Ethnoracial Differences in Premenopausal Hysterectomy: The Role of Symptom Severity

OBJECTIVE

To evaluate whether greater symptom severity can explain higher hysterectomy rates among premenopausal non-Hispanic Black compared with White patients in the U.S. South rather than potential overtreatment of Black patients.

METHODS

Using electronic health record data from 1,703 patients who underwent hysterectomy in a large health care system in the U.S. South between 2014 and 2017, we assessed symptom severity to account for differences in hysterectomy rates for noncancerous conditions among premenopausal non-Hispanic Black, non-Hispanic White, and Hispanic patients. We used Poisson generalized linear mixed modeling to estimate symptom severity (greater than the 75th percentile on composite symptom severity scores of bleeding, bulk, or pelvic pain) as a function of race-ethnicity. We calculated prevalence ratios (PRs). We controlled for factors both contra-indicating and contributing to hysterectomy.

RESULTS

The overall median age of non-Hispanic White (n=1,050), non-Hispanic Black (n=565), and Hispanic (n=158) patients was 40 years. The White and Black patients were mostly insured (insured greater than 95%), whereas the Hispanic patients were often uninsured (insured 58.9%). White and Black patients were mostly treated outside academic medical centers (nonmedical center: 63.7% and 58.4%, respectively); the opposite was true for Hispanic patients (nonmedical center: 34.2%). Black patients had higher bleeding severity scores compared with Hispanic and White patients (median 8, 7, and 4 respectively) and higher bulk scores (median 3, 1, and 0, respectively), but pain scores differed (median 3, 5, and 4, respectively). Black and Hispanic patients were disproportionately likely to have severe symptoms documented on two or more symptoms (referent: not severe on any symptoms) (adjusted PR [Black vs White] 3.02, 95% CI 2.29-3.99; adjusted PR [Hispanic vs White] 2.61, 95% CI 1.78-3.83). Although Black and Hispanic patients were more likely to experience severe symptoms, we found no racial and ethnic differences in the number of alternative treatments attempted before hysterectomy.

CONCLUSION

We did not find evidence of overtreatment of Black patients. Our findings suggest potential undertreatment of Black and Hispanic patients with uterine-sparing alternatives earlier in their disease progression.

Racial differences in body composition and cardiometabolic risk during the menopause transition: a prospective, observational cohort study

BACKGROUND

Obesity disproportionately affects more women than men. The loss of ovarian function during the menopause transition coincides with weight gain, increases in abdominal adiposity, and impaired metabolic health. Racial differences in obesity prevalence that results from the menopause transition are not well understood.

OBJECTIVE

The purpose of the study was to assess longitudinal changes in body composition and cardiometabolic risk among black and white women during the menopausal transition.

STUDY DESIGN

In a secondary analysis of a prospective, observational cohort study (the Healthy Transitions study), 161 women ≥43 years old with a body mass index of 20-40 kg/m² and who had not yet transitioned through menopause were enrolled at Pennington Biomedical Research Center. Women were seen annually for body composition by dual-energy X-ray absorptiometry, for abdominal adipose tissue distribution by computed tomography, for sex steroid hormones, and for cardiometabolic risk factors that include fasting glucose, insulin, and lipids. Surrogate measures of insulin sensitivity were also calculated.

RESULTS

Ninety-four women (25 black, 69 white) transitioned through menopause and were included within the analyses. At menopause onset, black women weighed more (77.8±3.0 vs 70.8±1.8 kg) and had a higher systolic (125±16 vs 118±14 mm Hg) and diastolic (80±8 vs 74±7 mm Hg) blood pressure compared with white women (all P≤.05). No other differences in body composition, sex steroid hormones, or cardiometabolic risk factors were observed at menopause onset. Before menopause, white women gained significant weight (3 kg), total body adiposity (6% percent body fat, 9% fat mass, 12% trunk fat mass) and abdominal adipose tissue (19% subcutaneous fat, 15% visceral fat, 19% total adipose tissue), which coincided with significant decreases in estradiol, sex hormone-binding globulin, and estrone sulfate and increases in follicle-stimulating hormone, total cholesterol, and low-density lipoprotein cholesterol. Conversely, black women had more abdominal adipose tissue before menopause, which was maintained across the menopause transition. Black women also had significant decreases in estrone sulfate and total testosterone and increases in follicle-stimulating hormone before menopause. In the postmenopausal years, abdominal subcutaneous adipose tissue, total adipose tissue, follicle-stimulating hormone, total cholesterol, and low-density and high-density lipoprotein cholesterol increased only in white women.

CONCLUSION

White women gained more abdominal adiposity during the menopause transition compared with black women, which, in part, may be due to differences in the pattern of sex steroid hormone changes between women of different racial backgrounds. The gains in abdominal adiposity in white women were observed in tandem with increased cardiometabolic risk factors. Future studies should consider comprehensive lifestyle approaches to target these increased gains in abdominal adiposity (ie, nutrition and physical activity coaching), while taking into account the potential interactions of race, body adiposity, sex steroid hormones, and their influence on cardiometabolic risk.

Polycystic Ovary Syndrome Signs and Metabolic Syndrome in Premenopausal Hispanic/Latina Women: the HCHS/SOL Study

CONTEXT

Polycystic ovary syndrome (PCOS), a condition of androgen excess in women, is associated with cardiometabolic risk factors; however, this association is not fully characterized in a population-based sample of premenopausal women and high-risk groups such as Hispanics/Latinas.

OBJECTIVE

We examined the association of PCOS signs and metabolic syndrome (MetS) in premenopausal Hispanic/Latina women.

METHODS

This cross-sectional analysis includes 1427 women age 24 to 44 years from the Hispanic Community Health Study/Study of Latinos. PCOS signs included menstrual cycle greater than 35 days or irregular, self-reported PCOS, and oral contraceptive use to regulate periods or acne, and a composite of 1 or more PCOS signs. We calculated odds ratios (OR) and 95% CI for MetS, accounting for sociodemographic factors and the complex survey design; an additional model included body mass index (BMI).

RESULTS

The mean age was 34 years and 30% reported any PCOS sign. The odds of MetS were higher in women reporting cycles greater than 35 days or irregular (OR 1.63; CI: 1.07-2.49) vs cycles 24 to 35 days, self-reported PCOS (OR 2.49; CI: 1.38-4.50) vs no PCOS, and any PCOS sign (OR 1.58; CI: 1.10-2.26) vs none. We found no association between OC use to regulate periods or acne and MetS (OR 1.1; CI: 0.6-1.8). When adjusting for BMI, only the association of self-reported PCOS and MetS was attenuated (OR 1.78; CI: 0.92-3.44).

CONCLUSIONS

In Hispanic/Latina women, irregular menstrual cycles, self-reported PCOS, and any PCOS sign were associated with MetS and could indicate women at metabolic disease risk.

Association of high-density lipoprotein, triglycerides, and homocysteine with bone mineral density in young Indian tribal women

This study investigated association between lipids and homocysteine (Hcy) with bone mineral density (BMD) in young women as opposed to previous studies on elderly women. HDL, triglyceride, and Hcy are significantly associated with BMD in young women and tobacco and alcohol consumption have no effect on this association.

PURPOSE

The present study investigates whether the association of serum lipids and homocysteine (Hcy) with bone mineral density (BMD) reported mostly in elderly population can be generalized to young or premenopausal women, consequently suggesting screening of young women with low BMD for dyslipidemia or any cardiovascular events and vice versa.

METHODS

Women (n = 293, aged 20-47 years) from Northeast India belonging to Tibeto-Burman origin were enrolled. Information about their physical and clinical attributes were collected by a structured questionnaire. Their BMDs at lumbar spine and femur were measured by dual-energy X-ray absorptiometry (DXA) and sera were profiled for lipid parameters and Hcy by auto-analyzer and ELISA, respectively. Women consuming tobacco and/or alcohol were grouped as consumers and others as non-consumers for the analysis.

