Addressing sociodemographic, socioeconomic, and gendered disparities for equity in menopause care.

Menopause experiences and care vary widely because of biological, sociodemographic, and sociocultural factors. Treatments for troublesome symptoms are not uniformly available or accessed. Intersectional factors may affect the experience and are poorly understood. Disparities across populations highlight the opportunity for a multifaceted equitable approach that includes patient-centered care, education, and policy change.

Disparities in Reproductive Aging and Midlife Health between Black and White women: The Study of Women's Health Across the Nation (SWAN).

This paper reviews differences in the experience of the menopause transition and midlife health outcomes between Black and White women who participated in the Study of Women's Health Across the Nation (SWAN), a 25-year, longitudinal, multi-racial/ethnic cohort study. We identify health disparities, i.e., instances in which Black women's outcomes are less favorable than those of White women, and consider whether structural racism may underlie these disparities. Although SWAN did not explicitly assess structural racism, Black women in SWAN grew up during the Jim Crow era in the United States, during which time racism was legally sanctioned. We consider how we might gain insight into structural racism by examining proxy exposures such as socioeconomic characteristics, reports of everyday discrimination, and a range of life stressors, which likely reflect the longstanding, pervasive and persistent inequities that have roots in systemic racism in the US. Thus, this paper reviews the presence, magnitude, and longitudinal patterns of racial disparities observed in SWAN in six areas of women's health - menopause symptoms, sleep, mental health, health related quality of life, cardio-metabolic health, and physical function -and elucidates the contextual factors that are likely influencing these disparities. We review the strengths and weaknesses of SWAN's design and approach to analysis of racial disparities and use this as a springboard to offer recommendations for future cohort studies.

Depressive Symptoms and Associated Health-Related Variables in Older Adult Breast Cancer Survivors and Non-Cancer Controls.

OBJECTIVES: To examine the prevalence of depressive symptoms and associated risk factors in older adult breast cancer survivors (BCS) and age-matched non-cancer controls. SAMPLE & SETTING: Using the Surveillance, Epidemiology, and End Results-Medicare Health Outcome Survey linked dataset from 1998 to 2012, BCS and non-cancer controls aged 65 years or older were identified. METHODS & VARIABLES: Depressive symptoms, comorbidities, functional limitations, socio-demographics, and health-related information were examined. Univariate and multivariable logistic regression and marginal models were performed. RESULTS: 5,421 BCS and 21,684 controls were identified. BCS and non-cancer controls had similar prevalence of depressive symptoms. Having two or more comorbidities and functional limitations were strongly associated with elevated risk of depressive symptoms in BCS and non-cancer controls. IMPLICATIONS FOR NURSING: Having multiple comorbidities and multiple functional status are key factors associated with depressive symptoms in older adult BCS and non-cancer controls. Nurses are in an ideal position to screen older adult BCS and non-cancer controls at risk for depressive symptoms.

Longitudinal Assessment of Physical Activity and Cognitive Outcomes Among Women at Midlife.

