1.4-22.6) for MeFOSAA, and 19.1% (95% CI: 4.2, 29.0) for PFAS mixtures. The percentage of the disparities in hypertension between Black versus White women that could have been eliminated if everyone's PFAS concentrations were dropped to the 10th percentiles observed in this population was 10.2% (95% CI: 0.9-18.6) for PFOS, 7.5% (95% CI: 0.2-14.9) for EtFOSAA, and 17.5% (95% CI: 2.1-29.8) for MeFOSAA. CONCLUSIONS These findings suggest differences in PFAS exposure may be an unrecognized modifiable risk factor that partially accounts for racial/ethnic disparities in timing of hypertension onset among midlife women. The study calls for public policies aimed at reducing PFAS exposures that could contribute to reductions in racial/ethnic disparities in hypertension.
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Affiliation(s)
- Ning Ding
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA.
| | | | - Ami R Zota
- Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Bhramar Mukherjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Sung Kyun Park
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA; Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, USA
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Swanson LM, Hood MM, Hall MH, Avis NE, Joffe H, Colvin A, Ruppert K, Kravitz HM, Neal-Perry G, Derby CA, Hess R, Harlow SD. Sleep timing, sleep regularity, and psychological health in early late life women: Findings from the Study of Women's Health Across the Nation (SWAN). Sleep Health 2023; 9:203-210. [PMID: 36509657 PMCID: PMC10478033 DOI: 10.1016/j.sleh.2022.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To examine the associations of actigraphy-assessed sleep timing and regularity with psychological health in early late life women, whose circadian rhythms may be impacted by aging. DESIGN Cross-sectional. PARTICIPANTS A racially/ethnically diverse sample of 1197 community-dwelling women (mean age 65 years) enrolled in the Study of Women's Health Across the Nation. MEASURES Actigraphy-assessed sleep measures included timing (mean midpoint from sleep onset to wake-up) and regularity (standard deviation of midpoint in hours). Psychological health measures included a composite well-being score, the Center for Epidemiological Studies Depression Scale, and the Generalized Anxiety Disorder-7 Scale. Linear and logistic regression models, adjusted for covariates (including sleep duration), tested associations between sleep and psychological health measures. RESULTS After covariate adjustment, a sleep midpoint outside of 2:00-4: 00 AM was significantly associated with depressive symptoms (β = 0.88, 95% CI = 0.06, 1.70) and scoring above the cut-point for clinically significant depressive symptoms (OR = 1.72, 95% CI = 1.15, 2.57). Sleep irregularity was significantly associated with lower psychological well-being (β = -0.18, 95% CI = -0.33, -0.03), depressive (β = 1.36, 95% CI = 0.29, 2.44) and anxiety (β = 0.93, 95% CI = 0.40, 1.46) symptoms, and scoring above the cut-point for clinically significant depressive (OR = 1.68, 95% CI = 1.01, 2.79) and anxiety (OR = 1.62, 95% CI = 1.07, 2.43) symptoms. CONCLUSION Above and beyond sleep duration, a sleep midpoint outside of 2:00-4:00 AM was associated with depressive symptoms while sleep irregularity was associated with multiple psychological health domains in late life women.
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Affiliation(s)
- Leslie M Swanson
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA.
| | - Michelle M Hood
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Martica H Hall
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nancy E Avis
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Hadine Joffe
- Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alicia Colvin
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kristine Ruppert
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Howard M Kravitz
- Department of Psychiatry and Behavioral Sciences and Department of Preventive Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Genevieve Neal-Perry
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Carol A Derby
- The Saul R. Korey Department of Neurology, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Rachel Hess
- Department of Population Health Sciences, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Siobán D Harlow
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan, USA
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Sanders WM, Harlow SD, Ylitalo KR, Lange-Maia BS, Leis AM, McConnell DS, Karvonen-Gutierrez CA. The Association of Inflammatory Factors With Peripheral Neuropathy: The Study of Women's Health Across the Nation. J Clin Endocrinol Metab 2023; 108:962-970. [PMID: 36260527 PMCID: PMC10211489 DOI: 10.1210/clinem/dgac612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/27/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE Previous work has focused on the role of diabetes in peripheral neuropathy (PN), but PN often occurs before, and independently from, diabetes. This study measures the association of cardiometabolic and inflammatory factor with PN, independent of diabetes. METHODS Study of Women's Health Across the Nation participants (n = 1910), ages 60 to 73 (mean 65.6) were assessed for PN by symptom questionnaire and monofilament testing at the 15th follow-up visit (V15). Anthropometric measures and biomarkers were measured at study baseline approximately 20 years prior, and C-reactive protein (CRP) and fibrinogen were measured longitudinally. Log-binomial regression was used to model the association between metabolic syndrome (MetS), obesity (≥35 body mass index), CRP, and fibrinogen with PN, adjusting for sociodemographic and health behavior measures. RESULTS Baseline MetS [prevalence ratio (PR) 1.79, 95% CI (1.45, 2.20)], obesity [PR 2.08 (1.65, 2.61)], median CRP [PR 1.32 per log(mg/dL), (1.20, 1.45)], and mean fibrinogen (PR 1.28 per 100 mg/dL, (1.09, 1.50)] were associated with PN symptoms at V15. After excluding participants with baseline diabetes or obesity, MetS [PR 1.59 (1.17, 2.14)] and CRP [PR 1.19 per log(mg/dL), (1.06, 1.35)] remained statistically significantly associated with PN. There was a negative interaction between MetS and obesity, and the association between these conditions and PN was mediated by CRP. CONCLUSIONS Cardiometabolic factors and inflammation are significantly associated with PN, independent of diabetes and obesity. CRP mediates the relationship of both obesity and MetS with PN, suggesting an etiological role of inflammation in PN in this sample.
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Affiliation(s)
- Wade M Sanders
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Kelly R Ylitalo
- Department of Public Health, Robbins College of Health and Human Sciences, Baylor University, Waco, TX
| | - Brittney S Lange-Maia
- Rush Alzheimer's Disease Center and Department of Preventative Medicine, Rush University Medical Center, Chicago, IL
| | - Aleda M Leis
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Daniel S McConnell
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI
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10
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Dugan SA, Karavolos K, Zhang Y, Avery E, Janssen I, Farhi M, Harlow SD, Kravitz HM. Childhood Sexual Abuse and Pelvic Floor Dysfunction in Midlife Women in the Study of Women's Health Across the Nation. J Womens Health (Larchmt) 2023; 32:293-299. [PMID: 36735600 PMCID: PMC9993161 DOI: 10.1089/jwh.2022.0211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Objectives: Research has shown a link between childhood sexual abuse (CSA) and lower urinary tract and sexual disorders in clinical settings. We examined whether CSA was associated with two specific aspects of high tone, elevated resting tension pelvic floor dysfunction (PFD) in community-dwelling women. Materials and Methods: Data were from 2068 participants (25.5% Black, 9.6% Chinese, 10.8% Japanese, 5.0% Hispanic, and 49.1% Non-Hispanic White) in the Study of Women's Health Across the Nation (SWAN), a multirace/multiethnic longitudinal observational study of women's midlife health. At baseline, enrolled women were 42-52 years old and premenopausal or early perimenopausal. Annual or biennial assessments conducted over 20 years (1996 through 2017) included single-item queries about urgency urinary incontinence and pain with sexual activity used to assess PFD outcomes. The 12th follow-up visit conducted in 2009-2011 assessed the primary exposure, history of CSA, using a single-item response. Multivariate logistic regression models tested study objectives. Results: The prevalence of CSA was 15%, self-reported in 313/2068 women. CSA and PFD, both pain with sexual activity (odds ratio [OR] = 1.56 confidence interval [95% CI = 1.12-2.18]) and urgency urinary incontinence (OR = 1.87 [95% CI = 1.29-2.71]), were significantly associated in unadjusted models. The final adjusted model that included sociodemographic variables and physical and behavioral risk factors was significant for pain with sexual activity (OR = 1.48 [95% CI = 1.08-2.02]), but not for urgency urinary incontinence (OR = 1.38 [95% CI = 0.96-1.98]). Conclusions: In midlife women, pain with sex, but not urgency urinary incontinence, was associated with a history of CSA. A multidisciplinary diagnostic and therapeutic approach to PFD is key, inclusive of CSA screening.
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Affiliation(s)
- Sheila A. Dugan
- Department of Physical Medicine & Rehabilitation and Rush University Medical Center, Chicago, Illinois, USA
- Department of Preventive Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Kelly Karavolos
- Department of Preventive Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Yanyu Zhang
- Rush Bioinformatics and Biostatics Core, Rush University Medical Center, Chicago, Illinois, USA
| | - Elizabeth Avery
- Department of Preventive Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Imke Janssen
- Department of Preventive Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Mary Farhi
- Department of Obstetrics and Gynecology, Rush University Medical Center, Chicago, Illinois, USA
| | - Siobán D. Harlow
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Howard M. Kravitz
- Department of Preventive Medicine, Rush University Medical Center, Chicago, Illinois, USA
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA
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11
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Ding N, Zheutlin E, Harlow SD, Randolph JF, Mukherjee B, Park SK. Associations Between Repeated Measures of Urinary Phthalate Metabolites With Hormones and Timing of Natural Menopause. J Endocr Soc 2023; 7:bvad024. [PMID: 36846211 PMCID: PMC9945847 DOI: 10.1210/jendso/bvad024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Indexed: 02/05/2023] Open
Abstract
Phthalates, ubiquitous endocrine-disrupting chemicals, may affect ovarian folliculogenesis and steroidogenesis. We examined the associations of urinary phthalate metabolites with hormones including estradiol, testosterone, follicle-stimulating hormone (FSH), sex hormone-binding globulin (SHBG), and anti-Müllerian hormone (AMH), and timing of natural menopause in midlife women. Data were from 1189 multiracial/multiethnic women aged 45 to 56 years without hormone therapy from the Study of Women's Health Across the Nation (SWAN). Urinary concentrations of 12 phthalate metabolites and hormones were repeatedly measured in 1999 to 2000 and 2002 to 2003, resulting in a total of 2111 observations. Linear mixed-effect models were used to calculate percentage differences (%D) and 95% CIs in serum concentrations of estradiol, testosterone, FSH, SHBG, and AMH. Cox proportional-hazards models were used to calculate hazard ratios (HRs) and 95% CIs of natural menopause. We observed statistically significant associations of phthalate metabolites with lower testosterone concentrations: MCOP with testosterone (%D: -2.08%; 95% CI, -3.66 to -0.47) and MnBP with testosterone (%D: -1.99%; 95% CI, -3.82 to -0.13), after adjusting for multiple comparisons with false discovery rates less than 5%. Lower AMH concentrations were also found with higher MECPP (%D: -14.26%; 95% CI, -24.10 to -3.14), MEHHP (%D: -15.58%; 95% CI, -24.59 to -5.50), and MEOHP (%D: -13.50%; 95% CI, -22.93 to -2.90). No associations were observed for other hormones or timing of natural menopause. These results suggest that exposure to phthalates may affect circulating levels of testosterone and diminish the ovarian reserve in midlife women. Given the widespread exposure, reduced exposure to phthalates may be a key step to prevent reproductive effects of phthalates.
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Affiliation(s)
- Ning Ding
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109-2029, USA
| | - Emily Zheutlin
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI 48109-2029, USA
| | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109-2029, USA
| | - John F Randolph
- Department of Obstetrics and Gynecology, School of Medicine, University of Michigan, Ann Arbor, MI 48109-2029, USA
| | - Bhramar Mukherjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI 48109-2029, USA
| | - Sung Kyun Park
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109-2029, USA
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI 48109-2029, USA
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12
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Wang X, Ding N, Harlow SD, Randolph JF, Mukherjee B, Gold EB, Park SK. Exposure to heavy metals and hormone levels in midlife women: The Study of Women's Health Across the Nation (SWAN). Environ Pollut 2023; 317:120740. [PMID: 36436662 PMCID: PMC9897061 DOI: 10.1016/j.envpol.2022.120740] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/06/2022] [Accepted: 11/22/2022] [Indexed: 05/24/2023]
Abstract
Exposure to heavy metals may alter the circulating levels of sex hormones. However, epidemiologic studies on heavy metals and sex hormones have been limited, and results have been inconsistent. We assessed the associations of heavy metals assayed in urine, including arsenic, cadmium, lead, and mercury, with repeated measures of serum estradiol (E2), follicle-stimulating hormone (FSH), testosterone, and sex hormone-binding globulin (SHBG) levels in the Study of Women's Health Across the Nation Multi-Pollutant Study. The sample included 1355 White, Black, Chinese, and Japanese women, aged 45-56 years at baseline (1999-2000), whose serum hormone levels were repeatedly measured through 2017. Urinary metal concentrations were measured at baseline. Linear mixed effect models were used to calculate percent changes in serum hormone levels per doubling of urinary metal concentrations, adjusting for demographics, socioeconomic status, lifestyle, health-related factors, and urinary creatinine. After multivariable adjustment, a doubling of urinary metal concentration was associated with lower E2 levels by 2.2% (95% CI: 4.0%, -0.3%) for mercury and 3.6% (95% CI: 5.7%, -1.6%) for lead; higher FSH levels by 3.4% (95% CI: 0.9%, 5.9%) for lead; and higher SHBG levels by 3.6% (95% CI: 1.3%, 5.9%) for cadmium. The overall joint effect using the Bayesian kernel machine regression showed that metal mixtures were inversely associated with E2 and positively associated with FSH levels. No association was found between metals and testosterone levels. Results from this prospective cohort study demonstrate that environmental heavy metal exposures, including cadmium, mercury, and lead, may disturb circulating levels of E2, FSH, and SHBG in midlife women.
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Affiliation(s)
- Xin Wang
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Ning Ding
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - John F Randolph
- Department of Obstetrics and Gynecology, School of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Bhramar Mukherjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Ellen B Gold
- Department of Public Health Sciences, University of California, Davis, School of Medicine, Davis, CA, United States
| | - Sung Kyun Park
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, United States; Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, United States.