RESULTS

Positive correlation of BMD with HDL (spine and femur r = 0.38, p < 0.0001) and triglyceride (spine r = 0.534, p < 0.0001; femur r = 0.423, p < 0.0001) was observed, whereas Hcy correlated negatively with BMD (spine r = - 0.189, p = 0.0026; femur r = - 0.273, p < 0.0001). LDL showed a weak negative correlation with BMD (spine r = - 0.128, p = 0.0283; femur r = - 0.199, p = 0.0006). However, after adjusting for age, BMI, and consumption, HDL, triglyceride, and Hcy continued to show significant correlation with BMD at both the sites. Logistic regression analyses indicated that HDL, triglyceride, and Hcy were significant predictors of osteopenia and osteoporosis in our study cohort; however, consumption did not contribute to its prediction.

CONCLUSION

Low levels of HDL and triglyceride and high levels of Hcy are significantly associated with osteopenia and osteoporosis in young Northeast Indian women.

Menstrual Cycle Hormone Changes in Women Traversing Menopause: Study of Women's Health Across the Nation

CONTEXT

Menstrual cycle hormone patterns in women approaching menopause are inadequately studied.

OBJECTIVE

To describe day-to-day menstrual cycle hormones in women as they approach menopause from the Study of Women's Health Across the Nation Daily Hormone Study (DHS).

DESIGN

DHS enrollees collected daily urine for one entire menstrual cycle or up to 50 days, whichever came first, annually, up to the final menstrual period (FMP) or for up to 10 years.

SETTING

Seven sites across the United States.

PARTICIPANTS

A total of 511 premenopausal or early perimenopausal women at enrollment, within 10 years before menopause.

INTERVENTION

Time-to-FMP measurement.

MAIN OUTCOME MEASURES

Evidence of luteal activity (ELA), determined using objective algorithms. Menstrual cycle/segment length; whole cycle, and segment integrated urinary luteinizing hormone, follicle-stimulating hormone, estrone conjugates, and pregnanediol glucuronide (Pdg) for each year, organized around the FMP.

RESULTS

Mean menstrual cycle length was remarkably preserved at 26 to 27 days in ELA cycles; non-ELA cycles had greater variability. The percentage of cycles that were ELA remained high until 5 years before the FMP (87.9%); only 22.8% of cycles within 1 year of the FMP were ELA. Whole cycle hormones remained relatively stable up to 3 years before the FMP, when gonadotropins began to increase. Pdg excretion declined slowly with progress to the FMP, but Pdg patterns of ELA cycles remained distinguishable from non-ELA.

CONCLUSIONS

Menstrual cycle hormone patterns in perimenopausal women resemble those of midreproductive-aged women until 5 years before menopause, and presumably ovulatory cycles retain a potentially fertile pattern up to the end of reproductive life.

Haematological reference intervals in a multiethnic population

INTRODUCTION

Similar to other populations, full blood count reference (FBC) intervals in Malaysia are generally derived from non-Malaysian subjects. However, numerous studies have shown significant differences between and within populations supporting the need for population specific intervals.

METHODS

Two thousand seven hundred twenty five apparently healthy adults comprising all ages, both genders and three principal races were recruited through voluntary participation. FBC was performed on two analysers, Sysmex XE-5000 and Unicel DxH 800, in addition to blood smears and haemoglobin analysis. Serum ferritin, soluble transferrin receptor and C-reactive protein assays were performed in selected subjects. All parameters of qualified subjects were tested for normality followed by determination of reference intervals, measures of central tendency and dispersion along with point estimates for each subgroup.

RESULTS

Complete data was available in 2440 subjects of whom 56% (907 women and 469 men) were included in reference interval calculation. Compared to other populations there were significant differences for haemoglobin, red blood cell count, platelet count and haematocrit in Malaysians. There were differences between men and women, and between younger and older men; unlike in other populations, haemoglobin was similar in younger and older women. However ethnicity and smoking had little impact. 70% of anemia in premenopausal women, 24% in postmenopausal women and 20% of males is attributable to iron deficiency. There was excellent correlation between Sysmex XE-5000 and Unicel DxH 800.

CONCLUSION

Our data confirms the importance of population specific haematological parameters and supports the need for local guidelines rather than adoption of generalised reference intervals and cut-offs.

Racial differences in adiponectin and leptin in healthy premenopausal women

The aim of this article is to longitudinally investigate racial differences in serum adiponectin and leptin in European-American (EA) and African-American (AA) women in the overweight and weight-reduced states. Sixty-two EA and 58 AA premenopausal women were weight reduced from body mass index (BMI) 27-30 kg/m(2) to BMI ≤ 24. Fasting serum adiponectin and leptin were determined; body composition and intra-abdominal adipose tissue (IAAT) were measured with dual-energy X-ray absorptiometry and computed tomography, respectively. In repeated-measure MANOVA, there was a significant race effect for IAAT and total fat mass; compared to AA women, EA women had higher IAAT and total fat mass (p < 0.0001 and p = 0.027, respectively). In the mixed-model for adiponectin that adjusted for IAAT, limb fat, and total fat, race was significantly associated with adiponectin (p = 0.046). AA women had significantly lower adjusted adiponectin compared to EA women at baseline [7.67 (6.85, 8.60) vs. 9.32 (8.34, 10.4) μg/ml, p < 0.05] and following weight loss [9.75 (8.70, 10.9) vs. 11.8 (10.6, 13.2) μg/ml, p < 0.05]. In a mixed-model for leptin that adjusted for insulin, estradiol, and fat mass, race was significantly associated with leptin (p < 0.0001). AA women had significantly higher adjusted leptin compared to EA women at baseline [24.7 (22.3, 27.4) vs. 19.9 (18.1, 21.8) ng/dl, p < 0.05] and following weight loss [11.7 (10.2, 13.3) vs. 8.48 (7.50, 9.57) ng/dl, p < 0.05]. Despite having a more favorable body fat distribution, AA women had lower adjusted adiponectin and higher leptin. Differences in body composition and fat distribution do not appear to be significant factors in explaining lower adiponectin and higher leptin in AA women.

Associations between body size and serum estradiol and sex hormone-binding globulin levels in premenopausal African American women

CONTEXT

African American (AA) women have the highest rates of premenopausal breast cancer; however, it is unclear whether body size contributes to the hormonal patterns potentially associated with increased breast cancer risk in these women.

OBJECTIVE

To characterize the association between body size and serum levels of estradiol and sex hormone-binding globulin (SHBG) levels in a sample of premenopausal AA women.

DESIGN

A total of 164 premenopausal AA women who were not pregnant or breastfeeding were recruited for this study. Serum samples were collected during the early follicular phase, and trained staff collected body size measurements. Multiple linear regression models were performed to assess potential associations.

MAIN OUTCOME MEASURES

Serum estradiol and SHBG levels.

RESULTS

Many (81%) of the women enrolled were overweight or obese. Both waist-to-hip ratio (WHR) (β = 2.68, P = .008) and waist circumference (WC) (β = 2.02, P = .046) were positively associated with higher levels of estradiol. All measures of body was significantly and inversely associated with SHBG levels (all P < .05).

CONCLUSIONS

Premenopausal AA women with higher WHR or larger WC may have higher levels of estradiol and lower levels of SHBG. Thus, WHR or WC may be better indicators for assessing hormonal patterns implicated in breast cancer pathogenesis in these women.

Volumetric bone mineral density at the spine and hip in Chinese American and White women

This study evaluated racial differences in bone size and volumetric density at the spine and hip in pre- and postmenopausal Chinese American and White women. Compared with White women, Chinese American women have greater cortical volumetric bone density (vBMD) at the hip, congruent with the results at the peripheral skeleton.

INTRODUCTION

Chinese American women have lower rates of fracture than White women despite lower areal bone density. At the forearm and tibia, however, Chinese American women have higher cortical vBMD as well as greater trabecular and cortical thickness, but smaller bone area as measured by high-resolution peripheral quantitative computed tomography (HR-pQCT) compared with White women. Since HR-pQCT data are obtained at peripheral sites, it is unclear whether these differences are relevant to the clinically important lumbar spine and hip. This study assesses racial differences in bone size and vBMD at the spine and hip in Chinese American and White women.