Importance: The increasing prevalence of cognitive decline, impairment, and dementia spurs intense interest in cognitive preservation strategies. Objective: To explore the longitudinal association between physical activity (PA) and cognitive performance among women at midlife. Design, Setting, and Participants: This cohort study is an analysis from the Study of Women's Health Across the Nation. Enrollment occurred from 1996 through 1997, and follow-up extended into 2017. Included individuals were those who had undergone cognitive measures during the first 3 cognitive test visits and had at least 1 additional cognitive measurement. Stroke prior to baseline was an exclusion, and observations were censored for subsequent stroke. Data were analyzed from June 2018 through August 2019. Exposures: Engaging in sport or exercise PA (self-reported). Main Outcomes and Measures: The Symbol Digit Modalities Test (SDMT) was used to assess cognitive processing speed. The East Boston Memory Test-Delayed (EBMT-D) was used to measure verbal episodic memory. The digit span backwards (DSB) test was used to evaluate working memory. Results: Among 1718 women with a median (range) observation time of 11.9 (0.60-13.5) years, the mean (SD) baseline age was 45.7 (2.5) years. From baseline through age 61 years, mean change in SDMT score was -0.20 annually (95% CI, -0.26 to -0.15; P < .001). After age 61 years, the mean change in SDMT was -0.51 yearly (95% CI, -0.54 to -0.41; P < .001). Beginning at age 58 years of the mean change in EBMT was -0.03 yearly (95% CI, -0.04 to -0.02; P < .001). Starting at age 61 years, mean (SD) change in DSB was -0.03 annually (95% CI, -0.04 to -0.01; P = .001). When adjusted for attrition and practice effect, PA was associated with higher concurrent SDMT and EBMT scores and a smaller decrease in SDMT score. For each unit increment in PA, there was a 0.36 increment in concurrent SDMT score (95% CI, 0.14 to 0.59; P = .002) and a 0.10 increment in concurrent EBMT score (95% CI, 0.05 to 0.15; P < .001). Greater PA was associated with a smaller annual mean decrease in SDMT score (0.06 yearly; 95% CI, 0.02 to 0.09; P = .001). After additional adjustment for demographic characteristics, menopause symptoms, hormone therapy use, and the presence of diabetes and hypertension, PA was not associated with trajectories (ie, levels or slopes) of any cognitive outcome. Conclusions and Relevance: This cohort study found no association between greater PA levels and cognitive outcomes among women in midlife, unlike cohort studies that begin observations at later ages, which may be associated with confounding by reverse causation (ie, cognitive decline associated with an outcome of lower PA levels).

A non-compensatory analysis of quality of life in breast cancer survivors using multivariate hidden Markov modeling.

PURPOSE: Health-related quality of life (HRQoL) is a multidimensional concept comprising multiple domains such as physical, emotional, and social well-being. Many analyses use a sum score to represent the construct. However, this approach implies that gain in one domain can compensate for a deficit in another, and thus such analyses may not capture HRQoL profiles. Additionally, within-individual change over time, such as improvement in one domain but deterioration in another, may not be detected. The objectives of this research are to demonstrate the utility of a non-compensatory approach by (1) evaluating this approach applied to HRQoL data, and (2) comparing the approach to a compensatory method. METHODS: Data from a sample of 653 breast cancer survivors (BCS) provided five measurement time points over 18 months. We analyzed the scores from five domains on the FACT-B questionnaire (physical, functional, social, and emotional well-being and breast cancer-related concerns) using the multivariate hidden Markov model (MHMM), a non-compensatory approach that identifies different HRQoL states and associated BCS subgroups and their trajectories. RESULTS: The MHMM delineated six states. States 1 and 2 had low well-being scores across all domains, with state 2 slightly better than state 1. States 3 and 4 had similar overall HRQoL scores, but different profiles with compensation occurring across the domains of both physical and social well-being. States 5 and 6 had almost identical overall scores with compensation occurring between the domains of both social and emotional well-being. Over time, states 3-6 mostly "communicated" with each other (with moderate probabilities of transitioning between states). Compensation across domains could mask subtle changes occurring in BCS. We found that a trend analysis using both compensatory and non-compensatory approaches showed improvement in the HRQoL in BCS over time. CONCLUSION: The non-compensatory analysis of FACT-B shows differential profiles and trajectories in the HRQoL of BCS not captured by the sum score or one-domain-at-a-time approach.

Rural cancer survivors' health information needs post-treatment.

OBJECTIVE: This study describes the most common cancer-related health information needs among rural cancer survivors and characteristics associated with reporting more information needs. METHODS: Rural breast, prostate, and colorectal cancer survivors, two to five years post-diagnosis, identified from an institutional cancer registry, completed a mailed/telephone-administered survey. Respondents were asked about 23 health information needs in eight domains (tests and treatment, side effects and symptoms, health promotion, fertility, interpersonal, occupational, emotional, and insurance). Poisson regression models were used to assess relationships between number of health information needs and demographic and cancer characteristics. RESULTS: Participants (n = 170) reported an average of four health information needs, with the most common domains being: side effects and symptoms (58 %), health promotion (54 %), and tests and treatment (41 %). Participants who were younger (compared to 5-year increase, rate ratio [RR] = 1.11, 95 % CI = 1.02-1.21), ethnic minority (RR = 1.89, 95 % CI = 1.17-3.06), less educated (RR = 1.49, 95 % CI = 1.00-2.23), and financially stressed (RR = 1.87, 95 % CI = 1.25-2.81) had a greater number of information needs. CONCLUSIONS: Younger, ethnic minority, less educated, and financially strained rural survivors have the greatest need for informational support. PRACTICE IMPLICATIONS: The provision of health information for rural cancer survivors should consider type of cancer, treatments received, and sociocultural differences to tailor information provided.