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13
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Reeves A, Elliott MR, Lewis TT, Karvonen-Gutierrez CA, Herman WH, Harlow SD. Study Selection Bias and Racial or Ethnic Disparities in Estimated Age at Onset of Cardiometabolic Disease Among Midlife Women in the US. JAMA Netw Open 2022; 5:e2240665. [PMID: 36342714 PMCID: PMC9641536 DOI: 10.1001/jamanetworkopen.2022.40665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 09/21/2022] [Indexed: 11/09/2022] Open
Abstract
Importance Racial disparities in cardiometabolic health are consistently observed in cohort studies. However, most studies neither evaluate differences in age at onset nor account for systematic exclusion stemming from "weathering" (accelerated health declines for minoritized groups due to structural social and economic marginalization). Objective To evaluate racial or ethnic disparities in age at onset of 4 cardiometabolic outcomes (hypertension, isolated systolic hypertension [ISH], insulin resistance [IR], and diabetes), accounting for multiple forms of potential selection bias. Design, Setting, and Participants This cohort study used data from the Study of Women's Health Across the Nation longitudinal cohort (1995-2016) and a cross-sectional screening sample (1995-1997). Data were analyzed from July 2019 to October 2021. Participants were eligible for the cohort if they were aged 42 to 52 years, had not received hormone therapy in the past 3 months, were not pregnant, had an intact uterus and at least 1 ovary, and were premenopausal or early perimenopausal (most recent menses ≤3 months). Exposures Self-reported racial or ethnic group (Black, Chinese, Hispanic, Japanese, or White). Main Outcomes and Measures The main outcomes were hypertension (systolic blood pressure [BP] ≥140 mm Hg and diastolic BP ≥90 mm Hg or use of antihypertensive medication), ISH (systolic BP ≥140 mm Hg and diastolic BP <90 mm Hg or use of antihypertensive medication), IR (homeostasis model assessment for IR value >5.9 or insulin use), and diabetes (fasting serum glucose level ≥126 mg/dL [to convert to mmol/L, multiply by 0.0555], use of insulin or oral antidiabetic medication, or physician diagnosis). Selection into the cohort was addressed via inverse probability weighting and interval-censored survival models and selection out via multiple imputation. Accelerated failure time models were used to examine racial or ethnic differences in age at disease onset and estimate the median age at onset. Results A total of 3302 women were included in the study, with a median age of 46.2 years (range, 42-52 years) at baseline. In the sample, 42.6% had a bachelor's degree or higher and 36.3% self-rated their health as "very good" at baseline; 23.9% had hypertension, 43.7% had ISH, 13.5% had IR, and 4.6% had diabetes at baseline. Hypertension occurred a median of 5.0 years (95% CI, 5.4-5.5 years) earlier and metabolic outcomes (diabetes and IR) a median of 11.3 years (95% CI, 9.7-12.9 years) earlier for Black and Hispanic women vs White women; ISH occurred a median of 7.7 years (95% CI, 7.3-8.1 years) earlier for Black women vs White women. Adjustment for selection was associated with a mean 20-year decrease in estimated median age at onset, with greater decreases among Black and Hispanic women. Conclusions and Relevance In this multiracial cohort of midlife women, failure to account for selection biases, especially at study onset, was associated with falsely high estimates of age at cardiometabolic onset, with greater misestimation among Black and Hispanic women. The results suggest that hypertension and metabolic interventions, particularly for Black and Hispanic women, should be targeted to women aged as young as 30 years for hypertension and 40 years for metabolic interventions. Considering the timing of disease and fully addressing inherent selection biases in research are critical to understanding aging and disease risk, especially for racial and ethnic minoritized populations.
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Affiliation(s)
- Alexis Reeves
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor
| | - Michael R. Elliott
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
- Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor
| | - Tené T. Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - William H. Herman
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Siobán D. Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor
- Department of Obstetrics and Gynecology, Michigan Medicine, University of Michigan, Ann Arbor
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14
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Harlow SD, Burnett-Bowie SAM, Greendale GA, Avis NE, Reeves AN, Richards TR, Lewis TT. Correction: Disparities in Reproductive Aging and Midlife Health between Black and White women: The Study of Women's Health Across the Nation (SWAN). Womens Midlife Health 2022; 8:10. [PMID: 36271444 PMCID: PMC9587535 DOI: 10.1186/s40695-022-00082-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Siobán D Harlow
- Department of Epidemiology, University of Michigan, School of Public Health, United States, 1415 Washington Heights, Ann Arbor, MI, 48104-2029, USA.
| | - Sherri-Ann M Burnett-Bowie
- Endocrine Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Gail A Greendale
- Division of Geriatrics, David Gefen School of Medicine, University of California at Los Angeles, Los Angeles, USA
| | - Nancy E Avis
- Department of Social Sciences & Health Policy Wake Forest School of Medicine, Winston-Salem, USA
| | - Alexis N Reeves
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, USA
| | - Thomas R Richards
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, USA
| | - Tené T Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, USA
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15
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Ding N, Karvonen-Gutierrez CA, Mukherjee B, Calafat AM, Harlow SD, Park SK. Per- and Polyfluoroalkyl Substances and Incident Hypertension in Multi-Racial/Ethnic Women: The Study of Women's Health Across the Nation. Hypertension 2022; 79:1876-1886. [PMID: 35695012 PMCID: PMC9308661 DOI: 10.1161/hypertensionaha.121.18809] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 04/13/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Perfluoroalkyl and polyfluoroalkyl substances (PFAS) are ubiquitous synthetic chemicals that may disrupt blood pressure controls; however, human evidence to support this hypothesis is scant. We examined the association between serum concentrations of PFAS and risks of developing hypertension. METHODS This study included 1058 midlife women initially free of hypertension from the multiracial and multiethnic SWAN (Study of Women's Health Across the Nation) with annual follow-up visits between 1999 and 2017. Hypertension was defined as blood pressure ≥140 mm Hg systolic or ≥90 mm Hg diastolic or receiving antihypertensive treatment. Cox proportional hazards models were utilized to calculate hazard ratios and 95% CIs. Quantile g-computation was implemented to evaluate the joint effect of PFAS mixtures. RESULTS During 11 722 person-years of follow-up, 470 participants developed incident hypertension (40.1 cases per 1000 person-years). Compared with the lowest tertile, women in the highest tertile of baseline serum concentrations had adjusted hazard ratios of 1.42 (95% CI, 1.19-1.68) for perfluorooctane sulfonate (P trend=0.01), 1.47 (95% CI, 1.24-1.75) for linear perfluorooctanoate (P trend=0.01), and 1.42 (95% CI, 1.19-1.70) for 2-(N-ethyl-perfluorooctane sulfonamido) acetate (P trend=0.01). No significant associations were observed for perfluorononanoate and perfluorohexane sulfonate. In the mixture analysis, women in the highest tertile of overall PFAS concentrations had a hazard ratio of 1.71 (95% CI, 1.15-2.54; P trend=0.008), compared with those in the lowest tertile. CONCLUSIONS Several PFAS showed positive associations with incident hypertension. These findings suggest that PFAS might be an underappreciated contributing factor to women's cardiovascular disease risk.
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Affiliation(s)
- Ning Ding
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI
| | | | - Bhramar Mukherjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Antonia M. Calafat
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA
| | - Siobán D. Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Sung Kyun Park
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI
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16
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Park SK, Wang X, Ding N, Karvonen-Gutierrez CA, Calafat AM, Herman WH, Mukherjee B, Harlow SD. Per- and polyfluoroalkyl substances and incident diabetes in midlife women: the Study of Women's Health Across the Nation (SWAN). Diabetologia 2022; 65:1157-1168. [PMID: 35399113 PMCID: PMC9177697 DOI: 10.1007/s00125-022-05695-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 02/03/2022] [Indexed: 01/28/2023]
Abstract
AIMS/HYPOTHESIS Diabetogenic effects of per- and polyfluoroalkyl substances (PFAS) have been suggested. However, evidence based on prospective cohort studies is limited. We examined the association between serum PFAS concentrations and incident diabetes in the Study of Women's Health Across the Nation Multi-Pollutant Study (SWAN-MPS). METHODS We included 1237 diabetes-free women aged 45-56 years at baseline (1999-2000) who were followed up to 2017. At each follow-up visit, women with incident diabetes were identified by the presence of one or more of the following conditions: (1) use of a glucose-lowering medication at any visit; (2) fasting glucose ≥7 mmol/l on two consecutive visits while not on steroids; and (3) any two visits with self-reported diabetes and at least one visit with fasting blood glucose ≥7 mmol/l. Serum concentrations of 11 PFAS were quantified by online solid-phase extraction-HPLC-isotope dilution-tandem MS. Seven PFAS with high detection rates (>96%) (n-perfluorooctanoic acid [n-PFOA], perfluorononanoic acid [PFNA], perfluorohexane sulfonic acid [PFHxS], n-perfluorooctane sulfonic acid [n-PFOS], sum of perfluoromethylheptane sulfonic acid isomers [Sm-PFOS], 2-[N-methyl-perfluorooctane sulfonamido] acetic acid [MeFOSAA] and 2-[N-ethyl-perfluorooctane sulfonamido] acetic acid) were included in data analysis. Cox proportional hazards models were used to compute HRs and 95% CIs. Quantile-based g-computation was used to evaluate the joint effects of PFAS mixtures. RESULTS After adjustment for race/ethnicity, site, education, smoking status, alcohol consumption, total energy intake, physical activity, menopausal status and BMI, the HR (95% CI) comparing the lowest with the highest tertile was 1.67 (1.21, 2.31) for n-PFOA (ptrend = 0.001), 1.58 (1.13, 2.21) for PFHxS (ptrend = 0.003), 1.36 (0.97, 1.90) for Sm-PFOS (ptrend = 0.05), 1.85 (1.28, 2.67) for MeFOSAA (ptrend = 0.0004) and 1.64 (1.17, 2.31) for the sum of four common PFAS (n-PFOA, PFNA, PFHxS and total PFOS) (ptrend = 0.002). Exposure to seven PFAS as mixtures was associated with an HR of 2.62 (95% CI 1.12, 6.20), comparing the top with the bottom tertiles for all seven PFAS. CONCLUSIONS/INTERPRETATION This study suggests that PFAS may increase diabetes risk in midlife women. Reduced exposure to these 'forever and everywhere chemicals' may be an important preventative approach to lowering population-wide diabetes risk.
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Affiliation(s)
- Sung Kyun Park
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA.
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, USA.
| | - Xin Wang
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Ning Ding
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | - Antonia M Calafat
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - William H Herman
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Bhramar Mukherjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
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17
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Ding N, Harlow SD, Randolph JF, Mukherjee B, Batterman S, Gold EB, Park SK. Perfluoroalkyl Substances and Incident Natural Menopause in Midlife Women: The Mediating Role of Sex Hormones. Am J Epidemiol 2022; 191:1212-1223. [PMID: 35292812 PMCID: PMC9393069 DOI: 10.1093/aje/kwac052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 02/24/2022] [Accepted: 03/11/2022] [Indexed: 01/28/2023] Open
Abstract
Perfluoroalkyl and polyfluoroalkyl substances (PFAS) have been associated with earlier natural menopause; however, the underlying mechanisms are not well understood, particularly the extent to which this relationship is mediated by sex hormones. We analyzed data (1999-2017) on 1,120 premenopausal women from the Study of Women's Health Across the Nation (SWAN). Causal mediation analysis was applied to quantify the degree to which follicle-stimulating hormone (FSH) and estradiol levels could mediate the associations between PFAS and incident natural menopause. Participants with higher PFAS concentrations had shorter times to natural menopause, with a relative survival of 0.82 (95% confidence interval (CI): 0.69, 0.96) for linear perfluorooctane sulfonate (n-PFOS), 0.84 (95% CI: 0.69, 1.00) for sum of branched-chain perfluorooctane sulfonate (Sm-PFOS), 0.79 (95% CI: 0.66, 0.93) for linear-chain perfluorooctanoate (n-PFOA), and 0.84 (95% CI: 0.71, 0.97) for perfluorononanoate (PFNA), comparing the highest tertile of PFAS concentrations with the lowest. The proportion of the effect mediated through FSH was 8.5% (95% CI: -11.7, 24.0) for n-PFOS, 13.2% (95% CI: 0.0, 24.5) for Sm-PFOS, 26.9% (95% CI: 15.6, 38.4) for n-PFOA, and 21.7% (6.8, 37.0) for PFNA. No significant mediation by estradiol was observed. The effect of PFAS on natural menopause may be partially explained by variations in FSH concentrations.
