The clinical features of the menopause and its relation to the length of pregnancies and lactation

The clinical features of the menopause and the influence of the length of pregnancies and lactation on the age of menopause and on the incidence of hot flushes were studied in 154 women aged 50–85 yr. The mean age at menopause was 46.6 ± 4.7 SD yr. The cessation of menses occurred abruptly in 43.5% of the cases or after a period of menstrual irregularities (56.4% of the cases). The prevalent abnormalities were oligomenorrhea (45.4%) or functional bleeding (10.4%), both of short duration in the majority of the cases. Hot flushes were experienced more frequently (68.9%) in women with menstrual irregularities before the onset of menopause and especially those who presented an oligo-menorrhea (71.4%) than in women with abrupt cessation of menses (41.7%). The length of pregnancies did not seem to influence the age at menopause. The mean age at menopause in 17 nulligravida women was 46.5 yr and did not differ significantly from the mean age at menopause of women with 1–19, 20–39, 40–59 and 60–110 mth of pregnancies. The duration of pregnancies, however, seemed to influence the incidence of hot flushes. Women with more than 20 mth of pregnancy had a significantly smaller incidence of hot flushes than nulligravida or women with 1–19 mth of pregnancy.

The length of lactation was also not correlated with the age at menopause. Finally, the age of last pregnancy was not found to be related with the menopause or the incidence of hot flushes.     

Attitudes towards the menopause and hormone therapy over the turn of the century

Objective

To assess attitudes and beliefs about the menopausal transition in a population of peri- and postmenopausal women, and if these attitudes differed before and after publication of studies on risks and benefits with hormone therapy (HT).

Materials and methods

In 1999 and 2003 all women aged 53 and 54 years in the community of Linköping, Sweden, were sent a questionnaire about use of HT, menopausal status and attitudes regarding menopause and HT.

Results

Most women regarded menopause as a natural process characterized by both hormonal deficiency and aging and these views did not differ between 1999 and 2003. A majority of women thought that significant climacteric symptoms were a good reason to use HT, but not that women without symptoms should use HT. The fraction of women who supported HT use was, however, significantly lower in 2003 than in 1999. Most women agreed that menopause leads to increased freedom and that it is a relief not to have to think about contraception and pregnancies.

Conclusions

Most Swedish women had a mainly biological view on menopause but nevertheless they thought that only women with climacteric symptoms should use HT. Women's attitudes towards HT have changed after recent reports on risks from long-term use of HT whereas the attitudes towards the menopausal transition were stable. Other factors than attitudes towards menopause affect women's actual use of HT. Probably women's and health care provider's apprehension of the risk-benefit balance of HT use is one such factor.     

Age at menopause and determinants of hysterectomy and menopause in a multi-ethnic community: The Hilo Women's Health Study

Objectives

A lifespan approach was used to evaluate age at menopause, and determinants of surgical and natural menopause, in the multi-ethnic community of Hilo, Hawaii.

Study design

Participants aged 40–60 years (n = 898) were drawn from a larger, randomly generated sample recruited by postal questionnaires. Median age at natural menopause was computed by probit analysis. Logistic regression analysis was applied to examine determinants of hysterectomy, and Cox regression analysis was used to examine risk factors for an earlier age at menopause.

Main outcome measures

History of hysterectomy, age at menopause.

Results

Frequency of hysterectomy was 19.2% at a mean age of 40.5 years. The likelihood of hysterectomy increased with older ages, lower education, mixed ancestry, having been overweight at age 30, and married 20 years prior to survey. Median age at natural menopause was 53.0 years. Smoking and not being married 10 years before survey were associated with an earlier age at menopause.

Conclusions

Median age at menopause was later than the national average. Ethnicity and education were determinants of hysterectomy, but not associated with age at natural menopause. Events later in the lifespan (e.g., smoking and not being married 10 years prior to the survey) were more important than earlier events (e.g., childhood residence) in relation to age at menopause. The timing of weight gain and marital status appear to be important in relation to surgical menopause, and the timing of marital status appears to be important in relation to the timing of natural menopause.     