Health-related quality of life and medical comorbidities in older patients with pancreatic adenocarcinoma: An analysis using the 1998-2011 surveillance, epidemiology, and end results-medicare health outcomes survey data.

OBJECTIVES: This study compares health-related quality of life (HRQoL) of older patients with pancreatic ductal adenocarcinoma (PDAC) to controls without cancer, and examines the impact of medical comorbidities on HRQoL. MATERIALS AND METHODS: We conducted a case-control study using the 1998-2011 Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey (SEER-MHOS) linked dataset. Cases were Medicare beneficiaries aged 65 and older diagnosed with PDAC (N = 128) and matched controls were without a history of cancer (N = 512). We used the Short Form 36 (SF-36) and Veterans-RAND-12 (VR-12) to examine HRQoL and calculated mental (MCS) and physical (PCS) component scores. Linear regression and mixed effects models were used to examine the impact of medical comorbidities on MCS and PCS for cases and controls, respectively. RESULTS: Cases reported significantly poorer PCS (29.3 vs. 36.3) and MCS (44.8 vs. 49.9) compared to controls. Comorbidities were significantly associated with lower PCS and MCS in controls. However, neither total number of comorbidities or comorbidities grouped by organ systems (cardiopulmonary disease, musculoskeletal disease, diabetes) were significantly related to PCS or MCS for cases. Comparison of regression coefficients estimates did not indicate that lack of significance was due to differences in sample size. CONCLUSIONS: The results of this study highlight the poor HRQoL reported by older patients with PDAC. HRQoL scores were very low in this population, particularly in physical health status, which were not explained by comorbidities.

Psychosocial and health-related risk factors for depressive symptom trajectories among midlife women over 15 years: Study of Women's Health Across the Nation (SWAN).

BACKGROUND: Psychosocial and health-related risk factors for depressive symptoms are known. It is unclear if these are associated with depressive symptom patterns over time. We identified trajectories of depressive symptoms and their risk factors among midlife women followed over 15 years. METHODS: Participants were 3300 multiracial/ethnic women enrolled in a multisite longitudinal menopause and aging study, Study of Women's Health Across the Nation. Biological, psychosocial, and depressive symptom data were collected approximately annually. Group-based trajectory modeling identified women with similar longitudinal patterns of depressive symptoms. Trajectory groups were compared on time-invariant and varying characteristics using multivariable multinomial analyses and pairwise comparisons. RESULTS: Five symptom trajectories were compared (50% very low; 29% low; 5% increasing; 11% decreasing; 5% high). Relative to whites, blacks were less likely to be in the increasing trajectory and more likely to be in the decreasing symptom trajectory and Hispanics were more likely to have a high symptom trajectory than an increasing trajectory. Psychosocial/health factors varied between groups. A rise in sleep problems was associated with higher odds of having an increasing trajectory and a rise in social support was associated with lower odds. Women with low role functioning for 50% or more visits had three times the odds of being in the increasing symptom group. CONCLUSIONS: Changes in psychosocial and health characteristics were related to changing depressive symptom trajectories. Health care providers need to evaluate women's sleep quality, social support, life events, and role functioning repeatedly during midlife to monitor changes in these and depressive symptoms.

Vasomotor Symptoms Across the Menopause Transition: Differences Among Women.

Vasomotor symptoms (VMS) are the primary menopausal symptoms, occurring in up 80% of women and peaking around the final menstrual period. The average duration is 10 years, longer in women with an earlier onset. Compared with non-Hispanic white women, black and Hispanic women are more likely and Asian women are less likely to report VMS. Risk factors include greater body composition (in the early stage of menopausal transition), smoking, anxiety, depression, sensitivity to symptoms, premenstrual syndrome, lower education, and medical treatments, such as hysterectomy, oophorectomy, and breast cancer-related therapies. VMS patterns over time and within higher-risk subgroups are heterogeneous across women.