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Affiliation(s)
| | | | | | | | | | | | - Sung Kyun Park
- Correspondence to Dr. Sung Kyun Park, Department of Epidemiology, School of Public Health, University of Michigan, M5541 SPH II, 1415 Washington Heights, Ann Arbor, MI 48109-2029 (e-mail: )
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Verdiesen RMG, van der Schouw YT, van Gils CH, Verschuren WMM, Broekmans FJM, Borges MC, Gonçalves Soares AL, Lawlor DA, Eliassen AH, Kraft P, Sandler DP, Harlow SD, Smith JA, Santoro N, Schoemaker MJ, Swerdlow AJ, Murray A, Ruth KS, Onland-Moret NC. Genome-wide association study meta-analysis identifies three novel loci for circulating anti-Müllerian hormone levels in women. Hum Reprod 2022; 37:1069-1082. [PMID: 35274129 PMCID: PMC9071229 DOI: 10.1093/humrep/deac028] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 10/22/2021] [Indexed: 12/05/2022] Open
Abstract
STUDY QUESTION Can additional genetic variants for circulating anti-Müllerian hormone (AMH) levels be identified through a genome-wide association study (GWAS) meta-analysis including a large sample of premenopausal women? SUMMARY ANSWER We identified four loci associated with AMH levels at P < 5 × 10-8: the previously reported MCM8 locus and three novel signals in or near AMH, TEX41 and CDCA7. WHAT IS KNOWN ALREADY AMH is expressed by antral stage ovarian follicles in women, and variation in age-specific circulating AMH levels has been associated with disease outcomes. However, the physiological mechanisms underlying these AMH-disease associations are largely unknown. STUDY DESIGN, SIZE, DURATION We performed a GWAS meta-analysis in which we combined summary statistics of a previous AMH GWAS with GWAS data from 3705 additional women from three different cohorts. PARTICIPANTS/MATERIALS, SETTING, METHODS In total, we included data from 7049 premenopausal female participants of European ancestry. The median age of study participants ranged from 15.3 to 48 years across cohorts. Circulating AMH levels were measured in either serum or plasma samples using different ELISA assays. Study-specific analyses were adjusted for age at blood collection and population stratification, and summary statistics were meta-analysed using a standard error-weighted approach. Subsequently, we functionally annotated GWAS variants that reached genome-wide significance (P < 5 × 10-8). We also performed a gene-based GWAS, pathway analysis and linkage disequilibrium score regression and Mendelian randomization (MR) analyses. MAIN RESULTS AND THE ROLE OF CHANCE We identified four loci associated with AMH levels at P < 5 × 10-8: the previously reported MCM8 locus and three novel signals in or near AMH, TEX41 and CDCA7. The strongest signal was a missense variant in the AMH gene (rs10417628). Most prioritized genes at the other three identified loci were involved in cell cycle regulation. Genetic correlation analyses indicated a strong positive correlation among single nucleotide polymorphisms for AMH levels and for age at menopause (rg = 0.82, FDR = 0.003). Exploratory two-sample MR analyses did not support causal effects of AMH on breast cancer or polycystic ovary syndrome risk, but should be interpreted with caution as they may be underpowered and the validity of genetic instruments could not be extensively explored. LARGE SCALE DATA The full AMH GWAS summary statistics will made available after publication through the GWAS catalog (https://www.ebi.ac.uk/gwas/). LIMITATIONS, REASONS FOR CAUTION Whilst this study doubled the sample size of the most recent GWAS, the statistical power is still relatively low. As a result, we may still lack power to identify more genetic variants for AMH and to determine causal effects of AMH on, for example, breast cancer. Also, follow-up studies are needed to investigate whether the signal for the AMH gene is caused by reduced AMH detection by certain assays instead of actual lower circulating AMH levels. WIDER IMPLICATIONS OF THE FINDINGS Genes mapped to the MCM8, TEX41 and CDCA7 loci are involved in the cell cycle and processes such as DNA replication and apoptosis. The mechanism underlying their associations with AMH may affect the size of the ovarian follicle pool. Altogether, our results provide more insight into the biology of AMH and, accordingly, the biological processes involved in ovarian ageing. STUDY FUNDING/COMPETING INTEREST(S) Nurses' Health Study and Nurses' Health Study II were supported by research grants from the National Institutes of Health (CA172726, CA186107, CA50385, CA87969, CA49449, CA67262, CA178949). The UK Medical Research Council and Wellcome (217065/Z/19/Z) and the University of Bristol provide core support for ALSPAC. This publication is the work of the listed authors, who will serve as guarantors for the contents of this article. A comprehensive list of grants funding is available on the ALSPAC website (http://www.bristol.ac.uk/alspac/external/documents/grant-acknowledgements.pdf). Funding for the collection of genotype and phenotype data used here was provided by the British Heart Foundation (SP/07/008/24066), Wellcome (WT092830M and WT08806) and UK Medical Research Council (G1001357). M.C.B., A.L.G.S. and D.A.L. work in a unit that is funded by the University of Bristol and UK Medical Research Council (MC_UU_00011/6). M.C.B.'s contribution to this work was funded by a UK Medical Research Council Skills Development Fellowship (MR/P014054/1) and D.A.L. is a National Institute of Health Research Senior Investigator (NF-0616-10102). A.L.G.S. was supported by the study of Dynamic longitudinal exposome trajectories in cardiovascular and metabolic non-communicable diseases (H2020-SC1-2019-Single-Stage-RTD, project ID 874739). The Doetinchem Cohort Study was financially supported by the Ministry of Health, Welfare and Sports of the Netherlands. The funder had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. Ansh Labs performed the AMH measurements for the Doetinchem Cohort Study free of charge. Ansh Labs was not involved in the data analysis, interpretation or reporting, nor was it financially involved in any aspect of the study. R.M.G.V. was funded by the Honours Track of MSc Epidemiology, University Medical Center Utrecht with a grant from the Netherlands Organization for Scientific Research (NWO) (022.005.021). The Study of Women's Health Across the Nation (SWAN) has grant support from the National Institutes of Health (NIH), DHHS, through the National Institute on Aging (NIA), the National Institute of Nursing Research (NINR) and the NIH Office of Research on Women's Health (ORWH) (U01NR004061; U01AG012505, U01AG012535, U01AG012531, U01AG012539, U01AG012546, U01AG012553, U01AG012554, U01AG012495). The SWAN Genomic Analyses and SWAN Legacy have grant support from the NIA (U01AG017719). The Generations Study was funded by Breast Cancer Now and the Institute of Cancer Research (ICR). The ICR acknowledges NHS funding to the NIHR Biomedical Research Centre. The content of this manuscript is solely the responsibility of the authors and does not necessarily represent official views of the funders. The Sister Study was funded by the Intramural Research Program of the National Institutes of Health (NIH), National Institute of Environmental Health Sciences (Z01-ES044005 to D.P.S.); the AMH assays were supported by the Avon Foundation (02-2012-065 to H.B. Nichols and D.P.S.). The breast cancer genome-wide association analyses were supported by the Government of Canada through Genome Canada and the Canadian Institutes of Health Research, the 'Ministère de l'Économie, de la Science et de l'Innovation du Québec' through Genome Québec and grant PSR-SIIRI-701, The National Institutes of Health (U19 CA148065, X01HG007492), Cancer Research UK (C1287/A10118, C1287/A16563, C1287/A10710) and The European Union (HEALTH-F2-2009-223175 and H2020 633784 and 634935). All studies and funders are listed in Michailidou et al. (Nature, 2017). F.J.M.B. has received fees and grant support from Merck Serono and Ferring BV. D.A.L. has received financial support from several national and international government and charitable funders as well as from Medtronic Ltd and Roche Diagnostics for research that is unrelated to this study. N.S. is scientific consultant for Ansh Laboratories. The other authors declare no competing interests.
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Affiliation(s)
- Renée M G Verdiesen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Yvonne T van der Schouw
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Carla H van Gils
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - W M Monique Verschuren
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - Frank J M Broekmans
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Maria C Borges
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Ana L Gonçalves Soares
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Deborah A Lawlor
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol NIHR Biomedical Research Centre, Bristol, UK
| | - A Heather Eliassen
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Peter Kraft
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Dale P Sandler
- Epidemiology Branch, National Institute of Environmental Health Sciences, Durham, NC, USA
| | - Siobán D Harlow
- Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer A Smith
- Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Colorado, USA
| | - Minouk J Schoemaker
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK
| | - Anthony J Swerdlow
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK
- Division of Breast Cancer Research, The Institute of Cancer Research, London, UK
| | - Anna Murray
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Katherine S Ruth
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - N Charlotte Onland-Moret
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Harlow SD, Burnett-Bowie SAM, Greendale GA, Avis NE, Reeves AN, Richards TR, Lewis TT. Disparities in Reproductive Aging and Midlife Health between Black and White women: The Study of Women's Health Across the Nation (SWAN). Womens Midlife Health 2022; 8:3. [PMID: 35130984 PMCID: PMC8822825 DOI: 10.1186/s40695-022-00073-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 01/03/2022] [Indexed: 01/28/2023] Open
Abstract
This paper reviews differences in the experience of the menopause transition and midlife health outcomes between Black and White women who participated in the Study of Women's Health Across the Nation (SWAN), a 25-year, longitudinal, multi-racial/ethnic cohort study. We identify health disparities, i.e., instances in which Black women's outcomes are less favorable than those of White women, and consider whether structural racism may underlie these disparities. Although SWAN did not explicitly assess structural racism, Black women in SWAN grew up during the Jim Crow era in the United States, during which time racism was legally sanctioned. We consider how we might gain insight into structural racism by examining proxy exposures such as socioeconomic characteristics, reports of everyday discrimination, and a range of life stressors, which likely reflect the longstanding, pervasive and persistent inequities that have roots in systemic racism in the US. Thus, this paper reviews the presence, magnitude, and longitudinal patterns of racial disparities observed in SWAN in six areas of women's health - menopause symptoms, sleep, mental health, health related quality of life, cardio-metabolic health, and physical function -and elucidates the contextual factors that are likely influencing these disparities. We review the strengths and weaknesses of SWAN's design and approach to analysis of racial disparities and use this as a springboard to offer recommendations for future cohort studies.
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Affiliation(s)
- Siobán D Harlow
- Department of Epidemiology, University of Michigan, School of Public Health, United States, 1415 Washington Heights, Ann Arbor, MI, 48104-2029, USA.
| | - Sherri-Ann M Burnett-Bowie
- Endocrine Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Gail A Greendale
- Division of Geriatrics, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, USA
| | - Nancy E Avis
- Department of Social Sciences & Health Policy Wake Forest School of Medicine, Winston-Salem, USA
| | - Alexis N Reeves
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, USA
| | - Thomas R Richards
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, USA
| | - Tené T Lewis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, USA
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Wang X, Ding N, Harlow SD, Randolph JF, Mukherjee B, Gold EB, Park SK. Urinary metals and metal mixtures and timing of natural menopause in midlife women: The Study of Women's Health Across the Nation. Environ Int 2021; 157:106781. [PMID: 34311223 PMCID: PMC8490279 DOI: 10.1016/j.envint.2021.106781] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/21/2021] [Accepted: 07/15/2021] [Indexed: 05/02/2023]
Abstract
BACKGROUND Exposure to metals and metal mixtures may influence ovarian aging. However, epidemiologic evidence of their potential impact is lacking. OBJECTIVE We prospectively examined the associations of 15 urinary metal concentrations and their mixtures with natural menopause in the Study of Women's Health Across the Nation Multi-Pollutant Study. METHODS The study population consisted of 1082 premenopausal women from multiple racial/ethnic groups, aged 45-56 years at baseline (1999-2000), with the median follow-up of 4.1 years. Urinary concentrations of 15 metals, including arsenic, barium, cadmium, cobalt, cesium, copper, mercury, manganese, molybdenum, nickel, lead, antimony, tin, thallium, and zinc, were measured at baseline. Natural menopause was defined as the final bleeding episode prior to at least 12 months of amenorrhea, not due to surgery or hormone therapy. Cox proportional hazards models were used to examine associations between individual metal concentrations and timing of natural menopause. The associations between metal mixtures and natural menopause were evaluated using elastic net penalized Cox regression, and an environmental risk score (ERS) was computed to represent individual risks of natural menopause related to metal mixtures. RESULTS The median age at natural menopause was 53.2 years. Using the Cox proportional hazards models, the adjusted hazard ratio (HR) (and its 95% confidence interval (CI)) for natural menopause was 1.32 (1.03, 1.67) for arsenic and 1.36 (1.05, 1.76) for lead, comparing the highest with the lowest quartiles of metal concentrations. The predicted ages at natural menopause in the highest and lowest quartiles were 52.7 and 53.5 years for arsenic; and 52.9 and 53.8 years for lead. A significant association between ERS and menopause was also observed. Women in the highest vs. the lowest quartiles of ERS had an HR of 1.71 (1.36, 2.15), equivalent to a 1.6 year earlier median time to natural menopause. CONCLUSION This study suggests that arsenic, lead, and metal mixtures are associated with earlier natural menopause, a risk factor for adverse health outcomes in later life.
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Affiliation(s)
- Xin Wang
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Ning Ding
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - John F Randolph
- Department of Obstetrics and Gynecology, School of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Bhramar Mukherjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Ellen B Gold
- Department of Public Health Sciences, University of California, Davis, School of Medicine, Davis, CA, United States
| | - Sung Kyun Park
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, United States; Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, United States.
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Harlow SD, Hood MM, Ding N, Mukherjee B, Calafat AM, Randolph JF, Gold EB, Park SK. Per- and Polyfluoroalkyl Substances and Hormone Levels During the Menopausal Transition. J Clin Endocrinol Metab 2021; 106:e4427-e4437. [PMID: 34181018 PMCID: PMC8677593 DOI: 10.1210/clinem/dgab476] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Indexed: 01/28/2023]
Abstract
CONTEXT Per- and polyfluoroalkyl substances (PFAS) are widespread chemicals that may affect sex hormones and accelerate reproductive aging in midlife women. OBJECTIVE To examine associations between serum PFAS concentrations at baseline (1999-2000) and longitudinal serum concentrations of follicle-stimulating hormone (FSH), estradiol, testosterone, and sex hormone-binding globulin (SHBG) at baseline and through 2015-2016. DESIGN Prospective cohort. SETTING General community. PARTICIPANTS 1371 midlife women 45 to 56 years of age at baseline in the Study of Women's Health Across the Nation (SWAN). MAIN OUTCOME MEASURE(S) FSH, estradiol, testosterone, SHBG. RESULTS In linear mixed models fitted with log-transformed hormones and log-transformed PFAS adjusting for age, site, race/ethnicity, smoking status, menopausal status, parity, and body mass index, FSH was positively associated with linear perfluorooctanoate [n-PFOA; 3.12% (95% CI 0.37%, 5.95%) increase for a doubling in serum concentration), linear perfluorooctane sulfonate [PFOS; 2.88% (0.21%, 5.63%)], branched perfluorooctane sulfonate [2.25% (0.02%, 4.54%)], total PFOS (3.03% (0.37%, 5.76%)), and 2-(N-ethyl-perfluorooctane sulfonamido) acetate [EtFOSAA; 1.70% (0.01%, 3.42%)]. Estradiol was inversely associated with perfluorononanoate [PFNA; -2.47% (-4.82%, -0.05%)) and n-PFOA (-2.43% (-4.97%, 0.18%)]. Significant linear trends were observed in the associations between PFOS and EtFOSAA with SHBG across parity (Ps trend ≤ 0.01), with generally inverse associations among nulliparous women but positive associations among women with 3+ births. No significant associations were observed between PFAS and testosterone. CONCLUSIONS This study observed positive associations of PFOA and PFOS with FSH and inverse associations of PFNA and PFOA with estradiol in midlife women during the menopausal transition, consistent with findings that PFAS affect reproductive aging.