Climacteric expression and social context

Though on questioning, women everywhere would probably admit to subjective sensations, known to be associated with climacteric physiological changes, few actively complain of any discomfort these produce. ‘Climacteric symptoms’ are confined to the West. Their absence elsewhere has hitherto been explained by the stress-free-climacteric women enjoy in most other cultures. The rewards of middle life in these cultures are, however, generally limited to women who have raised sons. Others are as liable to stress as Western women. This article suggests that the absence of climacteric symptoms among them is because middle-life stress is not associated in these cultures with illness but is expressed in practical social counteraction.The expression of climacteric stress in medical terms also depends on the manner the climacteric is reached and its general relationship to the menstrual history. The onset of the climacteric tends to have a much higher profile when families are limited, a social custom almost confined to the West. Avoidance of pregnancy and promiscuity also result in troublesome morbid changes at this time. In fact it was these which first brought climacteric women to doctors. As this occurred when, coincidentally, care of the sick became an important aspect of Western culture, the welding of climacteric disturbances and medicine became inevitable.Biologically ‘worthless’, a climacteric woman is regarded as ‘nothing’ in most cultures. Her social standing depends entirely on her sons. Childless women have, however, evolved various compensatory strategems. They manage to obtain social children or, at times, even profit by their very worthlessness. The climacteric expression resembling the menopausal syndrome most, in non-Western countries, is the almost universal fear, throughout the southern and eastern Mediterranean, that a husband may discover the climacteric sterility of his wife and marry a second young and fertile woman. Nonetheless neither this syndrome, nor other behavioral disorders at this time, utilize the physiological sensations of the climacteric as symptoms.     

The frequency distribution of age at natural menopause among Saudi Arabian women

Objective: Hormonal changes at the menopause are associated with the onset of a number of medical conditions. The distribution of age-at-menopause (AAM) within a given population can, therefore, indicate how the disease prevalence changes with age. The objective of this study was to estimate the distribution of AAM among Saudi Arabian women, in order to predict local trends in the prevalence of osteoporosis. Methods: Patient age, AAM, medical history and associated information for 858 Saudi Arabian women were extracted from a Dual Energy Absorptiometry database at King Faisal Specialist Hospital and Research Centre, resulting in an AAM distribution for 391 postmenopausal women with natural menopause. This was preprocessed using a Fast Fourier Transform 0.15 cycles/year low-pass filter, eliminating last-digit-preference errors and high frequency noise, and facilitating quantitative comparison with other published results. Results: Mean AAM was 48.94 years (S.E. 0.290 years) with a median of 50 years (25th/75th percentiles: 45 and 53 years, respectively). The AAM distribution was described by a quadruple-Gaussian curve with a major peak at almost 51 years and minor peaks at approximately 36, 44 and 59 years. Although both the central peaks were similar to that observed in other populations (UK, USA and Finland), the early menopause peak at 36 years was larger. The peak over 55 years may be unique to the Kingdom of Saudi Arabia. It may reflect local cultural and childbearing practices. Conclusions: Although the median menopause age and general shape of the AAM distribution in Saudi Arabia appear similar to that observed in the West, the parameters governing the distribution are different, and there is evidence that it may have a unique fourth peak.     

The impact of hormonal therapy for infertility on the age at menopause

Objectives: To look for possible association between past history of ovulation induction and age at menopause. Design: Women attending our postmenopausal outpatient clinic were asked to fill questionnaires with demographic data, obstetrical history (including treatment for infertility), and medical details related to menopause. Patients: The study group (n=31) consisted of women with a history of ovulation induction, and a control group (n=200) included women who did not experience such intervention. Results: The age at the final menstrual bleeding was 46.4±5 in the study group, and 50±4 for the control group (P<0.001). This difference was most prominent for women who had induction of ovulation prior to age 35 years: they entered menopause at age 43.8±5 years. Smoking had a weak effect on the age at menopause (48.5±4 for current, vs. 49.9±4 for non- or past-smokers; P<0.03). Conclusions: This retrospective and preliminary study raises the question whether hormonal manipulations and ovarian over-stimulation during fertility treatments could be a risk factor for premature menopause.     