METHODS

QCT of the spine and hip was measured to assess racial differences in bone size, structure, and vBMD in pre- (n = 83) and postmenopausal (n = 50) Chinese American and White women. Data were adjusted for weight, height, physical activity, total calcium intake, parathyroid hormone, and 25-hydroxyvitamin D levels.

RESULTS

Among premenopausal women, lumbar spine trabecular vBMD was 5.8% greater in Chinese American versus White women (p = 0.01). At the hip, cortical vBMD was 3% greater at the femoral neck (p = 0.05) and 3.6% greater at the total hip (p = 0.01) in premenopausal Chinese American compared with White women. Among postmenopausal women, there was no difference in lumbar spine trabecular vBMD. Cortical vBMD was 4% greater at the total hip (p = 0.02) and tended to be greater at the femoral neck (p = 0.058) in Chinese American versus White women.

CONCLUSIONS

Consistent with earlier findings in the peripheral skeleton, cortical vBMD is greater at the hip in Chinese American versus White women.

Ethnic differences in composite indices of femoral neck strength

Bone mineral density does not explain race/ethnicity differences in hip fracture risk. In this study, we demonstrated that race/ethnicity differences in composite hip strength indices were consistent with documented race/ethnicity differences in hip fracture risk, suggesting that unlike bone density, the composite indices may represent ethnicity-independent measures of bone strength.

INTRODUCTION

African-American and Asian women have lower risks of hip fracture than Caucasian women, but such racial/ethnic variation in hip fracture risk cannot be explained by bone mineral density (BMD). The composite indices of femoral neck strength integrate femoral neck and body size with BMD and predict hip fracture risk in Caucasian women. We hypothesize that unlike race/ethnic differences in BMD, race/ethnic differences in the composite strength indices would be consistent with race/ethnic differences in hip fracture risk.

METHODS

We studied a community-based sample of Caucasian (n = 968), African-American (n = 512), Chinese (n = 221), and Japanese (n = 239) women, premenopausal or in early perimenopause, from the Study of Women's Health Across the Nation.

RESULTS

Unadjusted indices were similar in Caucasian and African-American women but higher in Asian women. After adjusting for age, body mass index, and menopause status, all three minority groups had higher composite strength indices than Caucasian women. Foreign-born Japanese women had higher unadjusted and adjusted composite strength indices than US-born Japanese women, but such differences by nativity were not observed in Chinese women.

CONCLUSION

We concluded that composite strength indices have the potential to explain racial/ethnic differences in hip fracture risk, suggesting that composite strength indices may represent ethnicity-independent measures of bone strength. This contention needs to be verified by further research on the fracture predictive ability of composite strength indices in multi-ethnic longitudinal cohorts.

Site-specific differences in bone mineral density in black and white premenopausal South African women

SUMMARY

We examined ethnic differences in bone mineral density (BMD) and the contribution of body composition, lifestyle and socioeconomic factors in South African women. Femoral neck and total hip BMD were higher, but lumbar spine BMD was lower in black women, with body composition, lifestyle and socioeconomic status (SES) factors contributing differently in ethnic groups.

INTRODUCTION

There is a paucity of data on the relative contribution of body composition, lifestyle factors and SES, unique to different ethnic groups in South Africa, to BMD. We examined differences in femoral neck (FN), total hip (TH) and lumbar spine (LS) BMD between black and white premenopausal South African women and the associations between BMD and body composition, lifestyle factors and SES in these two ethnic groups.

METHODS

BMD and body composition were measured in 240 black (27 ± 7; 18-45 years) and 187 white (31 ± 8; 18-45 years) women using dual-energy X-ray absorptiometry. Questionnaires were administered to examine SES, physical activity and dietary intake.

RESULTS

After co-varying for age, FN and TH were higher in black than white women (FN 0.882 ± 0.128 vs. 0.827 ± 0.116 g/cm(2), P < 0.001; TH 0.970 ± 0.130 vs. 0.943 ± 0.124 g/cm(2), P = 0.018). When adjusting for ethnic differences in body composition, LS was higher in white than black women. In black women, fat-free soft tissue mass, SES and injectable contraceptive use explained 33-42% of the variance in BMD at the hip sites and 22% at the LS. In white women, fat-free soft tissue mass and leisure activity explained 24-30% of the variance in BMD at the hip sites, whereas fat mass, leisure activity and oral contraceptive use explained 11% of the variance at the LS.

CONCLUSION

FN and TH BMD were higher, but LS BMD was lower in black than white South African women with body composition, lifestyle and SES factors contributing differently to BMD in these women.

Associations of fat mass and fat distribution with bone mineral density in pre- and postmenopausal Chinese women

Fat mass (FM) is closely related to bone mineral density (BMD). However, the associations of FM and fat distribution with BMD in pre- and postmenopausal women are still poorly understood. The present study showed android fat mass accumulation after menopause had a negative association with BMD.

INTRODUCTION

FM is closely related to BMD. However, it is unknown whether FM and central fat distribution have different associations with BMD in pre- and postmenopausal women. The study aims to investigate the associations of FM and fat distribution with BMD in pre- and postmenopausal Chinese women.

METHODS

Two hundred sixty premenopausal and 267 postmenopausal women aged 18 to 79 years were analyzed. Lean mass (LM), FM, percent body fat (%BF), android FM, gynoid FM, and total and regional BMD were measured using dual-energy X-ray absorptiometry. Fat distribution was assessed by android to gynoid FM ratio (AOI). Multiple regression analysis was performed to examine the associations of BMD with FM, LM, and AOI.

RESULTS

FM, %BF, android FM, and AOI were significantly higher, whereas total and regional BMD were significantly lower in postmenopausal women (all р < 0.01). In premenopausal women, FM was positively associated with total and regional BMD (all р < 0.05). AOI had no significant association with BMD. In postmenopausal women, FM was significantly associated with total and regional BMD even additionally adjusting for LM (all р < 0.01). AOI had significantly negative association with total, head, arm, and leg BMD (all р < 0.05). The results remained unchanged when replacing FM with %BF.

CONCLUSIONS

There were different associations of FM and fat distribution with BMD in pre- and postmenopausal Chinese women. Increased central body fat had a negative association with BMD. Our findings may have significant implications in the prevention of menopause-related osteoporosis through reducing centralized fat deposition.

Fat distribution, aerobic fitness, blood lipids, and insulin sensitivity in African-American and European-American women

The purpose of this study was to determine independent relationships of intra-abdominal adipose tissue (IAAT), leg fat, and aerobic fitness with blood lipids and insulin sensitivity (S(i)) in European-American (EA) and African-American (AA) premenopausal women. Ninety-three EA and ninety-four AA with BMI between 27 and 30 kg/m(2) had IAAT by computed tomography, total fat and leg fat by dual-energy X-ray absorptiometry, aerobic fitness by a graded exercise test, African admixture (AFADM) by ancestry informative markers, blood lipids by the Ektachem DT system, and S(i) by glucose tolerance test. Independent of age, aerobic fitness, AFADM, and leg fat, IAAT was positively related to low-density lipoprotein-cholesterol (LDL-C), cholesterol-high-density lipoprotein (HDL) ratio, triglycerides (TGs), and fasting insulin (standardized beta varying 0.16-0.34) and negatively related to HDL-cholesterol (HDL-C) and S(i) (standardized beta -0.15 and -0.25, respectively). In contrast, independent of age, aerobic fitness, AFADM, and IAAT, leg fat was negatively related to total cholesterol, LDL-C, cholesterol-HDL ratio, TGs, and fasting insulin (standardized beta varying -0.15 to -0.21) and positively related to HDL-C and S(i) (standardized beta 0.16 and 0.23). Age was not independently related to worsening of any blood lipid but was related to increased S(i) (standardized beta for S(i) 0.25, insulin -0.31). With the exception of total cholesterol and LDL-C, aerobic fitness was independently related to worsened blood lipid profile and increased S(i) (standardized beta varying 0.17 to -0.21). Maintenance of favorable fat distribution and aerobic fitness may be important strategies for healthy aging, at least in premenopausal EA and AA women.