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Affiliation(s)
- Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Michelle M Hood
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Ning Ding
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Bhramar Mukherjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Antonia M Calafat
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - John F Randolph
- Department of Obstetrics and Gynecology, School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Ellen B Gold
- Department of Public Health Sciences, University of California, Davis, School of Medicine, Davis, CA, USA
| | - Sung Kyun Park
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, USA
- Correspondence: Sung Kyun Park, ScD, MPH, Departments of Epidemiology and Environmental Health Sciences, University of Michigan, School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109-2029.
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22
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Lee S, Karvonen-Gutierrez C, Mukherjee B, Herman WH, Harlow SD, Park SK. Urinary concentrations of phenols and parabens and incident diabetes in midlife women: The Study of Women's Health Across the Nation. Environ Epidemiol 2021; 5:e171. [PMID: 34934892 PMCID: PMC8683147 DOI: 10.1097/ee9.0000000000000171] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 09/06/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Environmental phenols have been suggested as diabetogens but evidence from prospective cohort studies is limited. We examined associations between urinary concentrations of phenols and parabens, assessed at two time-points, and incident diabetes in the Study of Women's Health Across the Nation (SWAN). METHODS We examined 1,299 women, aged 45-56 years, who were diabetes-free at baseline of the SWAN Multi-Pollutant Study (MPS) (1999-2000) and were followed through January 2017. Urinary concentrations of bisphenol-A, bisphenol-F, triclosan, 2,4-dichlorophenol, 2,5-dichlorophenol, benzophenone-3, methyl-paraben, ethyl-paraben, propyl-paraben, and butyl-paraben were measured twice at MPS baseline and 3 years later (2002-2003), and the two average concentrations were used as exposure variables. Associations of incident diabetes with individual phenols and parabens were examined using Cox regression. We evaluated the overall joint effects using quantile-based g-computation. RESULTS Adjusted hazard ratios (HRs) for incident diabetes of the third tertile compared with the first tertile of urinary concentrations were 0.40 (95% confidence interval [CI] = 0.29, 0.56) for methyl-paraben; 0.42 (0.30, 0.58) for propyl-paraben; 0.53 (0.38, 0.75) for 2,5-diclrorophenol; and 0.55 (0.39, 0.80) for benzophenone-3. Nonlinear associations were found for bisphenol-A and 2,4-dichlorophenol (significant positive associations in the second tertile but no associations in the third tertile compared with the first tertile). No significant associations were observed for the other individual chemicals or the joint effect of mixtures. CONCLUSIONS Our findings do not support diabetogenic effects of urinary parabens which were inversely associated with incident diabetes among mid-life women. Epidemiologic findings for biomarkers with short half-lives and high within-person variability need to be interpreted with caution.
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Affiliation(s)
- Seulbi Lee
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | | | - Bhramar Mukherjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - William H. Herman
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Siobán D. Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Sung Kyun Park
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, Michigan
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23
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Swanson LM, Hood MM, Hall MH, Kravitz HM, Matthews KA, Joffe H, Thurston RC, Butters MA, Ruppert K, Harlow SD. Associations between sleep and cognitive performance in a racially/ethnically diverse cohort: the Study of Women's Health Across the Nation. Sleep 2021; 44:5904755. [PMID: 32918472 DOI: 10.1093/sleep/zsaa182] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 08/25/2020] [Indexed: 01/04/2023] Open
Abstract
STUDY OBJECTIVES To determine whether actigraphy-assessed indices of sleep are associated with cognitive performance in women, and explore whether these associations vary by race/ethnicity. METHODS Participants were 1,126 postmenopausal community-dwelling females (mean age 65 years) from the observational Study of Women's Health Across the Nation (SWAN); 25% were black, 46% white, 13% Chinese, 11% Japanese, and 5% Hispanic. Actigraphy-assessed sleep measures included total sleep time, wake after sleep onset (WASO), and fragmentation. Cognitive measures included immediate and delayed verbal memory, working memory, and information processing speed. All measures were assessed in conjunction with SWAN annual visit 15. RESULTS Across the sample, after covariate adjustment, greater WASO and fragmentation were concurrently associated with slower information processing speed. Black participants had significantly worse sleep relative to other race/ethnic groups. Significant race/sleep interactions were observed; in black, but not white, participants, greater fragmentation was concurrently associated with worse verbal memory and slower information processing speed, and greater WASO was concurrently associated with slower information processing speed. Sleep-cognitive performance associations were not different in Chinese and Japanese participants relative to white participants. CONCLUSIONS Greater wakefulness and fragmentation during sleep are concurrently associated with slower information processing. Sleep continuity impacted concurrent cognitive performance in black, but not white, women. This effect may not have been detected in white women because their sleep was largely within the normal range. Future longitudinal studies in diverse samples are critical to further understand whether race/ethnicity moderates the influence of sleep on cognitive performance.
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Affiliation(s)
| | - Michelle M Hood
- Department of Epidemiology, University of Michigan, Ann Arbor, MI
| | | | - Howard M Kravitz
- Department of Psychiatry and Behavioral Sciences and Department of Preventive Medicine, Rush University Medical Center, Chicago, IL
| | | | - Hadine Joffe
- Connors Center for Women's Health and Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | | | | | - Siobán D Harlow
- Department of Epidemiology, University of Michigan, Ann Arbor, MI
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Matthews KA, Kravitz HM, Lee L, Harlow SD, Bromberger JT, Joffe H, Hall MH. Does midlife aging impact women's sleep duration, continuity, and timing?: A longitudinal analysis from the Study of Women's Health Across the Nation. Sleep 2021; 43:5601413. [PMID: 31633180 DOI: 10.1093/sleep/zsz259] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 09/25/2019] [Indexed: 02/06/2023] Open
Abstract
Our study objectives were to evaluate the age-related changes in actigraphy measures of sleep duration, continuity, and timing across 12 years in midlife women as they traversed the menopause, and to take into account factors affecting women's sleep that also change with age. Black, white, and Chinese women were recruited from the Study of Women's Health Across the Nation (SWAN) to participate in an ancillary sleep study on two occasions over 3 years apart and a third assessment 12 years after the first (N = 300, mean ages, 52, 55, and 64 at the three assessments). Women had at least four consecutive nights of actigraphy (95% with 7 nights) and sleep diaries, and self-reported sleep complaints measured at each time point. Partial correlations adjusted for time between assessments across the 12 years were significant and moderate in size (r's = .33-.58). PROC MIXED/GLIMMIX multivariate models showed that sleep duration increased over time; wake after sleep onset (WASO) declined, midpoint of sleep interval increased, and sleep latency and number of sleep complaints did not change between the first and third assessments. Blacks and whites had a greater increase in sleep duration than Chinese. Taken together, the results of this longitudinal study suggest that sleep may not worsen, in general, in midlife women. Perhaps, the expected negative effect of aging in midlife into early old age on sleep is overstated.
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Affiliation(s)
- Karen A Matthews
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA.,Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Howard M Kravitz
- Department of Psychiatry, Rush University Medical Center, Chicago, IL.,Department of Preventive Medicine, Rush University Medical Center, Chicago, IL
| | - Laisze Lee
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - Siobán D Harlow
- Department of Epidemiology, University of Michigan, Ann Arbor, MI.,Departments of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Joyce T Bromberger
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA.,Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Hadine Joffe
- Connors Center for Women's Health and Gender Biology, Harvard Medical School, Brigham and Women's Hospital, Boston, MA.,Department of Psychiatry, Harvard Medical School, Brigham and Women's Hospital, Boston, MA
| | - Martica H Hall
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
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Reeves AN, Elliott MR, Brooks MM, Karvonen-Gutierrez CA, Bondarenko I, Hood MM, Harlow SD. Symptom clusters predict risk of metabolic-syndrome and diabetes in midlife: the Study of Women's Health Across the Nation. Ann Epidemiol 2021; 58:48-55. [PMID: 33631313 DOI: 10.1016/j.annepidem.2021.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 01/20/2021] [Accepted: 02/18/2021] [Indexed: 11/15/2022]
Abstract
PURPOSE Women's cardio-metabolic risk increases in midlife. Previous work relating menopause symptoms to diabetes/Metabolic Syndrome (MetS) does not consider the adverse impact of multiple concurrent physical and psychological symptoms in midlife. METHODS Data are from 3097 participants in the Study of Women's Health Across the Nation, a cohort of midlife women followed for over 20 years. Baseline latent symptom classes (LSC) were derived from 58 questions assessing physical, psychological and menopausal symptoms. Six identified LSCs ranged from 1 (most symptoms present at high severity) to 6 (few symptoms present at low severity). Accelerated failure time models estimated time to onset of type 2 diabetes and MetS for each LSC. RESULTS Women with multiple high/moderate severity symptoms had an earlier onset of diabetes (13.2%, 14.1% and 20.8% earlier onset in LSCs 1, 2, 3, respectively) and MetS (15.5%, 13.0% and 19.7% earlier onset in LSCs 1, 2, 3, respectively) than women with few/low severity symptoms. CONCLUSIONS Having multiple concurrent moderate to high intensity physical and psychological symptoms in midlife are associated with early onset of diabetes and MetS. Monitoring and subsequent intervention on a broad range of symptoms in midlife may significantly mitigate cardio-metabolic risk during this critical life stage.
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Affiliation(s)
- Alexis N Reeves
- Epidemiologic Science, School of Public Health, University of Michigan, Ann Arbor, MI.
| | - Michael R Elliott
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI; Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, MI
| | - Maria M Brooks
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA
| | | | - Irina Bondarenko
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Michelle M Hood
- Epidemiologic Science, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Siobán D Harlow
- Epidemiologic Science, School of Public Health, University of Michigan, Ann Arbor, MI; Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
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Wang X, Mukherjee B, Karvonen-Gutierrez CA, Herman WH, Batterman S, Harlow SD, Park SK. Urinary metal mixtures and longitudinal changes in glucose homeostasis: The Study of Women's Health Across the Nation (SWAN). Environ Int 2020; 145:106109. [PMID: 32927284 PMCID: PMC7577932 DOI: 10.1016/j.envint.2020.106109] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/19/2020] [Accepted: 08/30/2020] [Indexed: 05/04/2023]
Abstract
BACKGROUND Epidemiologic studies on associations between metals and insulin resistance and β-cell dysfunction have been cross-sectional and focused on individual metals. OBJECTIVE We assessed the association of exposure to metal mixtures, based on assessment of 15 urinary metals, with both baseline levels and longitudinal changes in homeostatic model assessments for insulin resistance (HOMA-IR) and β-cell function (HOMA-β). METHODS We examined 1262 women, aged 45-56 years at baseline (1999-2000), who were followed through 2015-2016, from the Study of Women's Health Across the Nation. Urinary concentrations of 15 metals (arsenic, barium, cadmium, cobalt, cesium, copper, mercury, manganese, molybdenum, nickel, lead, antimony, tin, thallium, and zinc) were determined at baseline. HOMA-IR and HOMA-β were repeatedly measured over 16 years of follow-up. A two-stage modeling was used to account for correlations in dependent and independent variables: In stage-1, linear mixed effects models were used to estimate the participant-specific baseline HOMA levels from random intercepts and participant-specific rates of changes from random slopes. In stage-2, adaptive elastic-net (AENET) models were fit to identify components of metal mixtures associated with participant-specific baseline levels and rates of changes in HOMA-IR and HOMA-β, respectively. An environmental risk score (ERS) was used to integrate metal mixture effects from AENET results. RESULTS In multivariable adjusted AENET models, urinary zinc was associated with higher HOMA-IR at baseline, whereas molybdenum was associated with lower HOMA-IR at baseline. The estimated changes in baseline HOMA-IR for one standard deviation increase in log-transformed urinary metal concentrations were 5.76% (3.05%, 8.55%) for zinc and -3.25% (-5.45%, -1.00%) for molybdenum, respectively. Urinary zinc was also associated with lower HOMA- β at baseline. Arsenic was associated with a slightly faster rate of decline in HOMA-β in the AENET model evaluating associations between metals and rate of changes. Significant associations of ERS with both HOMA-IR and HOMA-β at baseline were observed. ERS for the rate of changes was not calculated and examined in relation to rates of changes in HOMA-IR and HOMA-β because only a single metal was selected by AENET. CONCLUSION Exposure to metal mixtures may be exerting effects on insulin resistance and β-cell dysfunction, which might be mechanisms by which metal exposures lead to elevated diabetes risks.
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Affiliation(s)
- Xin Wang
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Bhramar Mukherjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | | | - William H Herman
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Stuart Batterman
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Sung Kyun Park
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, United States; Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, United States.
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Kim C, Saran R, Hood M, Karvonen-Gutierrez C, Peng MQ, Randolph JF, Harlow SD. Changes in kidney function during the menopausal transition: the Study of Women's Health Across the Nation (SWAN) - Michigan site. Menopause 2020; 27:1066-1069. [PMID: 32852461 DOI: 10.1097/gme.0000000000001579] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The aim of the study was to examine changes in kidney function during the menopausal transition (MT) and associations with levels of sex hormones (follicle stimulating hormone [FSH], sex hormone binding globulin [SHBG], estradiol, and testosterone). METHODS We used data from the Michigan site of Study of the Women's Health Across the Nation, a longitudinal study of the MT. For this analysis, we included women who had at least one creatinine measure before the final menstrual period (FMP) and at least one creatinine measure after the FMP (n = 101 women with 440 observations). To determine whether the declines in estimated glomerular filtration rate (eGFR) remained constant during the MT, we used local weighted regression curves to fit eGFR estimates. We examined the association between sex hormones and eGFR with longitudinal mixed models adjusting for baseline age, day of menstrual cycle, and time from FMP. RESULTS At baseline, women had a mean age of 45.4 ± 2.5 years; 54% were African-American and 46% were white. Although eGFR declined significantly over time, declines were linear, consistent with declines in eGFR due to age alone rather than the MT. Total testosterone, estradiol, ratio of testosterone:estradiol, and free androgen index were not significantly associated with eGFR, whereas lower FSH (-0.039, 95% confidence interval [CI] -0.067 to -0.012) and higher SHBG (0.050, 95% CI 0.004-0.096) were associated with higher eGFR. CONCLUSIONS Kidney function declines during the MT. Although associated with levels of FSH and SHBG, the rate of decline in eGFR is consistent with what would be expected of age alone.