Preprocessing histograms of age at menopause using the fast Fourier transform

Objective: In epidemiological and biological studies, the interpretation of frequency distributions (histograms) of the age at menopause (AAM) is hampered by the presence of background noise such as the last-digit-preference (LDP) of each woman. The objective of this study was to develop a standard method of preprocessing the AAM histogram such that noise can be effectively eliminated, thereby enabling a more thorough investigation of the underlying properties of the distribution. Methods: The Fast Fourier transform (FFT) is a technique which eliminates individual sources of noise based on their characteristic frequencies. Its effectiveness in eliminating noise from AAM data was explored using both simulated and published data, especially in regard to the elimination of cyclical LDP errors. Results: By preprocessing the histogram ‘signal’ using a low-pass filter of 0.15 cycles per year (cpy), common LDP noise is eliminated. Furthermore, this preprocessing also eliminates other forms of high-frequency noise, revealing a true AAM ‘signal’ which comprises three separate low-frequency components. The two major peaks correspond in the time domain to Gaussian functions with means at 51 and 43 years and peak-widths of 6 years; a smaller peak also exists at 35 years. Conclusions: The FFT is an effective tool in preprocessing AAM frequency distributions to reveal their underlying shape, which appears similar across several previously published studies and is characterized by three distinct peaks. These currently have no definitive interpretation, but call into question the analysis of epidemiological risk factors for AAM using statistical techniques which assume a single distribution.     

Women's status and experience of the menopause in a Newfoundland fishing village

Recent studies attribute cross-cultural variations in the experience of the climacteric to changes in female status at middle age. An analysis of women's life cycles in a Newfoundland fishing village, where there is no dramatic change in status at middle age, contributes to the understanding of the dynamics of interaction between female and climacteric symptoms. Newfoundland concepts of bio-social self are examined in terms of folk notions of nerves and blood. Conclusions are drawn about the relative importance of somatic components, folk notions and female status in the experience of the climacteric.     

Climacteric symptoms: A study in the Indian context

The climacteric is a universal phenomenon which has received relatively little attention from psychiatrists, psychologists, sociologists, anthropologists and social workers all over the world, but almost no research on this subject has been carried out in the third-world countries. This study, carried out in India, has been conducted for the purpose of unravelling the difficulties that Indian women have to face during the climacteric.405 married women between 40 and 55 yr of age from the general population were contacted and interviewed.The results, obtained with the menopausal symptom checklist prepared by the authors, indicate (as do other recent surveys) that hot flushes, night sweats and insomnia seem to be clearly associated with the menopause. Also the incidence of other symptoms is described. Despite embarrassment or discomfort experienced from these symptoms by a majority of women, only 10% had apparently sought medical treatment. This study underlines the necessity of a multidisciplinary approach to the problems of menopause and ageing.     

Bone density patterns after normal and premature menopause

Objectives: The investigation of the effect of time and type of menopause on bone mineral density (BMD) at different ages. Methods: Five hundred and fourteen women, who had never received any hormonal substitution were studied in a cross-sectional design: 177 with normal (NMP), 210 with surgical (SUMP) and 127 with premature natural (EMP) menopause. Age at menopause was 49.1±3.9, 38.3±4.7 and 38.1±4.2 years (mean±1 S.D.), respectively. BMD was measured at L2–L4 vertebrae and proximal femur by the DEXA method. Results: EMP women presented significantly lower vertebral BMD than NMP women in the 45–55-years segments (P<0.001), but did not differ from SUMP women. This group exhibited lower vertebral BMD than NMP between 45 and 50 years (P<0.001). Regarding femoral neck, EMP women exhibited lower values than SUMP in the 45–50 and 55–65 age segments (P<0.001) whereas SUMP women presented significantly higher BMD values than NMP women after 55 years of age (P<0.001). The percentages of women with vertebral BMD (T-score values) in the osteoporotic range were significantly greater in EMP compared with either NMP or SUMP groups (both P<0.001) whereas in femoral neck lower in SUMP than the other two categories. Conclusions: Women with either natural or surgical premature menopause exhibit lower BMD of trabecular bone compared with normal menopause women at the age segments 45–55 and 45–50, respectively. However, surgical menopause women exceed normal menopause women in their mixed bone BMD values after 60 years as well as premature natural menopause women at almost all age segments.     