Racial differences in body fat distribution among reproductive-aged women

We examined the influence of race/ethnicity on body fat distribution for a given body mass index (BMI) among reproductive-aged women. Body weight, height, and body fat distribution were measured with a digital scale, wall-mounted stadiometer, and dual-energy x-ray absorptiometry, respectively, on 708 healthy black, white, and Hispanic women 16 to 33 years of age. Multiple linear regression was used to model the relationship between race/ethnicity and different body fat distribution variables after adjusting for BMI, age at menarche, and demographic and lifestyle variables. For a given BMI, white women had the highest total fat mass (FM(total)), trunk fat mass (FM(trunk)), and leg fat mass (FM(leg)), whereas Hispanic women had the highest percentage of FM(trunk) (%FM(trunk)) and trunk-to-limb fat mass ratio (FMR(trunk-to-limb)). Conversely, black women had the lowest FM(total), FM(trunk), percentage body fat mass (%FM), %FM(trunk), and FMR(trunk-to-limb), and the highest percentage of FM(leg). The %FM was similar in whites and Hispanics and lower in blacks. The race x BMI interactions were significant for almost all of the body fat distribution variables. Increasing in differences with increasing BMI were apparent between blacks and whites in FM(trunk), %FM(trunk), FMR(trunk-to-limb), %FM(leg), and %FM, and between blacks and Hispanics in FM(trunk), %FM(trunk), FMR(trunk-to-limb), and FM(leg). In summary, the distribution of body fat for a given BMI differs by race among reproductive-aged women. These findings raise questions regarding universally applied BMI-based guidelines for obesity and have implications for patient education regarding individual risk factors for cardiovascular disease and metabolic complications.

IAAT, catecholamines, and parity in African-American and European-American women

OBJECTIVE

We have recently reported that parous European-American (EA) women have disproportionately more intra-abdominal adipose tissue (IAAT) than their nulliparous counterparts. Mediating mechanisms for IAAT accumulation remain unknown; however, some evidence suggests a possible catecholamine link. The objective of this study was to determine whether the IAAT-parity relationship found in EA women exists in African-American (AA) women and to determine whether catecholamines play a mediating role.

METHODS AND PROCEDURES

Subjects included 44 EA and 47 AA premenopausal women. Free-living physical activity by doubly labeled water (activity-related time equivalent (ARTE)), body composition (air plethysmography, computed tomography), and 24-h fractionated urinary catecholamines were measured.

RESULTS

Repeated measures ANOVA revealed parous EA and AA women had significantly higher IAAT than their nulliparous counterparts (100.1 +/- 28.5 and 76.2 +/- 34.8 cm(2) vs. 75.9 +/- 29.1 and 59.6 +/- 15.0 cm(2)). In AA women and nulliparous women, 24-h urinary dopamine was significantly higher (AA parous 260.8 +/- 88; EA parous 197.2 +/- 78.8; AA nulliparous 376.5 +/- 81; EA nulliparous 289.6 +/- 62). Multiple regression analysis for modeling IAAT indicated that race, parity, dopamine, ARTE, and VO(2max) were all significant and independent contributors to the model (Unstandardized betas: race -32.6 +/- 7.4; parity (number of births) 10.0 +/- 3.4; 24-h urinary dopamine 0.08 +/- 0.04; ARTE (min/day) -0.09 +/- 0.04; VO(2max) (ml/kg/min) -2.8 +/- 1.0).

DISCUSSION

Independent of the potential confounders: age, race, percent body fat, IAAT, 24-h fractionated urinary catecholamines, physical activity, and VO(2max), parous EA and AA women had more IAAT than their nulliparous counterparts. Of the catecholamines, dopamine was found to be significantly lower in parous women and higher in AA's. Dopamine, however, did not explain racial or parity differences in IAAT.

Higher post-absorptive skeletal muscle LPL activity in African American vs. non-Hispanic White pre-menopausal women

OBJECTIVE

Higher post-absorptive post-heparin plasma lipoprotein lipase (LPL) activity has been reported in African Americans as compared to non-Hispanic whites but differences in tissue-specific LPL activity are unclear.

METHODS AND PROCEDURES

Post-absorptive skeletal muscle (SM)-LPL (vastus lateralis ) and subcutaneous abdominal adipose tissue (AT)-LPL activity was measured in overweight, sedentary African American females (n = 11) as well as in their non-Hispanic white counterparts (n = 6) during a period of controlled low fat (30%) diet (for 10 days) combined with physical activity (for days 8-10). Post-absorptive substrate utilization was measured on day 10; fasting blood levels and SM and AT biopsies were obtained on day 11.

RESULTS

African Americans had significantly greater post-absorptive SM-LPL activity (P = 0.04) when compared to non-Hispanic whites. There were no significant differences in post-absorptive AT-LPL activity, free fatty acids, and systemic fat oxidation or respiratory quotient between African American and white non-Hispanic women in this study (P > 0.2 for all).

DISCUSSION

During a controlled low fat (30%) diet post-absorptive vastus lateralis SM-LPL activity is higher in sedentary pre-menopausal African American as compared to non-Hispanic white women.

The Association Between Mammographic Breast Density and Bone Mineral Density in the Study of Women's Health Across the Nation

BACKGROUND

Bone mineral density and mammographic breast density are each associated with markers of lifetime estrogen exposure. The association between mammographic breast density and bone mineral density in early perimenopausal women is unknown.

METHODS

We analyzed data from a cohort (n = 501) of premenopausal (no change in menstrual regularity) and early perimenopausal (decreased menstrual regularity in past 3 months) participants of African-American, Caucasian, Chinese, and Japanese ethnicity in the Study of Women's Health Across the Nation. Using multivariable linear regression, we examined the cross-sectional association between percent mammographic density and bone mineral density (BMD).

RESULTS

Percent mammographic density was statistically significantly inversely associated with hip BMD and lumbar spine BMD after adjustment (body mass index, ethnicity, age, study site, parity, alcohol intake, cigarette smoking, physical activity, age at first childbirth) in early perimenopausal, but not premenopausal, women. In early perimenopausal women, every 0.1g/cm(2) greater hip BMD predicted a 2% lower percent mammographic density (95% confidence interval -37.0 to -0.6%, p = 0.04).

CONCLUSION

Mammographic breast density is inversely associated with BMD in the perimenopausal participants of this community-based cohort. The biological underpinnings of these findings may reflect differential responsiveness of breast and bone mineral density to the steroid milieu.

Ethnic differences in C-peptide secretion but not in non-esterified fatty acid metabolism in pre-menopausal women with and without abdominal obesity

The present study aimed to reveal racial differences in the metabolic pattern of C-peptide and non-esterified fatty acids (NEFA), and in their associations with cardiovascular measures in healthy urban African (102) and Caucasian women (115) from South Africa. An oral glucose tolerance test was performed with measurements before and at 30, 60, 90 and 120min. Various cardiovascular parameters and blood lipids were assessed. Statistical analyses were done in a sub-sample of pre-menopausal women. Fasting C-peptide and hepatic insulin extraction were significantly higher in lean African women compared to their Caucasian counterparts, with no racial differences between women with abdominal obesity. Postchallenge C-peptide response and hepatic insulin extraction were significantly higher in Caucasians with abdominal obesity. There were no racial differences in insulin sensitivity and resistance. Despite different associations of C-peptide and NEFA with cardiovascular measures between the ethnicities both showed significant positive correlations with triglycerides. Increased fasting C-peptide levels and unfavorable associations of C-peptide and NEFA with triglycerides and cardiovascular measures implicate a higher cardiovascular risk in lean African women only. This may be of importance for the development of hypertension in this population group.