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Affiliation(s)
- Catherine Kim
- Department of Medicine, University of Michigan, Ann Arbor, MI
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Rajiv Saran
- Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Michelle Hood
- Department of Epidemiology, University of Michigan, Ann Arbor, MI
| | | | - Mia Q Peng
- Department of Epidemiology, University of Michigan, Ann Arbor, MI
| | - John F Randolph
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Siobán D Harlow
- Department of Epidemiology, University of Michigan, Ann Arbor, MI
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Ding N, Harlow SD, Randolph Jr JF, Loch-Caruso R, Park SK. Perfluoroalkyl and polyfluoroalkyl substances (PFAS) and their effects on the ovary. Hum Reprod Update 2020; 26:724-752. [PMID: 32476019 PMCID: PMC7456353 DOI: 10.1093/humupd/dmaa018] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/03/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Perfluoroalkyl and polyfluoroalkyl substances (PFAS) are found widespread in drinking water, foods, food packaging materials and other consumer products. Several PFAS have been identified as endocrine-disrupting chemicals based on their ability to interfere with normal reproductive function and hormonal signalling. Experimental models and epidemiologic studies suggest that PFAS exposures target the ovary and represent major risks for women's health. OBJECTIVE AND RATIONALE This review summarises human population and toxicological studies on the association between PFAS exposure and ovarian function. SEARCH METHODS A comprehensive review was performed by searching PubMed. Search terms included an extensive list of PFAS and health terms ranging from general keywords (e.g. ovarian, reproductive, follicle, oocyte) to specific keywords (including menarche, menstrual cycle, menopause, primary ovarian insufficiency/premature ovarian failure, steroid hormones), based on the authors' knowledge of the topic and key terms. OUTCOMES Clinical evidence demonstrates the presence of PFAS in follicular fluid and their ability to pass through the blood-follicle barrier. Although some studies found no evidence associating PFAS exposure with disruption in ovarian function, numerous epidemiologic studies, mostly with cross-sectional study designs, have identified associations of higher PFAS exposure with later menarche, irregular menstrual cycles, longer cycle length, earlier age of menopause and reduced levels of oestrogens and androgens. Adverse effects of PFAS on ovarian folliculogenesis and steroidogenesis have been confirmed in experimental models. Based on laboratory research findings, PFAS could diminish ovarian reserve and reduce endogenous hormone synthesis through activating peroxisome proliferator-activated receptors, disrupting gap junction intercellular communication between oocyte and granulosa cells, inducing thyroid hormone deficiency, antagonising ovarian enzyme activities involved in ovarian steroidogenesis or inhibiting kisspeptin signalling in the hypothalamus. WIDER IMPLICATIONS The published literature supports associations between PFAS exposure and adverse reproductive outcomes; however, the evidence remains insufficient to infer a causal relationship between PFAS exposure and ovarian disorders. Thus, more research is warranted. PFAS are of significant concern because these chemicals are ubiquitous and persistent in the environment and in humans. Moreover, susceptible groups, such as foetuses and pregnant women, may be exposed to harmful combinations of chemicals that include PFAS. However, the role environmental exposures play in reproductive disorders has received little attention by the medical community. To better understand the potential risk of PFAS on human ovarian function, additional experimental studies using PFAS doses equivalent to the exposure levels found in the general human population and mixtures of compounds are required. Prospective investigations in human populations are also warranted to ensure the temporality of PFAS exposure and health endpoints and to minimise the possibility of reverse causality.
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Affiliation(s)
- Ning Ding
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - John F Randolph Jr
- Department of Obstetrics and Gynecology, School of Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Rita Loch-Caruso
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
| | - Sung Kyun Park
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI 48109, USA
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Ding N, Harlow SD, Randolph JF, Calafat AM, Mukherjee B, Batterman S, Gold EB, Park SK. Associations of Perfluoroalkyl Substances with Incident Natural Menopause: The Study of Women's Health Across the Nation. J Clin Endocrinol Metab 2020; 105:dgaa303. [PMID: 32491182 PMCID: PMC7418447 DOI: 10.1210/clinem/dgaa303] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 05/20/2020] [Indexed: 01/09/2023]
Abstract
CONTEXT Previous epidemiologic studies of per- and polyfluoroalkyl substances (PFASs) and menopausal timing conducted in cross-sectional settings were limited by reverse causation because PFAS serum concentrations increase after menopause. OBJECTIVES To investigate associations between perfluoroalkyl substances and incident natural menopause. DESIGN AND SETTING A prospective cohort of midlife women, the Study of Women's Health Across the Nation, 1999-2017. PARTICIPANTS 1120 multiracial/ethnic premenopausal women aged 45-56 years. METHODS Serum concentrations of perfluoroalkyls were quantified by high-performance liquid chromatography isotope dilution tandem mass spectrometry. Natural menopause was defined as the bleeding episode prior to at least 12 months of amenorrhea not due to surgery or hormone use. Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS Participants contributed 5466 person-years of follow-up, and 578 had incident natural menopause. Compared with the lowest tertile, women at the highest tertile of baseline serum concentrations had adjusted HR for natural menopause of 1.26 (95% CI: 1.02-1.57) for n-perfluorooctane sulfonic acid (n-PFOS) (Ptrend = .03), 1.27 (95% CI: 1.01-1.59) for branched-PFOS (Ptrend = .03), and 1.31 (95% CI: 1.04-1.65) for n-perfluorooctanoic acid (Ptrend = .01). Women were classified into four clusters based on their overall PFAS concentrations as mixtures: low, low-medium, medium-high, and high. Compared with the low cluster, the high cluster had a HR of 1.63 (95% CI: 1.08-2.45), which is equivalent to 2.0 years earlier median time to natural menopause. CONCLUSION This study suggests that select PFAS serum concentrations are associated with earlier natural menopause, a risk factor for adverse health outcomes in later life.
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Affiliation(s)
- Ning Ding
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - John F Randolph
- Department of Obstetrics and Gynecology, School of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Antonia M Calafat
- Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Bhramar Mukherjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Stuart Batterman
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, Michigan
- Department of Civil and Environmental Engineering, College of Engineering, University of Michigan, Ann Arbor, Michigan
| | - Ellen B Gold
- Department of Public Health Sciences, University of California, Davis, School of Medicine, Davis, California
| | - Sung Kyun Park
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, Michigan
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Jackson EA, Ruppert K, Derby CA, Lian Y, Chae CU, Kazlauskaite R, Neal-Perry G, El Khoudary SR, Harlow SD, Solomon DH. Is race or ethnicity associated with under-utilization of statins among women in the United States: The study of women's health across the nation. Clin Cardiol 2020; 43:1388-1397. [PMID: 32862481 PMCID: PMC7724205 DOI: 10.1002/clc.23448] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 12/14/2022] Open
Abstract
Background Rates of statin use among minority women are unclear. Hypothesis We hypothesized that statin use would vary by race/ethnicity with lower rates among minority women compared with Whites. Methods Data from the study of women's health across the nation, a multiethnic cohort of women collected between 2009 to 2011 were used to examine reported statin use by race/ethnicity and risk profile. Multivariable logistic modeling was performed to estimate the odds ratio (OR) of statin treatment. Results Of the 2399 women included, 234 had a diagnosis of atherosclerotic disease (ASCVD), 254 were diabetic (without ASCVD), 163 had an LDL ≥190 mg/dL, and 151 had a 10 year ASCVD pooled risk score ≥7.5%. Statins were used by 49.6% of women with CVD; 59.8% of women with diabetes without known ASCVD; 42.3% of women with an LDL ≥190 mg/dL; and 19.9% of women with an ASCVD risk ≥7.5%. Rates of statin use were 43.8% for women with ≥ two prior ASCVD events and 69.4% for women with ≥ one prior ASCVD event plus multiple high‐risk conditions. Among women eligible for statins, Black women had a significantly reduced adjusted odds of being on a statin (OR 0.53, 95% confidence interval [CI] 0.36‐0.78) compared with White women. Conclusions In this cohort of multiethnic women, rates of statin use among women who would benefit were low, with Black women having lower odds of statin use than White women.
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Affiliation(s)
- Elizabeth A Jackson
- Division of Cardiovascular Disease, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kristine Ruppert
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Carol A Derby
- The Saul R. Korey Department of Neurology, and Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Yinjuan Lian
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Claudia U Chae
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rasa Kazlauskaite
- Department of Medicine, Rush University Medical Center, chicago, Illinois, USA
| | - Genevieve Neal-Perry
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Samar R El Khoudary
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel H Solomon
- Division of Rheumatology, Division of Pharmacoepidemiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Wang X, Karvonen-Gutierrez CA, Herman WH, Mukherjee B, Harlow SD, Park SK. Urinary metals and incident diabetes in midlife women: Study of Women's Health Across the Nation (SWAN). BMJ Open Diabetes Res Care 2020; 8:e001233. [PMID: 32747380 PMCID: PMC7398092 DOI: 10.1136/bmjdrc-2020-001233] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 06/12/2020] [Accepted: 06/27/2020] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Environmental exposure to metals may play a role in the pathogenesis of diabetes; however, evidence from human studies is limited. We prospectively evaluated the associations of 20 urinary metal concentrations and their mixtures with incident diabetes in the Study of Women's Health Across the Nation, a multisite, multiethnic cohort study of midlife women. RESEARCH DESIGN AND METHODS The sample included 1237 white, black, Chinese and Japanese-American women, aged 45-56 years, free of diabetes at baseline (1999-2000) who were followed through 2016. Concentrations of 20 metals (arsenic, barium, beryllium, cadmium, cobalt, chromium, cesium, copper, mercury, manganese, molybdenum, nickel, lead, antimony, tin, thallium, uranium, vanadium, tungsten and zinc) were measured in urine specimens at baseline. Incident diabetes was identified annually by fasting glucose ≥126 mg/dL, self-reported doctor-diagnosed diabetes, or self-reported use of antidiabetic medications. A non-parametric clustering method, k-means clustering, was used to identify subgroups with different exposure patterns to metal mixtures. RESULTS After multivariable adjustment, the HR (95% CI) for diabetes associated with each doubling increase in urinary metal concentrations was 1.19 (1.10 to 1.30) for arsenic and 1.20 (1.05 to 1.37) for lead, in Cox proportional hazards models after controlling for multiple comparisons. A doubling in urinary excretion of zinc was associated with higher risk of diabetes (adjusted HR 1.31, 95% CI 1.11 to 1.53). Two distinct exposure patterns to metal mixtures-'high' versus 'low'-were identified. Participants assigned to the 'high' pattern had higher overall concentrations of all metals compared with those classified into the 'low' pattern. Adjusted HR for diabetes associated with 'high' pattern compared with 'low' was 1.42 (1.08 to 1.87). CONCLUSIONS Higher urinary concentrations of arsenic and lead, increased urinary excretion of zinc, as well as higher overall exposure to metal mixtures were associated with elevated risk of diabetes. Future studies should further investigate the underlying mechanisms.
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Affiliation(s)
- Xin Wang
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | | | - William H Herman
- Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Bhramar Mukherjee
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Siobán D Harlow
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
| | - Sung Kyun Park
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
- Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
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Ding N, Harlow SD, Batterman S, Mukherjee B, Park SK. Longitudinal trends in perfluoroalkyl and polyfluoroalkyl substances among multiethnic midlife women from 1999 to 2011: The Study of Women's Health Across the Nation. Environ Int 2020; 135:105381. [PMID: 31841808 PMCID: PMC7374929 DOI: 10.1016/j.envint.2019.105381] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/08/2019] [Accepted: 12/01/2019] [Indexed: 05/18/2023]
Abstract
BACKGROUND Limited information exists regarding longitudinal trends in midlife women's exposure to perfluoroalkyl and polyfluoroalkyl substances (PFAS). Further, little is known about how patterns of exposure differ by race/ethnicity and reproductive characteristics including parity and menopause. OBJECTIVE We aimed to examine temporal variations in serum PFAS concentrations among midlife women from the Study of Women's Health Across the Nation. METHODS Serum concentrations of 11 PFAS homologues were measured in 75 White, Black and Chinese women with blood samples collected in 1999-2000, 2002-2003, 2005-2006, and 2009-2011. Rates of changes in PFAS concentrations were calculated assuming a first-order elimination model. Associations between PFAS concentrations and race/ethnicity, menstruation and parity were evaluated with linear mixed models, adjusting for age, body mass index and study site. RESULTS Serum concentrations of linear-chain perfluorooctanoic acid (n-PFOA), linear- and branched-chain perfluorooctane sulfonic acid (n-PFOS and sm-PFOS) decreased significantly (-6.0%, 95% CI: -8.3%, -3.6% per year for n-PFOA; -14.8%, 95% CI: -17.3%, -12.3% per year for n-PFOS; -16.9%, 95% CI: -19.1%, -14.6% per year for sm-PFOS); whereas perfluorononanoic acid (PFNA) increased (16.0%, 95% CI: 10.6%, 21.6% per year). Detection rates of perfluorodecanoic acid (PFDeA) and perfluoroundecanoic acid (PFUA) doubled. Temporal trends varied significantly by race/ethnicity. Chinese women tended to have consistently higher PFNA concentrations at each follow-up visit, compared with White and Black women. Serum PFHxS concentrations significantly decreased in White and Black women, but not in Chinese. Menstruating women consistently had lower concentrations. Parity was associated with lower concentrations at baseline but the differences between nulliparous and parous women became smaller over time. CONCLUSIONS Our results suggest longitudinal declines in serum concentrations of legacy PFAS and increases in serum concentrations of emerging compounds from 1999 to 2011 in midlife women. Temporal trends in PFAS concentrations are not uniform across race/ethnicity and parity groups.
