Do psycho-social factors contribute more to symptom reporting by middle-aged women than hormonal status?

Six hundred women aged between 45 and 54 were randomly selected from the electoral roll in Brisbane, Australia. A questionnaire addressing their symptoms, hormone status and psycho-social factors was successfully administered to 381 women (64% of the original sample; 83% of those contactable). Although cardiovascular symptoms were experienced by 25% of the sample, the most common (hot flushes) ranked only tenth on a list of recently experienced symptoms. The association of hormone status with symptoms was weak in comparison with other factors. Most symptoms were reported by women who were perimenopausal, had undergone a hysterectomy, or were currently using hormone replacement therapy. A poor mental health index was strongly associated with all groups reporting symptoms. It is concluded that clinicians responding to symptoms from middle-aged women should continue to address psychosocial factors just as vigorously as those related to their hormone status.     

Vasomotor symptoms and well-being in the climacteric years

To determine more closely the relationship between vasomotor symptoms, well-being and climacteric status according to the last menstrual bleeding and according to the women themselves. Methods: A population-based cross-sectional study was executed using a postal questionnaire. Well-being of women with and without vasomotor symptoms was compared, for the different menopausal statuses. All 2729 women living in a commuter suburb of Rotterdam aged 45–60 years were approached of whom 1947 (71.3%) responded. Well-being was measured by the Inventory of Subjective Health (ISH) and three subscales of the Sickness Impact Profile (SIP). Results: The results showed that the relationship between vasomotor symptoms and well-being was dependent on climacteric status. Pre-and (middle and late) postmenopausal women with vasomotor symptoms more often experienced a relatively lower level of well-being compared to women without these symptoms. However, when the prevalence of vasomotor symptoms is as its peak, i.e. in late perimenopause, a difference in the level of well-being between women with and without vasomotor symptoms was absent. Conclusions: It is concluded that well-being and vasomotor symptoms were inversely related in all menopausal statuses except for the (late) perimenopausal phase. For this no somatic explanation seems plausible. A more social scientific explanation is suggested.     

On the calculation of climacteric symptoms

Survey techniques, which are widely used to estimate the prevalence of climacteric symptoms, are generally unable to distinguish symptoms which relate to physiological changes from those which may be attributable to other factors. New data collection techniques developed in a study of menopause among a group of American Indians are reported here, which permit the evaluation of the cause of the reported symptoms. Two classes of complaints were then calculated: “gross” symptoms and “climacteric” symptoms. It was found that differences between prevalence, as estimated by the two classes of complaints, were smallest for vasomotor symptoms and greatest for psychological complaints, reflecting presumed physiological relationships. Further, climacteric-related symptoms demonstrated a clearer relationship to factors hypothesized by other researchers as affecting the experience of climacteric symptoms. While not feasible for all studies, these techniques demonstrate that more accurate estimates of symptom experience are possible.     

Changes in Australian women''s perception of the menopause and menopausal symptoms before and after the climacteric

The symptoms and perceptions of menopause of 60 Australian women were studied, by questionnaire, when they were premenopausal and 10 years later when they were postmenopausal. Menopausal symptoms expected and experienced by the women were compared, fewer women experiencing hot flushes, headache, depression and nervousness and more experiencing insomnia, increase in appetite, abdominal fullness, numbness and muscular problems. The symptoms women thought were due to hormonal changes at menopause were compared. In 1993 more women cited osteoporosis, insomnia, loss of libido, obesity and loss of muscle tone as due to hormone change while fewer cited depression. The premenstrual symptoms and their severity experienced by a woman when she was premenopausal significantly predicts the type and severity of the menopausal symptoms experienced by the woman. The expected menopausal symptoms and their severity cited by a woman also significantly predicts the type of severity of the menopausal symptoms experienced. More premenstrual symptoms predict the menopausal symptoms than those menopausal symptoms the women expected. The expectation menopause will be ‘a relief’ or ‘a nuisance’ significantly predicted the overall menopause experience described by the women. Their negative attitudes about doctors' understanding and information available about menopause remained unchanged but they forget menstrual cycle problems over the 10 years. The results suggest a possible physiological basis for premenstrual and menopausal symptoms. Assistance for women with their premenstrual and menstrual cycle symptoms may improve their quality of life at menopause.     