Symptom experience and self-care strategies among healthy, midlife African-American women

The transition into menopause is an experience that is unique to every woman. This experience can encompass anything from an occasional hot flash to complete and utter distress. Considerable attention is being paid to African-American women as they transition through menopause, but their use of symptom self-care strategies is an area that would benefit from further research. Findings from this study are part of a larger five-year study exploring biopsychosocial health and wellness among diverse midlife women. This report includes identification of symptom prevalence, symptom distress, and self-care strategies used by midlife African-American women during a six-month time period. Prevalent or severe symptoms included fatigue, headaches, cramps, night sweats, and depression. Most self-care strategies were "passive" strategies, such as 'faith," "think," "accept," or "value/believe/forgive self". It is recommended that health-care providers inquire about other symptoms that might accompany classic vasomotor menopausal symptoms and identify "active" self-care strategies that ameliorate specific symptoms.

Genetic and environmental influences on bone mineral density in pre- and post-menopausal women

Genetic factors influencing acquisition of peak bone mass account for a substantial proportion of the variation in bone mineral density (BMD), although the extent to which genes also contribute to variation in bone loss is debatable. Few prospective studies of related individuals have been carried out to address this issue. To gain insights into the nature of the genetic factors contributing to variation in BMD, we studied 570 women from large Amish families. We evaluated and compared the genetic contributions to BMD in pre- and post-menopausal women, with the rationale that genetic variation in pre-menopausal women is due primarily to genetic determinants of peak bone mass, while genetic variation in post-menopausal women is due to the combined genetic effects of peak bone mass and bone loss. Bone mineral density was measured at one point in time at the hip and spine by dual energy X-ray absorptiometry (DXA). We used variance decomposition procedures to partition variation in BMD into genetic and environmental effects common to both groups and to pre- and post-menopausal women separately. Total variation in BMD was higher in post- compared to pre-menopausal women. Genes accounted for 58-88% of the total variation in BMD in pre-menopausal women compared to 37-54% of the total variation in post-menopausal women. In absolute terms, however, the genetic variance was approximately similar between the two groups because the environmental variance was 3 1/2- to 4-fold larger in the post-menopausal group. The genetic correlation in total hip BMD was 0.81 between pre- and post-menopausal women and differed significantly from one, consistent with the presence of at least some non-overlapping genetic effects in the two groups for BMD at this site. Overall, these analyses suggest that many, but not all, of the genetic factors influencing variation in BMD are common to both pre- and post-menopausal women.

Ethnic differences in osteocalcin gamma-carboxylation, plasma phylloquinone (vitamin K1) and apolipoprotein E genotype

OBJECTIVE

To investigate plasma osteocalcin gamma-carboxylation and its relationship to plasma phylloquinone concentration and apolipoprotein E (apoE) genotype in women from three ethnic groups with differing osteoporotic fracture risk.

DESIGN AND SUBJECTS

Fasted blood samples were collected from postmenopausal Gambian (n=50), British (n=31) and Chinese women (n=23), and 11 premenopausal women in each group from three cross-sectional studies.

RESULTS

After adjustment for total osteocalcin, plasma undercarboxylated osteocalcin (adjusted ucOC) was lowest in Chinese and highest in British women postmenopause (British vs Chinese 103% higher, P<0.0001; Gambian vs Chinese 66% higher, P<0.01). No differences were observed premenopause. Within each ethnic group, adjusted ucOC was similar pre- and postmenopause. Postmenopause, plasma phylloquinone was higher in Chinese women (1.0 ng/ml) than in British (0.31 ng/ml) and Gambian women (0.36 ng/ml) (P<0.0001). Premenopause, plasma phylloquinone was higher in Gambian and Chinese women (0.6 ng/ml) than in British women (0.3 ng/ml; P=0.01). Plasma phylloquinone and adjusted ucOC were inversely related in postmenopausal British women (R2=32.4%; P=0.0008). ApoE4 frequency was Gambian 32.6%, British 13.8% and Chinese 6%. A lower adjusted ucOC was associated with apoE2 genotype in British and Chinese women. Ethnic differences in adjusted ucOC persisted after adjustment for phylloquinone and apoE genotype.

CONCLUSION

These preliminary data indicate suboptimal vitamin K status in postmenopausal British compared to Chinese and Gambian women. Ethnic differences in apoE genotype may also influence osteocalcin gamma-carboxylation status. The study highlights the need for larger epidemiological investigations of ethnic differences in vitamin K status and the possible implications to bone health.

Genetic predictors of coronary heart disease risk factors in premenopausal African-American women

PURPOSE

This study examined polymorphisms at the loci HLA-DQB1, HLA-DRB1, TNFa microsatellite, and D6S89, all which lie within or telomeric to the major histocompatibility complex (MHC) and the apolipoprotein E (APOE) and THO-1 loci in premenopausal African-American women (AAW) for their association with known coronary heart disease (CHD) risk factors. The sample, drawn from community and military sources, included premenopausal AAW (mean age=34.18) who were at low risk (n=117) and high risk (n=173) for CHD.

METHODS

In this case- (high risk) control (low risk) study, venous blood was used for DNA extraction. Polymorphisms were assessed by using a variety of standard polymerase chain reaction (PCR) methods. Allelic controls were used in all reactions, and two individuals sized and concurred on allele assignment in each analysis. Vertical auto profile (VAPI), glucose challenge tests, measurement of insulin levels, blood pressure, body mass index (BMI), and waist-hip ratio (WHR) assessments were conducted by using standardized procedures. Pearson's correlation coefficients and assessment of allele distributions via relative frequency and frequency variance were conducted in relation to military status, risk group, and risk factors by using exact P values and likelihood ratio chi-squared (Irchi2) statistic. The significance level was set at .05.

RESULTS

Of the 237 women (low and high risk), 116 of the women in the sample were in Stage I obesity or heavier. Of 237 women (low and high risk), 85 (36%) of the women in this sample were insulin resistant. The frequency of D6589 allele 185, D6S89 allele 191, TNFa allele 97, and TNFa allele 103 alleles were higher in the high-risk than the low-risk group; and the D6S89 195 allele was higher in the low-risk group. Elevated systolic blood pressure (SBP) was associated with HLA-DRB1*09 and TNFa 117 alleles. APOE*4, TNFa 109, and DRB1*107 alleles were associated with increased relative risk for elevated total cholesterol to high-density lipoprotein (HDL) ratios. APOE*4 and D6589 193 alleles were associated with an elevated risk for low-density lipoprotein (LDL) or LDL sub-fraction levels. APOE*2 was associated with a lower relative risk for total cholesterol to HDL ratios. Metabolic syndrome was identified in 26.6% of the sample and was associated with the presence of DRB1*09, DRB1*12, and DRB1*15 alleles. Lp(a) levels were positively associated with risks for HDL, HDL2, HDL3, LDL, and total cholesterol. Lp(a) was negatively associated with risks for very low-density lipoprotein (VLDL), triglyceride, fasting blood sugar (FBS), insulin resistance, SBP, weight, and WHR.

CONCLUSION

The association of APOE, DRB1, D6589 and TNFa alleles with risk of CHD suggest that these are candidate genes or linked to genes for CHD in this cohort of AAW. Our data supported elevated plasma Lp(a) as a potential risk factor in AAW; however, its role is still unclear. The premenopausal AAW in this sample had a higher than expected rate of metabolic syndrome, which was associated with DRB1 alleles.

The relation between nutritional factors and insulin?like growth factor?I in premenopausal women of different ethnicity

BACKGROUND

Alterations in the insulin-like growth factor-I (IGF-I) system have been proposed as a metabolic link between nutritional factors and cancer risk.

AIM OF THE STUDY

This study explored dietary determinants of circulating IGF-I and IGF binding protein-3 (IGFBP-3) levels among premenopausal women from different ethnic groups.

METHODS

In a cross-sectional design, 258 women with a mean age of 43 +/- 2.7 years donated blood approximately 5 days after ovulation and completed a validated Food Frequency Questionnaire. The majority of the 97 Caucasian, 96 Asian, and 65 Mixed/Other subjects were born in the US. Serum concentrations of IGF-I and IGFBP-3 were measured by double-antibody ELISA. After creating quartiles for 13 food and 13 nutrient density variables, least-square means of IGF-I, IGFBP-3, and the IGF-I/IGFBP-3 ratio were calculated by quartile, while adjusting for age, ethnicity, body mass index, and year of laboratory analysis.