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Affiliation(s)
- Ning Ding
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Stuart Batterman
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, United States; Department of Civil and Environmental Engineering, College of Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Bhramar Mukherjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Sung Kyun Park
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, United States; Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, United States.
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Harlow SD, Elliott MR, Bondarenko I, Thurston RC, Jackson EA. Monthly variation of hot flashes, night sweats, and trouble sleeping: effect of season and proximity to the final menstrual period (FMP) in the SWAN Menstrual Calendar substudy. Menopause 2020; 27:5-13. [PMID: 31567864 PMCID: PMC6934911 DOI: 10.1097/gme.0000000000001420] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Although reproductive function is influenced by season, few studies have evaluated seasonal effects on menopausal symptoms. We assessed the impact of season and proximity to the final menstrual period (FMP) on frequency of symptom reporting. METHODS In all, 955 participants in the Study of Women's Health Across the Nation recorded whether or not they had experienced menopausal symptoms on a monthly menstrual calendar over a 10-year period. We modeled the log-odds of presence of a given symptom each month using a logistic mixed-effects model, assuming a third-order polynomial before the FMP and a different third-order polynomial after the FMP. We assumed sine and cosine functions for month of the year. RESULTS Five to 10 years before the FMP, ∼20% of women reported hot flashes and night sweats, whereas ∼40% reported trouble sleeping. Prevalence rose ∼4 years before the FMP with a sharp jump in hot flash (∼60%) and night sweats (∼40%) prevalence coincident with the FMP. Peaks in hot flashes and trouble sleeping were observed in July with troughs in January. The peak and trough in night sweats occurred about 1 month earlier. Odds of hot flashes, night sweats, and trouble sleeping were 66%, 50%, and 24% greater, respectively, at the seasonal peak versus the seasonal minimum. CONCLUSION Menopausal symptoms exhibit seasonal variation associated with the summer and winter equinoxes. Seasonal increases in night sweats precede increases in hot flashes. Prospectively recorded monthly symptom data demonstrate that hot flashes and night sweats increase notably coincident with the FMP. : Video Summary:http://links.lww.com/MENO/A476.
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Affiliation(s)
- Siobán D Harlow
- Department of Epidemiology, University of Michigan, Ann Arbor, MI
| | | | - Irina Bondarenko
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
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Wang D, Jackson EA, Karvonen-Gutierrez CA, Elliott MR, Harlow SD, Hood MM, Derby CA, Sternfeld B, Janssen I, Crawford SL, Huang MH, El Khoudary SR, Chae CU, Baylin A. Healthy Lifestyle During the Midlife Is Prospectively Associated With Less Subclinical Carotid Atherosclerosis: The Study of Women's Health Across the Nation. J Am Heart Assoc 2019; 7:e010405. [PMID: 30482079 PMCID: PMC6405552 DOI: 10.1161/jaha.118.010405] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Measures of subclinical atherosclerosis are predictors of future cardiovascular outcomes as well as of physical and cognitive functioning. The menopausal transition is associated with accelerated progression of atherosclerosis in women. The prospective association between a healthy lifestyle during the midlife and subclinical atherosclerosis is unclear. Methods and Results Self‐reported data on smoking, diet, and physical activity from 1143 women in the Study of Women's Health Across the Nation were used to construct a 10‐year average Healthy Lifestyle Score (HLS) during the midlife. Markers of subclinical atherosclerosis were measured 14 years after baseline and included common carotid artery intima‐media thickness (CCA‐IMT), adventitial diameter (CCA‐AD), and carotid plaque. The associations of average HLS with CCA‐IMT and CCA‐AD were estimated using linear models; the association of average HLS with carotid plaque was estimated using cumulative logit models. Average HLS was associated with smaller CCA‐IMT and CCA‐AD in the fully adjusted models (P=0.0031 and <0.001, respectively). Compared with participants in the lowest HLS level, those in the highest level had 0.024 mm smaller CCA‐IMT (95% confidence interval: −0.048, 0.000), which equals 17% of the SD of CCA‐IMT, and 0.16 mm smaller CCA‐AD (95% confidence interval: −0.27, −0.04), which equals 24% of the SD of CCA‐AD. Among the 3 components of the HLS, abstinence from smoking had the strongest association with subclinical atherosclerosis. Conclusions Healthy lifestyle during the menopausal transition is associated with less subclinical atherosclerosis, highlighting the growing recognition that the midlife is a critical window for cardiovascular prevention in women.
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Affiliation(s)
- Dongqing Wang
- 1 Department of Epidemiology University of Michigan Ann Arbor MI
| | | | | | - Michael R Elliott
- 3 Department of Biostatistics University of Michigan Ann Arbor MI.,4 Survey Research Center University of Michigan Ann Arbor MI
| | - Siobán D Harlow
- 1 Department of Epidemiology University of Michigan Ann Arbor MI
| | - Michelle M Hood
- 1 Department of Epidemiology University of Michigan Ann Arbor MI
| | - Carol A Derby
- 5 Department of Neurology Albert Einstein College of Medicine Bronx NY.,6 Department of Epidemiology and Population Health Albert Einstein College of Medicine Bronx NY
| | | | - Imke Janssen
- 8 Department of Preventive Medicine Rush University Medical Center Chicago IL
| | | | - Mei-Hua Huang
- 10 Division of Geriatrics University of California Los Angeles Los Angeles CA
| | | | - Claudia U Chae
- 12 Cardiology Division Massachusetts General Hospital Boston MA
| | - Ana Baylin
- 1 Department of Epidemiology University of Michigan Ann Arbor MI.,13 Department of Nutritional Sciences University of Michigan Ann Arbor MI
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Somers EC, Lee J, Hassett AL, Zick SM, Harlow SD, Helmick CG, Barbour KE, Gordon C, Brummett CM, Minhas D, Padda A, Wang L, McCune WJ, Marder W. Prescription Opioid Use in Patients With and Without Systemic Lupus Erythematosus - Michigan Lupus Epidemiology and Surveillance Program, 2014-2015. MMWR Morb Mortal Wkly Rep 2019; 68:819-824. [PMID: 31557148 PMCID: PMC6762189 DOI: 10.15585/mmwr.mm6838a2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Iglesias-Rios L, Harlow SD, Burgard SA, Kiss L, Zimmerman C. Gender differences in the association of living and working conditions and the mental health of trafficking survivors. Int J Public Health 2019; 64:1015-1024. [PMID: 31243470 PMCID: PMC10506657 DOI: 10.1007/s00038-019-01269-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/05/2019] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES To assess the association of living and working conditions experienced during trafficking with mental health of female and male survivors. METHODS We analyzed a cross-sectional study of 1015 survivors who received post-trafficking services in Cambodia, Thailand, and Vietnam. Modified Poisson regression models were conducted by gender to estimate prevalence ratios. RESULTS For females, the elevated prevalence of anxiety, depression, and post-traumatic stress disorder (PTSD) symptoms was associated with adverse living conditions, while for males the prevalence of anxiety (PR = 2.21; 95% CI 1.24-3.96) and depression (PR = 2.63; 95% CI 1.62-4.26) more than doubled and almost tripled for PTSD (PR = 2.93; 95% CI 1.65-5.19) after adjustment. For males in particular, excessive and extreme working hours per day were associated with more than a four- and threefold greater prevalence of PTSD. Being in a detention center or jail was associated with all three mental health outcomes in males. CONCLUSIONS Providers and stakeholders need to consider the complex mental health trauma of the differential effects of living and working conditions for female and male survivors during trafficking to support treatment and recovery.
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Affiliation(s)
- Lisbeth Iglesias-Rios
- Department of Epidemiology, Center for Midlife Science, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109-2029, USA.
| | - Siobán D Harlow
- Department of Epidemiology, Center for Midlife Science, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109-2029, USA
| | - Sarah A Burgard
- Department of Sociology, College of Literature Science, and the Arts, University of Michigan, 500 S State St, Ann Arbor, MI, 48109, USA
| | - Ligia Kiss
- Department of Global Health and Development, Gender Violence and Health Centre, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, London, UK
| | - Cathy Zimmerman
- Department of Global Health and Development, Gender Violence and Health Centre, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, London, UK
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Dusendang JR, Reeves AN, Karvonen-Gutierrez CA, Herman WH, Ylitalo KR, Harlow SD. The association between perceived discrimination in midlife and peripheral neuropathy in a population-based cohort of women: the Study of Women's Health Across the Nation. Ann Epidemiol 2019; 37:10-16. [PMID: 31447292 PMCID: PMC6755046 DOI: 10.1016/j.annepidem.2019.07.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 06/01/2019] [Accepted: 07/11/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE Peripheral neuropathy (PN) is a highly prevalent condition with serious sequelae. Many studies of the condition have been restricted to populations with diabetes, limiting evidence of potential contributing risk factors including salient psychosocial risk factors such as discrimination. METHODS The longitudinal Study of Women's Health Across the Nation was used to assess the relationship between perceived discrimination and prevalent PN in 1718 ethnically diverse midlife women. We used multivariable logistic regression to determine the association between perceived discrimination (Detroit Area Study Everyday Discrimination Scale) and PN (symptom questionnaire and monofilament testing) and conducted an assessment of the mediating effects of body mass index (BMI). RESULTS The prevalence of PN was 26.1% in the total sample and 40.9% among women with diabetes. Women who reported perceived discrimination had 29% higher odds of PN compared with women who did not report perceived discrimination (95% confidence interval, 1.01-1.66). Approximately 30% of the total effect of discrimination on PN was mediated indirectly by BMI. CONCLUSIONS More research is needed to determine the contributing factors to nondiabetic PN. Our findings reaffirm the impact of financial strain, BMI, and diabetes as significant correlates of PN and highlight discrimination as an important risk factor.
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Affiliation(s)
- Jennifer R Dusendang
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor
| | - Alexis N Reeves
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor
| | | | - William H Herman
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor; Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor
| | | | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor.
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Park SK, Peng Q, Ding N, Mukherjee B, Harlow SD. Determinants of per- and polyfluoroalkyl substances (PFAS) in midlife women: Evidence of racial/ethnic and geographic differences in PFAS exposure. Environ Res 2019; 175:186-199. [PMID: 31129528 PMCID: PMC6579633 DOI: 10.1016/j.envres.2019.05.028] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 05/16/2019] [Accepted: 05/17/2019] [Indexed: 05/09/2023]
Abstract
BACKGROUND Per- and poly-fluoroalkyl substances (PFAS) are public health concerns because of widespread exposure through contaminated foods/drinking water. Although some determinants of PFAS exposure have been suggested, the role of geographic location and race/ethnicity in PFAS exposure has not been well characterized. OBJECTIVES We examined potential determinants of PFAS from the Study of Women's Health Across the Nation (SWAN). METHODS This study includes 1302 women aged 45-56 years from 5 SWAN sites where white women and women from one minority group were recruited (black from Southeast Michigan, Pittsburgh, Boston; Chinese from Oakland; Japanese from Los Angeles). We determined concentrations of 11 PFAS in serum samples collected in 1999-2000 and examined 7 PFAS detected in most women (>97%). Linear regression with backward elimination was used to identify important determinants of PFAS serum concentrations among a set of pre-specified variables (age, body mass index, site, race/ethnicity, education, financial hardship, occupation, born outside the United States (US), parity, menstrual bleeding within the past year, smoking status, alcohol consumption, and consumption of fish, dairy, pizza, salty snack, and French fries). RESULTS Site and race/ethnicity were two major determinants of PFAS. White women had higher concentrations of linear perfluorooctanoic acid (PFOA) compared with the Chinese in Oakland (p < 0.0001) and blacks in Pittsburgh (p = 0.048). Black women in Southeast Michigan and Boston (vs. white women) had higher concentrations of linear (p < 0.001 for Southeast Michigan; p < 0.0001 for Boston) and total perfluorooctane sulfonic acid (PFOS) (p < 0.001 for both Southeast Michigan and Boston) and 2-(N-methyl-perfluorooctane sulfonamido) acetic acid (p = 0.02 for Southeast Michigan; p < 0.001 for Boston). Chinese (Oakland) and Japanese (Los Angeles) women had higher concentrations of perfluorononanoic acid (PFNA) compared with white women in each site (p < 0.01 for both). Within white women, those in Pittsburgh had relatively higher concentrations of PFAS. Within Chinese and Japanese women, those who were born outside the US had significantly lower concentrations of most PFAS but significantly higher PFNA concentrations. Menstrual bleeding and parity were significantly associated with lower PFAS concentrations. Higher intake of salty snacks including popcorn was significantly associated with higher concentrations of linear PFOA, PFOS and 2-(N-ethyl-perfluorooctane sulfonamido) acetic acid. DISCUSSION Geographic locations and race/ethnicity play an important role in differential exposure to PFAS, with racial/ethnic burdens differing between PFOS, PFOA and PFNA. Menstruation and parity were also determinants of PFAS concentrations possibly as an elimination route.