Bleeding pattern and climacteric symptoms during different sequential combined HRT regimens in current use

Four sequential combined oestrogen and progestogen regimens were compared in terms of bleeding pattern and relief of climacteric symptoms. Treatment was with either 2 mg 17β-oestradiol with I mg norethisterone acetate [E₂ + NEta]; 2 mg oestradiol valerate with 75 μg levonorgestrel [E₂V + Lng]; 2 mg oestradiol valerate with 10 mg medroxyprogesterone acetate [E₂V + Mpa]; or 1.5 mg 17β-oestradiol with 150 βg desogestrel [E₂ + DG]. A placebo-controlled study lasting 12–24 months was completed by 143 healthy early postmenopausal women. Bleeding lengths were not substantially different; in all regimens the majority of women were bleeding for 3–6 days. Bleeding onset showed differences when related to the 11th day of progestogen addition; in the regimen with E₂V + LNG, 21% of the women were bleeding before the 11th day of progestogen addition 26% on, and 53% after that day. In the regimen with E₂V + MPA, 56% of the women were bleeding before the 11th day, 28% on, and 17% after that day, whereas in the regimen with E₂ + DG, 15% of the women were bleeding before the 11th day, 5% on, and 80% after that day. All regimens reduced climacteric symptoms to the same extent. Breast tenderness occurred in all the regimens, except in the E₂ + DG. Conclusively, the differences between the responses to treatment were not conspicuous. However, our data indicate that one regimen (E₂ + DG) resulted in optimal bleeding control, optimal effect on climacteric symptoms, and no production of breast tenderness.     

The climacteric of Chinese factory workers

Chinese factory workers (427) mainly of Fujian origin were found to have few climacteric symptoms. Of these, 65% and 50% reported having no circulatory and nervosity symptoms, respectively. Only 18% of women experienced hot flushes. The climacteric symptoms were more pronounced at the perimenopausal period (P < 0.001) when these women experienced more irregular menstruation. Low socio-economic status and educational level did not have adverse effects on the symptom reporting. High parity and employment may be positive factors in this period of change of life. A majority of women (74%) felt that the climacteric and menopause is a natural process which caused them no concern. Of those who were still menstruating 80% did not anticipate that they would have problems with the climacteric and menopause. These women's different climacteric pattern could be related to their introspective abilities to cope adequately or in an impersonal manner.     

Efficacy of soy isoflavones for depressive symptoms of the climacteric syndrome

Objectives

To evaluate the efficacy of soy isoflavones extract (SIE) in the treatment of depressive symptoms in women with climacteric syndrome.

Methods

Placebo-controlled double-blind randomized study with 84 climacteric outpatients attended in the Lauro Wanderley University Hospital in Joao Pessoa (PB), Brazil. In the assessment of the depressive symptoms, the Brazilian version of the Center of Epidemiologic Studies of Depression (CES-D) scale was used, on the pre-treatment visits (VT1), 8th (VT2) and 16th (VT3) weeks after treatment. The experimental group (EG) received the daily dose of 120 mg SIE and the control group (CG), placebo. The primary efficacy measure was the comparison of the percent reductions in the CES-D scores from VT1 to VT3 between EG and CG (t-test, p < 0.05). The security analysis consisted of laboratory and clinical evaluation of adverse events.

Results

The CES-D scores in the EG reduced from 12.5 (±4.2) in VT1 to 9.9 (±3.6) in VT2 (VT2 < VT1, p = 0.001) and 8.2 (±3.8) in VT3 (VT3 < VT2, p = 0.007), while the CG, reduced from 13.0 (±4.8) in VT1 to 10.1 (±4.1) in VT2 (VT2 < VT1, p = 0.001) and 9.4 (±4.1) in VT3 (VT2 = VT3, p > 0.05). In the outcome of the 16-week treatment (VT1–VT3), reduction of the CES-D scores did not reach statistical significance between groups. There were no clinically relevant adverse events attributable to the treatment.

Conclusions

The treatment with soy isoflavones did not produce significant reduction on the depressive symptoms of a predominantly affective nature evaluated in this study. The symptomatic reduction initially observed was apparently a nonspecific response to treatment, corroborating evidences from the literature on the placebo phenomenon in treatment of the climacteric syndrome.     