Body mass index trajectories and age at menopause in a British birth cohort

OBJECTIVE: This study investigates the influence of body mass index (BMI) at ages 15, 20, 26, 36, and 43, and of BMI trajectories from 20 to 36 years on the timing of menopause and hormone therapy (HT) use until age 57 years. METHODS: A nationally representative British cohort of 1583 women born in March 1946 with prospective data across the life course. RESULTS: By age 57, a total of 695 women had experienced natural menopause while 431 women had started HT prior to menopause. Cox regression models indicated no significant associations between BMI at any age, or BMI trajectory, and timing of natural menopause. At every age BMI was strongly (p< or =0.01) and linearly associated with age at HT use and BMI from 26 years onwards was associated with age at first event (menopause or HT use). Decreasing BMI was associated with earlier HT use at all ages. These associations were not accounted for by parity, cigarette smoking or childhood and adult social class. CONCLUSION: BMI across the reproductive lifespan did not influence age at menopause to an extent that would be clinically relevant for postmenopausal health. Lower BMI at all ages and underweight trajectory were related to an earlier start of HT. Further studies are required to understand whether such relationships are due to underweight women experiencing menopause earlier (and because of menopausal symptoms starting HT earlier) than heavier women, or having behavioural characteristics related to earlier HT use, independent of menopause.     

Parity and age at menopause in a Danish sample

A random sample of 151 Danish women who had undergone natural menopause reported the age at which this occurred and answered a questionnaire. A significant association was found between parity and age at menopause after correction for the effects of age at the first and last births, weight, smoking and occupation.

However, there is no evidence that the age at menopause has fallen in recent decades, even though the average parity in developed populations has dropped dramatically over this period. It is therefore possible that potential fertility is a confounding variable in the relationship between parity and age at menopause.     

Age at natural menopause in three Central and Eastern European urban populations: The HAPIEE study

Objectives

To investigate the age at menopause in three urban populations in Central and Eastern Europe and to assess whether the (suspected) differences can be explained by a range of socioeconomic, reproductive and behavioural factors.

Methods

The Health, Alcohol and Psychosocial factors in Eastern Europe (HAPIEE) Study examined random samples of populations aged 45–69 years in Novosibirsk (Russia), Krakow (Poland) and six Czech towns. Participants completed a questionnaire and attended an examination in clinic. A total of 12,676 of women were included in these analyses.

Results

The median age at menopause was 50 years in Novosibirsk, 51 years in Czech towns and 52 years in Krakow; the Cox regression hazard ratios of menopause, compared with Krakow, were 1.47 (95% CI 1.40–1.55) for Novosibirsk and 1.10 (1.04–1.16) for Czech women. In multivariate analyses, higher education, using vitamin and mineral supplements and ever use of oral contraceptives were associated with later menopause, while smoking, abstaining from alcohol and low physical activity were associated with earlier menopause. These factors, however, did not explain the differences between populations; the multivariate hazard ratios of menopause, compared with Krakow, were 1.48 (1.40–1.57) for Novosibirsk and 1.11 (1.05–1.17) for Czech women.

Conclusions

In this large population based study, differences in age at menopause between Central and Eastern Europe populations were substantial and unexplained by a range of risk factors. Associations of age at menopause with risk factors were largely consistent with studies in other populations.     