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Affiliation(s)
- Sung Kyun Park
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, United States; Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, United States.
| | - Qing Peng
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Ning Ding
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Bhramar Mukherjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, United States
| | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, United States
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Wang X, Mukherjee B, Batterman S, Harlow SD, Park SK. Urinary metals and metal mixtures in midlife women: The Study of Women's Health Across the Nation (SWAN). Int J Hyg Environ Health 2019; 222:778-789. [PMID: 31103473 PMCID: PMC6583796 DOI: 10.1016/j.ijheh.2019.05.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 04/29/2019] [Accepted: 05/02/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Little is known about the extent of exposure to metals and metal mixtures among midlife women. OBJECTIVES We assessed exposure to multiple metals in the Study of Women's Health Across the Nation (SWAN), a multi-site, multi-racial/ethnic cohort of women at midlife. METHODS We measured urinary concentrations of 21 metals (arsenic, barium, beryllium, cadmium, cobalt, chromium, cesium, copper, mercury, manganese, molybdenum, nickel, lead, platinum, antimony, tin, thallium, uranium, vanadium, tungsten and zinc) using high-resolution inductively coupled plasma-mass spectrometry among 1335 white, black, Chinese and Japanese women aged 45-56 years at the third SWAN annual visit (1999-2000). Least squared geometric mean concentrations were compared across race/ethnicity, education, financial hardship, smoking, secondhand smoking, seafood intake and rice intake groups. Overall exposure patterns of multiple metals were derived using k-means clustering method. RESULTS The percentage of women with detectable concentrations of metals ranged from 100% for arsenic, cesium, molybdenum and zinc, to less than 5% for platinum; 15 metals had detection rates of 70% or more. Asian women, both Chinese and Japanese, had higher urinary concentrations of arsenic, cadmium, copper, mercury, molybdenum, lead and thallium, compared with other race/ethnic groups, independent of sociodemographic, lifestyle, dietary, and geographic characteristics. Seafood and rice intake were important determinants of urinary arsenic, cesium, mercury, molybdenum and lead levels. Two distinct overall exposure patterns- "high" vs. "low" -- were identified. Women in the "high" overall exposure pattern were more likely to be Asians, current smokers, and to report high consumption of seafood and rice. Black women were less likely to have the high exposure pattern. CONCLUSIONS Metal exposure of midlife women differs by racial/ethnic, sociodemographic, lifestyle, dietary, and geographic characteristics. Asian women may be experiencing the highest exposures to multiple metals compared with other racial/ethnic groups in the United States.
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Affiliation(s)
- Xin Wang
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Bhramar Mukherjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Stuart Batterman
- Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Sung Kyun Park
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA; Department of Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, USA.
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40
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Peng Q, Karvonen-Gutierrez CA, Randolph, JF, Nan B, McConnell D, Harlow SD. Age at Onset of Metabolic Syndrome Among Women With and Without Polycystic Ovary Syndrome-Like Status. J Clin Endocrinol Metab 2019; 104:1429-1439. [PMID: 30517661 PMCID: PMC6435100 DOI: 10.1210/jc.2018-01428] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 11/28/2018] [Indexed: 01/14/2023]
Abstract
CONTEXT Women with polycystic ovary syndrome (PCOS) have a higher prevalence of metabolic syndrome (MetS), but whether they develop MetS earlier than women without PCOS is unknown. Understanding the impact of PCOS on the timing of MetS onset is important for screening and clinical care in this population. DESIGN Women with PCOS-like status (PCOSp) were identified from participants of the Michigan Bone Health and Metabolism Study based upon history of irregular menstrual cycles, high free-androgen index, and high levels of antimüllerian hormone. MetS was defined according to the Adult Treatment Panel III criteria. Age at MetS onset was compared between women with and without PCOSp using an accelerated failure time model adjusted for baseline education, lifestyle factors, and midlife body weight. RESULTS Among the 496 women in the analysis, 11.7% (n = 58) were determined to have PCOSp. Over a mean follow-up of 11 years, 20 women with PCOSp and 136 women without PCOSp developed MetS. After adjusting for smoking, education, and physical activity, women with PCOSp developed MetS at an age 14.4% (95% CI -22.7, -5.2) younger than women without PCOSp. The magnitude of the association was attenuated to 5.4% in models additionally adjusted for body mass index (95% CI -12.4, 2.1). Because a typical study participant without PCOSp developed MetS at 51.5 years old, 5.4% translates to almost 3 years earlier onset of MetS for a comparable woman with PCOSp. CONCLUSIONS Women with PCOSp develop MetS at a younger age. Earlier screening for MetS in women with PCOS may be warranted.
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Affiliation(s)
- Qing Peng
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan
- Correspondenceand Reprint Requests: Qing Peng, MPH, University of Michigan School of Public Health. 1415 Washington Heights, Room 6622 SPH I, Ann Arbor, Michigan 48109-2029. E-mail:
| | | | - John F Randolph,
- 2Division of Reproductive Endocrinology and Infertility, University of Michigan Health System, Ann Arbor, Michigan
| | - Bin Nan
- 3Department of Statistics, University of California at Irvine, Irvine, California
| | - Daniel McConnell
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Siobán D Harlow
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan
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Iglesias-Rios L, Harlow SD, Burgard SA, Kiss L, Zimmerman C. Mental health, violence and psychological coercion among female and male trafficking survivors in the greater Mekong sub-region: a cross-sectional study. BMC Psychol 2018; 6:56. [PMID: 30541612 PMCID: PMC6292017 DOI: 10.1186/s40359-018-0269-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 11/12/2018] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Human trafficking is a pervasive global crime with important public health implications that entail fundamental human rights violations in the form of severe exploitation, violence and coercion. Sex-specific associations between types of violence or coercion and mental illness in survivors of trafficking have not been established. METHODS We conducted a cross-sectional study with 1015 female and male survivors of trafficking (adults, adolescents and children) who received post-trafficking assistance services in Cambodia, Thailand or Vietnam and had been exploited in various labor sectors. We assessed anxiety and depression with the Hopkins Symptoms Checklist (HSCL-25) and post-traumatic stress disorder (PTSD) symptoms with the Harvard Trauma Questionnaire (HTQ), and used validated questions from the World Health Organization International Study on Women's Health and Domestic Violence to measure physical and sexual violence. Sex-specific modified Poisson regression models were estimated to obtain prevalence ratios (PRs) and their 95% confidence intervals (CI) for the association between violence (sexual, physical or both), coercion, and mental health conditions (anxiety, depression and PTSD). RESULTS Adjusted models indicated that for females, experiencing both physical and sexual violence, compared to not being exposed to violence, was a strong predictor of symptoms of anxiety (PR = 2.08; 95% CI: 1.64-2.64), PTSD (PR = 1.55; 95% CI: 1.37-1.74), and depression (PR = 1.57; 95% CI: 1.33-1.85). Among males, experiencing physical violence with additional threats made with weapons, compared to not being exposed to violence, was associated with PTSD (PR = 1.59; 95% CI: 1.05-2.42) after adjustment. Coercion during the trafficking experience was strongly associated with anxiety, depression, and PTSD in both females and males. For females in particular, exposure to both personal and family threats was associated with a 96% elevated prevalence of PTSD (PR = 1.96; 95% CI: 1.32-2.91) and more than doubling of the prevalence of anxiety (PR = 2.11; 95% CI: 1.57-2.83). CONCLUSIONS The experiences of violence and coercion in female and male trafficking survivors differed and were associated with an elevated prevalence of anxiety, depression, and PTSD in both females and males. Mental health services must be an integral part of service provision, recovery and re-integration for trafficked females and males.
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Affiliation(s)
- Lisbeth Iglesias-Rios
- Department of Epidemiology, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA.
| | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Sarah A Burgard
- Department of Sociology, College of Literature Science, and the Arts, University of Michigan, Ann Arbor, MI, USA
| | - Ligia Kiss
- Gender Violence and Health Centre, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Cathy Zimmerman
- Gender Violence and Health Centre, Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Abstract
Increased variability in menstrual cycle length marks the onset of the menopausal transition, with the likelihood of long cycles increasing as women approach menopause. This article describes the STRAW+10 bleeding criteria for recognizing onset of the early and late menopausal transition, as well as the specific bleeding changes a woman may experience during this life stage, including how women's bleeding experiences differ. The high probability of episodes of excessive and prolonged bleeding as women approach their final menstrual period is documented, as is the continuing probability of ovulation as women reach their final menstrual period.
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Affiliation(s)
- Siobán D Harlow
- Department of Epidemiology, School of Public Health of the University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA.
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Depmann M, Eijkemans MJC, Broer SL, Tehrani FR, Solaymani-Dodaran M, Azizi F, Lambalk CB, Randolph JF, Harlow SD, Freeman EW, Sammel MD, Verschuren WMM, van der Schouw YT, Mol BW, Broekmans FJM. Does AMH relate to timing of menopause? Results of an Individual Patient Data meta- analysis. J Clin Endocrinol Metab 2018; 103:5055544. [PMID: 30032277 DOI: 10.1210/jc.2018-00724] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 07/13/2018] [Indexed: 02/13/2023]
Abstract
CONTEXT Anti-Müllerian hormone based (AMH) age at menopause predictions remain cumbersome due to predictive inaccuracy. OBJECTIVE To perform an Individual Patient Data (IPD) meta-analysis, regarding AMH based menopause prediction. DATA SOURCES A systematic literature search was performed using PubMed, Embase and Cochrane databases. STUDY SELECTION Prospective cohort studies regarding menopause prediction using serum AMH levels were selected by consensus discussion. DATA SELECTION Individual cases were included if experiencing a regular cycle at baseline. Exclusion criteria were hormone use and gynecological surgery. DATA SYNTHESIS 2596 women were included, 1077 experienced menopause. A multivariable Cox regression analysis assessed time to menopause (TTM) using age and AMH. AMH predicted TTM, however, added value on top of age was poor (age alone C-statistic 84%; age + AMH HR 0.66 95% CI 0.61-0.71, C-statistic 86%). Moreover, the capacity of AMH to predict early (≤45 years) and late menopause (≥55 years) was assessed. An added effect of AMH was demonstrated for early menopause (age alone C-statistic 52%; age + AMH HR 0.33, 95% CI 0.24-0.45, C-statistic 80%). A Weibull regression model calculating individual age at menopause revealed that predictive inaccuracy remained present and increased with decreasing age at menopause. Lastly, a check of non-proportionality of the predictive effect of AMH demonstrated a reduced predictive effect with increasing age. CONCLUSION AMH was a significant predictor of TTM and especially of time to early menopause. However, individual predictions of age at menopause demonstrated a limited precision, particularly when concerning early age at menopause, making clinical application troublesome.
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Affiliation(s)
- M Depmann
- University Medical Center Utrecht, Department of Reproductive Medicine & Gynecology, Utrecht, The Netherlands
| | - M J C Eijkemans
- Julius Center for Health Sciences and Primary Care, Department of Biostatistics and Research Support, Utrecht, The Netherlands
| | - S L Broer
- University Medical Center Utrecht, Department of Reproductive Medicine & Gynecology, Utrecht, The Netherlands
| | - F Ramezani Tehrani
- Reproductive Endocrinology Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - M Solaymani-Dodaran
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - F Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - C B Lambalk
- VU University Medical Center, Department of Obstetrics and Gynecology, IVF Center, Amsterdam, The Netherlands
| | - J F Randolph
- University of Michigan Medical Center, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Ann Arbor, Michigan
| | - S D Harlow
- University of Michigan, Department of Epidemiology, School of Public Health, Ann Arbor, MI, USA
| | - E W Freeman
- Perelman School of Medicine, Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - M D Sammel
- Perelman School of Medicine, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - W M M Verschuren
- Julius Center for Health Sciences and Primary Care, Department of Biostatistics and Research Support, Utrecht, The Netherlands
| | - Y T van der Schouw
- Julius Center for Health Sciences and Primary Care, Department of Biostatistics and Research Support, Utrecht, The Netherlands
| | - B W Mol
- Monash Medical Center, Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - F J M Broekmans
- University Medical Center Utrecht, Department of Reproductive Medicine & Gynecology, Utrecht, The Netherlands
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Novak NL, Lira N, O'Connor KE, Harlow SD, Kardia SLR, Stern AM. Disproportionate Sterilization of Latinos Under California's Eugenic Sterilization Program, 1920-1945. Am J Public Health 2018; 108:611-613. [PMID: 29565671 DOI: 10.2105/ajph.2018.304369] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To compare population-based sterilization rates between Latinas/os and non-Latinas/os sterilized under California's eugenics law. METHODS We used data from 17 362 forms recommending institutionalized patients for sterilization between 1920 and 1945. We abstracted patient gender, age, and institution of residence into a data set. We extracted data on institution populations from US Census microdata from 1920, 1930, and 1940 and interpolated between census years. We used Spanish surnames to identify Latinas/os in the absence of data on race/ethnicity. We used Poisson regression with a random effect for each patient's institution of residence to estimate incidence rate ratios (IRRs) and compare sterilization rates between Latinas/os and non-Latinas/os, stratifying on gender and adjusting for differences in age and year of sterilization. RESULTS Latino men were more likely to be sterilized than were non-Latino men (IRR = 1.23; 95% confidence interval [CI] = 1.15, 1.31), and Latina women experienced an even more disproportionate risk of sterilization relative to non-Latinas (IRR = 1.59; 95% CI = 1.48, 1.70). CONCLUSIONS Eugenic sterilization laws were disproportionately applied to Latina/o patients, particularly Latina women and girls. Understanding historical injustices in public health can inform contemporary public health practice.