Evaluation of a continuous oestrogen-progestogen regimen for climacteric complaints

Subjective complaints, endometrial histopathology, vaginal cytology and bleeding patterns were recorded in 26 patients treated with a continuous oestrogen-progestogen regimen for 12 mth. A marked reduction of hot flushes and sweats were noted and the evaluation of endometrial specimens revealed that the mucosae were mostly inactive-atrophic. The karyopyknotic index proved to be a poor indicator of oestrogenic activity. The number of recorded bleedings in the peri-menopausal women differed markedly from the post-menopausal women during treatment; they were very slight in the latter group. Even in those cases where bleeding occurred, the endometrial samples were found to be atrophic. Vaginal bleeding seemed to be an unreliable indicator of endometrial histopathology. The present combination of hormones used in a continuous regimen is a good alternative for post-menopausal women in need of hormonal therapy.     

Dose-response and withdrawal effects on climacteric symptoms after hormonal replacement therapy. A placebo-controlled therapeutic trial

Out of a sample of 162 early post-menopausal women, aged 45–54 yr, 131 completed a placebo-controlled study to investigate the effect of sex hormones on mild climacteric symptoms with special reference to the dose-response relationship and withdrawal effects. The women were followed up for 42 mth under four different study programmes. All the women were examined every 3 mth and a blind assessment made of the menopausal index estimated according to Kupperman et al. The data revealed a highly significant reduction in climacteric symptoms in the hormone-treated women as compared with the placebo group (P < 0.001), a highly significant dose relationship between climacteric symptoms and treatment with 4, 2 and 1 mg oestradiol, respectively (P < 0.001), a highly significant and dose-dependent rebound phenomenon after withdrawal of hormone treatment (P < 0.001) - which levelled off after 6 mth following withdrawal — and complete relief of hot flushes with the two highest doses of oestradiol (4 and 2 mg oestradiol). It is concluded that sex hormones have a beneficial effect in post-menopausal women with even mild symptoms.     

Treatment of climacteric symptoms in breast cancer patients: A retrospective study from a medication databank

Introduction

Women affected by breast cancer (BC) will often go through menopause at an earlier age and display more frequent and severe symptoms than women who have a natural menopause. The safety of hormone replacement therapy (HRT) and vaginal estrogens for BC survivors has been debated over time and remains unclear. Non hormonal therapies such as antidepressants, gabapentine and clonidine may be useful for those patients but there are few data about their safety.

Aim

This retrospective study analyses the use by BC patients of treatments known to alleviate climacteric symptoms.

Material and method

Post-menopausal Estrogen Receptors positive (ER+) BC patients, aged 45–69, were identified as having bought, at least once, an aromatase inhibitor (AI) or tamoxifen between the years 2000 and 2012 through a pharmaceutical databank in Belgium. Among them, we defined users of a climacteric treatment those who bought, at least once, HRT, vaginal topical estrogens, antidepressants, clonidine and gabapentine.

Results

We identified 2530 BC patients. Among them, 45% were buying a treatment known to alleviate menopausal symptoms. The majority of these treatments were non-HRT therapies. HRT and vaginal estrogens were seldom bought (respectively 1.1% and 6%), but 3% bought vaginal estrogens while buying AI. About 9.2% of tamoxifen users patients bought antidepressants implicated in tamoxifen metabolism at the same time as tamoxifen.

Conclusions

Most BC patients follow current guidelines contra-indicating the use of HRT after BC, they use non hormonal therapies. In some cases they use unfortunately antidepressants that may alter the metabolism of tamoxifen.     

A randomised, double-blind, cross-over study into the effect of sequential mestranol and norethisterone on climacteric symptoms and biochemical parameters

A randomised, double-blind, cross-over study into the effect of graded sequential mestranol and norethisterone on climacteric symptoms was performed. The study group consisted of 23 post-menopausal women who had previously undergone hysterectomy. Active therapy resulted in a significant reduction in hot flushes and night sweats. There was a slight improvement in insomnia, lack of energy and confidence but the other symptoms were not significantly altered. A small placebo effect was noted but this was only significant 1 mth after active treatment had been discontinued in the group of women receiving placebo second. Active treatment also resulted in a significant reduction in serum sodium, calcium, albumin, alkaline phosphatase and cholesterol, and increase in serum triglycerides, but no alteration in the other biochemical parameters, weight or blood pressure.     