Longitudinal Examination of Symptom Profiles Among Breast Cancer Survivors.

CONTEXT: Identification of cancer patients with similar symptom profiles may facilitate targeted symptom management. OBJECTIVES: To identify subgroups of breast cancer survivors based on differential experience of symptoms, examine change in subgroup membership over time, and identify relevant characteristics and quality of life (QOL) among subgroups. METHODS: Secondary analyses of data from 653 breast cancer survivors recruited within eight months of diagnosis who completed questionnaires at five time points. Hidden Markov modeling was used to 1) formulate symptom profiles based on prevalence and severity of eight symptoms commonly associated with breast cancer and 2) estimate probabilities of changing subgroup membership over 18 months of follow-up. Ordinal repeated measures were used to 3) identify patient characteristics related to subgroup membership and 4) evaluate the relationship between symptom subgroup and QOL. RESULTS: A seven-subgroup model provided the best fit: 1) low symptom burden, 2) mild fatigue, 3) mild fatigue and mild pain, 4) moderate fatigue and moderate pain, 5) moderate fatigue and moderate psychological, 6) moderate fatigue, mild pain, mild psychological, and 7) high symptom burden. Seventy percent of survivors remained in the same subgroup over time. In multivariable analyses, chemotherapy and greater illness intrusiveness were significantly related to greater symptom burden, while not being married or partnered, no difficulty paying for basics, and greater social support were protective. Higher symptom burden was associated with lower QOL. Survivors who reported psychological symptoms had significantly lower QOL than did survivors with pain symptoms. CONCLUSION: Cancer survivors can be differentiated by their symptom profiles.

Symptom clusters in women with breast cancer: an analysis of data from social media and a research study.

PURPOSE: User-generated content on social media sites, such as health-related online forums, offers researchers a tantalizing amount of information, but concerns regarding scientific application of such data remain. This paper compares and contrasts symptom cluster patterns derived from messages on a breast cancer forum with those from a symptom checklist completed by breast cancer survivors participating in a research study. METHODS: Over 50,000 messages generated by 12,991 users of the breast cancer forum on MedHelp.org were transformed into a standard form and examined for the co-occurrence of 25 symptoms. The k-medoid clustering method was used to determine appropriate placement of symptoms within clusters. Findings were compared with a similar analysis of a symptom checklist administered to 653 breast cancer survivors participating in a research study. RESULTS: The following clusters were identified using forum data: menopausal/psychological, pain/fatigue, gastrointestinal, and miscellaneous. Study data generated the clusters: menopausal, pain, fatigue/sleep/gastrointestinal, psychological, and increased weight/appetite. Although the clusters are somewhat different, many symptoms that clustered together in the social media analysis remained together in the analysis of the study participants. Density of connections between symptoms, as reflected by rates of co-occurrence and similarity, was higher in the study data. CONCLUSIONS: The copious amount of data generated by social media outlets can augment findings from traditional data sources. When different sources of information are combined, areas of overlap and discrepancy can be detected, perhaps giving researchers a more accurate picture of reality. However, data derived from social media must be used carefully and with understanding of its limitations.

Trajectories of Posttraumatic Growth and Associated Characteristics in Women with Breast Cancer.

BACKGROUND: Cancer survivors may experience posttraumatic growth (PTG), positive psychological changes resulting from highly stressful events; however, the longitudinal course of PTG is poorly understood. PURPOSE: The purpose of the present study was to determine trajectories of PTG in breast cancer survivors and associated characteristics. METHODS: Women (N = 653) participating in a longitudinal observational study completed questionnaires within 8 months of breast cancer diagnosis and 6, 12, and 18 months later. Group-based modeling identified PTG trajectories. Chi-square tests and ANOVA detected group differences in demographic, medical, and psychosocial variables. RESULTS: Six trajectory groups emerged. Three were stable at different levels of PTG, two increased modestly, and one increased substantially over time. Trajectory groups differed by age, race, receipt of chemotherapy, illness intrusiveness, depressive symptoms, active-adaptive coping, and social support. CONCLUSIONS: This first examination of PTG trajectories in US cancer survivors elucidates heterogeneity in longitudinal patterns of PTG. Future research should determine whether other samples exhibit similar trajectories and whether various PTG trajectories predict mental and physical health outcomes.