RESULTS

Whereas body mass index and dietary intakes varied significantly by ethnicity, IGF-I, IGFBP-3, and their ratio were similar by group. As the only food, fish showed a suggestive inverse association with IGF-I and the IGF-I/ IGFBP-3 ratio. Dietary fiber and vitamin A were positively related to IGF-I (p = 0.004 and 0.03), zinc with IGFB-3 (p = 0.0008), and iron with the IGF-I/IGFBP-3 ratio (p = 0.048), but the differences between the bottom and top quartile were less than 10%. Total energy, protein, carbohydrates, and total fat intake were not related to any serum measurements.

CONCLUSIONS

This study detected no ethnic differences in serum IGF-I, but it showed weak associations with dietary variables that require further investigation.

Cigarette smoking is associated with energy balance in premenopausal African-American adult women differently than in similarly aged white women

OBJECTIVE

To investigate the differential association of cigarette smoking with energy balance in African-American and white premenopausal women.

DESIGN

Cross-sectional study of energy balance, weight, and smoking in women.

SUBJECT

A total of 374 women: 191 African-American (mean age=29.8+/-6.5 y) and 183 white women (mean age=28.9+/-7.1 y).

MEASUREMENTS

Weight, cigarette smoking habits, resting energy expenditure, dietary intake, and physical activity.

RESULTS

There were no significant differences in dietary intake by race or smoking status. The model for physical activity was significant (P=0.0004), with body mass index (BMI) having the largest effect on activity (P<0.001). Smoking status was related to activity, with the heaviest smokers reporting more activity than nonsmokers (P=0.008) or light smokers (P=0.028). The model for resting energy expenditure (REE) was significant (P<0.0001), with the largest again being BMI (P<0.001). There was also an interaction between ethnicity and smoking status (P<0.0001) such that African-American nonsmokers and light smokers tended to have lower REE than several other groups, most often the African-American moderate heavy smokers. The model for BMI was significant (P<0.0001) with an interaction for ethnicity and smoking status (P=0.0009). African-American nonsmokers and light smokers had significantly higher BMIs than most of the other groups.

CONCLUSION

African-American women who were the heaviest smokers had a lower adjusted BMI than the heaviest smoking white women. This effect, at least partially, may be related to an increased REE in the African-American smoking women. While energy intake did not appear to be important in this relationship, energy expended in physical activity appeared to be increased with smoking, as was REE.

Weight gain among women in the late reproductive years

BACKGROUND

Given the impact of obesity on mortality and morbidity in women, we evaluated correlates of weight gain in women ages 35-47 years.

METHODS

Three hundred and thirty-six African American and Caucasian American women, randomly selected from among urban residents aged 35-47 years and pre-menopausal at baseline, were included in the prospective cohort study. Participants were followed over a 4-year period. Baseline measures included anthropometric variables, socio-demographic factors, measures of anxiety, depressed mood, quality of life, and self-reported measures of diet, vigorous physical activity, alcohol consumption and cigarette smoking. Hormone measurements were obtained during the follicular phase of the menstrual cycle. Weight gain was assessed by comparing the baseline weight with weight measured at the end of the 4-year period.

RESULTS

Over 25% of the cohort gained > or =10 lb during follow-up. Five of the 14 women (36%) who were considered menopausal gained weight. Women aged 45-47 were 61% less likely to gain > or =10 lb compared with women aged 35-39 [odds ratio (OR) = 0.39, 95% confidence interval (CI) 0.18-0.87]. Depressed mood was a major correlate of weight gain (OR = 1.9, 95% CI 1.09-3.31). Other psychological measures, including anxiety and quality of life, were similarly correlated with weight gain. No association was detected for levels of sex hormones or self-reported measures of physical activity. Most recalled dietary factors were not predictive of subsequent weight gain in our population.

CONCLUSIONS

In this population-based sample of women aged 35-47 years, psychological factors were the major predictors of gaining > or =10 lb during a 4-year follow-up period. Few of the other measures, including baseline hormone values, were correlated with subsequent weight gain. These findings suggest that screening for depression and anxiety may be important clinical assessments to identify women at increased risk of substantial weight gain.

The association of endogenous hormone concentrations and bone mineral density measures in pre- and perimenopausal women of four ethnic groups: SWAN

We evaluated bone mineral density (BMD), hormone concentrations and menstrual cycle status to test the hypothesis that greater variations in reproductive hormones and menstrual bleeding patterns in mid-aged women might engender an environment permissive for less bone. We studied 2336 women, aged 42-52 years, from the Study of Women's Health Across the Nation (SWAN) who self-identified as African-American (28.2%), Caucasian (49.9%), Japanese (10.5%) or Chinese (11.4%). Outcome measures were lumbar spine, femoral neck and total hip BMD by dual-energy X-ray densitometry (DXA). Explanatory variables were estradiol, testosterone, sex hormone binding globulin (SHBG) and follicle stimulating hormone (FSH) from serum collected in the early follicular phase of the menstrual cycle or menstrual status [premenopausal (menses in the 3 months prior to study entry without change in regularity) or early perimenopause (menstrual bleeding in the 3 months prior to study entry but some change in the regularity of cycles)]. Total testosterone and estradiol concentrations were indexed to SHBG for the Free Androgen Index (FAI) and the Free Estradiol Index (FEI). Serum logFSH concentrations were inversely correlated with BMD (r = -10 for lumbar spine [95% confidence interval (CI): -0.13, -0.06] and r = -0.08 for femoral neck (95% CI: -0.11, -0.05). Lumbar spine BMD values were approximately 0.5% lower for each successive FSH quartile. There were no significant associations of BMD with serum estradiol, total testosterone, FEI or FAI, respectively, after adjusting for covariates. BMD tended to be lower (p values = 0.009 to 0.06, depending upon the skeletal site) in women classified as perimenopausal versus premenopausal, after adjusting for covariates. Serum FSH but not serum estradiol, testosterone or SHBG were significantly associated with BMD in a multiethnic population of women classified as pre- versus perimenopausal, supporting the hypothesis that alterations in hormone environment are associated with BMD differences prior to the final menstrual period.

Progesterone, estradiol and their receptors in leiomyomata and the adjacent normal myometria of black Kenyan women

The contents of progesterone and oestrogen, and their respective receptors in uterine leiomyomata and adjacent normal myometrial tissue in indigenous black women in Kenya were studied. A random selection of twenty women undergoing hysterectomy for uterine fibroids at Kenyatta National Hospital was used for the studies. The myometria contained higher levels of E(2 ) (181% : P < 0.001); and P(4 ) (240.6 % : P < 0.001); as compared to the leiomyomata. On the other hand uterine leiomyomata contained significantly higher levels of ER (147.6% : P < 0.001); and PR (178.7% : P < 0.001 ); than normal myometria. These findings differ slightly from those reported in black women in developed countries, but support the proposal that manipulation of sex steroids may be useful in the treatment and management of uterine leiomyomata.

Frame size, ethnicity, lifestyle, and biologic contributors to areal and volumetric lumbar spine bone mineral density in Indian/Pakistani and American Caucasian premenopausal women

Published data on the spinal bone mineral density (BMD) of premenopausal women originating from the Indian subcontinent (Indian/Pakistani) are few. We compared anteroposterior (AP) and lateral areal BMD (aBMD) using dual X-ray absorptiometry and calculated volumetric BMD (vBMD) in Indian/Pakistani (n = 47) vs American (n = 47) women with dissimilar statures and skeletal sizes. To account for differences, we "adjusted" lumbar aBMD separately for vertebral size (aBMD/the square root of the projected area), height (aBMD/height), and hip skeletal width (aBMD/hip width). We "corrected" bone mineral content (BMC), aBMD, and vBMD for frame size, collectively using height, hip width, and vertebral size. Unadjusted mean aBMD values for AP lumbar (L1-L4, p = 0.0086; L3-L4, p = 0.044) spine were higher in Americans than Indians/Pakistanis,whereas lateral vBMD (p = 0.56) or aBMD (p = 0.060) values were not different. After adjusting for height, hip width, or vertebral size, or correcting for frame size, differences in aBMD disappeared. Regression analyses indicated that the best measures to correct for frame size were: vertebral area for BMC, hip width for aBMD, and vertebral width for lateral vBMD. Height was not significant in any model. In correcting for frame size, we accounted for 73-85% of the variability in BMC, 22-28% in aBMD, and 27% in lateral vBMD. After frame size was corrected, we accounted for 34% of the variability in AP BMC and aBMD, in contrast with 6-9% in the lateral models. Five significant biologic and lifestyle factors remained in AP models; only body weight remained for lateral spine. Upon accounting for frame size using regression, much variability in BMD, aBMD, and vBMD was explained by lifestyle and biologic factors, not by ethnicity.