Factor analysis of climacteric symptoms in Japan

OBJECTIVES: To identify menopausal and climacteric symptoms among midlife Japanese women by factor analysis of symptom frequency and severity data. METHODS: Demographic information, anthropometric data, 2-week recalls of 82 symptoms, and assessment of epidemiological menopausal and self-defined konenki (climacteric) status were collected from 140 Japanese women living in Kyoto and Fukushima prefectures. Factor analysis was performed using symptom frequency scores and frequency-severity scores. To identify the symptoms constituting menopausal and climacteric syndromes in Japan, regression scores for individual factors were compared by menopausal and konenki status groups using non-parametric tests. RESULTS: Among 140 women aged 49.5+/-3.0 years (mean+/-S.D.), the three most prevalent symptoms were shoulder stiffness, memory loss, and stress. Analysis of frequency data resulted in an eight-factor solution, and frequency-severity data in a seven-factor solution. Anxiety and depression factors and a sexual-vasomotor factor were observed in almost all factor solutions, with additional factors comprised of psychosomatic and somatic symptoms. Anxiety scores differed by menopausal status, depression scores by konenki status, and sexual-vasomotor scores by both. Chilliness was highly correlated with sexual-vasomotor symptoms and frequency scores differed significantly between menopausal but not konenki groups. CONCLUSIONS: Sexual-vasomotor symptoms constitute a robust menopausal and konenki symptom grouping among Japanese women, but do not include night sweats or the foreign word hotto furasshu, yet do include chilliness, which may reflect thermoregulatory instability. Overlap of factors displaying significant differences between menopausal and konenki groups indicate a transition to a more medicalized concept of konenki in use by Japanese women.     

A prospective study of the frequency of acute menopausal symptoms in Hong Kong Chinese women

A prospective study was conducted amongst Hong Kong Chinese women to determine the incidence of acute menopausal symptoms following surgical menopause. Cases where a laparotomy was performed for other indications were used as controls. Hot flushes and sweating developed in 8/33 (24.2%) and 6/33 (18.2%), respectively, of those women having had a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Whilst vasomotor symptoms were more frequent in those women who had undergone a surgical menopause than in the controls, women in this population were shown to suffer fewer symptoms than has been demonstrated in Caucasian women. Although this study does not help to explain why such differences exist, the relative absence of symptoms may contribute to the low demand for hormone replacement therapy in Hong Kong and other countries where climacteric symptoms are relatively infrequent.     

Influence of oral contraceptive use on bone density in climacteric women

The aim of the study was to investigate the influence of long-term administration of oral contraceptives on bone density in climacteric women. The existence of a correlation between long-term use and bone density was confirmed.     

Climacteric symptoms in an African community

Climacteric symptoms were studied in a rural community in Zimbabwe. The incidence of symptoms was found to be similar to that described among westernized societies. A positive correlation was observed between various “metabolic” type symptoms and the number of years that had elapsed since the menopause.     

Effect of prostaglandin inhibitor and oestrogen on climacteric symptoms and serum free fatty acids

Oestradiol and naproxen were compared in a double-blind, cross-over study of 20 women suffering from climacteric symptoms. Subjective symptoms were assessed before and after treatment. In addition, serum levels of prostaglandin precursors and of certain other free fatty acids were determined. Oestradiol was found to have a slightly more pronounced effect than naproxen on symptoms and on fatty acid levels. Nevertheless, a large number of the patients reported significant alleviation of their symptoms on naproxen. Some of the climacteric symptoms may thus be mediated by prostaglandins. In most patients the fatty acid levels decreased after treatment with both substances, but there were two exceptions. It is suggested that there may be two separate types of metabolic response to these drugs.     

Climacteric symptoms in an unselected sample of Swedish women

A questionnaire on climacteric symptoms was sent to every woman living in the city of Linköping, Sweden (120,000 inhabitants) who was born in 1928 or 1930. Of the 1246 women concerned, 1118 (90%) responded. At the time of the survey, 252 women (23%) were pre-menopausal. In the total sample, 10B had undergone hysterectomy and/or bilateral oophorectomy. The median age at natural menopause was 51 yr.

Climacteric symptoms were reported by 75% of the women, the predominating complaints being sweating attacks and hot flushes. Vaginal dryness and tenderness were experienced by 30% of the post-menopausal women, the discomfort tending to become more common as the duration of the post-menopausal period lengthened.

After the menopause, every third woman experienced periods of depression more often than previously. Depression was positively correlated to the severity of the vasomotor symptoms.

Fifty percent of the women expressed interest in receiving oestrogen treatment, although only 7% were using oestrogens at the time of the survey. This discrepancy is probably due to widespread apprehension in Swedish society - shared by the doctors - in regard to ‘hormonal treatment’.     