The age of menopause and the menopause transition in a multiracial population: a nation-wide Singapore study

OBJECTIVE: To describe the prevalence of menopausal symptoms, define the mean age of menopause, and determine contributory factors, which influence the experience of symptoms among Singaporean women of different racial groups. DESIGN: Cross-sectional nation-wide study of a random sample of 1000 women drawn from the entire population of Singaporean female (Chinese, Malay, and Indian) citizens between 45 and 60 years of age. Face-to-face interviews using structured questionnaires were conducted. RESULTS: The response rate was 69.9%. The mean age of natural menopause was 49.0 years. This was not significantly different between the three ethnic groups. Increasing parity delayed the age of menopause (P=0.007). Muscle and joint ache was the most commonly reported symptom (52.6%). Although the prevalence of significant hot flushes in the general study population was low (3.9%), it was the most commonly reported complaint by peri-menopausal women (14.6%). Prevalence of significant hot flushes decreased with time from menopause (P=0.007) and completely disappeared beyond the fifth year of menopause. Recent unhappy events were associated with an increased risk of symptoms (P<0.001). Women of Chinese origin experienced a lower risk of menopausal symptoms when compared with other ethnic groups (P<0.05). CONCLUSION: The mean age of menopause was 49.0 years among Singaporean women. Ethnicity and recent unhappy events were two major factors, which influenced the risk of experiencing menopausal symptoms. Among the three ethnic groups studied, Chinese women were the least likely to experience disturbing menopausal symptoms. The overall prevalence of menopausal symptoms was low when compared to studies on women in western societies.     

Perceptions and attitudes toward the menopause among middle aged women from Guayaquil, Ecuador

BACKGROUND: Studies reporting the perspective of Latin American women, Ecuador, included, regarding the menopausal phenomena are scarce or lacking. OBJECTIVES: Obtain information regarding the perception and attitudes toward the menopause among middle aged women of Guayaquil, Ecuador. METHODS: Women aged 40 or more, nursing staff members of two major associated teaching hospitals of the Universidad Católica de Santiago de Guayaquil, Ecuador, were surveyed with a structured questionnaire containing items intended to assess women's perception and attitudes toward the menopause. Secondarily level of information related to the menopause was explored. RESULTS: During the study period, 349 women were surveyed of which mean age was 48+/-6.8 years. A 41.3% were postmenopausal, 55% premenopausal and 3.7% had a history of hysterectomy with conserved ovaries. Women more frequently perceived the menopause as a positive event as they agreed that it is a normal (93.7%) and important event (73.6%), that it gives more confidence and maturity (78.8%), that they may fully enjoy sexual relations (74.8%), that there is a relief as the risk of becoming pregnant is null (65.3%) and that life becomes easier and calmer (60.7%). A relatively high rate demonstrated a preoccupying attitude toward the menopause as 79.4% responded to be concerned about it indicating that seeking medical attention was important, moreover, 77.9% responded that health during this phase be taken care of and life styles changed. Less than 50% of surveyed women considered having enough information regarding the menopause whereas a high rate indicated wanting to receive educational sessions related to the menopause. Married and lower educated women were not concerned about the menopause in a higher rate than their counterparts. CONCLUSIONS: Despite the fact that women perceived the menopause as a positive event, displaying a concerned attitude toward it, their related knowledge was low.     

A new way of looking at environmental variables that may affect the age at menopause

Environmental variables that might affect the age at menopause were analysed by means of the segmentation method AID. Marital status, occupation, smoking habits, age at last pregnancy and height were shown to be significant discriminating variables. The material and design of the study and the method of analysis are given and its results are discussed. A proposal is made concerning the nature of a ‘secular trend’.     

Bivariate genome-wide linkage analysis for traits BMD and AAM: Effect of menopause on linkage signals

Osteoporosis is an age-related systemic skeletal disease, characterized by low bone mineral density (BMD). Low BMD is closely associated with late age at menarche (AAM). Our previous bivariate genome-wide linkage analyses (GWLAs) between BMD and AAM identified two shared genomic regions in 2584 Caucasian females including both pre- and post-menopausal females. However, menopause often causes dramatic bone loss in post-menopausal females; this may introduce some confounding effects on the bivariate GWLA for BMD and AAM.