Increased serum levels of N-telopeptides (NTx) of bone collagen in postmenopausal Nigerian women

Serum levels of cross-linked N-telopeptides (NTx) of bone collagen, alkaline phosphatase (ALP), and intact parathyroid hormone (PTH) were determined in 64 premenopausal (PRM) and 86 postmenopausal (PSM) women living in northern Nigeria. Serum NTx values were correlated with ALP activity (r = 0.31-0.58, P < 0.01) and PTH (0. 32-0.35, P < 0.01)) in all of the subjects studied, and were also related to age (-0.47, P < 0.001) and body mass index (-0.45, P < 0. 001) in PRM women. Menopause had the effect of increasing the circulating concentrations of NTx and ALP activity by 15% (P = 0. 001) and 11% (P = 0.02), respectively; however, serum levels of PTH were not different between these two groups of women. Compared with Caucasian counterparts matched for age and body mass index, PSM Nigerian women had significantly increased circulating concentrations of NTx (21.7 versus 16.2 nmol BCE/liter, P = 0.01) and demonstrated a trend towards higher ALP activities and PTH levels. These results indicate that (1) discrete reference intervals should be defined for biochemical markers of bone metabolism in African populations, (2) Nigerian women have relatively higher rates of bone turnover, and (3) further investigation of the implications of increased serum NTx should be undertaken using physical methods such as dual X-ray absorptiometry (DXA) and bone ultrasound attenuation.

Symptom responses of midlife Filipina Americans

OBJECTIVE

The purpose of this study was to describe the perimenopausal symptom responses of Filipino American midlife women.

DESIGN

This cross-sectional, descriptive survey collected symptom response information on Filipino American midlife women aged 35 to 56 years (n = 165) who self-identified as Filipina American and were proficient in the English language. Women were recruited from community churches and social groups. A survey questionnaire comprised of health history questions and a symptom checklist with symptom response questions were completed by the participants.

RESULTS

The symptom responses of women were compared by age groups of 35 to 39 (n = 39), 40 to 44 (n = 40), 45 to 49 (n = 37), and 50 to 56 (n = 49) and by perimenopausal phases of premenopausal (n = 85), transitional (n = 33), and menopausal/postmenopausal (n = 47). Indications from chi 2 tests showed that women in the 35-to-39- and 50-to-56-year groups were more likely to take acetaminophen (Tylenol) or aspirin for symptoms, and women in the 45-to-49- and 50-to-56-year groups were more likely to be on hormone replacement therapy. Surprisingly, women in the 50-to-56-year group were less likely to use talking with friends as a symptom management strategy.

CONCLUSIONS

Nonpharmacologic symptom management strategies exceeded the use of medications (hormones, over-the-counter) by Filipina Americans. This may be a strong indicator of their positive attitude toward this phase in their life and sends a message to clinicians about the choices that these women make for symptom management. Culturally relevant care would include alternatives to hormone replacement therapy in education materials about the perimenopausal transition for midlife Filipinas.

Symptom experience of Filipino American midlife women

OBJECTIVE

The purpose of this study was to describe the perimenopausal symptom experience of Filipino American midlife women with particular emphasis upon estrogen-related menopause symptoms (day sweats, hot flashes, night sweats, and vaginal dryness).

DESIGN

A cross-sectional, descriptive survey was used to generate symptom experience data for 165 Filipina Americans between the ages of 35 and 56 who self-identified as Filipina American and were English-language proficient. The community-based sample completed questionnaires composed of sample characteristic questions and a 51-item menstrual symptom checklist with menopause-related symptoms embedded in it.

RESULTS

Sample characteristics and symptom experience were compared among age groups of 35 to 39 (n = 39), 40 to 44 (n = 40), 45 to 49 (n = 37), and 50 to 56 (n = 49) and by perimenopausal phase, defined as premenopausal (n = 85), transitional (n = 33), and menopausal/postmenopausal (n = 47). The most reported individual symptoms were "felt energetic" (86.1%) and "well-being" (83.6%). Estrogen-related menopause symptoms were reported as "vaginal dryness" (39.4%), "hot flashes" (37.6%), "day sweats" (27.9%), and "night sweats" (24.2%) by the total sample. Distress associated with estrogen-related menopause symptoms was reported by 17% (n = 28) of all women. Subjects' chi 2 tests indicated that 50-to-56-year-old women were more likely to report fatigue/sleep symptoms, physical symptoms, and estrogen-related menopause symptoms than all other age groups. When compared by perimenopausal phase, transitional women were more likely to report moderate or extreme severity for day sweats. Premenopausal women were more likely to report minimal or mild severity and women in the perimenopausal transition were more likely to report moderate or extreme severity on estrogen-related menopause symptoms.

CONCLUSIONS

Filipino American midlife women appear to consider the perimenopausal transition in a positive light and experience little distress associated with estrogen-related menopause symptoms experienced. Findings from this study suggest that Filipina Americans view perimenopausal symptoms as part of a normal life stage that does not warrant concern.

Gaining access to underresearched populations in women's health research

Culture is an important variable in women's health research, and sample selection must include plans to recruit participants who represent the overall cultural makeup of the population. However, gaining access to underresearched groups is a major challenge and requires specific planning. Salient access techniques utilized by epidemiological researchers include (a) obtaining the support and endorsement of community leaders, (b) advertising the research in community publications, and (c) utilizing age, gender, and culturally matched research assistants. Although these elements were included in the planning of a study of the perimenopausal transition of Filipino American midlife women, the more powerful attractors for this particular cultural group were their pride in participating in a study that was associated with a major university and their intense community service orientation. Since each cultural group has unique issues and concerns, researchers must familiarize themselves with the values of their target group and emphasize these in recruitment approaches.

Cardiovascular disease risk factors in 2 distinct ethnic groups: Indian and Pakistani compared with American premenopausal women

BACKGROUND

Although people from the Indian subcontinent have high rates of cardiovascular disease (CVD), studies of such in Indian and Pakistani women living in the United States are lacking.

OBJECTIVE

This study accounted for variability in serum lipid (total cholesterol and triacylglycerol) and lipoprotein [LDL cholesterol, lipoprotein(a), and HDL cholesterol] concentrations in Indian and Pakistani compared with American premenopausal women in the United States. Body composition, regional fat distribution, dietary intake, and energy expenditure were compared between groups.

DESIGN

The 2 groups were 47 Indian and Pakistani and 47 American women. Health was assessed via medical history, physical activity, body composition (via anthropometry and dual-energy X-ray absorptiometry), dietary intake (via 7-d food records), and serum lipids.

RESULTS

Serum total cholesterol, triacylglycerol, LDL cholesterol, lipoprotein(a), the ratio of total to HDL cholesterol, and the ratio of LDL to HDL cholesterol were greater (P <0.03), whereas HDL-cholesterol values were lower (P = 0.011) in Indians and Pakistanis than in Americans. Multiple regression analysis indicated that approximately 18% of the variance in total cholesterol (P = 0.0010) and LDL cholesterol (P = 0.0009) was accounted for by ethnicity, energy expenditure, and the ratio of the sum of central to the sum of peripheral skinfold thicknesses. Ethnicity, sum of central skinfold thicknesses, ratio of polyunsaturated to saturated fat, and monounsaturated fat intake accounted for approximately 43% of the variance in triacylglycerol concentration (P < 0.0001). Monounsaturated fat, percentage body fat, and alcohol intake accounted for approximately 26% of variance in HDL cholesterol. Ethnicity contributed approximately 22% of the 25% overall variance in lipoprotein(a).