Can climacteric women self-adjust therapeutic estrogen doses using symptoms as markers ?

Objectives: To investigate if disappearance of climacteric symptoms during hormone replacement therapy (HRT) also means good therapeutic level of serum estradiol. The study group comprised of 32 postmenopausal women who had frequent climacteric symptoms. Methods: The women increased the daily treatment doses of percutaneous estradiol every 2 weeks until they felt comfortable with it. Each woman continued at that treatment dose for up to 3 months. Blood samples for estradiol assay were drawn at baseline, every time before the estradiol dosage was increased and at the end of the study. Climacteric symptoms were scored according to the Kupperman menopausal index. Results: Despite the relief of climacteric symptoms, serum estradiol concentration was at a menopausal level (<50 pg/ml) in 22% of the women. In all, 45% of the subjects showed serum estradiol remaining under 60 pg/ml, 29% of the women showed levels of 60–100 pg/ml and 26% showed serum estradiol concentration more than 100 pg/ml. Conclusions: The disappearence of climacteric symptoms during HRT does not quarantee that estrogen levels are sufficiently high for obtaining long term benefits of HRT.     

Relationship between biological changes and symptoms and health behaviour during the climacteric

The object of this investigation was to assess the impact of biological (hormonal) changes during the climacteric on self-reported health status and health behaviour in a group of middle-aged women. The central research question was whether or not the menopausal phase (pre, peri, post) affects the number and frequency of the symptoms a women reports, the frequency of her visits to the primary-care clinic and her perception of her general state of health.The subjects comprised a random sample of 47 women aged 48–53 yr who were judged by their family doctors to be healthy or to be suffering from a chronic disease which was inactive at the time the study was carried out. The women were chosen from among a population of married couples under investigation in a larger study. The sample was homogeneous both ethnically (all subjects born in North Africa) and in terms of social class (lower to lower-middle class). No relationships were found between menopausal phase and any of the health criteria considered. The number and frequency of symptoms was low for all the women. Only a small number of women (2–10%) reported a frequent occurrence even of symptoms that are considered to be direct consequences of hormonal changes.These findings conflict with those deriving from studies of women attending gynaecological clinics, but confirm those of other community (non-clinic) studies.The results of this study bear out the general theoretical conclusion that climacteric symptoms are ‘psychological and cultural artifacts’ rather than consequences of biological changes.     

Physiopathological aspects of body overweight in the female climacteric

The correlation between overweight and the climacteric was studied in 550 menopause clinic patients by investigating certain clinical and sociocultural parameters (age, marital status, educational level, occupation and type of work, calorie intake, smoking habits, parity, blood pressure, previous hormonal therapy and climacteric symptoms), evaluating plasma levels of various hormones (17β-oestradiol, follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone, hydrocortisone, adrenocorticotrophic hormone (ACTH), triiodothyronine (T3), thyroxine (T4), growth hormone (GH) and insulin), glucose and various lipid fractions (total lipids, total cholesterol, nonesterified fatty acids (NEFA), triglycerides and phospholipids) and exploring the blood-clotting pattern (Owren's test, euglobulin lysis time, antithrombin III and prothrombin agglutination time (PAT). The subjects were classified as normal weight or overweight by reference to Broca's Index, as modified by Brusch, and the degree of overweight was determined by means of the Body Mass Index (BMI).Of the subjects examined, 49% were overweight and, in successive years following the menopause, there was a growing bipolarization of the weight increase. The correlation between overweight in the climacteric and the parameters considered was found to be significant only in regard to calorie intake, age and educational level. Post-menopausal gonadotrophin levels in blood were significantly lower in the overweight than in the normal-weight women. With the onset of menopause, the plasma level of testosterone fell in the normal-weight women, while it increased, along with that of hydrocortisone, in the overweight women. In the normal-weight women at menopause, it was found that there was a tendency towards a substantial increase in lipid fractions and glycaemia, as well as a state of hypercoagulability. In the overweight women, the tendency was towards an even more marked increase in both glycaemia and the various lipid fractions, and, besides the usual hypercoagulative state, there was an associated reduction in fibrinolytic activity.It is concluded that the menopause not only causes metabolic changes but also aggravates the metabolic and endocrine tendencies which characterize overweight subjects and thus, clinically, constitutes an obesity risk factor in those women who already demonstrate a tendency towards overweight in the pre-menopausal phase.