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Affiliation(s)
- Nicole L Novak
- Nicole L. Novak is with the Population Studies Center, Institute for Social Research, University of Michigan, Ann Arbor. Natalie Lira is with the Department of Latina/Latino Studies, University of Illinois at Urbana-Champaign. Kate E. O'Connor and Alexandra Minna Stern are with the Department of American Culture, University of Michigan. Siobán D. Harlow and Sharon L. R. Kardia are with the Department of Epidemiology, School of Public Health, University of Michigan
| | - Natalie Lira
- Nicole L. Novak is with the Population Studies Center, Institute for Social Research, University of Michigan, Ann Arbor. Natalie Lira is with the Department of Latina/Latino Studies, University of Illinois at Urbana-Champaign. Kate E. O'Connor and Alexandra Minna Stern are with the Department of American Culture, University of Michigan. Siobán D. Harlow and Sharon L. R. Kardia are with the Department of Epidemiology, School of Public Health, University of Michigan
| | - Kate E O'Connor
- Nicole L. Novak is with the Population Studies Center, Institute for Social Research, University of Michigan, Ann Arbor. Natalie Lira is with the Department of Latina/Latino Studies, University of Illinois at Urbana-Champaign. Kate E. O'Connor and Alexandra Minna Stern are with the Department of American Culture, University of Michigan. Siobán D. Harlow and Sharon L. R. Kardia are with the Department of Epidemiology, School of Public Health, University of Michigan
| | - Siobán D Harlow
- Nicole L. Novak is with the Population Studies Center, Institute for Social Research, University of Michigan, Ann Arbor. Natalie Lira is with the Department of Latina/Latino Studies, University of Illinois at Urbana-Champaign. Kate E. O'Connor and Alexandra Minna Stern are with the Department of American Culture, University of Michigan. Siobán D. Harlow and Sharon L. R. Kardia are with the Department of Epidemiology, School of Public Health, University of Michigan
| | - Sharon L R Kardia
- Nicole L. Novak is with the Population Studies Center, Institute for Social Research, University of Michigan, Ann Arbor. Natalie Lira is with the Department of Latina/Latino Studies, University of Illinois at Urbana-Champaign. Kate E. O'Connor and Alexandra Minna Stern are with the Department of American Culture, University of Michigan. Siobán D. Harlow and Sharon L. R. Kardia are with the Department of Epidemiology, School of Public Health, University of Michigan
| | - Alexandra Minna Stern
- Nicole L. Novak is with the Population Studies Center, Institute for Social Research, University of Michigan, Ann Arbor. Natalie Lira is with the Department of Latina/Latino Studies, University of Illinois at Urbana-Champaign. Kate E. O'Connor and Alexandra Minna Stern are with the Department of American Culture, University of Michigan. Siobán D. Harlow and Sharon L. R. Kardia are with the Department of Epidemiology, School of Public Health, University of Michigan
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Hedgeman E, Hasson RE, Karvonen-Gutierrez CA, Herman WH, Harlow SD. Perceived stress across the midlife: longitudinal changes among a diverse sample of women, the Study of Women's health Across the Nation (SWAN). Womens Midlife Health 2018; 4. [PMID: 29973982 PMCID: PMC6027744 DOI: 10.1186/s40695-018-0032-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Background In women, midlife is a period of social and physiological change. Ostensibly stressful, cross-sectional studies suggest women experience decreasing stress perceptions and increasing positive outlook during this life stage. The aim of this paper was to describe the longitudinal changes in perceived stress as women transitioned through the midlife. Methods Premenopausal women (n = 3044) ages 42-52 years at baseline, were recruited from seven sites in the Study of Women's Health Across the Nation, and followed approximately annually over 13 visits with assessment of perceived stress and change in menopausal status. Longitudinal regression models were used to assess the effects of age, menopausal status and baseline sociodemographic variables on the trajectory of perceived stress over time. Results At baseline, mean age was 46.4 ± 2.7 years; participants were white (47%), black (29%), Hispanic (7%), Japanese (9%), or Chinese (8%). Hispanic women, women with lesser educational attainment, and women reporting financial hardship were each more likely to report high perceived stress levels at baseline (all p < 0.0001). After adjustment for baseline sociodemographic factors, perceived stress decreased over time for most women (p < 0.0001), but increased for both Hispanic and white participants at the New Jersey site (p < 0.0001). Changing menopausal status was not a significant predictor of perceived stress. Conclusions Self-reported stress decreased for most women as they transitioned across the midlife; changing menopausal status did not play a significant role after adjustment for age and sociodemographic factors. Future studies should explore the stress experience for women by racial/ethnic identity and demographics.
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Affiliation(s)
- Elizabeth Hedgeman
- Department of Epidemiology, School of Public Health, University of Michigan, 6610B SPH I, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA
| | - Rebecca E Hasson
- School of Kinesiology, School of Public Health, University of Michigan, Ann Arbor, USA
| | - Carrie A Karvonen-Gutierrez
- Department of Epidemiology, School of Public Health, University of Michigan, 6610B SPH I, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA
| | - William H Herman
- Department of Internal Medicine, School of Public Health, University of Michigan, Ann Arbor, USA
| | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, 6610B SPH I, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA
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Cortés YI, Catov JM, Brooks M, Harlow SD, Isasi CR, Jackson EA, Matthews KA, Thurston RC, Barinas-Mitchell E. History of Adverse Pregnancy Outcomes, Blood Pressure, and Subclinical Vascular Measures in Late Midlife: SWAN (Study of Women's Health Across the Nation). J Am Heart Assoc 2017; 7:e007138. [PMID: 29288157 PMCID: PMC5778964 DOI: 10.1161/jaha.117.007138] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 10/30/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Adverse pregnancy outcomes, such as preterm birth (PTB), have been associated with elevated risk of maternal cardiovascular disease, but their effect on late midlife blood pressure (BP) and subclinical vascular measures remains understudied. METHODS AND RESULTS We conducted a cross-sectional analysis with 1220 multiethnic parous women enrolled in SWAN (Study of Women's Health Across the Nation) to evaluate the impact of self-reported history of adverse pregnancy outcomes (PTB, small-for-gestational-age, stillbirth), on maternal BP, mean arterial pressure, and subclinical vascular measures (carotid intima-media thickness, plaque, and pulse wave velocity) in late midlife. We also examined whether these associations were modified by race/ethnicity. Associations were tested in linear and logistic regression models adjusting for sociodemographics, reproductive factors, cardiovascular risk factors, and medications. Women were on average aged 60 years and 255 women reported a history of an adverse pregnancy outcome. In fully adjusted models, history of PTB was associated with higher BP (systolic: β=6.40; SE, 1.62 [P<0.0001] and diastolic: β=3.18; SE, 0.98 [P=0.001]) and mean arterial pressure (β=4.55; SE 1.13 [P<0.0001]). PTB was associated with lower intima-media thickness, but not after excluding women with prevalent hypertension. There were no significant associations with other subclinical vascular measures. CONCLUSIONS Findings suggest that history of PTB is associated with higher BP and mean arterial pressure in late midlife. Adverse pregnancy outcomes were not significantly related to subclinical cardiovascular disease when excluding women with prevalent hypertension. Future studies across the menopause transition may be important to assess the impact of adverse pregnancy outcomes on midlife progression of BP.
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Affiliation(s)
- Yamnia I Cortés
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Janet M Catov
- Departments of Obstetrics, Gynecology, and Reproductive Sciences and Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Magee, Women's Research Institute, Pittsburgh, PA
| | - Maria Brooks
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Siobán D Harlow
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI
| | - Carmen R Isasi
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Elizabeth A Jackson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health Systems, Ann Arbor, MI
| | - Karen A Matthews
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Rebecca C Thurston
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Emma Barinas-Mitchell
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
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47
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Harlow SD, Dusendang JR, Hood MM, Woods NF. Contraceptive preferences and unmet need for contraception in midlife women: where are the data? Womens Midlife Health 2017; 3:6. [PMID: 30766707 PMCID: PMC6299985 DOI: 10.1186/s40695-017-0026-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 08/27/2017] [Indexed: 12/27/2022] Open
Abstract
This commentary discusses the limited availability of information on contraceptive preferences and unmet need for contraception among midlife women in both high and low income countries. Given that risk of pregnancy continues until women reach menopause and given the increased risk of pregnancy complications, elective abortion, and maternal mortality in women aged 45 to 54 years old, increased focus on gathering basic data on midlife women's preferences and unmet need is warranted.
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Affiliation(s)
- Siobán D. Harlow
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan USA
- Department of Epidemiology, University of Michigan 1415 Washington Heights, Suite 6610 SPH I, Ann Arbor, Michigan USA
| | | | - Michelle M. Hood
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan USA
| | - Nancy Fugate Woods
- Biobehavioral Nursing and Health Informatics, University of Washington, Seattle, Washington USA
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48
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Park SK, Harlow SD, Zheng H, Karvonen-Gutierrez C, Thurston RC, Ruppert K, Janssen I, Randolph JF. Association between changes in oestradiol and follicle-stimulating hormone levels during the menopausal transition and risk of diabetes. Diabet Med 2017; 34:531-538. [PMID: 27973745 PMCID: PMC5352524 DOI: 10.1111/dme.13301] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2016] [Indexed: 01/30/2023]
Abstract
AIM To investigate the association between changes in oestradiol and follicle-stimulating hormone levels during the menopausal transition and incident diabetes. METHODS We followed 1407 pre-menopausal women, aged 42-52 years at baseline, who experienced natural menopause, from baseline to the 12th annual follow-up visit in the Study of Women's Health Across the Nation (SWAN). Diabetes was defined based on fasting glucose level, medication use and self-report of physician diagnosis. Cox proportional hazards regression was used to evaluate the associations of incident diabetes with three components of the rate of change in hormones: the intercept (pre-menopausal levels) and two piece-wise slopes representing change during the early and late transition, respectively. RESULTS During 15 years of follow-up, 132 women developed diabetes. After adjusting for potential confounders, a higher oestradiol intercept, but not its rate of change, was borderline significantly associated with lower risk of diabetes [hazard ratio for an interquartile range increase (75.2 pmol/L) 0.53, 95% CI 0.27-1.06]. For follicle-stimulating hormone, a greater rate of increase in the early transition, but not the intercept or late transition, was significantly associated with lower risk of diabetes [hazard ratio for an interquartile range increase (5.9 IU/L/year) 0.31, 95% CI 0.10-0.94]. CONCLUSIONS Lower pre-menopausal oestradiol levels and a slower rate of follicle-stimulating hormone change during the early transition were associated with higher risk of developing diabetes. Given that obesity plays an important role in diabetes risk and in the levels and changes in oestradiol and follicle-stimulating hormone over the menopausal transition, weight control in earlier mid-life is important to prevent future diabetes development.
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Affiliation(s)
- S K Park
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
- Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - S D Harlow
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - H Zheng
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - C Karvonen-Gutierrez
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - R C Thurston
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - K Ruppert
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - I Janssen
- Department of Preventive Medicine, Rush University Medical Center, Chicago, IL, USA
| | - J F Randolph
- Division of Reproductive Endocrinology and Infertility, University of Michigan Health System, Ann Arbor, MI, USA
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Jackson EA, Ruppert K, Derby CA, Lian Y, Neal-Perry G, Habel LA, Tepper PG, Harlow SD, Solomon DH. Effect of Race and Ethnicity on Antihypertensive Medication Utilization Among Women in the United States: Study of Women's Health Across the Nation (SWAN). J Am Heart Assoc 2017; 6:JAHA.116.004758. [PMID: 28232324 PMCID: PMC5524010 DOI: 10.1161/jaha.116.004758] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Antihypertensive medication use may vary by race and ethnicity. Longitudinal antihypertensive medication use patterns are not well described in women. Methods and Results Participants from the Study of Women's Health Across the Nation (SWAN), a prospective cohort of women (n=3302, aged 42–52), who reported a diagnosis of hypertension or antihypertensive medication use at any annual visit were included. Antihypertensive medications were grouped by class and examined by race/ethnicity adjusting for potential confounders in logistic regression models. A total of 1707 (51.7%) women, mean age 50.6 years, reported hypertension or used antihypertensive medications at baseline or during follow‐up (mean 9.1 years). Compared with whites, blacks were almost 3 times as likely to receive a calcium channel blocker (odds ratio, 2.92; 95% CI, 2.24–3.82) and twice as likely to receive a thiazide diuretic (odds ratio, 2.38; 95% CI, 1.93–2.94). Blacks also had a higher probability of reporting use of ≥2 antihypertensive medications (odds ratio, 1.95; 95% CI, 1.55–2.45) compared with whites. Use of angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers and thiazide diuretics increased over time for all racial/ethnic groups. Contrary to our hypothesis, rates of β‐blocker usage did not decrease over time. Conclusions Among this large cohort of multiethnic midlife women, use of antihypertensive medications increased over time, with angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers becoming the most commonly used antihypertensive medication, even for blacks. Thiazide diuretic utilization increased over time for all race/ethnic groups as did use of calcium channel blockers among blacks; both patterns are in line with guideline recommendations for the management of hypertension.
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Affiliation(s)
- Elizabeth A Jackson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI
| | - Kristine Ruppert
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA
| | - Carol A Derby
- The Saul R. Korey Department of Neurology, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Yinjuan Lian
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA
| | - Genevieve Neal-Perry
- Division of Reproductive Endocrinology & Infertility, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Laurel A Habel
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Ping G Tepper
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, PA
| | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Daniel H Solomon
- Division of Rheumatology, Division of Pharmacoepidemiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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50
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Paramsothy P, Harlow SD, Nan B, Greendale GA, Santoro N, Crawford SL, Gold EB, Tepper PG, Randolph JF. Duration of the menopausal transition is longer in women with young age at onset: the multiethnic Study of Women's Health Across the Nation. Menopause 2017; 24:142-149. [PMID: 27676632 PMCID: PMC5266650 DOI: 10.1097/gme.0000000000000736] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The menopausal transition (MT) is a critical period associated with physiologic changes that influence women's long-term health and longevity. Information is, however, limited regarding factors that influence age at the onset of the MT and its duration (ie, time from MT onset to the final menstrual period). METHODS We analyzed data for 1,145 women from four sites of the Study of Women's Health Across the Nation who participated in the menstrual calendar substudy, had the start of the MT identified, and had no missing covariate information. Participants included from four racial/ethnic groups: African American, white, Chinese, and Japanese. Women completed daily menstrual calendars from 1996 to 2006 and questions on hormone therapy use monthly. Baseline measures included education, economic strain, and menstrual cycle characteristics. Annual measures included height, weight, and smoking status. Cox proportional hazards models were used to analyze the data. RESULTS The adjusted median duration of the MT ranged from 4.37 years among the oldest age-at-onset quartile to 8.57 years among the youngest age-at-onset quartile (P < 0.001). Cigarette smoking was associated with an earlier onset (P < 0.001) and a shorter duration (P < 0.001). African American women had a longer duration (P = 0.012) than white women. Body mass index was associated with a later onset of the MT (P = 0.001) but not its duration. CONCLUSIONS The duration of the MT was largely influenced by the age at which it began: earlier onset was associated with a longer transition. This finding provides a strong rationale for developing improved markers of the onset of the early MT.
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Affiliation(s)
- Pangaja Paramsothy
- 1Department of Epidemiology 2Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI 3Division of Geriatrics, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA 4Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO 5Division of Preventive & Behavioral Medicine, University of Massachusetts Medical School, Worcester, MA 6Department of Public Health Sciences, University of California Davis, Davis, CA 7Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 8Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI
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