Factors related to age at natural menopause: longitudinal analyses from SWAN.

Early age at the natural final menstrual period (FMP) or menopause has been associated with numerous health outcomes and might be a marker of future ill health. However, potentially modifiable factors affecting age at menopause have not been examined longitudinally in large, diverse populations. The Study of Women's Health Across the Nation (SWAN) followed 3,302 initially premenopausal and early perimenopausal women from 7 US sites and 5 racial/ethnic groups, using annual data (1996-2007) and Cox proportional hazards models to assess the relation of time-invariant and time-varying sociodemographic, lifestyle, and health factors to age at natural FMP. Median age at the FMP was 52.54 years (n = 1,483 observed natural FMPs). Controlling for sociodemographic, lifestyle, and health factors, we found that racial/ethnic groups did not differ in age at the FMP. Higher educational level, prior oral contraceptive use, and higher weight at baseline, as well as being employed, not smoking, consuming alcohol, having less physical activity, and having better self-rated health over follow-up, were significantly associated with later age at the FMP. These results suggest that age at the natural FMP reflects a complex interrelation of health and socioeconomic factors, which could partially explain the relation of late age at FMP to reduced morbidity and mortality.

The impact of hormone therapy on health-related quality of life: longitudinal results from the Study of Women's Health Across the Nation.

OBJECTIVE: To determine the impact of hormone therapy (HT) on health-related quality of life (HRQOL) during the menopausal transition and to examine variation based on menopausal symptom status. DESIGN: The Study of Women's Health Across the Nation is a multisite, multiethnic study of mid-life women without baseline HT use. Women completed annual questionnaires including HT use, menstrual bleeding, symptoms, and HRQOL (Medical Outcomes Study Short Form-36). We compared baseline characteristics of women who initiated HT during follow-up with noninitiators. We examined the effect of HRQOL on the likelihood of initiating HT using survival analysis and the relationship between HT initiation and subsequent HRQOL using longitudinal random effects models. Among HT initiators, we compared change in HRQOL between women with frequent (>or=6 d/wk) and infrequent symptoms. RESULTS: Of the 3,102 participants, 813 initiated HT during the 6-year follow-up period. At baseline, women who subsequently initiated HT were more likely to report poor role physical functioning, higher socioeconomic status, and frequent symptoms and to be white. In longitudinal analyses, women reporting poor role emotional and physical functioning at the visit before initiation were less likely to subsequently initiate (hazard ratio [95% CI]: 0.76 [0.62-0.91] and 0.58 [0.47-0.71]; P<0.01 and <0.0001, respectively), and initiation was associated with subsequent poorer role physical functioning (odds ratio [95% CI]: 1.26 [1.02-1.56]; P=0.03). Among HT initiators, frequent symptom reporters showed improvements in vitality (+2.7) compared with other initiators (-2.9) (P<0.01). CONCLUSIONS: Poor HRQOL does not increase the likelihood of initiating HT, nor is HT use associated with HRQOL improvements. The exception is women reporting frequent symptoms who report improved vitality after initiation. Future studies may employ more frequent HRQOL measures to further discern this trend.

Disentangling cultural issues in quality of life data.

OBJECTIVE: To describe a process for understanding ethnic differences in health-related quality of life (HRQL). DESIGN: Analyses are based on the baseline data from the Study of Women's Health Across the Nation (SWAN), a multiethnic longitudinal study of women transitioning through menopause. There were a total of 3,302 women aged 42 to 52 entered into the cohort, which included white, African American, Hispanic, Chinese, and Japanese women enrolled at seven sites in the United States. Five domains from the Medical Outcomes Short Form Health Survey (SF-36) were used to measure HRQL. Acculturation was assessed by language of questionnaire completion. Covariates included socioeconomic status, sociodemographics, health, lifestyle, and social circumstances. Logistic regression was used to examine the relationship between acculturation and HRQL. RESULTS: Previous unadjusted analyses found ethnic differences on all five domains of the SF-36. However, ethnic differences largely disappeared after adjusting for covariates. Remaining differences showed that less acculturated Hispanic women reported more bodily pain and more impaired social functioning than non-Hispanic white women. Less acculturated Japanese women were less likely to report problems on the role-emotional scale. CONCLUSIONS: The majority of ethnic differences in HRQL could be explained by covariates. These findings highlight the importance of controlling for differences in sample characteristics in any multiethnic study.