CONCLUSIONS

Results suggest that these Indian and Pakistani women are at higher CVD risk than their American counterparts, but that increasing their physical activity is likely to decrease overall and regional adiposity, thereby improving their serum lipid profiles.

The perimenopausal transition of Filipino American midlife women: biopsychosociocultural dimensions

OBJECTIVES

To describe the biologic, psychological, social, and cultural (biopsychosociocultural) dimensions of the perimenopausal transition of Filipino American midlife women.

METHODS

A community-based sample of 165 women (a) self-identified as Filipino American, (b) ages 35 to 56 years, and (c) English language proficient was recruited from churches and social groups.

RESULTS

Women in the study were born in the Philippines (93.3%), had lived in the United States an average of 18.4 +/- 8.7 years, were married or partnered (74.6%), had completed college (62.8%) or a graduate degree (15.9%), worked (full-time, 77.9%; part-time, 12.9%), had household incomes greater than $50,000 (>58%). Menopause ages were calculated from reports of last menstrual periods (natural, 48.9 +/- 4.9 years; surgical, 42.2 +/- 5.7 years). Neither the age at menarche nor the number of pregnancies and children born was significantly related to age at menopause. Calcium from food sources was generally low, and the Center for Epidemiological Studies Depression Scale (CES-D) revealed a 24.8% depression rate. The low prevalence of physical health problems confirms previous research that foreign-born individuals have better health than those born in the United States.

CONCLUSIONS

The profile of this understudied group identified calcium intake, osteoporosis morbidity, and prevalence of depression as key areas for future study.

Leptin concentrations in women in the San Antonio Heart Study: effect of menopausal status and postmenopausal hormone replacement therapy

Leptin, the product of the human OB gene, is increased in obese individuals, suggesting resistance to its effect. However, there is variability in leptin levels at each level of body mass index, suggesting that genetic and environmental factors other than overall adiposity may regulate leptin concentrations. Leptin concentrations are higher in women relative to men, a difference that is only partially explained by the increased fat depots in women. The authors hypothesized that higher estrogen levels in women might be responsible for the sexual dimorphism in leptin concentrations. To test this hypothesis, they measured leptin concentrations in premenopausal women not on oral contraceptives (PRE) (n = 53), postmenopausal women on hormone replacement therapy (POSTY) (n = 28), and postmenopausal women not on hormone replacement therapy (POSTN) (n = 28) in the San Antonio Heart Study, a population-based study of diabetes and cardiovascular risk factors. Analyses were restricted to nondiabetic Mexican Americans. Subjects were well matched on obesity as assessed by body mass index (kg/m2): PRE = 31.0, POSTY = 29.8, and POSTN = 31.6. Leptin concentrations (ng/ml) were not significantly different among the three groups (PRE = 27.6, POSTY = 28.3, and POSTN = 27.8). The authors conclude that differences in estrogen levels are not likely to explain the sexual dimorphism in leptin concentrations.

Effects of ethnicity and age or menopause on the remodeling and turnover of iliac bone: implications for mechanisms of bone loss

We measured histologic indices of bone remodeling and turnover separately on the cancellous, endocortical, and intracortical subdivisions of the endosteal envelope, and on the combined total surface, in transiliac bone biopsies obtained after double tetracycline labeling in 142 healthy women, aged 20-74 years, 34 black and 108 white, 61 premenopausal and 81 postmenopausal. The data were analyzed by two-way analysis of variance of the four groups defined by age/menopause and ethnicity and by linear regression of the major variables on age. None of the interaction terms was significant and none of the regression slopes on age differed between blacks and whites, indicating that, as for the previously reported structural indices, the effects of ethnicity and of age/menopause are independent. Accordingly, the data were also analyzed separately for the effect of ethnicity (pre- and postmenopausal combined) and age/menopause (blacks and whites combined). The analyses led to the following conclusions. (1) The geometric mean bone formation rate on the combined total surface was 25% lower in blacks than in whites; other histologic differences between ethnic groups were inconsistent between surfaces. (2) Serum osteocalcin (OC) but not bone-specific alkaline phosphatase (BSAP) was lower by about 15% in blacks than in whites. (3) The lower bone turnover in blacks is most likely in the directed rather than in the stochastic component because of a higher bone mass and consequent reduced susceptibility to fatigue damage. (4) All Class 1 bone formation variables and the three resorption indices were significantly higher in the postmenopausal compared with the premenopausal subjects, reflecting a 33% increase in activation frequency. (5) BSAP, but not OC, was increased relatively more (66%) than the bone formation rate (BFR). Consequently, BSAP is more sensitive to the effects of menopause than OC, but OC is more sensitive to the effects of ethnicity than BSAP. (6) There were highly significant differences between the three subdivisions of the endosteal envelope for every non-cell-related variable. All Class 1 formation variables were highest on the endocortical surface, but the magnitude and pattern of the differences otherwise was inconsistent between variables. The contributions of the different subdivisions to the total bone formation rate were cancellous 54%, endocortical 13%, and intracortical 33%. (7) The previously reported changes in bone surface location, together with the presently reported changes in activation frequency and wall thickness indicated that there was no significant effect of age/menopause on erosion depth on the cancellous and intracortical surfaces but a large increase in erosion depth on the endocortical surface. (8) The increase in bone turnover that results from hormonal changes is most likely in the stochastic rather than in the directed component because it serves no purpose but has harmful effects on skeletal integrity.

Anthropometric, lifestyle and menstrual factors influencing size-adjusted bone mineral content in a multiethnic population of premenopausal women

We report associations of anthropometric, lifestyle and menstrual characteristics with peak bone mass in a multiethnic population of premenopausal women, ages 25-34 y. Four bone sites were examined: the spine, calcaneus, and distal and proximal radius. Body mass index (BMI) was positively associated with bone mass at the spine and calcaneus, the two most trabecular sites. The calcaneus, in addition, was positively associated with an index of calf muscle mass. The distal radius was associated with an arm muscle index, grip strength and the intensity of menstrual flow (light, moderate or heavy). Menstrual flow was also associated with spine bone mass in models not adjusted for BMI; light flow was an indicator of low distal radius or spine bone mass. We hypothesize that light flow may indicate a lack of regular ovulation. The cortical proximal radius was positively associated with milk consumption and height. The magnitude of associations varied by exposure and bone site. Among the strongest associations were BMI at the spine and calcaneus (4 and 7% differences in bone mass per standard deviation), and menstrual flow at the distal radius (a 7% difference between light and heavy menstrual flow). Ethnicity was not statistically significant in multivariable models at any of the four bone sites. However, the prevalence of exposures associated with bone mass varied substantially among the ethnic groups. Ethnic differences in bone mass may have derived indirectly through differences in exposure histories. Other influences of skeletal development may also occur indirectly. Sports activity during adolescence, for instance, was not an independent predictor of bone mass, but sports activity was associated with both strength and muscle mass. Our results suggest that many factors influence peak bone mass, and that the factors vary in importance by skeletal region, possibly related to bone composition and the local intensity of exposure.

Changing womanhood: perimenopause among Filipina-Americans

OBJECTIVE

To develop a conceptualization of perimenopause experienced by Filipina-American women.

DESIGN

Grounded theory methods of interviews and constant comparative analysis.

SETTING

Participants were interviewed in their homes or other location of their choosing.

PARTICIPANTS

Sixteen Filipina-American women who had not menstruated in the past 6 months or who identified themselves as perimenopausal.

MAIN OUTCOME MEASURES

Changing womanhood was the core category and was related to three major categories living in my changing body changing family relationships and changing community networks.

RESULTS

The women experienced changes such as hot flashes and irritability as well as role conflicts and broadening community involvement. The perimenopause is also a time to focus on oneself and to seek activities of a personal, familial, and community nature that are fulfilling in a different way than previous child-rearing activities.

CONCLUSION

Filipina-American women experience perimenopause as a normal process of aging rather than as symptomatic of disease, thus providing a health-oriented model of perimenopause.