Health-related quality of life in a multiethnic sample of middle-aged women: Study of Women's Health Across the Nation (SWAN).

BACKGROUND: Relatively little is known about the association between menopause and health-related quality of life (HRQL) across ethnic groups. OBJECTIVES: To examine the association between HRQL and early perimenopause and ethnicity, adjusting for health, lifestyle, psychosocial, and sociodemographic factors. RESEARCH DESIGN: Questionnaires were administered to pre- and early perimenopausal women. SUBJECTS: We studied a cohort of 3302 black, Chinese, Hispanic, Japanese, and white women aged 42 to 52 years from the multisite Study of Women's Health Across the Nation (SWAN). MEASURES: We measured HRQL, menstrual regularity, and a variety of covariates. HRQL was assessed with 5 subscales from the Short Form-36; impaired functioning was defined as being in the 25% most impaired on a subscale. RESULTS: In unadjusted, but not adjusted, analyses, significantly more early perimenopausal women, as compared with premenopausal women, were classified as having impaired functioning on each of the 5 subscales. For 4 of the subscales, the effect of menopausal status was explained by menopause-related symptoms. There were significant ethnic group differences across all 5 subscales in unadjusted analyses. Ethnicity was no longer significant for the Vitality or Role-Emotional subscales when adjusted for health variables or for the Role-Physical subscale when analyses were adjusted for socioeconomic status, health, lifestyle, or social circumstances. Ethnicity remained significant for the Bodily Pain and Social Functioning subscales, even in adjusted analyses. CONCLUSIONS: Early perimenopause is not associated with impaired functioning when adjusted for symptoms. Significant ethnic differences in HRQL exist. Some, but not all, differences can be explained by differences in health, lifestyle, and social circumstances.

Sexual functioning and practices in a multi-ethnic study of midlife women: baseline results from SWAN.

This study examined the sexual practices and function of midlife women by ethnicity (African American, Caucasian, Chinese, Hispanic, Japanese) and menopausal status. Sexual behavior was compared in 3,262 women in the baseline cohort of SWAN. Participants were 42 to 52 years old, premenopausal or early perimenopausal, and not hysterectomized or using hormones. Analysis used multivariate proportional odds regression. In our sample, 79% had engaged in sex with a partner in the last 6 months, and a third considered sex to be very important. Common reasons for no sex (n = 676) were lack of partner (67%), lack of interest (33%), and fatigue (16%). Compared with Caucasians, Japanese and Chinese women were less likely, and African Americans more likely, to report sex as very important (p < 0.005). Significant ethnic differences were found for frequency of all practices. Perimenopause status was associated only with higher frequencies of masturbation and pain during intercourse.

Persistent mood symptoms in a multiethnic community cohort of pre- and perimenopausal women.

To further our understanding of the relation between mood and menopause, the authors examined 1) the association between persistent mood symptoms and menopausal status and 2) factors that increase a woman's vulnerability to an overall dysphoric mood during the early perimenopausal period. The sample consisted of an ethnically diverse community cohort of 3,302 pre- and early perimenopausal women aged 42-52 years who were participants in the Study of Women's Health Across the Nation, an ongoing US multisite longitudinal study of menopause and aging. At study entry (1995-1997), women reported information on recent menstrual regularity and premenstrual symptoms, as well as on sociodemographic, symptom, health, sleep, psychosocial, and lifestyle variables. Rates of persistent mood symptoms were higher among early perimenopausal women (14.9%-18.4%) than among premenopausal women (8%-12%). In analyses adjusting for major covariates and confounders, early perimenopausal women had higher odds of irritability, nervousness, and frequent mood changes but not of feeling "blue." The effect of being early perimenopausal on overall dysphoric mood was greatest among women with an educational level of less than high school graduation. These findings suggest that persistent mood symptoms and overall dysphoric mood are associated with the early perimenopause, particularly among women with lower educational attainment.